Physician-patient sexual contact. Prevalence and problems.

To document the current prevalence of physician-patient sexual contact and to estimate its effect on involved patients, 10,000 family practitioners, internists, obstetrician-gynecologists, and surgeons were surveyed. Of the 1,891 respondents, 9% acknowledged sexual contact with 1 or more patients. Even in the unlikely case that none of the nonrespondents had sexual contact with patients, its prevalence among all 10,000 physicians surveyed would still be 2%. Of respondents, 23% had at least 1 patient who reported sexual contact with another physician; 63% thought this contact was "always harmful" to the patients. Almost all (94%) responding physicians opposed sexual contact with current patients; 37% also opposed sexual contact with former patients. More than half of respondents (56%) indicated that physician-patient sexual contact had never been addressed in their training; only 3% had participated in a continuing education course focusing on this issue. Clear and enforceable medical ethics codes concerning physician-patient sexual contact are needed, as well as preventive educational programs for medical schools and residency programs.     

Disparity in Physician Perception of Patients' Adherence to Medications by Obesity Status

Physician perception of medication adherence may alter prescribing patterns. Perception of patients has been linked to readily observable factors, such as race and age. Obesity shares a similar stigma to these factors in society. We hypothesized that physicians would perceive patients with a higher BMI as nonadherent to medication. Data were collected from the baseline visit of a randomized clinical trial of patient–physician communication (240 patients and 40 physicians). Physician perception of patient medication adherence was measured on a Likert scale and dichotomized as fully adherent or not fully adherent. BMI was the predictor of interest. We performed Poisson regression analyses with robust variance estimates, adjusting for clustering of patients within physicians, to examine the association between BMI and physician perception of medication adherence. The mean (s.d.) BMI was 32.6 (7.7) kg/m². Forty‐five percent of patients were perceived as nonadherent to medications by their physicians. Higher BMI was significantly and negatively associated with being perceived as adherent to medication (prevalence ratio (PrR) 0.76, 95% confidence interval (CI): 0.64–0.90; P = 0.002; per 10 kg/m² increase in BMI). BMI remained significantly and negatively associated with physician perception of medication adherence after adjustment for patient and physician characteristics (PrR 0.80, 95% CI: 0.66–0.96; P = 0.020). In this study, patients with higher BMI were less likely to be perceived as adherent to medications by their providers. Physician perception of medication adherence has been shown to affect prescribing patterns in other studies. More work is needed to understand how this perception may affect the care of patients with obesity.     

Prevalence and Causes of Prescribing Errors: The PRescribing Outcomes for Trainee Doctors Engaged in Clinical Training (PROTECT) Study

Objectives

Study objectives were to investigate the prevalence and causes of prescribing errors amongst foundation doctors (i.e. junior doctors in their first (F1) or second (F2) year of post-graduate training), describe their knowledge and experience of prescribing errors, and explore their self-efficacy (i.e. confidence) in prescribing.

Method

A three-part mixed-methods design was used, comprising: prospective observational study; semi-structured interviews and cross-sectional survey. All doctors prescribing in eight purposively selected hospitals in Scotland participated. All foundation doctors throughout Scotland participated in the survey. The number of prescribing errors per patient, doctor, ward and hospital, perceived causes of errors and a measure of doctors'' self-efficacy were established.

Results

4710 patient charts and 44,726 prescribed medicines were reviewed. There were 3364 errors, affecting 1700 (36.1%) charts (overall error rate: 7.5%; F1:7.4%; F2:8.6%; consultants:6.3%). Higher error rates were associated with : teaching hospitals (p<0.001), surgical (p = <0.001) or mixed wards (0.008) rather thanmedical ward, higher patient turnover wards (p<0.001), a greater number of prescribed medicines (p<0.001) and the months December and June (p<0.001). One hundred errors were discussed in 40 interviews. Error causation was multi-factorial; work environment and team factors were particularly noted. Of 548 completed questionnaires (national response rate of 35.4%), 508 (92.7% of respondents) reported errors, most of which (328 (64.6%) did not reach the patient. Pressure from other staff, workload and interruptions were cited as the main causes of errors. Foundation year 2 doctors reported greater confidence than year 1 doctors in deciding the most appropriate medication regimen.

Conclusions

Prescribing errors are frequent and of complex causation. Foundation doctors made more errors than other doctors, but undertook the majority of prescribing, making them a key target for intervention. Contributing causes included work environment, team, task, individual and patient factors. Further work is needed to develop and assess interventions that address these.     

Are Patient Views about Antibiotics Related to Clinician Perceptions,Management and Outcome? A Multi-Country Study in Outpatients with Acute Cough

Background

Outpatients with acute cough who expect, hope for or ask for antibiotics may be more unwell, benefit more from antibiotic treatment, and be more satisfied with care when they are prescribed antibiotics. Clinicians may not accurately identify those patients.

Objective

To explore whether patient views (expecting, hoping for or asking for antibiotics) are associated with illness presentation and resolution, whether patient views are accurately perceived by clinicians, and the association of all these factors with antibiotic prescribing and patient satisfaction with care.

Methods

Prospective observational study of 3402 adult patients with acute cough presenting in 14 primary care networks. Correlations and associations tested with multilevel logistic regression and McNemar ‘s tests, and Cohen’s Kappa, positive agreement (PA) and negative agreement (NA) calculated as appropriate.

Results

1,213 (45.1%) patients expected, 1,093 (40.6%) hoped for, and 275 (10.2%) asked for antibiotics. Clinicians perceived 840 (31.3%) as wanting to be prescribed antibiotics (McNemar’s test, p<0.05). Their perception agreed modestly with the three patient views (Kappa’s = 0.29, 0.32 and 0.21, PA’s = 0.56, 0.56 and 0.33, NA’s = 0.72, 0.75 and 0.82, respectively). 1,464 (54.4%) patients were prescribed antibiotics. Illness presentation and resolution were similar for patients regardless their views. These associations were not modified by antibiotic treatment. Patient expectation and hope (OR:2.08, 95% CI:[1.48,2.93] and 2.48 [1.73,3.55], respectively), and clinician perception (12.18 [8.31,17.84]) were associated with antibiotic prescribing. 2,354 (92.6%) patients were satisfied. Only those hoping for antibiotics were less satisfied when antibiotics were not prescribed (0.39 [0.17,0.90]).

Conclusion

Patient views about antibiotic treatment were not useful for identifying those who will benefit from antibiotics. Clinician perceptions did not match with patient views, but particularly influenced antibiotic prescribing. Patients were generally satisfied with care, but those hoping for but not prescribed antibiotics were less satisfied. Clinicians need to more effectively elicit and address patient views about antibiotics.     

Anti-infective therapy at the end of life: ethical decision-making in hospice-eligible patients

Clear guidelines addressing the ethically appropriate use of anti-infectives in the setting of hospice care do not exist. There is lack of understanding about key treatment decisions related to infection treatment for patients who are eligible for hospice care. Ethical concerns about anti-infective use at the end of life include: (1) delaying transition to hospice, (2) prolonging a dying process, (3) prescribing regimens incongruent with a short life expectancy and goals of care, (4) increasing the reservoir of potential resistant pathogens, (5) placing unreasonable costs on a capitated hospice system. Although anti-infectives are thought to be relatively safe, they can place a burden on patients and be inconsistent to particular care plans. The current complex, and at times fragmented, medical care often fails to address these issues in decision-making. In many ways, the ethics governing the end of life decisions related to dialysis, hydration/nutrition, and hypercalcemia parallel those of anti-infectives. In this article we articulate important elements in ethical decision-making in the application of anti-infectives for patients who are eligible for hospice care, and we point to the need for prospective studies to help refine particular guidelines in these cases.     

A practical approach for implementation of a basal-prandial insulin therapy regimen in patients with type 2 diabetes

Background

Osteopathic philosophy is consistent with an emphasis on primary care and suggests that osteopathic physicians may have distinctive ways of interacting with their patients.

Methods

The National Ambulatory Medical Care Survey (NAMCS) was used to derive national estimates of utilization of osteopathic general and family medicine physicians during 2003 and 2004 and to examine the patient characteristics and physician-patient interactions of these osteopathic physicians. All analyses were performed using complex samples software to appropriately weigh outcomes according to the multistage probability sample design used in NAMCS and multivariate modeling was used to control for potential confounders.

Results and discussion

When weighted according to the multistage probability sample design used, the 6939 patient visits studied represented an estimated 341.4 million patient visits to general and family medicine specialists in the United States, including 64.9 million (19%) visits to osteopathic physicians and 276.5 million (81%) visits to allopathic physicians. Osteopathic physicians were a major source of care in the Northeast (odds ratio [OR], 2.94; 95% confidence interval [CI], 1.42–6.08), providing more than one-third of general and family medicine patient visits in this geographic region. Pediatric and young adult patients (OR, 0.64; 95% CI, 0.45–0.91), Hispanics (OR, 0.63; 95% CI, 0.40–1.00), and non-Black racial minority groups (OR, 0.39; 95% CI, 0.18–0.82) were less likely to visit osteopathic physicians. There were no significant differences between osteopathic and allopathic physicians with regard to the time spent with patients, provision of five common preventive medicine counseling services, or a focus on preventive care during office visits.

Conclusion

Osteopathic physicians are a major source of general and family medicine care in the United States, particularly in the Northeast. However, pediatric and young adult patients, Hispanics, and non-Black racial minorities underutilize osteopathic physicians. There is little evidence to support a distinctive approach to physician-patient interactions among osteopathic physicians in general and family medicine, particularly with regard to time spent with patients and preventive medicine services.     

Improving benzodiazepine prescribing in family practice through review and education.

Indications for and dosages of four commonly prescribed benzodiazepines were recorded at a family medicine centre with the aid of a computerized data collection system. Four guidelines were then developed for appropriate prescribing of these drugs: (a) benzodiazepines should be used less frequently with increasing age; (b) short-acting drugs are preferable to long-acting drugs; (c) patients 65 years of age and over should receive half the daily dose prescribed for younger patients; and (d) use of these drugs for more than 1 month should be discouraged. After a year''s observation it was evident that none of the guidelines were being followed. The 30 physicians in the practice were then informed of the findings by an educational program. Another 6 months of observation showed a reduction in the prescribing of benzodiazepines to patients 65 years of age and over, a significant shift to the use of short-acting benzodiazepines, and some reduction in the daily dose and duration of administration of diazepam. Thus, such a review of drug prescribing in family practice can be a practical and effective method of improving prescribing patterns.     

The Enemy as a Patient: What can be Learned from the Emotional Experience of Physicians and Why does it Matter Ethically?

This qualitative research examines the influence of animosity on physicians during clinical encounters and its ethical implications. Semi‐structured interviews were conducted with ten Israeli‐Jewish physicians: four treated Syrians and six treated Palestinian terrorists/Hezbollah militants or Palestinian civilians. An interpretive phenomenological analysis was used to uncover main themes in these interviews. Whereas the majority of physicians stated they are obligated to treat any patient, physicians who treated Syrians exhibited stronger emotional expression and implicit empathy, while less referring to the presence of the Israeli‐Arab conflict. In contrast, physicians who treated enemy combatants or Palestinian civilians showed the exact opposite. Linking these results to the “Implicit Bias” theory, the role of empathy and the beneficence principle in medical ethics, we argue that: (a) the unconscious decreased emotional involvement among the latter group of physicians is a deficiency that needs to be recognized; and (b) this deficiency undermines the principle of beneficence, thereby possibly influencing the fulfillment of the commitment to treat patients. Acknowledging and addressing the potential emotional and ethical deficiencies entailed in encounters with the so‐called enemy‐patients are of importance to the global medical community, since such encounters are increasingly an integral part of the current political realities faced by both the developed and developing worlds.     

The somatically preoccupied patient in primary care: use of attachment theory to strengthen physician-patient relationships

Background

Individuals with somatic preoccupation constitute a substantial number of primary care patients. Somatically preoccupied patients are challenging to primary care physicians for several reasons including patient complaints consuming a great deal of physician time, expense to diagnose and treat and strain on the physician-patient relationship. This paper examines and discusses how disruptions in early attachment relationships such as often occurs when a female is a victim of child sexual abuse may result in somatic preoccupation in adulthood.

Treatment utilizing attachment theory

Attachment theory provides a useful framework for primary care physicians to conceptualize somatic preoccupation. Utilization and containment techniques grounded in an understanding of attachment dynamics aid the physician in developing a sound physician-patient relationship. Successfully engaging the patient in treatment prevents misunderstandings that frequently derail medical care for somatically preoccupied patients.     

Hormone replacement therapy: a survey of Ontario physicians' prescribing practices

BACKGROUND: Although much has been written about hormone replacement therapy (HRT), there are few clearcut recommendations on its use. The purpose of this study was to determine Ontario physicians'' patterns of and reasons for prescribing HRT, their use of pretreatment investigations and their surveillance of HRT users, and to determine whether physicians'' reported practice is consistent with existing recommendations. METHODS: A self-administered questionnaire was mailed to a nonproportional stratified sample of 327 Ontario physicians (23.9% gynecologists, 76.1% general practitioners/family physicians [GP/FPs]). Outcome measures were ranking of reasons for prescribing HRT, nature of preliminary testing, regimens prescribed, duration of HRT and frequency of follow-up. RESULTS: The response rate was 60.9% overall (70.9% of the gynecologists, 58.3% of the GP/FPs). Prevention of osteoporosis was reported by 97.4% as an important or very important reason for prescribing HRT; prevention of coronary artery disease was important or very important for 89.3%. When considering whether or not to prescribe HRT, 97.3% stated that breast cancer was an important or very important factor. When presented with hypothetical cases, 97.0% stated that they would prescribe combined estrogen-progestin for a symptomatic woman with an intact uterus; 13.6% stated that they would do so for a woman with no uterus. Most reported that they would prescribe HRT for 12 or more years (73.3%) and would follow up patients every 1 to 2 years (70.6%). INTERPRETATION: Despite controversy about HRT in the published literature, the Ontario physicians surveyed reported similar reasons and patterns of prescribing, pretreatment investigations, and surveillance of postmenopausal women using HRT. These results suggest that Ontario physicians'' knowledge about HRT is consistent with recommendations in the published literature.