Informal complaints procedure in general practice: first year's experience.

OBJECTIVE--To evaluate the first year''s experience of an informal patient complaints system that encourages extensive patient participation. DESIGN--Audit of an informal complaints procedure. SETTING--The Marylebone Health Centre, London. SUBJECTS--39 complaints received over the audit period. MAIN OUTCOME MEASURES--Types of complaints (administrative, about doctors or medical care or both, staff about patients, mixed, other) and resolution of complaints (how complaints were dealt with and their resolution). RESULTS--37 of the 39 complaints were resolved within two weeks. Two complaints sent direct to the family health services authority were resolved (with patients'' agreement) by the informal complaints procedure. CONCLUSIONS--The informal complaints procedure was more cost effective than the family health services authority system and was comparatively straightforward to implement within the practice without major organisational restructuring. The two way process of the procedure ensured patients received a quick response to complaints and helped morale of health centre staff.     

Standardised measures of needs,stigma and informal care in schizophrenia using a bottom-up,cross-cultural approach

Background There is a lack of instruments to measure the needs, stigma and informal care of people with schizophrenia that take account of sociocultural variation and patients'' and formal and informal carers'' opinions and experiences.Aims To develop questionnaires to measure stigma, needs and informal (non-professional) care for people with schizophrenia.Method We undertook the study in seven countries and in English, Spanish and Portuguese. We first held focus group discussions with patients, formal carers (professionals) and informal carers (family and friends) in Spain, the UK, Argentina, Brazil, Chile and Venezuela to elicit the main dimensions of needs, stigma and informal care. We then held nominal group discussions about these dimensions with patients, family members and professionals in Spain, Portugal and the UK, to develop the instruments.Results Three hundred and three people participated in 46 focus groups and results were discussed in three nominal groups, each involving eight participants. Three instruments were developed in this iterative process: needs for care (46 items), stigma (38 items) and informal care (20 items).Conclusions These instruments are based on service users'' and carers'' views and experiences and have cross-cultural validity. They will have application in assessment of outcomes for people with schizophrenia and their families.     

Informal Urban Settlements and Cholera Risk in Dar es Salaam,Tanzania

Background

As a result of poor economic opportunities and an increasing shortage of affordable housing, much of the spatial growth in many of the world''s fastest-growing cities is a result of the expansion of informal settlements where residents live without security of tenure and with limited access to basic infrastructure. Although inadequate water and sanitation facilities, crowding and other poor living conditions can have a significant impact on the spread of infectious diseases, analyses relating these diseases to ongoing global urbanization, especially at the neighborhood and household level in informal settlements, have been infrequent. To begin to address this deficiency, we analyzed urban environmental data and the burden of cholera in Dar es Salaam, Tanzania.

Methodology/Principal Findings

Cholera incidence was examined in relation to the percentage of a ward''s residents who were informal, the percentage of a ward''s informal residents without an improved water source, the percentage of a ward''s informal residents without improved sanitation, distance to the nearest cholera treatment facility, population density, median asset index score in informal areas, and presence or absence of major roads. We found that cholera incidence was most closely associated with informal housing, population density, and the income level of informal residents. Using data available in this study, our model would suggest nearly a one percent increase in cholera incidence for every percentage point increase in informal residents, approximately a two percent increase in cholera incidence for every increase in population density of 1000 people per km² in Dar es Salaam in 2006, and close to a fifty percent decrease in cholera incidence in wards where informal residents had minimally improved income levels, as measured by ownership of a radio or CD player on average, in comparison to wards where informal residents did not own any items about which they were asked. In this study, the range of access to improved sanitation and improved water sources was quite narrow at the ward level, limiting our ability to discern relationships between these variables and cholera incidence. Analysis at the individual household level for these variables would be of interest.

Conclusions/Significance

Our results suggest that ongoing global urbanization coupled with urban poverty will be associated with increased risks for certain infectious diseases, such as cholera, underscoring the need for improved infrastructure and planning as the world''s urban population continues to expand.     

A Taxonomy of Continuing Medical Education Endeavour

Five basic forms of continuing educational endeavour by physicians are listed in rank order. These components constitute an indivisible unit bound together by self-learning. The scholarly habit of planned daily reading and study in a home library-sanctuary as an integral part of a physician''s workday heads the list. Day-to-day informal and formal colleague-association in patient care in the community and teaching hospital, in group practice and by consultation is the present major form of continuing educational endeavour. Emphasized is the sabbatical return every three to five years for three months at least to the teaching hospital to reinforce scholarly motivation and attitudes and to acquire new skills and knowledge. Attendance at scientific sessions of learned professional societies and short courses should be accompanied by presession and post-session guided reading to be undertaken in the physician''s home library-sanctuary.     

Predictors of Costs in Dementia in a Longitudinal Perspective

Objective

To analyse predictors of costs in dementia from a societal perspective in a longitudinal setting.

Method

Healthcare resource use and costs were assessed retrospectively using a questionnaire in four waves at 6-month intervals in a sample of dementia patients (N = 175). Sociodemographic data, dementia severity and comorbidity at baseline, cognitive impairment and impairment in basic and instrumental activities of daily living were also recorded. Linear mixed regression models with random intercepts for individuals were used to analyse predictors of total and sector-specific costs.

Results

Impairment in activities of daily living significantly predicted total costs in dementia patients, with associations between basic activities of daily living and formal care costs on the one and instrumental activities of daily living and informal care costs on the other hand. Nursing home residence was associated with lower total costs than residence in the community. There was no effect of cognition on total or sector-specific costs.

Conclusion

Cognitive deficits in dementia are associated with costs only via their effect on the patients'' capacity for activities of daily living. Transition into a nursing home may reduce total costs from a societal perspective, owing to the fact that a high amount of informal care required by severely demented patients prior to transition into a nursing home may cause higher costs than inpatient nursing care.     

高职院校微生物实验改革探索

微生物实验课程是一门基础的专业实验课程。针对高职院校微生物学实验教学中存在的问题,通过对学生能动性的提高、教学内容的完善、实验操作技能的提升、考核方式的改革以及综合性实验的开设等方面的探讨,深化微生物学实验教学改革。     

Economic and political differentiation among Galole Orma women*

The Orma are cattle‐herders living close to Tana River in Kenya. This paper gives an outline of Orma propertyholding and of women's contributions to production in terms of labor. The relationship between control over resources (either outright ownership, rights over use, or indirect control through children's ownership) is discussed in relation to the influence women wield in issues considering sale of stock, decisions to shift or not, and the use of child labor. Formal and informal positions of power held by Orma women are analysed in relation to the effectiveness of women's influence over production decisions. The access that Orma women have to property varies with the degree of integration into the cash economy and to one's position on the nomadic‐sedentary continuum. With greater sedentarization and integration into cash economy women seem to lose control over economic resources in terms of outright ownership. They participate less in manual tasks of production. However, by a variety of informal and formal means, they gain more control over economic decision‐making.     

Comparison of Statistical and Clinical Predictions of Functional Outcome after Ischemic Stroke

Background

To determine whether the predictions of functional outcome after ischemic stroke made at the bedside using a doctor’s clinical experience were more or less accurate than the predictions made by clinical prediction models (CPMs).

Methods and Findings

A prospective cohort study of nine hundred and thirty one ischemic stroke patients recruited consecutively at the outpatient, inpatient and emergency departments of the Western General Hospital, Edinburgh between 2002 and 2005. Doctors made informal predictions of six month functional outcome on the Oxford Handicap Scale (OHS). Patients were followed up at six months with a validated postal questionnaire. For each patient we calculated the absolute predicted risk of death or dependence (OHS≥3) using five previously described CPMs. The specificity of a doctor’s informal predictions of OHS≥3 at six months was good 0.96 (95% CI: 0.94 to 0.97) and similar to CPMs (range 0.94 to 0.96); however the sensitivity of both informal clinical predictions 0.44 (95% CI: 0.39 to 0.49) and clinical prediction models (range 0.38 to 0.45) was poor. The prediction of the level of disability after stroke was similar for informal clinical predictions (ordinal c-statistic 0.74 with 95% CI 0.72 to 0.76) and CPMs (range 0.69 to 0.75). No patient or clinician characteristic affected the accuracy of informal predictions, though predictions were more accurate in outpatients.

Conclusions

CPMs are at least as good as informal clinical predictions in discriminating between good and bad functional outcome after ischemic stroke. The place of these models in clinical practice has yet to be determined.     

The unmet need for interpreting provision in UK primary care

Background

With increasing globalisation, the challenges of providing accessible and safe healthcare to all are great. Studies show that there are substantial numbers of people who are not fluent in English to a level where they can make best use of health services. We examined how health professionals manage language barriers in a consultation.

Methods and Findings

This was a cross-sectional study in 41 UK general practices . Health professionals completed a proforma for a randomly allocated consultation session.Seventy-seven (63%) practitioners responded, from 41(59%) practices. From 1008 consultations, 555 involved patients who did not have English as a first language; 710 took place in English; 222 were in other languages, the practitioner either communicating with the patient in their own language/using an alternative language. Seven consultations were in a mixture of English/patient''s own language. Patients'' first languages numbered 37 (apart from English), in contrast to health practitioners, who declared at least a basic level of proficiency in 22 languages other than English. The practitioner''s reported proficiency in the language used was at a basic level in 24 consultations, whereas in 21, they reported having no proficiency at all. In 57 consultations, a relative/friend interpreted and in 6, a bilingual member of staff/community worker was used. Only in 6 cases was a professional interpreter booked. The main limitation was that only one random session was selected and assessment of patient/professional fluency in English was subjective.

Conclusions

It would appear that professional interpreters are under-used in relation to the need for them, with bilingual staff/family and friends being used commonly. In many cases where the patient spoke little/no English, the practitioner consulted in the patient''s language but this approach was also used where reported practitioner proficiency was low. Further research in different setting is needed to substantiate these findings.     

Minimal Erythema Dose (MED) Testing

Ultraviolet radiation (UV) therapy is sometimes used as a treatment for various common skin conditions, including psoriasis, acne, and eczema. The dosage of UV light is prescribed according to an individual''s skin sensitivity. Thus, to establish the proper dosage of UV light to administer to a patient, the patient is sometimes screened to determine a minimal erythema dose (MED), which is the amount of UV radiation that will produce minimal erythema (sunburn or redness caused by engorgement of capillaries) of an individual''s skin within a few hours following exposure. This article describes how to conduct minimal erythema dose (MED) testing. There is currently no easy way to determine an appropriate UV dose for clinical or research purposes without conducting formal MED testing, requiring observation hours after testing, or informal trial and error testing with the risks of under- or over-dosing. However, some alternative methods are discussed.     

微视频资源在微生物学实验教学中的应用

微生物学实验是生物类各专业的一门基础课程,该课程对学生基础操作技能的提高和创新能力的培养至关重要。针对传统教学模式中存在的问题,本文结合微视频直观生动、短小精炼的特点,制备基本操作微视频、课件微视频及学生实验微视频3类教学资源。通过与其他教学手段和考评方法相结合,实现了微视频资源在实验教学环节中的有效应用,该教学模式激发了学生的学习兴趣和自学潜能,提升了课堂教学效果和学生的实践创新能力。     

Cultural Aspects of Health and Illness Behavior in Hospitals

Health care attitudes reflect the basic world view and values of a culture, such as how we relate to nature, other people, time, being, society versus community, children versus elders and independence versus dependence. Illness behavior determines who is vulnerable to illness and who agrees to become a patient—since only about one third of the ill will see a physician. Cultural values determine how one will behave as a patient and what it means to be ill and especially to be a hospital patient. They affect decisions about a patient''s treatment and who makes the decisions. Cultural differences create problems in communication, rapport, physical examination and treatment compliance and follow through. The special meaning of medicines and diet requires particular attention. The perception of physical pain and psychologic distress varies from culture to culture and affects the attitudes and effectiveness of care-givers as much as of patients. Religious beliefs and attitudes about death, which have many cultural variations, are especially relevant to hospital-based treatment. Linguistic and cultural interpreters can be essential; they are more available than realized, though there are pitfalls in their use. Finally, one must recognize that individual characteristics may outweigh the ethnic and that a good caring relationship can compensate for many cultural missteps.     

Multidisciplinary transmural rehabilitation for older persons with a stroke: the design of a randomised controlled trial

Background

Stroke is one of the major causes of loss of independence, decreased quality of life and mortality among elderly people. About half of the elderly stroke patients discharged after rehabilitation in a nursing home still experience serious impairments in daily functioning one year post stroke, which can lead to difficulties in picking up and managing their social life. The aim of this study is to evaluate the effectiveness and feasibility of a new multidisciplinary transmural rehabilitation programme for older stroke patients.

Methods

A two group multicentre randomised controlled trial is used to evaluate the effects of the rehabilitation programme. The programme consists of three care modules: 1) neurorehabilitation treatment for elderly stroke patients; 2) empowerment training for patient and informal caregiver; and 3) stroke education for patient and informal caregiver. The total programme has a duration of between two and six months, depending on the individual problems of the patient and informal caregiver. The control group receives usual care in the nursing home and after discharge.Patients aged 65 years and over are eligible for study participation when they are admitted to a geriatric rehabilitation unit in a nursing home due to a recent stroke and are expected to be able to return to their original home environment after discharge. Data are gathered by face-to-face interviews, self-administered questionnaires, focus groups and registration forms. Primary outcomes for patients are activity level after stroke, functional dependence, perceived quality of life and social participation. Outcomes for informal caregivers are perceived care burden, objective care burden, quality of life and perceived health. Outcome measures of the process evaluation are implementation fidelity, programme deliverance and the opinion of the stroke professionals, patients and informal caregivers about the programme. Outcome measures of the economic evaluation are the healthcare utilisation and associated costs. Data are collected at baseline, and after six and 12 months. The first results of the study will be expected in 2014.

Trial registration

International Standard Randomised Controlled Trial Register Number ISRCTN62286281, The Dutch Trial Register NTR2412

     

Relationship effects in psychological explanations of nonhuman behavior

Abstract

Research suggests that close relationships with animals encourage psychological explanations of their behavior. To determine the causal effect of ownership on psychological explanations, we conducted experiments in which we manipulated participants' ownership of a target imagined dog (experiment 1), animated object (experiment 2), and real pet fish (experiment 3). Adapting scales used in previous research, we obtained ratings of how intentional the target's behavior was, the target's reasons (rather than causes), and references to complex human-like emotions, motives or characteristics. In experiment 1, 26 volunteers and staff at an animal shelter imagined scenarios involving their dog, a neighbor's dog, their friend, or a visitor. Participants' intentionality ratings and the target's reasons were similar for a friend, a visitor, and their dog. In experiment 2, 36 participants watched a film of three moving objects. Half of the participants were told the small triangle was theirs. In the ownership condition, participants vilified the “aggressive” big triangle more, gave more causal history for reasons, and gave more social, humanlike narratives. In experiment 3, 82 university students and staff were given a Betta fish either to own or to care for temporarily, and they were to report daily or weekly on the fish's behavior. Ownership and reporting frequency did not directly influence outcomes. Rather, ownership predicted commitment to, and affection for, the fish. Affection, in turn, significantly predicted participants' psychological explanations including how smart the fish was, how much the fish liked the participant, how similar the fish was to the participant, and psychological explanations of social behavior such as turning toward a visitor. Automated analyses of participants' language showed that affection also predicted their use of social psychological and emotion words to describe the fish. We discuss alternative processes whereby social relationships give rise to psychological explanations of behavior.     

What do patients with medically unexplained physical symptoms (MUPS) think? A qualitative study

Context Medically unexplained physical symptoms (MUPS) are frequently encountered in family medicine, and lead to disability, discomfort, medicalisation, iatrogenesis and economic costs. They cause professionals to feel insecure and frustrated and patients to feel dissatisfied and misunderstood. Doctors seek answers for rather than with the patient.Objectives This study aimed to explore patients'' explanations of the medically unexplained physical symptoms that they were experiencing by eliciting their own explanations for their complaints, their associated fears, their expectations of the consultation, changes in their ideas of causality, and the therapeutic approach that they considered would be useful.Methodology A qualitative analysis was under-taken of interviews with 15 patients with MUPS in a family medicine unit, 6 months after diagnosis.Results Experience is crucial in construction of the meaning of symptoms and illness behaviour. Many patients identify psychosocial causes under-lying their suffering. These patients received more medication and fewer requests for diagnostic examinations than they had expected. Normalisation is a common behaviour in the clinical approach. Normalisation without explanation can be effective if an effective therapeutic relationship exists that may dispense with the need for words. Listening is the procedure most valued by patients. Diagnostic tests may denote interest in patients'' problems. The clinician''s flexibility should allow adaptation to the patient''s phases of acceptance of the significance of their physical, emotional and social problems.Conclusion Patients with MUPS have explanations and fears associated with their complaints. The patient comes to the consultation not because of the symptom, but because of what he or she thinks about the symptom. The therapeutic relationship, therapeutic listening, and flexibility should be the basis for approaching patients with MUPS. Patients do not always expect medication, although it is what they most often receive. Diagnostic tests, although used sparingly, can be a way to maintain and build a relationship. Drugs and tests can be a ritual statement of clinical interest in the patient and their symptoms.     

Subspecialty consultations in a teaching hospital.

A chart review of 60 consultations by the nephrology service of a teaching hospital was carried out to determine their diagnostic and therapeutic utility. General medicine residents on elective rotations in nephrology performed 72% of the consultations, only 26% being written by residents in the subspecialty. Consultants made an average of 2.2 diagnoses per patient, of which 57% confirmed the working diagnosis already in the medical record. They made an average of 3.0 recommendations for further investigation per patient, but referring physicians implemented only 58% of these. An average of 1.6 recommendations for therapy were made per patient, of which 64% were implemented. The apparent neglect of the consultant''s advice for investigation and therapy suggests that the written consultation to some extent fails to convey information useful for the referring physician and the patient. Further study is needed to determine if this failure reflects inadequate training of house officers as consultants.     

Soft networks for bridging the gap between research and practice: illuminative evaluation of CHAIN

Objectives To explore the process of knowledge exchange in an informal email network for evidence based health care, to illuminate the value of the service and its critical success factors, and to identify areas for improvement.Design Illuminative evaluation.Setting Targeted email and networking service for UK healthcare practitioners and researchers.Participants 2800 members of a networking service.Main outcome measures Tracking of email messages, interviews with core staff, and a qualitative analysis of messages, postings from focus groups, and invited and unsolicited feedback to the service.Results The informal email network helped to bridge the gap between research and practice by serving as a rich source of information, providing access to members'' experiences, suggestions, and ideas, facilitating cross boundary collaboration, and enabling participation in networking at a variety of levels. Ad hoc groupings and communities of practice emerged spontaneously as members discovered common areas of interest.Conclusion This study illuminated how knowledge for evidence based health care can be targeted, personalised, and made meaningful through informal social processes. Critical success factors include a broad based membership from both the research and service communities; a loose and fluid network structure; tight targeting of messages based on members'' interests; the presence of a strong network identity and culture of reciprocity; and the opportunity for new members to learn through passive participation.     

The United States and the revision of the 1982 convention on the law of the sea

Abstract

It may now be possible to breach the 1982 Law of the Sea Convention impasse. The UN Secretary‐General's informal consultations have opened realistic discussions on the deep seabed regime. Many important changes have occurred since the Convention was signed. Dramatic developments have taken place in the international community. Nations now appreciate the limited potential of deep seabed mining. While United States reliance on customary law provides some benefits, other more important U.S. interests cannot be protected absent entry into force of the Convention with widespread participation. Many alternative procedures are available to forge an accommodation. The approach taken in the Secretary‐General's consultations is to make specific changes in deficient articles. Alternatively, the present regime might be jettisoned in favor of a framework regime. Such a regime would preserve only the essential basic policies of the Convention's seabed regime. It would contain a system for constructing a viable mining system if a deep seabed regime is needed.