"Death talk": debating euthanasia and physician-assisted suicide in Australia.
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American College of Physicians Ethics Manual. Part I: History of medical ethics, the physician and the patient, the physician's relationship to other physicians, the physician and society. Ad Hoc Committee on Medical Ethics, American College of Physicians.
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Perceptions of the role of the physician assistant: degree of agreement between physician and physician assistant concerning activities, settings, and responsibility in primary care settings.
An investigation of the differences in the perceptions of the role of physician assistant between physicians and physician assistants in the same primary care practice was conducted. A sample of six practices (one physician and one physician assistant from each practice), obtained from six Appalachian counties in New York State, was examined. Data was collected through the administration of a questionnaire, personal interviews, and on-site activity observations. Comparisons were made for two items: Number of errors between physicians' or physician assistants' perceptions and actual observations for a specified group of 23 activities, and the number of discrepancies between physicians' and physician assistants' perceptions for the same 23 activities. Study results produced significant numbers of errors and discrepancies suggesting that certain barriers to communication exist between the physicians and physician assistants and that a substantial amount of physician-physician assistant activity interaction is necessary to ensure positive conformance of standard duties and functions to practice goals and objectives.
Attitude of Health Personnel↗
Involving physicians in TQM. To gain physician support for quality management, hospital administrators must treat physicians as customers.
The process of integrating physicians into a hospital's total quality management (TQM) program is not simple. Physicians will not view TQM as an acceptable strategy in the absence of a positive working relationship with hospital managers. Physicians must see hospital managers as colleagues who can help improve their medical practices both in efficiency and patient care. The first step in involving physicians in TQM is creating an environment that enhances physician relationships. The CEO should be actively involved with the medical staff, and senior hospital managers should work at cultivating physician relationships. Physician needs and the centrality of the physician-management relationship should enter into every management discussion. Also, managers must solicit physician feedback regularly. Managers can introduce physicians to TQM by accompanying them to off-site TQM programs for a few days. Managers should also coordinate a continuing education program at the hospital, inviting a physician to address medical staff about TQM. Physicians are more likely to respond positively to one of their peers than they would to a consultant or business manager. Managers should then invite hospital-based physicians to participate on TQM interdisciplinary teams to resolve a problem chosen by the senior medical staff. The problem should be one that promises to be a quick fix, thereby ensuring demonstrable success of TQM and allaying any doubts. After an initial demonstration of TQM's success, the cycle is repeated. A year or two later, managers should invite off-site clinicians to join interdisciplinary teams on issues important to them.
Hospital Administration↗
Physician, practice, and patient characteristics related to primary care physician physical and mental health: results from the Physician Worklife Study.
OBJECTIVE: To study the impact that physician, practice, and patient characteristics have on physician stress, satisfaction, mental, and physical health. DATA SOURCES: Based on a survey of over 5,000 physicians nationwide. Four waves of surveys resulted in 2,325 complete responses. Elimination of ineligibles yielded a 52 percent response rate; 1,411 responses from primary care physicians were used. STUDY DESIGN: A conceptual model was tested by structural equation modeling. Physician job satisfaction and stress mediated the relationship between physician, practice, and patient characteristics as independent variables and physician physical and mental health as dependent variables. PRINCIPLE FINDINGS: The conceptual model was generally supported. Practice and, to a lesser extent, physician characteristics influenced job satisfaction, whereas only practice characteristics influenced job stress. Patient characteristics exerted little influence. Job stress powerfully influenced job satisfaction and physical and mental health among physicians. CONCLUSIONS: These findings support the notion that workplace conditions are a major determinant of physician well-being. Poor practice conditions can result in poor outcomes, which can erode quality of care and prove costly to the physician and health care organization. Fortunately, these conditions are manageable. Organizational settings that are both "physician friendly" and "family friendly" seem to result in greater well-being. These findings are particularly important as physicians are more tightly integrated into the health care system that may be less clearly under their exclusive control.
Adult↗
Professional performance of physician's assistants: a comparison of physician's assistant and physician ratings.
Physician's assistant educational programs have used surveys of their graduates as one method of evaluating educational objectives and curricula. A concern is the validity of physician's assistant self-ratings as measures of job performance. Ratings by supervising physicians have been suggested as more valid measures. In the present study ratings of physician's assistants and their supervising physicians were compared. Physician's assistants and their supervising physicians were interviewed using an interview instrument developed to cover the performance of the physician's assistant in the major activities of primary care practice. While the physicians and physician's assistants disagreed on several measures, in all cases the ratings of the physician's assistants were more conservative. Thus, the physician's assistants did not show any tendency to inflate ratings of their own performance.
Analysis of Variance↗
Physician religious beliefs and the physician-patient relationship: a study of devout physicians.
The purpose of this study was to determine the type and frequency of religious interactions that occur between devout physicians and their patients. Physicians identified by their peers as having religious or spiritual beliefs that were an important part of their lives were surveyed. Forty physicians responded (response rate 77%). In general, these physicians agreed that their religious beliefs have an important influence on their practice of medicine. Thirty-two percent reported having shared their beliefs with patients. Praying aloud with patients occurred with only 13% of patients, but 67% of respondents reported having done this on at least one occasion. Multivariate analysis showed the physician's religious group to be the most important determinant of sharing beliefs with patients, occurring most commonly with Protestant physicians. In this small sample of devout physicians, physician religious beliefs appear to influence the interactions between physicians and their patients.
Adult↗
Physician attitudes toward physician extenders: a comparison of nurse practitioners and physician assistants.
A survey of all physicians in the Eighth District Medical Society (Western New York) was conducted in 1975 to determine physician attitudes toward employment of and task delegation to nurse practitioners. The results of this study and one other similar study of nurse practitioners are compared to results of two previous studies examining physician attitudes toward physician assistants. It appears that physicians are somewhat more willing to employ and delegate tasks to a physician's assistant. Some correlates of physician attitudes toward each of the two types of physician extenders are also compared and discussed.
Attitude of Health Personnel↗
Weekly work hours and clinical activities of Canadian family physicians: results of the 1997/98 National Family Physician Survey of the College of Family Physicians of Canada.
BACKGROUND: Health systems planning is a challenging task, exacerbated by a lack of detailed information on the role played by family physicians, as indicated by practice variations across regions and demographic characteristics. Outcome measures used in past studies of family physician practice patterns were not uniform. Furthermore, past research has generally been limited to narrowly defined geographic regions. A national study of family physician practice patterns was undertaken to allow regional-level comparisons of clinical workload and range of medical services offered. METHODS: The 1997/98 National Family Physician Survey was mailed to a sample of 5198 Canadian family physicians and general practitioners (FP/GPs); the overall response rate was 58.4% (3036 questionnaires returned, of which 3004 were analyzable). Sampling strata were based on College of Family Physicians of Canada (CFPC) membership status and regions of Canada. RESULTS: Clinical workload varied considerably across the demographic categories studied. Male physicians reported 8.9 more total weekly work hours than female physicians, but the mean number of medical and clinical services offered did not differ between the sexes. Solo practitioners reported 53.8 (95% confidence interval [CI] 52.7-55.0) total weekly work hours, whereas those practising in multidisciplinary clinics reported 45.0 (95% CI 43.2-46.8) hours. FP/GPs in the Atlantic and Prairie provinces reported 5.6 and 5.1 more weekly work hours, respectively, than the national average of 51.4 (95% CI 50.8-52.0) hours. Finally, FP/GPs who served inner-city populations reported 48.6 (95% CI 46.8-50.5) total weekly work hours, whereas those serving rural populations reported 57.0 (95% CI 54.7-59.2) hours. Mean weekly work hours were similar for all age cohorts less than 65 years. FP/GPs practising in less populated provinces and in rural areas reported the highest numbers of work hours, medical services offered and clinical procedures performed. INTERPRETATION: These data suggest significant variations in FP/GP clinical workload in relation to key demographic variables.
Adult↗
Physician may be liable for failing to disclose financial conflict of interest. Neade v. Portes.
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Conflict of Interest↗
Calibrating the physician. Personal awareness and effective patient care. Working Group on Promoting Physician Personal Awareness, American Academy on Physician and Patient.
Physicians' personal characteristics, their past experiences, values, attitudes, and biases can have important effects on communication with patients; being aware of these characteristics can enhance communication. Because medical training and continuing education programs rarely undertake an organized approach to promoting personal awareness, we propose a "curriculum" of 4 core topics for reflection and discussion. The topics are physicians' beliefs and attitudes, physicians' feelings and emotional responses in patient care, challenging clinical situations, and physician self-care. We present examples of organized activities that can promote physician personal awareness such as support groups, Balint groups, and discussions of meaningful experiences in medicine. Experience with these activities suggests that through enhancing personal awareness physicians can improve their clinical care and increase satisfaction with work, relationships, and themselves.
Attitude of Health Personnel↗
Case management by physician assistants and primary care physicians vs emergency physicians.
OBJECTIVES: To determine whether physician assistants' (PAs') and primary care physicians' (PCPs') case management for 5 common primary care medical problems is similar to that of emergency physicians (EPs). METHODS: An anonymous survey was used to compare PAs, PCPs, and EPs regarding intended diagnostic and treatment options for hypothetical cases of asthma, pharyngitis, cystitis, back strain, and febrile child. Published national practice guidelines were used as a comparison criterion standard where available. The participants stated that they treated all of the patients and responded to all of the cases to be included in the survey. The responses of the PA and PCP groups were compared with those of the EP group, and financial charges for care by each group were analyzed. RESULTS: The EPs tended to follow treatment guidelines closer than did other primary care specialists. The management of PCPs and PAs differed from that of EPs, as follows: [table: see text] CONCLUSION: The EPs more closely followed clinical guidelines than did the PAs and PCPs for these standardized clinical scenarios. Although the relationship of such theoretical practice to actual practice remains unknown, use of these clinical scenarios may identify intended practice patterns warranting attention.
Adult↗
Emergency physicians and physician-assisted suicide, Part II: emergency care for patients who have attempted physician-assisted suicide.
Part I of this article reviewed key terms, events, and arguments in the heated national debate regarding physician-assisted suicide (PAS). Part II of the article examines the role of emergency physicians in caring for patients who present to the emergency department after an incomplete or unsuccessful attempt at PAS. The article considers the analogous cases of emergency care for other patients who have attempted suicide and care for terminally ill patients who refuse life-sustaining treatment. Morally relevant features of these situations are identified, including the decisionmaking capacity and the choices of the patient, the opinions of the patient's family or other surrogate decisionmakers, the presenting condition and medical history of the patient, the nature of the patient's suicide attempt, and the physician's own moral convictions. The article evaluates the 3 management options: aggressive intervention to preserve life, palliative care only, and assistance in completing the suicide. It concludes with several general recommendations for addressing these situations.
Emergency Medicine↗
Emergency physicians and physician-assisted suicide, Part I: a review of the physician-assisted suicide debate.
Physician-assisted suicide (PAS) has been one of the most hotly debated bioethics and health policy issues of the past decade. Part I of this 2-part article defines key terms in the debate, reviews the history of the debate, and articulates leading arguments for and against legalization of the practice of PAS. Part II of the article will examine the role of emergency physicians in caring for patients who present to the emergency department after an incomplete or unsuccessful attempt at PAS.
Cross-Cultural Comparison↗
The physician assistant in rural primary care practices: physician assistant activities and physician supervision at satellite and non-satellite practice sites.
Nineteen practice sites in Iowa were studied to determine the differences in the types of physician (MD) supervision the physician assistant (PA) received at work at satellite (separate from the major practice site of the supervising MD) and non-satellite practice sites. The MDs supervised PA functions in 12.9 per cent of the patients seen by the PAs at non-satellite and 15.9 per cent of patients they saw at satellite practice sites. All patients with presenting manifestations that suggested life-threatening conditions were seen by MDs at satellite and non-satellite sites. The MD spent 9.2 minutes per patient at satellite clinics, compared to 4.4 minutes per patient at non-satellite clinics. PAs working at satellite sites appeared to receive as much supervision as PAs working at non-satellite clinics.
Clinical Competence↗
The changing interface between district hospital cardiology and the major cardiac centres. British Cardiac Society, with the Royal College of Physicians of London, the Royal College of Physicians of Edinburgh, and the Royal College of Physicians and Surgeons of Glasgow.
The national priority for reducing mortality and morbidity from cardiovascular disease, the resulting expansion in the number of consultant cardiologists, and the reforms of the National Health Service have produced significant changes in delivery of care for cardiac patients and in the relations between district general hospitals (DGH) and the old regional cardiac centres. 1.2 The British Cardiac Society, the Medical Royal Colleges of Physicians of London and Edinburgh, and the Royal College of Physicians and Surgeons of Glasgow established a working group to make recommendations on the most appropriate evolution of these changes to secure high quality care in a cost-effective and professionally rewarding environment. The principal conclusions of the working group were: i) The establishment of new cardiac catheterisation laboratories in DGHs remote from a major cardiac centre should be encouraged provided the workload is adequate to ensure efficient use of the facility. ii) Cardiologists working in districts close to a major centre should be encouraged to catheterise their patients at the centre. iii) Close liaison of the district cardiologist with a cardiac surgeon and interventionist is vitally important. iv) The centres will be required to provide tertiary care for emergency and urgent cases from their traditional catchment area, specialised expertise for the management of rare and difficult cases, and angioplasty. Some centres will also offer complex electrophysiology, and ablation techniques. v) The centres must also provide routine cardiology services for their local district, facilities for cardiac catheterisation for DGH cardiologists, and training for doctors, nurses, technicians, and radiographers. vi) Some centres will be linked with paediatric cardiology and paediatric cardiac surgical units. vii) District cardiac centres will be required to provide a full non-invasive diagnostic service and emergency care for patients referred by general practitioners and hospital colleagues as well as facilities for preventative and rehabilitation cardiology. Arrangements for invasive investigation and treatment of their patients will vary according mainly to the distance from the major centre. viii) Both the major centres and the district cardiac units should participate in training and research.
Cardiac Care Facilities↗
[Physicians pilloried? On physicians' blunders and blundering physicians in Norwegian tabloids].
Doctors frequently claim that the tabloid press focuses too much on malpractice cases and that the identity of the individual physicians is also revealed. A systematic review of two Norwegian tabloids over six months in 1994 showed that articles on malpractice occurred less often than expected. We found 1.6 articles each week, on average. In addition, the doctors were identified in only three of 42 articles. The situation leading to the complaint was commented by the doctor involved in one article, while criticism from a colleague who was not directly involved was included in two of 42 articles. The results indicate that doctors need to be trained to handle the press.
Confidentiality↗
The influence of physician race, age, and gender on physician attitudes toward advance care directives and preferences for end-of-life decision-making.
OBJECTIVE: To determine whether physicians' preferences for end-of-life decision-making differ between blacks and whites in the same pattern as patient preferences, with blacks being more likely than whites to prefer life-prolonging treatments. DESIGN: A mailed survey. SETTING AND PARTICIPANTS: American Medical Association (AMA) and National Medical Association (NMA) databases. To enrich the sample of black physicians, we targeted physicians in the AMA database practicing in high minority area zip codes and graduates of the traditionally black medical schools. MAIN OUTCOME MEASURES: Self-reported physician attitudes toward end-of-life decision-making and preference of treatment for themselves in persistent vegetative state or organic brain disease compared by race, controlling for age and gender. RESULTS: The 502 physicians (28%) who returned the questionnaire included 280 white and 157 black physicians. With regard to attitudes toward patient care, 58% of white physicians agreed that tube-feeding in terminally ill patients is "heroic," but only 28 % of black physicians agreed with the statement (P < .001). White physicians were more likely than black physicians to find physician-assisted suicide an acceptable treatment alternative (36.6% vs 26.5% of black physicians) (P < .05). With regard to the physicians preferences for future treatment of themselves for the persistent vegetative state scenario, black physicians were more than six times more likely than white physicians to request aggressive treatments (cardiopulmonary resuscitation, mechanical ventilation, or artificial feeding) for themselves (15.4% vs 2.5%) (P < .001). White physicians were almost three times as likely to want physician-assisted suicide (29.3% vs 11.8%) (P < .001) in this scenario. For a state of brain damage with no terminal illness, the majority of all physicians did not want aggressive treatment, but black physicians were nearly five times more likely than white physicians (23.0% vs 5.0%) (P < .001) to request these treatments. White physicians, on the other hand, were more than twice as likely to request physician-assisted suicide (22.5% vs 9.9%), P < .001 in this scenario. CONCLUSIONS: Physicians preferences for end-of-life treatment follow the same pattern by race as patient preferences, making it unlikely that low socioeconomic status or lack of familiarity with treatments account for the difference. Self-denoted race may be a surrogate marker for other, as yet undefined, factors. The full spectrum of treatment preferences should be considered in development of guidelines for end-of-life treatment in our diverse society.
Adult↗