Patient-physician sexual involvement: a Canadian survey of obstetrician-gynecologists.

OBJECTIVE: To determine obstetrician-gynecologists'' (ob-gyns'') awareness of and experience with sexual abuse of patients and former patients and their opinions about appropriate consequences. DESIGN: Mailed survey. SETTING: Canada. PARTICIPANTS: All 792 members of the Society of Obstetricians and Gynaecologists of Canada (SOGC); 618 (78%) responded. Approximately half of all ob-gyns in Canada belong to the SOGC. MAIN OUTCOME MEASURES: Knowledge of sexual involvement by an ob-gyn colleague with a patient or former patient (as defined by the respondents and by the College of Physicians and Surgeons of Ontario [CPSO]), self-report of such involvement, attitudes toward physician sexual abuse, desirable length of time a physician should wait before seeing a former patient in a situation that could lead to a sexual encounter, suggested consequences of sexual abuse. RESULTS: Overall, 10% of the respondents indicated that they knew about another ob-gyn who at some time had been sexually involved with a patient. In all, 3% of the male respondents and 1% of the female respondents reported sexual involvement with a patient; the corresponding proportions of those who reported having been accused of sexual abuse by a patient were 4% and 2%. Significantly more of the female ob-gyns than of their male counterparts (37% v. 19%) reported awareness of a colleague''s sexual involvement with a patient that would meet the CPSO''s definition of sexual impropriety, transgression or violation. Most of the respondents felt that the consequence of proven sexual impropriety should be reprimand and fine (chosen by 33%) or rehabilitation without loss of licence (28%). Most of the physicians supported loss of licence for proven sexual transgression (57%) or proven sexual violation (74%), but fewer felt that loss of licence should be permanent for these types of abuse (4% and 24% respectively). The female ob-gyns supported stronger sanctions against sexual transgression and sexual violation than the male ob-gyns. A wide range of opinion was seen regarding the propriety of sexual relationships with former patients. CONCLUSIONS: Ob-gyns have varied opinions about how sexual abuse of patients should be defined and how it should be sanctioned. There is a discrepancy between proposed public policy and the beliefs of physicians to whom the policy is to be applied.     

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.     

Effect of Supervised Students' Involvement on Diagnostic Accuracy in Hospitalized Medical Patients �� A Prospective Controlled Study

Background

During internships most medical students engage in history taking and physical examination during evaluation of hospitalized patients. However, the students'' ability for pattern recognition is not as developed as in medical experts and complete history taking is often not repeated by an expert, so important clues may be missed. On the other hand, students'' history taking is usually more extensive than experts'' history taking and medical students discuss their findings with a Supervisor. Thus the effect of student involvement on diagnostic accuracy is unclear. We therefore compared the diagnostic accuracy for patients in the medical emergency department with and without student involvement in the evaluation process.

Methodology/Principal Findings

Patients in the medical emergency department were assigned to evaluation by either a supervised medical student or an emergency department physician. We only included patients who were admitted to our hospital and subsequently cared for by another medical team on the ward. We compared the working diagnosis from the emergency department with the discharge diagnosis. A total of 310 patients included in the study were cared for by 41 medical students and 21 emergency department physicians. The working diagnosis was changed in 22% of the patients evaluated by physicians evaluation and in 10% of the patients evaluated by supervised medical students (p = .006). There was no difference in the expenditures for diagnostic procedures, length of stay in the emergency department or patient comorbidity complexity level.

Conclusion/Significance

Involvement of closely supervised medical students in the evaluation process of hospitalized medical patients leads to an improved diagnostic accuracy compared to evaluation by an emergency department physician alone.     

Violence in the emergency department: a survey of health care workers

BACKGROUND: Violence in the workplace is an ill-defined and underreported concern for health care workers. The objectives of this study were to examine perceived levels of violence in the emergency department, to obtain health care workers'' definitions of violence, to determine the effect of violence on health care workers and to determine coping mechanisms and potential preventive strategies. METHODS: A retrospective written survey of all 163 emergency department employees working in 1996 at an urban inner-city tertiary care centre in Vancouver. The survey elicited demographic information, personal definition of violence, severity of violence, degree of stress as a result of violence and estimate of the number of encounters with violence in the workplace in 1996. The authors examined the effects of violence on job performance and job satisfaction, and reviewed coping and potential preventive strategies. RESULTS: Of the 163 staff, 106 (65%) completed the survey. A total of 68% (70/103) reported an increased frequency of violence over time, and 60% (64/106) reported an increased severity. Most of the respondents felt that violence included witnessing verbal abuse (76%) and witnessing physical threats or assaults (86%). Sixty respondents (57%) were physically assaulted in 1996. Overall, 51 respondents (48%) reported impaired job performance for the rest of the shift or the rest of the week after an incident of violence. Seventy-seven respondents (73%) were afraid of patients as a result of violence, almost half (49%) hid their identities from patients, and 78 (74%) had reduced job satisfaction. Over one-fourth of the respondents (27/101) took days off because of violence. Of the 18 respondents no longer working in the emergency department, 12 (67%) reported that they had left the job at least partly owing to violence. Twenty-four-hour security and a workshop on violence prevention strategies were felt to be the most useful potential interventions. Physical exercise, sleep and the company of family and friends were the most frequent coping strategies. INTERPRETATION: Violence in the emergency department is frequent and has a substantial effect on staff well-being and job satisfaction.     

Family physicians' attitudes toward advance directives.

OBJECTIVE: To examine the attitudes toward, the experience with and the knowledge of advance directives of family physicians in Ontario. DESIGN: Cross-sectional survey. PARTICIPANTS: A questionnaire was mailed to 1000 family physicians, representing a random sample of one-third of the active members of the Ontario College of Family Physicians; 643 (64%) responded. RESULTS: In all, 86% of the physicians favoured the use of advance directives, but only 19% had ever discussed them with more than 10 patients. Most of the physicians agreed with statements supporting the use of advance directives and disagreed with statements opposing their use. Of the respondents 80% reported that they had never used a directive in managing an incompetent patient. Of the physicians who responded that they had such experience, over half said that they had not always followed the directions contained in the directive. The proportions of physicians who responded that certain patient groups should be offered the opportunity to complete an advance directive were 96% for terminally ill patients, 95% for chronically ill patients, 85% for people with human immunodeficiency virus infection, 77% for people over 65 years of age, 43% for all adults, 40% for people admitted to hospital on an elective basis and 33% for people admitted on an emergency basis. The proportions of physicians who felt that the following strategies would encourage them to offer advance directives to their patients were 92% for public education, 90% for professional education, 89% for legislation protecting physicians against liability when following a directive, 80% for legislation supporting the use of directives, 79% for hospital policy supporting the use of directives, 73% for reimbursement for time spent discussing directives with patients and 64% for hospital policy requiring that all patients be routinely offered the opportunity to complete a directive at the time of admission. CONCLUSIONS: Family physicians favour advance directives but use them infrequently. Most physicians support offering them to terminally or chronically ill patients but not to all patients at the time of admission to hospital. Although governments emphasize legislation, most physicians believe that public and professional education programs would be at least as likely as legislation to encourage them to offer advance directives to their patients.     

AIDS awareness among rural Utah physicians.

Studies of physicians'' attitudes and knowledge of the acquired immunodeficiency syndrome (AIDS) and the clinical precautions they take against exposure to the human immunodeficiency virus (HIV) have focused on urban physicians. To determine rural physicians'' knowledge and attitudes about AIDS, a questionnaire was mailed to 321 physicians practicing in rural Utah. Of the 169 physicians who completed questionnaires, 96% thought that their community or area of service had only a minor or no problem with AIDS; 89%, however, thought that their chance of seeing a patient who was HIV-positive was fair to moderate. Of the 169 respondents, 3% were not sure whether they would even treat a patient who had AIDS, 67% said they would, and 30% said they would not. Although all physicians are at risk of seeing a patient who has had exposure to HIV and other blood-borne diseases such as hepatitis B, only 55% of the respondents felt a need to take clinical precautions to prevent their exposure to the virus. Our study shows the need for all rural Utah physicians to reevaluate their risk of exposure to HIV, to increase precautionary measures for their own protection, to consider the ethical responsibility of treating AIDS patients, and to take a more active role in teaching their patients how to protect themselves from exposure to the virus.     

Physicians' perceptions of the effect on clinical services of an alternative funding plan at an academic health sciences centre

BACKGROUND: In July 1994 an alternative funding plan for clinical services (global funding instead of fee-for-service payment) was established at the Southeastern Ontario Health Sciences Centre, Kingston, Ont. This study describes the perceptions of the referring physicians and consultants of the effects of the alternative funding plan 2.5 years after it was initiated. METHODS: A questionnaire was mailed to all physicians in the Kingston area in November 1996. Information was collected on demographics, referring physicians'' perceptions of the funding plan''s impact on their practices, consultants'' perceptions of its impact on their activities, perceptions of referring and consultant physicians of its impact on services provided by consultants, and attitudes toward alternative funding in the context of the Ontario health care system. RESULTS: Of the 772 physicians 531 (68.8%) returned a completed questionnaire (323 referring physicians and 208 consultants). A sizeable proportion of the referring physicians (126 [39.0%]) indicated that they were referring fewer patients to consultants at the study centre. They did not think that their practice volume had increased, but they did report spending more time on complex cases and on patient care after referral or hospital stay, and more time coordinating community care after hospital stay. Of the consultants 81 (38.9%) believed that their time spent on patient care had increased. No consistent impact on time spent on research or teaching activities was perceived. A total of 54 (26.0%) of the consultants were concerned about the impact of the alternative funding plan on quality of care. A significant proportion of the respondents (399 [75.1%]) believed that outpatient waiting times had increased, and 116 (35.9%) of the referring physicians believed that consultants were not as available by telephone. Most (220 [68.1%]) of the referring physicians believed that the funding change had had a negative effect on health care services in the region, and 87 (41.8%) of the consultants agreed. Nevertheless, the respondents believed that other factors such as funding cuts, hospital bed closures and staff layoffs were much more responsible than the alternative funding plan for their negative perceptions. INTERPRETATION: The alternative funding plan appears to have had an impact on the practices of individual physicians. However, it was not the focus for significant opposition or support from either consultants participating in the funding plan or referring physicians.     

Effect of medicolegal liability on patterns of general and family practice in Canada.

As part of the Federal/Provincial/Territorial Review on Liability and Compensation Issues in Health Care, in 1988 we surveyed Canadian general practitioners and family physicians to determine the effect of liability concerns on their practices in the previous 5 years. Questionnaires were sent to a random, stratified national sample of 1295 physicians, with a response rate of 64.6%. However, a high proportion of the returned questionnaires were ineligible because the physicians were not in general or family practice, were not involved in direct patient care, or had died or moved; thus, the corrected response rate was 50.8%. The newsletter of the Canadian Medical Protective Association was the source of information on liability most frequently cited (by 88.1% of the physicians) and most influential (to 62.4%). Only 15.5% of the physicians cited personal involvement with medicolegal issues as a source of information; the rate was higher for Ontario physicians and those in urban areas generally. A total of 74.6% of the respondents had altered their style of practice in the previous 5 years, and 56.3% reported changes in the scope of their practice. Concern about litigation was the most important reason for changing style of practice and reducing or eliminating administration of anesthesia, whereas lifestyle and other issues along with liability concerns most influenced decisions to reduce obstetric care and emergency department work. Our findings suggest that physicians'' perceptions of liability issues have had a profound influence on primary care practice in Canada in the past several years.     

Ontario Maternal Serum Screening Program: practices,knowledge and opinions of health care providers

OBJECTIVE: To determine the practices, knowledge and opinions of health care providers regarding a prenatal genetic screening program in Ontario. DESIGN: Cross-sectional self-reported survey. SETTING: Ontario. PARTICIPANTS: Random sample of 2000 family physicians, all 565 obstetricians and all 62 registered midwives in the province. Among subjects who were eligible (those providing antenatal care or attending births) the response rates were 91% (778/851), 76% (273/359) and 78% (46/59) respectively. MAIN OUTCOME MEASURES: Which patients were offered maternal serum screening (MSS), how results were being communicated, knowledge of the test''s sensitivity, likes and dislikes about MSS and recommendations regarding the program. RESULTS: Most (97%) of respondents stated that they were offering MSS to the pregnant women in their practices; 88% were offering it routinely to all pregnant women (87% of the family physicians, 90% of the obstetricians and 100% of the midwives). Most (92%) of the respondents stated that they communicate positive results to their patients personally as soon as they are received; 23% did so for negative results. The respondents correctly identified the initial positive rate but underestimated the false-positive rate. About one-third did not respond to these knowledge questions. Of those who gave feedback on the screening program, 50% recommended that it not be changed, 29% suggested that it be changed, and 22% recommended that it be scrapped. CONCLUSIONS: Participation in the Ontario Maternal Serum Screening Program by health care providers has been good, although knowledge about MSS is far from ideal. Many providers have reservations about the program. In light of concerns raised about the high false-positive rate and the anxiety such results generate in pregnant women, there is a need for more education of providers and patients and a better understanding of women''s experiences with genetic screening.     

Patterns of practice among older physicians in Ontario

BACKGROUND: Policy-makers interested in the supply of doctors in Canada have recently begun focusing attention on older physicians. This study informs the policy debate by analysing the practice patterns of Ontario physicians aged 65 years and over. METHODS: A cross-sectional and longitudinal analysis of physician claims data for fiscal years 1989/90 through 1995/96 was conducted. The number of full-time equivalent (FTE) physicians by age category, urban or rural status, and specialty was calculated by means of an established method, and differences between older physicians, established physicians and recent graduates (in practice for 5 years or less), in terms of the types of services provided and patients seen, were examined. RESULTS: The proportion of FTE physicians aged 65 or more increased from 5.3% to 7.0% during the study period, whereas the proportion of recent graduates decreased from 19.6% to 16.3%. Of the older physicians, 61.4% practised part time (less than 1 FTE). Half of the physicians aged 75 in 1989/90 were still in practice 6 years later. Older physicians were less likely than those under age 65 to practice obstetrics (4.6% v. 16.9%), provide emergency department services (1.1% v. 14.8%) or house calls (38.7% v. 60.4%), or perform many minor procedures (38.7% v. 62.3%) (p < or = 0.001 for all comparisons). Older physicians tended to be male and had older patients in their practices than did younger physicians. Rural regions had higher proportions of older specialists. INTERPRETATION: Ontario''s physician corps is aging. This may result in decreasing availability of obstetrics and emergency department coverage in the future. Encouraging retirement may create more openings for recent graduates, but if such policies are enacted, special attention should be paid to ensure that rural communities and older patients continue to be served.     

Managing erotic feelings in the physician-patient relationship.

In spite of prohibitions against the sexual involvement of physicians with their patients, erotic feelings sometimes arise in physician-patient relationships. The authors suggest that physicians can protect themselves and their patients from the harm that results from sexual involvement by establishing behavioural limits for their professional relationships, responding to patients'' sexual overtures in a firm but nonjudgemental manner, examining their own sexual feelings rationally, seeking consultation if necessary and terminating the relationship if sexual feelings are compromising patient care. The challenge for physicians is to acknowledge that sexual feelings can arise and to manage such feelings for the sake of their own and their patients'' well-being.     

Coronary thrombolysis--clinical guidelines and public policy: results of an Ontario practitioner survey.

The Ontario Medical Association (OMA) guidelines for intravenous thrombolysis in acute myocardial infarction were released in March 1988 and contributed to a government decision against special per-case funding to assist hospitals using tissue-type plasminogen activator (tPA). In October 1988, 1512 cardiologists, internists and physician-administrators who were OMA members were mailed a questionnaire seeking their views on the OMA guidelines and related issues. Of the 419 questionnaires (28%) that were returned, 392 contained usable responses. Among the respondents 268 (68%) had used thrombolytic drugs in the preceding 12 months; the mean number of cases was 10.6 (standard deviation 12.9). A strong or a mild preference for tPA over streptokinase was registered by 64% of the respondents; 28% had no preference. However, the self-reported ratio of actual streptokinase:tPA use was about 3:1, and 73% indicated that the government''s funding policy had limited the availability of tPA in their hospital. The respondents were almost equally divided as to whether the policy should be changed. The guidelines were deemed helpful by 85% of the noncardiologists, as opposed to 52% of the cardiologists (p less than 0.005). OMA involvement in developing and circulating such guidelines was supported by 74% of the respondents and opposed by 18%; opposition was more likely to come from those who found the guidelines unhelpful (p less than 0.001). Support for involvement by the College of Physicians and Surgeons of Ontario was much weaker (supported by 32%, opposed by 62%). Overwhelming opposition to government involvement was evident.     

Deciding about mechanical ventilation in end-stage chronic obstructive pulmonary disease: how respirologists perceive their role

OBJECTIVE: To determine when respirologists approach patients with end-stage chronic obstructive pulmonary disease (COPD) to decide about the use of mechanical ventilation, what information they provide to patients and how they provide it. DESIGN: Self-administered national survey. PARTICIPANTS: All Canadian specialists in respiratory medicine; of 401 eligible respirologists, 279 (69.6%) returned a completed questionnaire. OUTCOME MEASURES: Timing and content of doctor-patient discussions regarding mechanical ventilation; physicians'' perception of their level of involvement in the decision-making process; and patient and physician characteristics that may influence decisions. RESULTS: Discussions were reported to occur most often at advanced stages of COPD: when the patient''s dyspnea was severe (reported by 235 [84.2%] of the respondents) or when the patient''s forced expiratory volume in the first second was 30% or less than predicted value (reported by 210 [75.3%]). A total of 120 respondents (43.0%) stated that they discuss mechanical ventilation with 40% or less of their COPD patients before an exacerbation necessitates ventilatory support. Most (154 [55.2%]) described the decision-making process as a collaboration between patient and physician; 83 (29.7%) reported that the patient decides after he or she has considered the physician''s opinion. Over half (148 [53.0%]) of the respondents indicated that they occasionally, often or always modify the information provided to patients in order to influence their decision about mechanical ventilation. CONCLUSIONS: Discussions with COPD patients concerning end-of-life decisions about mechanical ventilation are reported to occur in advanced stages of the disease or not at all, with patients'' input where possible. Information presented to patients is often modified in order to influence the decision. Future studies should explore ways to involve patients further in the decision-making process and to improve the process for both patients and physicians.     

Emergency department use following incentives to provide after-hours primary care: a retrospective cohort study

BACKGROUND:Access to primary care outside of regular working hours is limited in many countries. This study investigates the relation between the after-hours premium, an incentive for primary care physicians to provide services after hours, and less-urgent visits to the emergency department in Ontario, Canada.METHODS:We analyzed a retrospective cohort of a random sample of Ontario residents from April 2002 to March 2006, and a subcohort of patients followed from April 2005 to March 2016. We linked patient and primary care physician data with emergency department visit data. We used fixed-effects regression models to analyze the association between the introduction of the after-hours premium, as well as subsequent increases in the value of the premium, and the number of monthly emergency department visits.RESULTS:The sample consisted of 586 534 patients between 2002 and 2006, and 201 594 patients from 2005 to 2016. After controlling for patient and physician characteristics, seasonality and time-invariant patient confounding factors, introduction of the after-hours premium was associated with a reduction of 1.26 less-urgent visits to the emergency department per 1000 patients per month (95% confidence interval −1.48 to −1.04). Most of this reduction was observed in after-hours visits. Sensitivity analysis showed that the monthly reduction in less-urgent visits to the emergency department was in the range of −1.24 to −1.16 per 1000 patients. Subsequent increases in the after-hours premium were associated with a small reduction in less-urgent visits to the emergency department.INTERPRETATION:Ontario’s experience suggests that incentivizing physicians to improve access to after-hours primary care reduces some less-urgent visits to the emergency department. Other jurisdictions may consider incentives to limit less-urgent visits to the emergency department.

One prominent health policy issue confronting many countries is overcrowding of the emergency department.¹ Not only does overcrowding result in longer wait times in the emergency department, but it may be associated with patient dissatisfaction and higher risk of death,^2–4 as well as contribute to higher health system costs.^5–7 Use of the emergency department by patients with conditions treatable in primary care may be a factor that contributes to emergency department overcrowding,^4,8,9 and improved after-hours access to primary care is a potential solution.¹⁰Following Canada’s initiatives on primary care reform in the early 2000s, the Ontario government introduced several patient enrolment models (PEMs) for primary care delivery.¹¹ These models were characterized by mandatory patient enrolment, group-based practice and blended remuneration, including retrospective and prospective payments and pay-for-performance incentives. In July 2003, the Ontario government introduced the after-hours premium, an incentive for physicians practising in PEMs to claim an additional 10% on specific services provided to enrolled patients after regular business hours (5 pm to 8 am on weekdays, and any time on weekends and holidays). The after-hours premium increased to 15% in April 2005, 20% in April 2006 and to 30% in September 2011. One study examined the effect of enrolment in a PEM on overall emergency department visits, thereby masking any differential effects on urgent and less-urgent visits.¹² Using physician-level data, a recent study examined the impact of the increase in the after-hours premium from 10% to 20%.¹³ We build on this literature and examine whether the introduction of Ontario’s after-hours premium, and subsequent increases in the premium, were associated with changes in emergency department visits, stratified by visit urgency. In particular, we examine whether the premium was associated with reductions in less-urgent visits to the emergency department.     

Hyperosmolar Therapy in Severe Traumatic Brain Injury: A Survey of Emergency Physicians from a Large Canadian Province

Introduction

Worldwide, severe traumatic brain injury is a frequent pathology and is associated with high morbidity and mortality. Mannitol and hypertonic saline are therapeutic options for intracranial hypertension occurring in the acute phase of care. However, current practices of emergency physicians are unknown.

Methods

We conducted a self-administered survey of emergency physicians in the province of Québec, Canada, to understand their attitudes surrounding the use of hyperosmolar solutions in patients with severe traumatic brain injury. Using information from a systematic review of hypertonic saline solutions and experts'' opinion, we developed a questionnaire following a systematic approach (items generation and reduction). We tested the questionnaire for face and content validity, and test-retest reliability. Physicians were identified through the department head of each eligible level I and II trauma centers. We administered the survey using a web-based interface and planned email reminders.

Results

We received 210 questionnaires out of 429 potentials respondents (response rate 49%). Most respondents worked in level II trauma centers (69%). Fifty-three percent (53%) of emergency physicians stated using hypertonic saline to treat severe traumatic brain injury. Most reported using hyperosmolar therapy in the presence of severe traumatic brain injury and unilateral reactive mydriasis, midline shift or cistern compression on brain computed tomography.

Conclusion

Hyperosmolar therapy is believed being broadly used by emergency physicians in Quebec following severe traumatic brain injury. Despite the absence of clinical practice guidelines promoting the use of hypertonic saline, a majority of them said to use these solutions in specific clinical situations.     

A study to assess changes in myocardial perfusion after treatment with spinal cord stimulation and percutaneous myocardial laser revascularisation; data from a randomised trial

Background

What constitutes a "clinical trial" is inconsistently defined in the medical literature. With an initiative by Cancer Care Ontario (CCO) to report institutional clinical trials activity across the province of Ontario, Canada, we sought to investigate the variability in the interpretation of the term by local oncology professionals.

Methods

A survey amongst the physicians and nurses at the Juravinski Cancer Centre at Hamilton Health Sciences, Ontario was conducted. The survey included 12 summaries of local clinical research studies, and respondents were asked which they believed represented a clinical trial. Subsequently, they were asked which of the same 12 studies they believed should be labeled as clinical trials when considering separate definitions provided by CCO and by the Ontario Cancer Research Network (OCRN).

Results

A total of 66 (54%) of 123 surveys were completed; 32/46 (70%) by physicians, 21/59 (36%) by primary care nurses, and 13/18 (72%) by clinical trial nurses. Without a standardized definition, all studies, 12/12, were considered to be clinical trials by at least 50% of respondents. When provided with the CCO definition only 6/12 studies were considered to be clinical trials by the majority of respondents, while with the OCRN definition it was 9/12 studies. Studies evaluating natural health products, non-traditional medical interventions, and non-randomized studies with standard interventions consistently ranked the lowest, regardless of the definition used.

Conclusion

Oncology professionals appear to have a broadly inclusive baseline definition of what constitutes a clinical trial. Establishing rigor and consistency in the definition of a clinical trial is important for any program, institutional or jurisdictional based comparisons of clinical trials activity, especially when used as a quality indicator of patient care.     

Topics to ponder: Part-time practice and pay parity

Background: The medical profession has undergone a significant demographic change, with a dramatic increase in the number of women applying to medical school and practicing medicine.Objectives: In recognition of the changing demographics in the medical profession, the American Medical Association's Women Physicians Congress (AMA-WPC) conducted a members' survey to identify the issues affecting women physicians and to ascertain certain practice characteristics.Methods: In 2008, an e-mail survey link was sent to a randomly selected nationwide sample of 4992 WPC members, and a second, identical survey was sent to 596 female AMA members, utilizing the Epocrates database (Epocrates, Inc., San Mateo, California). Two e-mail reminders were sent for the first survey, which had a 15% response rate. A quota of 148 physicians was received within 4 days and was utilized to interpret results from the second survey.Results: Achieving work-life balance was a significant concern for 91% of the respondents (n = 884). Half of the respondents believed that pay is gender neutral, and 28% indicated that they were “somewhat or very concerned about sexual harassment”. When queried regarding practice patterns, 29% of respondents indicated that they had worked part-time at some point during their careers.Conclusions: In this survey, women physicians indicated that gender pay disparity and sexual harassment remain important issues in the medical profession. Less than a third of respondents had ever worked part-time, which should be a consideration for physician workforce studies. Barriers to part-time practice may exist.     

Residents' experiences of abuse,discrimination and sexual harassment during residency training. McMaster University Residency Training Programs.

OBJECTIVE: To assess the prevalence of psychological abuse, physical assault, and discrimination on the basis of gender and sexual orientation, and to examine the prevalence and impact of sexual harassment in residency training programs. DESIGN: Self-administered questionnaire. SETTING: McMaster University, Hamilton, Ont. PARTICIPANTS: Residents in seven residency training programs during the academic year from July 1993 to June 1994. Of 225 residents 186 (82.7%) returned a completed questionnaire, and 50% of the respondents were women. OUTCOME MEASURES: Prevalence of psychological abuse, physical assault and discrimination on the basis of gender and sexual orientation experienced by residents during medical training, prevalence and residents'' perceived frequency of sexual harassment. RESULTS: Psychological abuse was reported by 50% of the residents. Some of the respondents reported physical assault, mostly by patients and their family members (14.7% reported assaults by male patients and family members, 9.8% reported assaults by female patients and family members), 5.4% of the female respondents reported assault by male supervising physicians. Discrimination on the basis of gender was reported to be common and was experienced significantly more often by female residents than by male residents (p < 0.01). Ten respondents, all female, reported having experienced discrimination on the basis of their sexual orientation. Most of the respondents experienced sexual harassment, especially in the form of sexist jokes, flirtation and unwanted compliments on their dress or figure. On average, 40% of the respondents, especially women (p < 0.01), reported experiencing offensive body language and receiving sexist teaching material and unwanted compliments on their dress. Significantly more female respondents than male respondents stated that they had reported events of sexual harassment to someone (p < 0.001). The most frequent emotional reactions to sexual harassment were embarassment (reported by 24.0%), anger (by 23.4%) and frustration (20.8%). CONCLUSION: Psychological abuse, discrimination on the basis of gender and sexual harassment are commonly experienced by residents in training programs. A direct, progressive, multidisciplinary approach is needed to label and address these problems.     

Variation in emergency department use of cervical spine radiography for alert,stable trauma patients

OBJECTIVE: To, assess the emergency department use of cervical spine radiography for alert, stable adult trauma patients in terms of utilization, yield for injury and variation in practices among hospitals and physicians. DESIGN: Retrospective survey of health records. SETTING: Emergency departments of 6 teaching and 2 community hospitals in Ontario and British Columbia. PATIENTS: Consecutive alert, stable adult trauma patients seen with potential cervical spine injury between July 1, 1994, and June 30, 1995. MAIN OUTCOME MEASURES: Total number of eligible patients, referral for cervical spine radiography (overall, by hospital and by physician), presence of cervical spine injury, patient characteristics and hospitals associated with use of radiography. RESULTS: Of 6855 eligible patients, cervical spine radiography was ordered for 3979 (58.0%). Only 60 (0.9%) patients were found to have an acute cervical spine injury (fracture, dislocation or ligamentous instability); 98.5% of the radiographic films were negative for any significant abnormality. The demographic and clinical characteristics of the patients were similar across the 8 hospitals, and no cervical spine injuries were missed. Significant variation was found among the 8 hospitals in the rate of ordering radiography (p < 0.0001), from a low of 37.0% to a high of 72.5%. After possible differences in case severity and patient characteristics at each hospital were controlled for, logistic regression analysis revealed that 6 of the hospitals were significantly associated with the use of radiography. At 7 hospitals, there was significant variation in the rate of ordering radiography among the attending emergency physicians (p < 0.05), from a low of 15.6% to a high of 91.5%. CONCLUSIONS: Despite considerable variation among institutions and individual physicians in the ordering of cervical spine radiography for alert, stable trauma patients with similar characteristics, no cervical spine injuries were missed. The number of radiographic films showing signs of abnormality was extremely low at all hospitals. The findings suggest that cervical spine radiography could be used more efficiently, possibly with the help of a clinical decision rule.