AIDS and medical confidentiality.

In summary, I have argued that the arguments offered or hinted at in favour of doctors'' breaking medical confidentiality by passing on information about their patients'' HIV state to others, including other doctors, when this is against the patient''s considered wishes are generally unconvincing. Although in highly exceptional cases there may be justifications for overriding confidentiality, the requirement of medical confidentiality is a very strong, though not absolute, obligation. Patients, their contacts, doctors and their staff, and the common good are most likely to be best served if that tradition continues to be honoured.     

Consultations in general practice: a comparison of patients' and doctors' satisfaction.

OBJECTIVE--To provide an objective means of assessing patients'' and doctors'' satisfaction with a consultation. DESIGN--Questionnaire study of patients and general practitioners after consultations. SETTING--Urban general practice. SUBJECTS--250 Patients attending consecutive consultations conducted by five general practitioners. MAIN OUTCOME MEASURE--Identification of deficiencies within a consultation as perceived by both doctors and patients. RESULTS--The doctor''s and patient''s questionnaires for each consultation were matched and the results analysed on a group basis. The response rate for individual questions was high (81-89%). The doctors and patients significantly disagreed about the doctors'' ability to assess and put patients at ease, to offer explanations and advice on treatment, and to allow expression of emotional feelings and about the overall benefit that the patients gained from the consultation. In all cases of disagreement the doctor had a more negative view of the consultation than the patient. CONCLUSIONS--The results of giving structured questionnaires on consultations to both patients and doctors could be a useful teaching tool for established doctors or those in training to improve the quality and sensitivity of care they provide.     

Ignoring the obvious: doctors' wives as patients.

There is a widely held belief among doctors and nurses that when a colleague is in hospital, if anything can go wrong during the course of his illness it invariably will. To investigate this belief, we studied prospectively a group of pregnant doctors and doctors'' wives, comparing the number of obstetric, paediatric, and psychiatric complications with those in two control groups of similar social class, race, and parity. These were teachers and lecturers and a group of State registered nurses. The occurrence of obstetric and paediatric problems was similar in the three groups. Psychiatric problems, however, were more common among teachers and lecturers (p less than 0.001); this difference was due to the way the nurses on the postnatal wards failed to report mild psychiatric problems among doctors'' wives to their colleagues. This difference was not related to the amount of preferential treatment that doctors and doctors'' wives received while in hospital.     

Great Expectations: Teaching Ethics to Medical Students in South Africa

Many academic philosophers and ethicists are appointed to teach ethics to medical students. We explore exactly what this task entails. In South Africa the Health Professions Council's curriculum for training medical practitioners requires not only that students be taught to apply ethical theory to issues and be made aware of the legal and regulatory requirements of their profession, it also expects moral formation and the inculcation of professional virtue in students. We explore whether such expectations are reasonable. We defend the claim that physicians ought to be persons of virtuous character, on the grounds of the social contract between society and the profession. We further argue that since the expectations of virtue of health care professionals are reasonable, it is also sound reasoning to expect ethics teachers to try to inculcate such virtues in their students, so far as this is possible. Furthermore, this requires of such teachers that they be suitable role models of ethical practice and virtue, themselves. We claim that this applies to ethics teachers who are themselves not members of the medical profession, too, even though they are not bound by the same social contract as doctors. We conclude that those who accept employment as teachers of ethics to medical students, where as part of their contractual obligation they are expected to inculcate moral values in their students, ought to be prepared to accept their responsibility to be professionally ethical, themselves.     

Parental virtue: a new way of thinking about the morality of reproductive actions

In this paper I explore the potential of virtue ethical ideas to generate a new way of thinking about the ethical questions surrounding the creation of children. Applying ideas from neo‐Aristotelian virtue ethics to the parental sphere specifically, I develop a framework for the moral assessment of reproductive actions that centres on the concept of parental virtue. I suggest that the character traits of the good parent can be used as a basis for determining the moral permissibility of a particular reproductive action. I posit three parental virtues and argue that we can see the moral status of a reproductive action as determined by the relationship between such an action and (at least) these virtues. Using a case involving selection for deafness, I argue that thinking in terms of the question ‘would a virtuous parent do this?’ when morally assessing reproductive action is a viable and useful way of thinking about issues in reproductive ethics.     

Career destinations in 1994 of United Kingdom medical graduates of 1983: results of a questionnaire survey.

Cohort studies of doctors'' career choices and career progression since the mid-1970s have shown important changes in the medical workforce, in specialist training, and in employment. Examples of these changes are the increasing proportion of women doctors and of doctors who wish to work part time, the emigration patterns of doctors, and the development of vocational training for general practice. Studies enable the effects of longer term changes to be assessed, and sometimes they inform current debate.     

Improving compliance with requirements on junior doctors' hours

Problem Compliance with UK regulations on junior doctors'' working hours cannot be achieved by manipulating rotas that maintain existing tiers of cover and work practices. More radical solutions are needed.Design Audit of change.Setting Paediatric night rota in large children''s hospital.Key measures for improvement Compliance with regulations on working hours assessed by diary cards; workload assessed by staff attendance on wards; patient safety assessed through critical incident reports.Strategies for change Development of new staff roles, followed by change from a partial shift rota comprising 11 doctors and one senior nurse, to a full shift night team comprising three middle grade doctors and two senior nurses.Effects of change Compliance with regulations on working hours increased from 33% to 77%. Workload changed little and was well within the capacity of the new night team. The effect on patient care and on medical staff requires further evaluation.Lessons learnt Reduction of junior doctors'' working hours requires changes to roles, processes, and practices throughout the organisation.     

Heroin users: notifications to the Home Office Addict's Index by general practitioners.

In a study of 113 heroin users who attended a Scottish general practice of 11 doctors information was gathered retrospectively regarding notification of these patients to the Home Office. The doctors were questioned about their practices for notification. Surprisingly few of the patients had been correctly notified and renotified where appropriate, and there was great variation in the doctors'' notification practices, particularly with respect to defining addiction. General practitioners are now the largest source of notifications of controlled drug users, and the statistics issued by the Home Office must be interpreted in the light of their notification practices.     

Sartorial eloquence: does it exist in the paediatrician-patient relationship?

OBJECTIVE--To evaluate children''s and parents'' perceptions of hospital doctors'' attire. DESIGN--Questionnaire study asking children and parents to assign positive and negative attributes to five photographs of a male or female doctor dressed formally and informally. SETTING--Outpatient department, Children''s Hospital, Birmingham. SUBJECTS--203 consecutive child-parent pairs attending outpatient clinics over three months. MAIN OUTCOME MEASURES--Children''s and parents'' preferences, assessed by comparing proportions. RESULTS--70% (286/406) of children and parents rated doctors'' dress as important; more children rated it "very important" (27% (54/203) v 14% (29/203), P < 0.01, 95% confidence interval for difference 5% to 21%). Of the 99 children responding, 44 regarded the man in white coat as most competent (44% v 20% expected by chance, P < 0.01, 34% to 54%) and most concerned (32% v 20%, P < 0.01, 23% to 41%). Children also regarded the woman in white coat as most competent; however, male and female doctors in white coats rated lower for friendliness. Asians and regular surgical attenders preferred doctors in white coats. The man in polo shirt and trousers was rated as most friendly (40% v 20% expected by chance, P < 0.01, 30% to 50%) and most gentle (37% v 20%, P < 0.01, 27% to 46%). The woman in tee shirt and slacks also rated most friendly and gentle; however, both casually dressed doctors rated lower for competence. Parents preferred more casual dress but expressed preferences less strongly, and they poorly predicted which outfits their children preferred. CONCLUSIONS--Children regard formally dressed doctors as competent but not friendly; they regard casual dress as friendly but not competent.     

Doctors' experience with handheld computers in clinical practice: qualitative study

Objective To examine doctors'' perspectives about their experiences with handheld computers in clinical practice.Design Qualitative study of eight focus groups consisting of doctors with diverse training and practice patterns.Setting Six practice settings across the United States and two additional focus group sessions held at a national meeting of general internists.Participants 54 doctors who did or did not use handheld computers.Results Doctors who used handheld computers in clinical practice seemed generally satisfied with them and reported diverse patterns of use. Users perceived that the devices helped them increase productivity and improve patient care. Barriers to use concerned the device itself and personal and perceptual constraints, with perceptual factors such as comfort with technology, preference for paper, and the impression that the devices are not easy to use somewhat difficult to overcome. Participants suggested that organisations can help promote handheld computers by providing advice on purchase, usage, training, and user support. Participants expressed concern about reliability and security of the device but were particularly concerned about dependency on the device and over-reliance as a substitute for clinical thinking.Conclusions Doctors expect handheld computers to become more useful, and most seem interested in leveraging (getting the most value from) their use. Key opportunities with handheld computers included their use as a stepping stone to build doctors'' comfort with other information technology and ehealth initiatives and providing point of care support that helps improve patient care.     

Respecting the autonomy of cancer patients when talking with their families: qualitative analysis of semistructured interviews with patients.

OBJECTIVE: To discover cancer patients'' views about disclosure of information to their family, their family''s influence over the information given them, and their preferences for doctors'' behaviour if they and their family disagree, as a complement to applied ethical theory. DESIGN: Semistructured interviews followed by qualitative content analysis. SETTING: Mainly urban British general practice. SUBJECTS: 30 patients in whom cancer, excluding basal and squamous cell skin carcinomas, was diagnosed 1-7 years earlier. RESULTS: All subjects wished doctors to respect their views rather than those of their family, should they differ. With their consent, subjects favoured close family receiving information about their illness, all but one mentioning advantage to their family. Without such consent, six unconditionally favoured disclosure of information to their family while seven unconditionally opposed disclosure. Seventeen participants restricted their approval for such disclosure to specific circumstances. Only two participants approved of their family influencing the information that they received about their illness; all but seven wished to receive full information, the exceptions relating to information about bad prognosis. CONCLUSIONS: Subjects favoured openness with their family but most rejected unconditional disclosure of information without their consent and their family influencing what information they would be given. They valued respect for their autonomy more highly than beneficence and considered that their own needs took priority over those of their family.     

The truth about doctors' handwriting: a prospective study.

OBJECTIVES: To determine whether doctors have worse handwriting than other health professionals. DESIGN: Comparison of handwriting samples collected prospectively in a standardised 10 seconds'' task. SETTING: Courses on quality improvement. SUBJECTS: 209 health care professionals attending the courses, including 82 doctors. MAIN OUTCOME MEASURES: Legibility rated on a four-point scale by four raters. RESULTS: The handwriting of doctors was no less legible than that of non-doctors. Significantly lower legibility than average was associated with being an executive and being male. Overall legibility scores were normally distributed, with median legibility equivalent to a rating between "fair" and "good." CONCLUSION: This study fails to support the conventional wisdom that doctors'' handwriting is worse than others.'' Illegible writing is, however, an important cause of waste and hazard in medical care, but efforts to improve the safety and efficiency of written communication must approach the problem systemically- and assume that the problems are in inherent in average human writing-rather than treating doctors as if they were a special subpopulation.     

Out of hours service: the Danish solution examined.

In Denmark the provision of out of hours care by general practitioners came under increasing pressure in the 1980s because of growing demand for services by the public and increasing complaints from rural doctors about their heavy workload and disproportionately low remuneration in comparison with urban doctors. As a result, the out of hours service was reformed at the start of 1992: locally negotiated rota systems were replaced with county based services. Each county now has a coordination centre, where all patients'' calls are received by a team of doctors. The doctors may give a telephone consultation, advise the patient to attend one of the emergency clinics strategically placed about the county, or arrange for a home visit. Doctors on home visiting duty are located at bases throughout the county and keep in touch with the coordination centre with mobile telephones. Graded fees mean that doctors are encouraged to give telephone consultations rather than arrange for clinic consultations or home visits. The reforms have reduced doctors'' out of hours workload and the number of home visits made and have proved acceptable to patients, doctors, and administrators.     

Implications of managed care for health systems,clinicians, and patients.

The rhetoric and realities of managed care are easily confused. The rapid growth of managed care in the United States has had many implications for patients, doctors, employers, state and federal programmes, the health insurance industry, major medical institutions, medical research, and vulnerable patient populations. It has restricted patients'' choice of doctors and limited access to specialists, reduced the professional autonomy and earnings of doctors, shifted power from the non-profit to the for-profit sectors and from hospitals and doctors to private corporations. It has also raised issues about the future structuring and financing of medical education and research and about practice ethics. However, managed care has also accorded greater prominence to the assessment of patient satisfaction, profiling and monitoring of doctors'' work, the use of clinical guidelines and quality assurance procedures and indicated the potential to improve the integration and outcome of care.     

Assessment of training in psychosexual medicine.

The Institute of Psychosexual Medicine offers training in the treatment of psychosexual problems to medically qualified doctors. Training takes place in fortnightly seminars in which trainees present and discuss real cases. Assessment of cases presented at the beginning and end of the six term basic training showed appreciable improvement in doctors'' abilities. The proportion of doctors meeting each of the 14 predetermined clinical objectives rose. Factors which affected the amount of improvement were the initial score, the number of cases presented at the seminars, the occupation of the leader, and the duration of training. Accreditation by the Institute of Psychosexual Medicine was shown to be an appropriate outcome measure for the achievement of the required standards for practising psychosexual medicine.     

Pentecostal peacefulness: virtue ethics and the reception of theology in Nepal

The anthropology of Christianity has struggled to theorize the place of theology in Christian social life. Drawing on Alasdair MacIntyre's account of virtue ethics, in particular his concepts of practice, narrative, and moral tradition, I explore the reception of Pentecostal theology in the Nepali city of Bhaktapur. I show how local Christians have drawn on Pentecostal eschatology to develop a pacifistic ethics, allowing them to negotiate local social and religious conflicts. The belief that Christ has decisively defeated evil spirits allows local Christians to detach themselves from cycles of aggression connected with witchcraft accusations, providing a space of security in which to cultivate distinctive practices of care. Connecting this local theology with a wider tradition in Pentecostal moral thought, I argue that MacIntyre's virtue ethics provides a powerful tool for interpreting the relationship between local circumstance and extra‐local theology, and for studying cross‐cultural patterns of theological reception.     

Attitudes among NHS doctors to requests for euthanasia.

OBJECTIVES--To explore NHS doctors'' attitudes to competent patients'' requests for euthanasia and to estimate the proportion of doctors who have taken active steps to hasten a patient''s death. DESIGN--Anonymous postal questionnaire, with no possibility of follow up. The survey was conducted from December 1992 to March 1993. SUBJECTS--All (221) general practitioners and 203 hospital consultants in one area of England. RESULTS--273 doctors responded to a question on whether a patient had ever asked them to hasten death. Of these, 163 had been asked to; 124 of these had been asked to take active steps to hasten death; 38 of 119 (32%) of these had complied with such a request (95% confidence interval 23% to 40%). This proportion represented 12% of all those who returned a completed questionnaire and 9% of all those who had been sent a questionnaire (95% confidence interval 6.3% to 11.7%). A larger proportion of the respondents (142/307 (46%)), however, would consider taking active steps to bring about the death of a patient if it was legal to do so. CONCLUSIONS--Many doctors face difficult decisions about euthanasia. For the benefit of both patients and doctors euthanasia should be discussed more openly.     

The (extra)ordinary ethics of being HIV‐positive in rural Papua New Guinea

HIV/AIDS continues to be intimately entwined with the moral domain, and thus a positive diagnosis can cast doubt on a person's moral status. I draw on recent literature in the anthropology of ethics and morality, as well as feminist moral philosophy, to analyse the post‐diagnosis practices of HIV‐positive women in Papua New Guinea as they attempt to recuperate their moral personhood and make their ethical commitments visible to others. I argue that they carve out a repertoire of (extra)ordinary ethics from the ‘ordinary’ domain and that their practices tend towards a deontological ethics, rather than a virtue ethics, orientation.