Physician communication skills and malpractice claims. A complex relationship.

We assessed the relationship between patients'' opinions about their physicians'' communication skills and the physician''s history of medical malpractice claims. The sample consisted of 107 physicians and 2,030 of their patients who had had an operation or a delivery. Although patients tended to give their physicians favorable ratings, they were least satisfied with the amount of explanations they received. Patients gave higher ratings to general surgeons and obstetrician-gynecologists and poorer ratings to orthopedists and anesthesiologists. Women and better-educated patients gave higher ratings on explanations and communication to physicians with fewer claims. Men and patients with less education, however, gave higher ratings on these dimensions to physicians with more claims. These findings suggest the need for physicians to tailor their communications to a patient''s individual needs. Improved communication between physicians and patients may result in fewer nonmeritorious malpractice claims while leading to less costly resolution of meritorious claims.     

Education and Eminence in British Medicine

The educational background of eminent members of the British medical profession was examined by recourse to Who''s Who. Substantial differences in background were found among the various medical specialties. Members of specialties enjoying high prestige within the profession—physicians, surgeons—were more likely than other members of the sample to have been to an English school as opposed to one in Scotland, Wales, or Northern Ireland, and to a headmasters'' conference school as opposed to a grammar school. Educational background was also found to relate to the aspect of the patient''s body on which specialists normally worked. Specialists coming from English headmasters'' conference schools were more likely than others to work on living bodies rather than dead bodies or parts of bodies, on the head rather than on the lower trunk, on male bodies rather than female bodies, and on the body''s surface rather than its inside.     

The teacher, the physician and the person: how faculty's teaching performance influences their role modelling

Objective

Previous studies identified different typologies of role models (as teacher/supervisor, physician and person) and explored which of faculty''s characteristics could distinguish good role models. The aim of this study was to explore how and to which extent clinical faculty''s teaching performance influences residents'' evaluations of faculty''s different role modelling statuses, especially across different specialties.

Methods

In a prospective multicenter multispecialty study of faculty''s teaching performance, we used web-based questionnaires to gather empirical data from residents. The main outcome measures were the different typologies of role modelling. The predictors were faculty''s overall teaching performance and faculty''s teaching performance on specific domains of teaching. The data were analyzed using multilevel regression equations.

Results

In total 219 (69% response rate) residents filled out 2111 questionnaires about 423 (96% response rate) faculty. Faculty''s overall teaching performance influenced all role model typologies (OR: from 8.0 to 166.2). For the specific domains of teaching, overall, all three role model typologies were strongly associated with “professional attitude towards residents” (OR: 3.28 for teacher/supervisor, 2.72 for physician and 7.20 for the person role). Further, the teacher/supervisor role was strongly associated with “feedback” and “learning climate” (OR: 3.23 and 2.70). However, the associations of the specific domains of teaching with faculty''s role modelling varied widely across specialties.

Conclusion

This study suggests that faculty can substantially enhance their role modelling by improving their teaching performance. The amount of influence that the specific domains of teaching have on role modelling differs across specialties.     

Prevention should be the preferred insurance program for all physicians.

Recent fee increases announced to the Canadian Medical Protective Association (CMPA) and the Ontario government''s plan to stop its CMPA rebate program for the province''s physicians have put the spotlight on medical liability insurance. In this examination of the role played by the CMPA, Ottawa lawyer Karen Capen notes that quality service and attention to physician-patient communication will in most cases ensure a litigation-free professional life.     

Trends in malpractice litigation.

Physicians who make mistakes are not necessarily negligent, contrary to prevailing opinion in the medical community. The article discusses the legal concepts of "standard of care" and "proximate cause." The incidence of favorable jury verdicts in those cases in which malpractice suits are litigated is quite high. The effects of insurance company policies in decisions about settlements on the incidence of claims is discussed and alternatives are suggested. The prevailing belief that a consent form with a patient''s signature on it is sufficient to prevent a malpractice suit is also discussed.     

The sight test fee: effect on ophthalmology referrals and rate of glaucoma detection.

OBJECTIVE--To assess changes, if any, in the numbers of referrals and outcome of glaucoma referrals to the hospital eye service since the introduction of the sight test fee on 1 April 1989. DESIGN--Review of referral records and clinical notes. SETTING--Referrals to the Bristol Eye Hospital. SUBJECTS--51,919 patients referred to the Bristol Eye Hospital between 1984 and 1992. 9438 case notes of patients referred between 1987 and 1991 were examined in detail. MAIN OUTCOME MEASURES--Numbers of referrals; rate of adult true positive glaucoma referrals. RESULTS--Referrals to the Bristol Eye Hospital were between 13.7% and 19.0% fewer than expected after the introduction of the sight test fee. True positive glaucoma referrals were reduced by the same proportion. CONCLUSIONS--The numbers of patients being identified as requiring treatment or follow up for potentially blinding glaucoma have declined by nearly one fifth since the introduction of the sight test fee. An increased prevalence of preventable blindness may result.     

Physicians must cast off grief over change if they're to move forward,anthropologist advises

It''s time for physicians to stop grieving over the massive changes occurring in health care and instead create a new vision that will lead them forward into the future, a cultural anthropologist told the CMA''s 8th annual Leadership Conference in March. About 175 physicians attended the 2-day conference on regaining the perspective on values in times of change.     

In-lieu fee mitigation: coming into compliance with the new Compensatory Mitigation Rule

Under Section 404 of the federal U.S. Clean Water Act, the U.S. Army Corps of Engineers and U.S. Environmental Protection Agency require compensatory mitigation for unavoidable impacts stemming from the permitted discharge of dredged or fill material into waters of the United States. There are three primary mechanisms supported by the Corps and EPA for permittees to meet their compensatory mitigation obligations: permittee-responsible mitigation, purchasing credits from a mitigation bank, or making a payment to an approved in-lieu fee mitigation program. In 2005, the Environmental Law Institute studied the 38 approved, active in-lieu fee programs operating in the US. This paper seeks to assess how the in-lieu fee programs that were approved and active as of October 2005 will need to update their administrative and procedural practices to come into compliance with new regulations on compensatory mitigation published in April 2008. Of the 10 new requirements for in-lieu fee reviewed here, three in particular will likely have the most significant impact on whether the 2005 programs are able to seek authorization and continue to operate. These are the compensation planning framework, the cap on the number of advance credits that can be sold, and the requirement to provide financial assurances for all projects. Those programs that make the investment in meeting the new requirements by the June 2010 deadline are likely to overcome past concerns over the ability for in-lieu fee mitigation to replace lost aquatic resources in a timely and efficient fashion.

The Oslerian Tradition and Changing Medical Education: A Reappraisal

Although only 21 of Sir William Osler''s 45 years in academic medicine were spent in US medical schools (1884 to 1905), he played a major role in shaping modern medical education in this country. The integration of scholarship with patient care, together with the science and art of medicine, was central to Osler''s teaching and writing throughout his career. A classic generalist and a charismatic clinical teacher, he taught by example and was as concerned with the ideals of medicine as with its science and knowledge.Many changes have reshaped the content, process and concerns of American medical education since Osler''s time. Subspecialization and balkanization of medical education and practice have become dominant. Many of the important issues in medicine today do not fit neatly into the domain of any of the established specialties or medical organizations. There is now an urgent need to promote generalist attitudes in medicine, and the Oslerian tradition has much to offer in approaching today''s problems in medical education and practice.     

Domiciliary consultations: some facts and questions.

The domiciliary consultation scheme introduced at the start of the NHS enables joint consultation between a consultant and general practitioner in a patient''s home when the patient cannot attend hospital on medical grounds. Consultants claim a fee from the NHS, general practitioners do not. Data from the Department of Health and Social Security on domiciliary consultations in England and Wales during 1981-6 were analysed. The number of domiciliary consultations fell during 1981-6 from 429,759 in 1981 to 387,394 in 1986, a fall of 10%, whereas the numbers of consultants and general practitioners increased by 1404 (12%) and 2400 (10%), respectively. The yearly rate of domiciliary consultation per consultant fell by 19% from 36 in 1981 to 29 in 1986 and that per general practitioner by 18% from 18 to 15. In 1986 geriatric medicine had the highest rate of domiciliary consultation per consultant (187) followed by psychiatry (89), general medicine (52), dermatology (49), rheumatology (42), general surgery (36), gastroenterology (35), thoracic medicine (34), and orthopaedics (30). In 1986 all specialties apart from clinical pharmacology and therapeutics and clinical genetics showed a decrease in the yearly rate of domiciliary consultation when compared with the rate for 1981. Domiciliary consultation seems to have become a domiciliary visit by the consultant alone. At an estimated cost of about 20m pounds for 1988 the scheme needs critical evaluation.     

Is it possible to "achieve a balance" and meet the "safety net"? Paediatric Advisory Subcommittee to the North West Thames Regional Health Authority.

The government''s document Hospital Medical Staffing--Achieving a Balance--Plan for Action introduced the concept of a "safety net"--that is, a minimum safe level of staffing--of junior doctors in the acute specialties. The North West Thames Paediatric Advisory Group has therefore reviewed the implications and consequences of implementing the safety net in respect of children''s services. The group found that if a reasonable safety net was to be provided that enabled the services to stay within the projected junior staffing levels, maintain a balance, meet training needs, and reduce junior doctors'' hours of work, then changes in the organisation of the services would be required. Examining the options available showed that to achieve a safety net within the projected numbers of junior staff at least six paediatric units in the region would have to close. It is doubtful if there is the political will to support the very radical changes that would be needed in the distribution of services if the government''s recommendations in Achieving a Balance were to be implemented. The profession, the Department of Health, and the public must be made aware that the proposed changes in medical staffing will cause a fundamental change in the traditional pattern of delivery of health care.     

Bilateral nephrectomy for massive pulmonary hemorrhage in Goodpasture's syndrome

A case of Goodpasture''s syndrome is described in which bilateral nephrectomy was undertaken because of massive pulmonary hemorrhage. Similar cases recorded in the literature are reviewed. Various hypotheses to explain the beneficial effects of renal ablation on lung purpura are considered. It is suggested that the pulmonary hemorrhage in Goodpasture''s syndrome is mediated in part by a non-antibody humoral factor with permeability-increasing properties that is released from the nephritic kidney.     

Offshore energy boom providing opportunities outside medicare's umbrella

Physicians upset by limits imposed by the medicare system are getting a chance to spread their entrepreneurial wings on the East Coast. A boom in offshore exploration, led by Newfoundland''s massive Hibernia project, has led to numerous business opportunities for physicians.     

无居民海岛开发生态损害评估——以象山县大羊屿岛为例

无居民海岛独特的生态系统和地理位置决定了受损后的修复成本极高、开发难度极大,其保护与开发已经成为国内外学界关注的重点。基于海岛生态系统服务价值理论构建了无居民海岛开发的生态损害评估模型,以我国首个公开拍卖使用权的大羊屿岛为例验证模型的科学性和可行性,并与2018年调整后的无居民海岛使用金征收标准中生态损害成本额度进行对比分析。研究结果表明：（1）大羊屿岛开发的生态损害补偿金为1644.82万元。其中,陆域开发行为所需的生态损害补偿金为890.19万元,高于海洋开发行为所造成的生态损害补偿金;（2）通过本文计算的海岛陆域生态损害补偿金高出现行海岛使用金标准中的生态损害成本371.90万元,2018年旅游用岛使用金征收标准仍有上调空间。对无居民海岛开发的生态损害评估可以增强政府和企业对于海岛资源的保护意识,重新权衡无居民海岛开发的利弊,避免对海岛资源过度和盲目的开发。     

Understanding hospital referral rates: a user's guide.

Detailed referral information from one practice was used to investigate the effect of calculating referral rates in several different ways. Referral rates for individual general practitioners should be related to the number of consultations carried out and not to the number of registered patients; for whole practices list size may be used as the denominator. Most doctors will not need to control for age and sex of patients when comparing referral rates but may need to control for case mix when comparing referral rates to individual specialties. In addition, a method is described for distinguishing systematic variation between the referral rates of individual doctors from the random variation that may arise from data based on fairly small numbers of referrals. The method indicates whether systematic variation is greater than would be expected by chance, and it can be extended to indicate whether variability in referral rates is greater in one specialty than another. Because of random variation with time a year''s data may not be sufficient to allow reliable interpretation of referral rates to individual specialties, except for the largest. At present there is no known relation between high or low referral rates and quality of care. Nevertheless, if doctors are to interpret their own rates of referral they need those rates to be reliable and valid. Use of the 10 guidelines described in this paper will help to prevent unwarranted conclusions being drawn from information on general practitioners'' rates of referral to hospital.     

The Plaintiff's Attorney and Obstetrics

This paper was presented before a meeting of plaintiffs'' attorneys, including those who specialize in malpractice actions against physicians—the National Association of Claimants'' Compensation Attorneys (NACCA).Doctor Eastman is known internationally for his contribution in the field of obstetrics. In recent years his interests have led him into the field of forensic obstetrics, a complex and difficult subject. Some of these problems are explored by Dr. Eastman in this paper and his comments will be of interest to physicians and attorneys.It is to be hoped that NACCA members benefited by this accurate and scientific presentation.     

Specialist outreach clinics in general practice.

OBJECTIVES--To establish the extent and nature of specialist outreach clinics in primary care and to describe specialists'' and general practitioners'' views on outreach clinics. DESIGN--Telephone interviews with hospital managers. Postal questionnaire surveys of specialists and general practitioners. SETTING--50 hospitals in England and Wales. SUBJECTS--50 hospital managers, all of whom responded. 96 specialists and 88 general practitioners involved in outreach clinics in general practice, of whom 69 (72%) and 46 (52%) respectively completed questionnaires. 122 additional general practitioner fundholders, of whom 72 (59%) completed questionnaires. MAIN OUTCOME MEASURES--Number of specialist outreach clinics; organisation and referral mechanism; waiting times; perceived benefits and problems. RESULTS--28 of the hospitals had a total of 96 outreach clinics, and 32 fundholders identified a further 61 clinics. These clinics covered psychiatry (43), medical specialties (38), and surgical specialties (76). Patients were seen by the consultant in 96% (107) of clinics and general practitioners attended at only six clinics. 61 outreach clinics had shorter waiting times for first outpatient appointment than hospital clinics. The most commonly reported benefits for patients were ease of access and shorter waiting times. CONCLUSIONS--Specialist outreach clinics cover a wide range of specialties and are popular, especially in fundholding practices. These clinics do not seem to have increased the interaction between general practitioners and specialists.     

A quantitative ranking of Canada's research output of original human studies for the decade 1989 to 1998

BACKGROUND: Since 1987 research articles have been catalogued with the author''s affiliation address in the 40 databases of the Medical Literature Analysis and Retrieval System (MEDLARS) of the National Library of Medicine, Bethesda, Md. The present study was conducted to examine the Canadian entries in MEDLARS to interpret past and future trends and to combine the MEDLARS demographic data with data from other sources to rank Canadian research output of human studies both nationally and internationally. METHODS: The PubMed Web site of the National Library of Medicine was used to count medical articles archived in MEDLARS and published from Jan. 1, 1989, through Dec. 31, 1998. The articles attributed to Canadian authors were compared by country, province, city, medical school, hospital, article type, journal and medical specialty. RESULTS: During the study period Canadian authors contributed on average 3% (standard deviation [SD] 0.2%) of the worldwide MEDLARS content each year, which translated to a mean of 11,067 (SD 1037) articles per year; 49% were human studies, of which 13% were clinical or controlled trials, and 55% involved people aged 18 years or less. In total, 68% of the articles were by authors affiliated with Canadian medical schools; those affiliated with the University of Toronto accounted for the greatest number (8604), whereas authors affiliated with McGill University had the greatest rate of annual increase in the quantity published (8%). Over one-third (38%) of the articles appeared in Canadian journals. When counted by specialty, 17% of the articles were by authors with clinical specialties, 5% by those with surgical specialties and 3% by those with laboratory specialties. INTERPRETATION: The annual rate of increase in research output for Canada was more than 3 times higher than that seen world wide. Canada is now ranked seventh among countries contributing human studies to MEDLARS. The increase indicates that Canada''s medical schools are productive, competitive in making contributions to medical science and are supporting Canadian journals.     

Downsizing of acute inpatient beds associated with private finance initiative: Scotland's case study

ObjectivesTo evaluate whether the projected 24% reduction in acute bed numbers in Lothian hospitals, which formed part of the private finance initiative (PFI) plans for the replacement Royal Infirmary of Edinburgh, is being compensated for by improvements in efficiency and greater use of community facilities, and to ascertain whether there is an independent PFI effect by comparing clinical activity and performance in acute specialties in Lothian hospitals with other NHS hospitals in Scotland.DesignComparison of projected and actual trends in acute bed capacity and inpatient and day case admissions in the first five years (1995-6 to 2000-1) of Lothian Health Board''s integrated healthcare plan. Population study of trends in bed rate, hospital activity, length of stay, and throughput in Lothian hospitals compared with the rest of Scotland from 1990-1 to 2000-1.ResultsBy 2000-1, rates for inpatient admission in all acute, medical, surgical, and intensive therapy specialties in Lothian hospitals were respectively 20%, 6%, 28%, and 38% below those in the rest of Scotland. Day case rates in all acute and acute surgical specialties were 13% and 33% lower. The proportion of delayed discharges in staffed acute and post-acute NHS beds in Lothian hospitals exceeded the Scottish average (15% and 12% respectively; P<0.001).ConclusionThe planning targets and increase in clinical activity in acute specialties in Lothian hospitals associated with PFI had not been achieved by 2000-1. The effect on clinical activity has been a steeper decline in the number of acute beds and rates of admission in Lothian hospitals compared with the rest of Scotland between 1995-6 and 2000-1.

What is already known on this topic

The full business cases for the 15 first wave private finance initiative (PFI) hospitals in England and Scotland projected reductions in acute beds of about 30% in the five years before the opening of the new replacement hospitalsThe new PFI Royal Infirmary of Edinburgh, which will fully open in 2003, is the cornerstone of Lothian Health Board''s healthcare plan for its acute hospitals

What this study adds

Compared with other Scottish NHS hospitals, service delivery has been reduced across Lothian associated with PFI developmentThe planning targets and increase in clinical activity in acute specialties in Lothian hospitals had not been achieved by 2000-1There is evidence of an independent “PFI effect” on hospital downsizing and bed reductions, which in Lothian has resulted in severe capacity constraints across all acute specialties with a need for immediate expansion in acute and community provisionFurther hospital and community service downsizing may be required to meet the financial deficit, which is principally due to the high costs of PFI     

Pheo or not a pheo,that is the question.

The current fault-based tort system assumes that claims made against physicians are inversely related to the quality of care they provide. In this study we identified physician characteristics associated with elements of medical care that make physicians vulnerable to malpractice claims. A sample of physicians (n = 248) thought to be at high or low risk for claims was surveyed on various personal and professional characteristics. Statistical analysis showed that 9 characteristics predicted risk group. High risk was associated with increased age, surgical specialty, emergency department coverage, increased days away from practice, and the feeling that the litigation climate was "unfair." Low risk was associated with scheduling enough time to talk with patients, answering patients'' telephone calls directly, feeling "satisfied" with practice arrangements, and acknowledging greater emotional distress. Prediction was more accurate for physicians in practice 15 years or less. We conclude that a relationship exists between a history of malpractice claims and selected physician characteristics.