The friendship model: a reply to Illingworth

Patricia M.L. Illingworth, in an article in the January 1988 issue of Bioethics, maintained that a friendship model of the physician patient relationship violates the autonomy of patients who do not want to be friends with their physicians and diminishes the autonomy of patients who seek such friendship based on "psychological oppression" stemming from internalization of feelings of inferiority. James contends in this reply that much of Illingworth's critique of the model was beside the point. He argues that trust between doctor and patient is a moral good in the therapeutic relationship and that this trust has enough similarities to trust between friends to make a model which develops these similarities well worth exploring.     

The physician as a patient educator. From theory to practice.

Patient nonadherence to therapeutic regimens is a serious issue in the practice of medicine. Empiric studies done by professionals from diverse backgrounds have shown that physicians who use educational strategies can be effective in gaining the cooperation of patients to follow their recommendations. The educational model that currently is most familiar to physicians and the one they use most frequently when educating patients is pedagogy, the theoretic basis for teaching children. Andragogy, a theoretic basis for teaching adults, is now being suggested by medical educators as an alternative model. To illustrate the clinical relevance and application of the andragogic approach, studies focusing on physician behaviors associated with behavioral measures of adherence were reviewed, analyzed, and categorized according to a framework called the "ADULT" model. Physicians in a postgraduate training program who have had exposure to this framework and have incorporated it into their practices report less difficulty functioning as patient educators. The systematic use of this approach can have a positive effect on patient adherence.     

Instilling hope and respecting patient autonomy: reconciling apparently conflicting duties

In contemporary American medical practice, certain physicians are critical and wary of the current emphasis on patient autonomy in medicine, questioning whether it really serves the complex needs of severely ill patients. Physicians such as Eric Cassell and Thomas Duffy argue that the duty of beneficence should override the duty to respect autonomy when conflicts arise in clinical situations. After evaluating their claim that severe illness robs patients of their autonomy, I will argue that this perceived conflict between beneficence and autonomy is ill-conceived, resting on misperceptions about both the capacity for autonomy and the meaning of hope. Considering insights on hope from phenomenologist Gabriel Marcel and theologian William Lynch, as well as drawing upon a case study involving a bone marrow patient, I claim that respecting and nurturing patients' capacity for autonomy is a necessary condition for acting beneficently and fostering authentic hope.     

The new paternalism

The author argues that the belief that patient autonomy has great moral value has justified a new form of medical paternalism which can have effects similar to those of the old rejected form. He cites the argument that "all illness represents a state of diminished autonomy" and that therefore autonomy is not overridden when physicians make all decisions. Another view is that, in some situations, withholding information may prevent patient deterioration and loss of autonomy. Abridgement of present autonomy, then, is permissible if it promotes future autonomy. Strasser also rejects physician decision making based on patients' previously communicated values or on the theory that patient values are important but not decisive. He concludes that if we "allow paternalistic practices, then we should admit that we are denying autonomy in light of some other good rather than claim that, somehow, we are respecting autonomy by abridging it."     

Legal obligation of physicians to disclose information to patients.

Obtaining a patient''s consent is a routine daily process for physicians, although many are unaware of the scope of this legal obligation. In 1980 the Supreme Court of Canada changed the law relating to informed consent; promotion of patient autonomy shifted the focus from a standard of professional disclosure to one of a "reasonable patient." Physicians have a legal obligation to disclose to patients specific information, the scope of which is determined by a court on the basis of a reasonable patient''s expectation and the circumstances of the case. This gives rise to many controversies in the practice of clinical medicine. It is difficult for physicians to know which treatment risks require disclosure, since this is decided by a court in a retrospective analysis of the evidence. Will the court recognize exceptions to the duty of disclosing information? If several health care professionals are involved in a patient''s care who has the duty to disclose information? Can this duty be delegated? This paper provides physicians with guidelines that are consistent with the promotion of patient autonomy and comply with the doctrine of informed consent. In addition, it suggests ways of improving awareness of the doctrine and procedures to ease its application.     

Ethical decision making by Canadian family physicians.

Canadian family physicians were sent questionnaires that asked how they would handle the ethical problems posed by six sample cases and what reasons were relevant to their decisions. The ethical problems concerned how much information to divulge to patients, how extensively a physician should become involved in the lifestyles of patients and how to deal with a possible family problem. The study identified characteristics of family physicians that affect their ethical decision making and tested a theoretical model that regards ethical problems as conflicts between respecting patient autonomy and promoting patient welfare. The varied responses suggested that ethical issues are resolved on a case-by-case, rather than a theoretical, basis. Certification in family medicine was the only characteristic associated with a consistent pattern of responses; certificants were more likely than other physicians to involve patients in decisions.     

Doing what the patient orders: maintaining integrity in the doctor-patient relationship

No profession has undergone as much scrutiny in the past several decades as that of medicine. Indeed, one might well argue that no profession has ever undergone so much change in so short a time. An essential part of this change has been the growing insistence that competent, adult patients have the right to decide about the course of their own medical treatment. However, the familiar and widely accepted principle of patient self-determination entails a corollary that has received little attention in the growing literature on the ethics of physician-patient relations: if patients are to direct the course of their own medical treatment, then physicians are at least sometimes to be guided in their actions on behalf of patients by values that are not, and may even be incompatible with, their own values. Unless it is supposed that it would be best if physicians were simply to accommodate any and all patient requests, a possibility I consider and reject in this paper, there are bound to be numerous instances of legitimate moral conflict between the preferences of physicians and patients. In this paper, I examine the implications of this sort of moral conflict from the standpoint of the integrity of the physician....I have also considered the common practice of patient referral from the standpoint of physician integrity, and asked whether a physician who refuses to treat a patient as a matter of conscience can consistently refer the patient to another physician for the same treatment....     

Effects of perceived patient demand on prescribing anti-infective drugs

BACKGROUND: Although patient demand is frequently cited by physicians as a reason for inappropriate prescribing, the phenomenon has not been adequately studied. The objectives of this study were to determine the prevalence of perceived patient demand in physician-patient encounters; to identify characteristics of the patient, physician and prescribing situation that are associated with perceived demand; and to determine the influence of perceived demand on physicians'' prescribing behaviour. METHODS: An observational study using 2 survey approaches was conducted in February and March 1996. Over a 2-day period 20 family physicians in the Toronto area completed a brief questionnaire for each patient encounter related to suspected infectious disease. Physicians were later asked in an interview to select and describe 1 or 2 incidents from these encounters during which perceived patient demand influenced their prescribing (critical incident technique). RESULTS: Perceived patient demand was reported in 124 (48%) of the 260 physician-patient encounters; however, in almost 80% of these encounters physicians did not think that the demand had much influence on their decision to prescribe an anti-infective. When clinical need was uncertain, 28 (82%) of 34 patients seeking an anti-infective were prescribed one, and physicians reported that they were influenced either "moderately" or "quite a bit" by perceived patient demand in over 50% of these cases. Of the 35 critical prescribing incidents identified during the interviews, anti-infectives were prescribed in 17 (49%); the reasons for prescribing in these situations were categorized. INTERPRETATION: This study provides preliminary data on the prevalence and influence of perceived patient demand in prescribing anti-infectives. Patient demand had more influence on prescribing when physicians were uncertain of the need for an anti-infective.     

Een cultuurvergelijkend onderzoek naar behandelbesluiten van artsen met betrekking tot demente verpleeghuispatiënten met pneumonie

A cross-cultural study of physician treatment decisions for demented nursing home patients who develop pneumoniaThis qualitative interview study in the Netherlands and North Carolina (US) found that physician treatment decisions are influenced by contextual differences in physician training and healthcare delivery in the US and the Netherlands. Dutch physicians treating nursing home residents with dementia and pneumonia assumed active, primary responsibility for treatment decisions while US physicians were more passive and deferential to family preferences, even in cases where they considered the families’ wishes inappropriate. Dutch physicians knew their patients well and made treatment decisions based on what they perceived was in the best interest of the patient while US physicians reported limited knowledge of their nursing home patients due to a lack of contact time. Efforts to improve care for patients with poor quality of life who lack decision-making capacity must consider the context of societal values, physician training, and the processes by which physicians negotiate patient and family preferences.     

Fatal hyperthermia associated with cocaine use.

Health insurance in the United States is failing patients and physicians alike. In this country 37 million uninsured face economic barriers to care, and the health of many suffers as a result. The "corporatization" of medical care threatens professional values with an unprecedented administrative and commercial intrusion into the daily practice of medicine. Competitive strategies have also failed their most ostensible goal--cost control. In contrast, Canada offers a model of a national health insurance plan that provides universal and comprehensive coverage, succeeds at restraining health care inflation, and does little to abrogate the clinical autonomy of physicians in private practice. I propose that American physicians relent in their historical opposition to national health insurance and participate in the development of a universal, public insurance plan responsive to the needs of both patients and physicians.     

Improving clinical research and cancer care delivery in community settings: evaluating the NCI community cancer centers program

Background

While the evidence suggests that the way physicians provide information to patients is crucial in helping patients decide upon a course of action, the field of knowledge translation and exchange (KTE) is silent about how the physician and the patient influence each other during clinical interactions and decision-making. Consequently, based on a novel relationship-centered model, EXACKTE² (EXploiting the clinicAl Consultation as a Knowledge Transfer and Exchange Environment), this study proposes to assess how patients and physicians influence each other in consultations.

Methods

We will employ a cross-sectional study design involving 300 pairs of patients and family physicians from two primary care practice-based research networks. The consultation between patient and physician will be audio-taped and transcribed. Following the consultation, patients and physicians will complete a set of questionnaires based on the EXACKTE² model. All questionnaires will be similar for patients and physicians. These questionnaires will assess the key concepts of our proposed model based on the essential elements of shared decision-making (SDM): definition and explanation of problem; presentation of options; discussion of pros and cons; clarification of patient values and preferences; discussion of patient ability and self-efficacy; presentation of doctor knowledge and recommendation; and checking and clarifying understanding. Patients will be contacted by phone two weeks later and asked to complete questionnaires on decisional regret and quality of life. The analysis will be conducted to compare the key concepts in the EXACKTE² model between patients and physicians. It will also allow the assessment of how patients and physicians influence each other in consultations.

Discussion

Our proposed model, EXACKTE², is aimed at advancing the science of KTE based on a relationship process when decision-making has to take place. It fosters a new KTE paradigm by putting forward a relationship-centered perspective and has the potential to reveal unknown mechanisms that underline effective KTE in clinical contexts. This will result in better understanding of the mechanisms that may promote a new generation of knowledge transfer strategies.     

Physicians' participation in establishing criteria for hypertension management in the office: will patient outcomes be improved?

We designed this study to determine whether an intensive 1-day educational workshop involving family physicians in establishing essential criteria for hypertension management would significantly affect the short-term outcomes of hypertensive patients in their practices. Forty randomly selected physicians were separated into three groups: those who would be involved in establishing the criteria (15), those who would receive the criteria by mail (15) and those who would act as controls and not be aware of the criteria (10). We found no significant difference between the three groups in the number of hypertensive patients whose condition remained uncontrolled after the intervention. We conclude that physicians'' participation in the establishment of standards of care for conditions such as hypertension or their awareness of such standards does not independently result in significantly better patient outcomes. Consequently, we recommend that physicians and health care planners concerned with improving outcomes not rely on any single intervention strategy when planning change.     

Informing cancer patient in relation his type of personality: the emotional-hypothymic (depressive) patient

Informing patients with cancer has been a subject of great scientific interest. Initially the research was aimed at quantity evaluation, in other words, the number of doctors who break the news to the patient, the number of patients seeking informing etc. Since the 1980s to present, research has shifted its focus equally on quality evaluation. In other words, serious efforts are being made to answer the question: "Is it possible to determine who should be told what, when and how?" It seems that deepening on the patient s character traits offers the best starting point for understanding the patient. The aim of this paper was to describe the character of personality types based on the question: "How could characters or personality types be used in informing patients with cancer?" As method of research was used the qualitative method through groups with doctors and nurses, while research within groups lasted for 5 years. The degree of informing is similar to the degree of the hyperthymic personality; initially, is "minimal, then "small" until it reaches "medium". The degree of denial varies between "large" and "very large" to sometimes "medium". Family: similar to the emotional-hyperthymic person, with the added difficulty of introversy. There is a discordance between what the patient shows and what the family reports about him, especially when the compensation mechanism is that of a controlling - orderly patient.     

Information exchange among physicians caring for the same patient in the community

Background

The exchange of information is an integral component of continuity of health care and may limit or prevent costly duplication of tests and treatments. This study determined the probability that patient information from previous visits with other physicians was available for a current physician visit.

Methods

We conducted a multicentre prospective cohort study including patients discharged from the medical or surgical services of 11 community and academic hospitals in Ontario. Patients included in the study saw at least 2 different physicians during the 6 months after discharge. The primary outcome was whether information from a previous visit with another physician was available at the current visit. We determined the availability of previous information using surveys of or interviews with the physicians seen during current visits.

Results

A total of 3250 patients, with a total of 39 469 previous–current visit combinations, met the inclusion criteria. Overall, information about the previous visit was available 22.0% of the time. Information was more likely to be available if the current doctor was a family physician (odds ratio [OR] 1.75, 95% confidence interval [CI] 1.54–1.98) or a physician who had treated the patient before the hospital admission (OR 1.33, 95% CI 1.21–1.46). Conversely, information was less likely to be available if the previous doctor was a family physician (OR 0.38, 95% CI 0.32–0.44) or a physician who had treated the patient before the admission (OR 0.72, 95% CI 0.60–0.86). The strongest predictor of information exchange was the current physician having previously received information about the patient from the previous physician (OR 7.72, 95% CI 6.92–8.63).

Interpretation

Health care information is often not shared among multiple physicians treating the same patient. This situation would be improved if information from family physicians and patients'' regular physicians was more systematically available to other physicians.Continuity of care occurs when patients experience linked care over time and when discrete elements of care are connected.¹ Overall, most studies have shown a benefit of physician continuity, exemplified by lower utilization of emergency and hospital services,^2–5 greater use of preventive interventions,^6–8 improvements in disease-specific symptoms or quality-of-care measures,⁹ and greater patient satisfaction.^10,11Continuity of care has been conceptualized as having 3 primary components:¹ physician continuity, management continuity and information continuity. The root component of information continuity is the availability of data from previous visits by the patient with other physicians. In 3 previous studies, physicians were frequently missing necessary information from visits that patients had made to other physicians.^12–14 However, none of those studies prospectively followed a well-defined cohort of patients.To achieve a better understanding of how information exchange might be improved in the community setting, we sought to identify the patient- and physician-related factors that influence the availability of information from previous visits with other physicians.     

A survey of physician attitudes and practices concerning cost-effectiveness in patient care

Objective To identify physicians'' views regarding cost-containment and cost-effectiveness and their attitudes and experience using cost-effectiveness in clinical decision making. Design A close-ended 30-item written survey. Subjects 1,000 randomly selected physicians whose practices currently encompass direct patient care and who work in the California counties of Sacramento, Yolo, Placer, Nevada, and El Dorado. Outcome measures Physician attitudes about the role of cost and cost-effectiveness in treatment decisions, perceived barriers to cost-effective medical practice, and response of physicians and patients if there are conflicts about treatment that physicians consider either not indicated or not cost-effective. Results Most physicians regard cost-effectiveness as an appropriate component of clinical decisions and think that only the treating physician and patient should decide what is cost-worthy. However, physicians are divided on whether they have a duty to offer medical interventions with remote chances of benefit regardless of cost, and they vary considerably in their interactions with patients when cost-effectiveness is an issue. Conclusion Although physicians in the Sacramento region accept cost-effectiveness as important and appropriate in clinical practice, there is little uniformity in how cost-effectiveness decisions are implemented.The rising cost and the equitable distribution of health care resources are important social and political issues. A major contributor to cost inflation is the enormous capacity of biomedical science to create new and costly medical interventions.^1,2 Whereas purchasers—primarily employers and government—resist increases in health care premiums and reimbursements, physicians, medical groups, and health plans face legal, regulatory, and social pressures to provide all care that is “medically necessary.”^3,4Reconciling the tension between finite resources and ever-increasing demands is not easy. One approach is for physicians to use cost-effectiveness as an explicit criterion when developing clinical policies applicable to broad populations or when considering treatment alternatives for individual patients.^5,6 Although using cost-effectiveness criteria to develop clinical policies (eg, drug formularies or practice guidelines) has long been considered an appropriate physician role,^7,8 limiting marginally beneficial and costly interventions for individual patients is controversial.^{9,10,11,12,13} The literature on the cost-effectiveness of medical interventions is growing, but little is known about how physicians incorporate cost-effectiveness decisions at the bedside.To explore the acceptability of explicitly incorporating cost-effectiveness into clinical and coverage decisions, a regional 15-member consortium (listed at the end of article) created the Visible Fairness project. Its goal is to develop recommendations that reflect consumer and provider values, interests, and concerns regarding cost-effectiveness. The first component of Visible Fairness was a written survey of local physicians seeking their views on 3 principal issues: cost containment and the role of physicians in providing cost-effective care, barriers to practicing cost-effective medicine, and experience with patients who insist on treatment that is viewed as not cost-effective.     

Choosing to refuse: patients' rights and psychotropic medication

The author discusses the position of the plaintiffs in Rogers v. Okin, a legal case in which it was argued that involuntarily committed mental patients have the right to refuse psychotropic medication. She expresses reservations about paternalistic justifications for forced medication that are based on authority, on loss of autonomy by the mentally ill, on overriding autonomy for the patient's good, on the 'self paternalism' of the psychiatric will, and on intervention as restoring autonomy. Radden argues that the patient's right to choose is supported by an extension of the concept of competence to include competence to judge an issue. She asserts that neither patients nor physicians have sufficient knowledge of the side effects of psychotropic drugs to make rational decisions. Since neither possesses proper competence, the patient should choose.     

Patient autonomy naturalized

Traditional informed consent often promotes passive acquiescence rather than active exercise of autonomy. A more natural biologically based model of autonomy is needed, a model that both recognizes the biological roots and therapeutic benefits of active confident choices among real alternatives, and offers substantive guidelines for promoting patient autonomy. A biological model of patient autonomy explains the value of information to patients, outlines the circumstances under which patients make effective choices, and suggests complementary roles for patients and professional caregivers.     

An economic theory of patient decision-making

Patient autonomy, as exercised in the informed consent process, is a central concern in bioethics. The typical bioethicist's analysis of autonomy centers on decisional capacity--finding the line between autonomy and its absence. This approach leaves unexplored the structure of reasoning behind patient treatment decisions. To counter that approach, we present a microeconomic theory of patient decision-making regarding the acceptable level of medical treatment from the patient's perspective. We show that a rational patient's desired treatment level typically departs from the level yielding an absence of symptoms, the level we call ideal. This microeconomic theory demonstrates why patients have good reason not to pursue treatment to the point of absence of physical symptoms. We defend our view against possible objections that it is unrealistic and that it fails to adequately consider harm a patient may suffer by curtailing treatment. Our analysis is fruitful in various ways. It shows why decisions often considered unreasonable might be fully reasonable. It offers a theoretical account of how physician misinformation may adversely affect a patient's decision. It shows how billing costs influence patient decision-making. It indicates that health care professionals' beliefs about the 'unreasonable' attitudes of patients might often be wrong. It provides a better understanding of patient rationality that should help to ensure fuller information as well as increased respect for patient decision-making.     

Discrimination against gay,lesbian and bisexual family physicians by patients

BACKGROUND: Discrimination against gay, lesbian and bisexual (GLB) patients by physicians is well known. Discrimination against GLB physicians by their colleagues and superiors is also well known and includes harassment, denial of positions and refusal to refer patients to them. The purpose of this study was to identify and quantify the attitudes of patients toward GLB physicians. METHODS: Telephone interviews were conducted with 500 randomly selected people living in a large urban Canadian city. Subjects were asked if they would refuse to see a GLB family physician and, if so, to describe the reason why. They were then given a choice of 6 reasons obtained from consultation with 10 GLB people and 10 heterosexual people. RESULTS: Of the 500 subjects 346 (69.2%) were reached and agreed to participate. Of the 346 respondents 41 (11.8%) stated that they would refuse to see a GLB family physician. The 2 most common reasons for the discrimination (prevalence rate more than 50%) were that GLB physicians would be incompetent and the respondent would feel "uncomfortable" having a GLB physician. Although more male than female respondents discriminated against GLB physicians, the difference was not statistically significant. The proportion of male and female respondents who discriminated increased with age (p < 0.01). CONCLUSIONS: The observed prevalence of patient discrimination against GLB family physicians is significant. The results suggest that the discrimination is based on emotional reasons and is not related to such factors as misinformation about STDs and fear of being thought of sexually. Therefore, educational efforts should be directed against general perceptions of homosexuality rather than targeting specific medical concerns.     

A system dynamics model of clinical decision thresholds for the detection of developmental-behavioral disorders

Background

Clinical decision-making has been conceptualized as a sequence of two separate processes: assessment of patients’ functioning and application of a decision threshold to determine whether the evidence is sufficient to justify a given decision. A range of factors, including use of evidence-based screening instruments, has the potential to influence either or both processes. However, implementation studies seldom specify or assess the mechanism by which screening is hypothesized to influence clinical decision-making, thus limiting their ability to address unexpected findings regarding clinicians’ behavior. Building on prior theory and empirical evidence, we created a system dynamics (SD) model of how physicians’ clinical decisions are influenced by their assessments of patients and by factors that may influence decision thresholds, such as knowledge of past patient outcomes. Using developmental-behavioral disorders as a case example, we then explore how referral decisions may be influenced by changes in context. Specifically, we compare predictions from the SD model to published implementation trials of evidence-based screening to understand physicians’ management of positive screening results and changes in referral rates. We also conduct virtual experiments regarding the influence of a variety of interventions that may influence physicians’ thresholds, including improved access to co-located mental health care and improved feedback systems regarding patient outcomes.

Results

Results of the SD model were consistent with recent implementation trials. For example, the SD model suggests that if screening improves physicians’ accuracy of assessment without also influencing decision thresholds, then a significant proportion of children with positive screens will not be referred and the effect of screening implementation on referral rates will be modest—results that are consistent with a large proportion of published screening trials. Consistent with prior theory, virtual experiments suggest that physicians’ decision thresholds can be influenced and detection of disabilities improved by increasing access to referral sources and enhancing feedback regarding false negative cases.

Conclusions

The SD model of clinical decision-making offers a theoretically based framework to improve understanding of physicians’ behavior and the results of screening implementation trials. The SD model is also useful for initial testing of hypothesized strategies to increase detection of under-identified medical conditions.