Resource allocation and physician liability

Lawyer Karen Capen says funding cutbacks that have affected the services physicians can provide may cause legal problems for Canada''s doctors. If cutbacks affect the care that is being provided, they should be discussed with the patient and noted on the chart. She says physicians have "good reason to be concerned" about increasing pressures that create an imbalance between health care resources and the demand and need for services. For some doctors, these have resulted in court cases.     

Professional uncertainty and disempowerment responding to ethnic diversity in health care: a qualitative study

Background

While ethnic disparities in health and health care are increasing, evidence on how to enhance quality of care and reduce inequalities remains limited. Despite growth in the scope and application of guidelines on “cultural competence,” remarkably little is known about how practising health professionals experience and perceive their work with patients from diverse ethnic communities. Using cancer care as a clinical context, we aimed to explore this with a range of health professionals to inform interventions to enhance quality of care.

Methods and Findings

We conducted a qualitative study involving 18 focus groups with a purposeful sample of 106 health professionals of differing disciplines, in primary and secondary care settings, working with patient populations of varying ethnic diversity in the Midlands of the UK. Data were analysed by constant comparison and we undertook processes for validation of analysis. We found that, as they sought to offer appropriate care, health professionals wrestled with considerable uncertainty and apprehension in responding to the needs of patients of ethnicities different from their own. They emphasised their perceived ignorance about cultural difference and were anxious about being culturally inappropriate, causing affront, or appearing discriminatory or racist. Professionals'' ability to think and act flexibly or creatively faltered. Although trying to do their best, professionals'' uncertainty was disempowering, creating a disabling hesitancy and inertia in their practice. Most professionals sought and applied a knowledge-based cultural expertise approach to patients, though some identified the risk of engendering stereotypical expectations of patients. Professionals'' uncertainty and disempowerment had the potential to perpetuate each other, to the detriment of patient care.

Conclusions

This study suggests potential mechanisms by which health professionals may inadvertently contribute to ethnic disparities in health care. It identifies critical opportunities to empower health professionals to respond more effectively. Interventions should help professionals acknowledge their uncertainty and its potential to create inertia in their practice. A shift away from a cultural expertise model toward a greater focus on each patient as an individual may help.     

Night workload in one health district.

The night work (11 pm-7 am) in primary care in one health district (population 195 212 with 93 general practitioners) was studied over a three month period, starting 1 January 1983. The workload proved to be small (15% of all "out of hours" work for general practitioners). An average of three night visits was done a night in the whole health district, and 26 general practitioners were available for these. On average, over seven doctors were available each night for each patient who required a visit in primary care in the health district. It is concluded that there is only sufficient work for (at maximum) two doctors, and a system is proposed to make more efficient use of the general practitioner''s time.     

Refugees' perspectives on barriers to communication about trauma histories in primary care

Objective This study explores refugees'' perspectives regarding the nature of communication barriers that impede the exploration of trauma histories in primary care.Method Brief interviews were conducted with 53 refugee patients in a suburban primary care clinic in the Midwest USA. Participants were asked if they or their doctors had initiated conversations about the impact of political conflict in their home countries. Qualitative data analysis was guided by grounded theory. Peer debriefings of refugee healthcare professionals were incorporated into the analysis.Results Two-thirds of refugee patients reported that they never shared how they were affected by political conflict with their doctors and that their doctors never asked them about it. Most refugees stated that they would like to learn more about the impact of trauma on their health and to discuss their experiences with their doctors.Conclusion Refugees are hesitant to initiate conversations with physicians due to cultural norms requiring deference to the doctor''s authority. They also lack knowledge about how trauma affects health. Physicians should be educated to inquire directly about trauma histories with refugee patients. Refugees can benefit from education about the effects of trauma on health and about the collaborative nature of the doctor–patient relationship.     

Where is the silver lining? Anxious doctors ask.

When Nova Scotia elected a Liberal government in September 1993, a wave of optimism washed over the province''s medical community. One of their own, Dr. John Savage, was now premier, and another, Dr. Ron Stewart, was minister of health. However, anticipation soon turned to anger as Stewart took aim at physician fees and hospital costs to help reduce the province''s health care budget by $62 million. Last November, relations between him and the Medical Society of Nova Scotia (MSNS) hit bottom. In an uncharacteristically political move, the society launched an ad campaign featuring slogans such as "Death by 1000 cuts" and "Uncle Sam want me. Ron Stewart doesn''t." Four months later, the health department and the MSNS called a truce, with an agreement that many physicians consider a positive step. Today the province and its doctors are speaking again, and the medical society is working hard to help define physicians'' roles in a new, regionalized health care system. But has the mood of doctors really improved? Last spring, CMAJ interviewed a cross section of Nova Scotia physicians to find out.     

Do doctors accurately assess coronary risk in their patients? Preliminary results of the coronary health assessment study.

OBJECTIVE--To evaluate the ability of doctors in primary care to assess risk patients'' risk of coronary heart disease. DESIGN--Questionnaire survey. SETTING--Continuing medical education meetings, Ontario and Quebec, Canada. SUBJECTS--Community based doctors who agreed to enroll in the coronary health assessment study. MAIN OUTCOME MEASURE--Ratings of coronary risk factors and estimates by doctors of relative and absolute coronary risk of two hypothetical patients and the "average" 40 year old Canadian man and 70 year old Canadian woman. RESULTS--253 doctors answered the questionnaire. For 30 year olds the doctors rated cigarette smoking as the most important risk factor and raised serum triglyceride concentrations as the least important; for 70 year old patients they rated diabetes as the most important risk factor and raised serum triglyceride concentrations as the least important. They rated each individual risk factor as significantly less important for 70 year olds than for 30 year olds (all risk factors, P < 0.001). They showed a strong understanding of the relative importance of specific risk factors, and most were confident in their ability to estimate coronary risk. While doctors accurately estimated the relative risk of a specific patient (compared with the average adult) they systematically overestimated the absolute baseline risk of developing coronary disease and the risk reductions associated with specific interventions. CONCLUSIONS--Despite guidelines on targeting patients at high risk of coronary disease accurate assessment of coronary risk remains difficult for many doctors. Additional strategies must be developed to help doctors to assess better their patients'' coronary risk.     

Letter: Interferon in serum and cerebrospinal fluid in subacute sclerosing panencephalitis.

In a household health survey more than 15 000 individuals in four areas of Canada were interviewed as part of the World Health Organization/International Collaborative Study of Medical Care Utilization. Data were collected to describe the health services system in each area and to measure the population''s utilization of health professionals, hospitals, medicines and selected preventive services, perceived acute and chronic morbidity, attitudes and beliefs about health and health care, and sociodemographic characteristics. The proportion of persons with perceived morbidity was twice that of persons reporting visits with a physician in the same 2-week period. Prescribed and nonprescribed medications had been used by more than 50% of respondents in each area in the 2 days before the interview, nonprescribed medicines accounting for more than half of this use. Respondents were found to be more sceptical of medical doctors than of medical science.     

The quality of health care in prison: results of a year's programme of semistructured inspections.

OBJECTIVES: To assess, as part of wider inspections by HM Inspectorate of Prisons, the extent and quality of health care in prisons in England and Wales. DESIGN: Inspections based on a set of "expectations" derived mainly from existing healthcare quality standards published by the prison service and existing ethical guidelines; questionnaire survey of prisoners. SUBJECTS: 19 prisons in England and Wales, 1996-7. MAIN OUTCOME MEASURES: Appraisals of needs assessment and the commissioning and delivery of health care against the inspectorate''s expectations. RESULTS: The quality of health care varied greatly. A few prisons provided health care broadly equivalent to NHS care, but in many the health care was of low quality, some doctors were not adequately trained to do the work they faced, and some care failed to meet proper ethical standards. Little professional support was available to healthcare staff. CONCLUSIONS: The current policy for improving health care in prisons is not likely to achieve its objectives and is potentially wasteful. The prison service needs to recognise that expertise in the commissioning and delivery of health care is overwhelming based in the NHS. The current review of the provision of health care in prisons offers an opportunity to ensure that prisoners are not excluded from high quality health care.     

WHO fellowships--what do they achieve?

Training health professionals is one of WHO''s major strategies for improving health care in the developing world. The aim, to strengthen a country''s own capacity rather than injecting expertise from outside, is in the best tradition of sustainable development. But how effective is this so called "capacity building in human resources"? Since it accounted for $43m of WHO''s budget in 1992-3 and is considered by WHO to be a major contribution to health in individual countries, it deserves detailed examination.     

Croatian children's views towards importance of health care information

The aim of research was to investigate: the need for health care information of Croatian adolescents aged from 13 to 18 years; the difference in evaluation of the frequency of receiving information between hospitalized and healthy children; if the hospitalized children expectations about the frequency of receiving health care information differed significantly from information they have actually received; whose information was most comprehensible to the hospitalized children (doctors, parents, other health care givers). The children were either hospitalized in the pediatrics departments or were high schools pupils (healthy children). The hospitalized children "Completely agreed" (92.7%) with the statement "When I am sick, I should receive information about my health" in comparison to the healthy children (85.1%). In comparison to healthy children, the hospitalized children assessed that doctors, other health care givers and parents should give them information more frequently. The experience of hospitalized children indicate that they received less information then they have actually excepted. The information received from doctors was mostly in correlation with the understanding of this information. We concluded that the children want to be informed about their health, especially hospitalized children. Health care professionals should offer understandable health care information according to the children's expectation.     

Doctors' attitudes to risk in difficult clinical decisions: application of decision analysis in hepatobiliary disease.

Twelve doctors with special training in hepatology independently reviewed two to five cases each from a group of seven cases of complicated hepatobiliary problems. A doctor''s willingness to take risks to improve his patients'' health was quantified by a wagering technique based on the probability of achieving a successful intervention. These probabilities were then used to calculate "utilities," which represented the average opinion of the doctors about the relative worth of each of six predefined states of health. The results showed that, in the context of risky decisions for severely ill patients, a year of life was considered by the doctors to be worth 44% of a full recovery; being mobile for that year increased this value to 57%. Survival for up to five years with restricted mobility was considered to be worth 70% of a full recovery and the ability to work during that period increased this value to 85%. It is concluded that in clinical decision making the uncertainty and preferences implicit in a course of action can be quantified and thus made explicit.     

The health risks of new-wave vegetarianism

Many young people call themselves vegetarians because they don''t eat meat, but the eating style they are adopting is fraught with health risks. In this article, which won CMAJ''s 1996 Army Chouinard Memorial Essay Contest for Canadian journalism students, Laura Brydges Szabo looks at the "new vegetarianism" and the recommendations health care professionals are making to young people intent on following this incomplete diet. The contest encourages journalism students to write on health care topics.     

'I Used to Fight with Them but Now I Have Stopped!': Conflict and Doctor-Nurse-Anaesthetists' Motivation in Maternal and Neonatal Care Provision in a Specialist Referral Hospital

Background and Objectives

This paper analyses why and how conflicts occur and their influence on doctors and nurse-anaesthetists'' motivation in the provision of maternal and neonatal health care in a specialist hospital.

Methodology

The study used ethnographic methods including participant observation, conversation and in-depth interviews over eleven months in a specialist referral hospital in Ghana. Qualitative analysis software Nvivo 8 was used for coding and analysis of data. Main themes identified in the analysis form the basis for interpreting and reporting study findings.

Ethics Statement

Ethical clearance was obtained from the Ghana Health Service Ethics Review board (approval number GHS-ERC:06/01/12) and from the University of Wageningen. Written consent was obtained from interview participants, while verbal consent was obtained for conversations. To protect the identity of the hospital and research participants pseudonyms are used in the article and the part of Ghana in which the study was conducted is not mentioned.

Results

Individual characteristics, interpersonal and organisational factors contributed to conflicts. Unequal power relations and distrust relations among doctors and nurse-anaesthetists affected how they responded to conflicts. Responses to conflicts including forcing, avoiding, accommodating and compromising contributed to persistent conflicts, which frustrated and demotivated doctors and nurse-anaesthetists. Demotivated workers exhibited poor attitudes in collaborating with co-workers in the provision of maternal and neonatal care, which sometimes led to poor health worker response to client care, consequently compromising the hospital''s goal of providing quality health care to clients.

Conclusion

To improve health care delivery in health facilities in Ghana, health managers and supervisors need to identify conflicts as an important phenomenon that should be addressed whenever they occur. Effective mechanisms including training managers and health workers on conflict management should be put in place. Additionally promoting communication and interaction among health workers can foster team spirit. Also resolving conflicts using the collaborating response may help to create a conducive work environment that will promote healthy work relations, which can facilitate the delivery of quality maternal and neonatal health care. However, such an approach requires that unequal power relations, which is a root cause of the conflicts is addressed.     

Palliative care: views of patients and their families.

OBJECTIVE--To investigate the current problems and needs of terminally ill cancer patients and their family members, and to discover their views of hospital, community, and support team services. DESIGN--Prospective study of patients and families by questionnaire interviews in the patients'' homes. SETTING--Inner London and north Kent (London suburbs). SUBJECTS--65 Patients, each with a member of their family or a career. MAIN OUTCOME MEASURES--Ratings of eight current problems and ratings and comments on three services-hospital doctors and nurses, general practitioners and district nurses, and the support team staff-obtained after a minimum of two weeks'' care from palliative care support teams. RESULTS--Effect of anxiety on the patient''s nearest career. and symptom control were rated as the most severe current problems by both patients and families; a few patients and families identified other severe problems. Families'' ratings of pain control, symptom control, and effect of anxiety on the patient were significantly worse than the patients'' ratings (p less than 0.05). Support teams received the most praise, being rated by 58 (89%) patients and 59 (91%) of family members as good as excellent. General practitioners and district nurses were rated good or excellent by 46 (71%) patients and 46 (71%) family members, but six (9%) in each group rated the service as poor or very bad, and ratings in the inner London district were significantly worse than those in the outer London district. Hospital doctors and nurses were rated good or excellent by 22 (34%) patients and 35 (54%) of family members, and 14 (22%) patients and 15 (23%) family members rated this service as poor or very bad. Negative comments referred to communication (especially at diagnosis), coordination of services, the attitude of the doctor, delays in diagnosis, and difficulties in getting doctors to visit at home. Family members were more satisfied with the services than were patients. CONCLUSIONS--Palliative care needs to include both the patient and family because the needs of the family may exceed those of the patient. Support teams and some hospital and community doctors and nurses met the perceived needs of dying patients and families, but better education and organisation of services are needed.     

Health Care Professionals' Views on Discussing Sexual Wellbeing with Patients Who Have Had a Stroke: A Qualitative Study

Objectives

To examine the experiences of health care professionals discussing sexual wellbeing with patients who have had a stroke.

Design

In-depth qualitative interview study with purposive sampling and thematic analysis.

Participants

30 health care professionals purposively recruited to include different roles and settings along the stroke patient pathway in secondary and primary care.

Setting

Two hospitals and three general practices in the West Midlands, UK.

Results

Sexual wellbeing was a topic that participants did not raise with patients and was infrequently raised by patients. Barriers to raising discussion were on four levels: structural, health care professional, patient, and professional-patient interface. Barriers within these levels included: sexual wellbeing not present within hospital stroke policy; the perception that sexual wellbeing was not within participants'' role; participants'' concern that raising the issue could cause harm to the patient; and the views that discussion would be inappropriate with older people or unimportant to women. Resources exist to aid discussion but many participants were unaware of them, and most of those that were, did not use them routinely.

Conclusions

Participants lacked motivation, ownership, and the confidence and skills to raise sexual wellbeing routinely after stroke. Similar findings have been reported in cancer care and other taboo subjects such as incontinence potentially resulting in a sub-optimal experience for patients. Normalisation of the inclusion of sensitive topics in discussions post-stroke does not seem to need significant structural intervention and simple changes such as information provision and legitimisation through consideration of the issue in standard care policies may be all that is required. The experiences recounted by professionals in this study suggest that such changes are needed now.     

Comparison of out of hours care provided by patients' own general practitioners and commercial deputising services: a randomised controlled trial. II: The outcome of care.

OBJECTIVE: To compare the outcome of out of hours care given by general practitioners from patients'' own practices and by commercial deputising services. DESIGN: Randomised controlled trial. SETTING: Four urban areas in Manchester, Salford, Stockport, and Leicester. SUBJECTS: 2152 patients who requested out of hours care, and 49 practice doctors and 183 deputising doctors (61% local principals in general practice) who responded to the requests. MAIN OUTCOME MEASURES: Health status outcome, patient satisfaction, and subsequent health service use. RESULTS: Patients seen by deputising doctors were less satisfied with the care they received. The mean overall satisfaction score for practice doctors was 70.7 (95% confidence interval 68.1 to 73.2) and for deputising doctors 61.8 (59.9 to 63.7). The greatest difference in satisfaction was with the delay in visiting. There were no differences in the change in health or overall health status measured 24 to 120 hours after the out of hours call or subsequent use of the health service in the two groups. CONCLUSIONS: Patients are more satisfied with the out of hours care provided by practice doctors than that provided by deputising doctors. Organisation of doctors into large groups may produce lower levels of patient satisfaction, especially when associated with increased delays in the time taken to visit. There seem to be no appreciable differences in health outcome between the two types of service.     

Assistants to Primary Physicians in California

The mid-level practitioner movement is no longer experimental; nurse practitioners and physician''s assistants in California have proved to fill a necessary and viable professional role in the delivery of primary health care. The physician''s assistant law (AB2109) and the Experimental Manpower Act (AB1503) have facilitated the training and functioning of these new health care professionals; more comprehensive laws are still needed to permit optimal utilization. National agencies for approval of teaching programs and testing of individual graduates will play an increasing role in the accreditation and certification procedures. Professional role difficulties, issues of sex and questions of delegation of responsibility are being resolved and it is hoped that a more equitable and patient-oriented system is evolving.     

Treating anemia of chronic kidney disease in the primary care setting: cardiovascular outcomes and management recommendations

Background

Recent policy and organisational changes within UK primary care have emphasised graduated access to care, speed of access to the first available general practitioner (GP) and care being provided by a range of healthcare professionals. These trends have been strengthened by the current GP contract and Quality and Outcomes Framework (QOF). Concern has been expressed that the potential for personal care is being diminished as a result and that this will reduce quality standards. This paper presents data from a study that explored with patients and GPs what personal care means and whether it has continuing importance to them.

Methods

A semi-structured questionnaire was used to interview participants and Framework Analysis supported analysis of emerging themes. Twenty-nine patients, mainly women with young children, and twenty-three GPs were interviewed from seven practices in Lothian, Scotland, ranged by practice size and relative deprivation score.

Results and Discussion

Personal care was defined mainly, though not exclusively, as care given within the context of a continuing relationship in which there is an interpersonal connection and the doctor adopts a particular consultation style. Defined in this way, it was reported to have benefits for both health outcomes and patients' experience of care. In particular, such care was thought to be beneficial in attending to the emotions that can be elicited when seeking and receiving health care and in enabling patients to be known by doctors as legitimate seekers of care from the health service. Its importance was described as being dependent upon the nature of the health problem and patients' wider familial and social circumstances. In particular, it was found to provide support to patients in their parenting and other familial caring roles.

Conclusion

Personal care has continuing salience to patients and GPs in modern primary care in the UK. Patients equate the experience of care, not just outcomes, with high quality care. As it is mainly conceptualised and experienced as care within the context of a continuing relationship, policies and organisational arrangements that support and give incentives to this must be in place. These preferences are not strongly reflected in the QOF. Specific questions need to be addressed by future audit and research on the impact of the contract on these aspects of service.