The relationship of recent stressful life events with impulsiveness in triggering suicide attempts and how impulsiveness changes from one suicide attempt to another is unclear. This study used structured-interview tools and standardized measurements to examine the relationship between life stress and impulsiveness in a sample of patients who required hospitalization for a medically serious suicide attempt. After controlling for potentially confounding variables, the number of disrupted interpersonal relationships in the preceding year was a significant predictor of the impulsiveness of the suicide attempt, with three or more losses (but not other life stresses) associated with less impulsive attempts (T = 2.4, p = .02). Female gender (T = -1.98, p = .05) and lifetime DMS-III-R diagnoses (T = -2.45, p = .02) were significantly associated with more impulsive attempts. In 55 patients with at least two suicide attempts, impulsiveness, lethal intent, and communication of intent were significantly greater for the present compared to the prior attempt (p = 0.000). Certain stressful life events, gender, and total lifetime DSM-III-R diagnoses are associated with impulsiveness of failed suicide attempts; yet, impulsiveness is not necessarily consistent from one suicide attempt to another. This evidence supports and amplifies a stress-diathesis model of suicide behavior. Accordingly, efforts to increase personal resilience in individuals who have "failed suicide" may be more effective at preventing suicide morbidity than simple stress-reduction measures alone.
Culturally competent informed consent for particularly vulnerable populations of non-native speakers of English is possible. It requires both knowledge of specific cultural elements and the application of appropriate technology.
To the Editor.\p=m-\We strongly agree with Dr Hickson and colleagues1 that interpersonal aspects of care, especially those relating to physician-patient communication, are the most important predictors of patient satisfaction and consequent likelihood to institute a malpractice action. Our experience supports Dr Levinson's suggestion in the accompanying Edi-torial2 that experienced physicians and other clinicians can improve communication skills and patient satisfaction through education and practice.In 1991, the patient relations department ofthe Fallon Clinic, a 250-physician multispecialty group practice, reported that the obstetrics/gynecology department was receiving patient complaints and concerns that exceeded other clinic departments. A patient satisfaction survey found relatively low scores on four questions. The questions probed quality of care, physi ci an\x=req-\ patient communication, and access-risk factors similar to those demonstrated by Hickson et al to correlate with likelihood for suit. The departmental chair, the office of the medical director, and the University of Massachusetts Medical Center together developed a 7.5-hour training program focusing on communication skills. This program was presented in three sessions over 3 weeks in early 1992 to the 15 physicians, seven nurse midwives, and three nurse practitioners in the department. The program involves an active learner-centered approach using ex¬ perienced actors as "simulated patients" in role-playing exer¬ cises. A follow-up patient satisfaction survey with identical probes to the precourse survey was performed. Respondents reported on a Likert scale of 1 (poor) to 5 (excellent).Significant improvements in patient assessment of their visit to the obstetrics/gynecology department (Table) were observed after the communications course was completed, especially in areas of physician-patient interaction. A sus¬ tained decrease in the number of complaints received by the patient relations department regarding obstetrics/gynecol¬ ogy services from 1.44 complaints per 1000 visits in 1991 to 0.47 and 0.5 in 1993 and 1994, respectively, demonstrates persistence in improved patient satisfaction.Coincident with the communication skills training program, other changes to improve patient satisfaction with the ob¬ stetrics/gynecology service included improved staffing levels and remodeled offices with greater space and improved am¬ biance. Average waiting time in the office decreased from a mean of 16.3 to 12.4 minutes. However, improvements in patient evaluation of the visit occurred only for the physicians and not for the office staff who were not offered the com¬ munication skills training program (Table), suggesting a pow¬ erful role for this educational intervention in improving over¬ all patient satisfaction. Clearly, communication skills need to be taught to all medical staff in contact with patients.
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