BACKGROUND: Substance use disorders are highly prevalent and highly stigmatized. They are defined as conditions in which the use of one or more substances, in spite of negative consequences, leads to a clinically significant impairment or distress. Stigma is a characteristic deemed undesirable by society. Stigma is dependent on the relationship between the specific discrediting or undesirable characteristic and the social context. LITERATURE REVIEW FINDINGS: The various manifestations of stigma include public or external stigma, provider stigma, and internal stigma. External stigma is the negative beliefs that society holds about people in stigmatized groups, for example patients with substance use disorders or HIV. Another type of stigma is provider stigma, referring to the negative beliefs that providers hold about patients belonging to these stigmatized groups. Internal stigma is defined as the devaluation that people in stigmatized groups hold about themselves in relation to society. Stigma is continued when there is a lack of familiarity and education with a stigmatized condition or group. PROPOSED PROJECT: The proposed project aims to address and decrease provider stigma in physician assistant trainees before they begin their clinical training through an educational intervention. This thesis will propose the development and evaluation of a new curriculum to educate physician assistant students on substance use disorders and their treatments, frame substance use disorders as chronic diseases, and aid physician assistant student trainees on recognizing their attitudes and biases, or prejudices, toward working with patients with substance use disorders. The project will assess attitudes before and after the education intervention to analyze if attitudes toward patients with substance use disorders have changed as a result of the educational intervention. The goal of the educational curriculum is to improve physician assistant student attitudes toward working with patients with substance use disorders before they encounter this population in clinical practice. SIGNIFICANCE: Physician assistants are clinicians who diagnose illness, develop treatment plans, manage their own patients, and often serve as the primary clinician for patients. Physician assistants will encounter a number of patients with substance use disorders throughout the course of their careers. Addressing provider stigma in this group will help improve treatment outcomes in this patient population and give the students the confidence and knowledge to manage patients with substance use disorders. As a result of completing this curriculum, physician assistant students will have decreased stigma and better attitudes toward working with patients with substance use disorders.

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Master of Public Health - MPH / Since the anecdotal assumption is that GPs do not effectively diagnose and manage problem drinking amongst their patients, this study investigated the role of GPs in addressing problem drinking in Cape Town as well as the prevalence of problem drinking amongst their patients. / South Africa

Class of 2012 Abstract / Specific Aims: To assess physician approval of the MTM services provided. Specifically, to compare cost saving, guideline adherence, and safety concern interventions. Methods: A retrospective analysis of pharmacist interventions was performed using the MMC database for 2008. Data were collected on the type of intervention and approval by physicians. Physician specialty was also collected from state medical boards. Descriptive statistics were used to generate frequencies of approvals. Chi-square tests were used to compare physician approval by intervention type. Main Results: Pharmacists initiated 1,563 interventions that were faxed to physicians for approval. Of these interventions, cost saving, guideline adherence, and safety concerns were 33.2, 58.3, and 8.5 percent, respectively. Interventions primarily targeted diabetes (38.6%), cardiovascular disease (28.8%), gastroesophageal reflux disease (13.1%), and respiratory disease (8.4%). Physician approval for cost saving, guideline adherence, and safety concerns were 58.0, 44.4, and 41.0 percent, respectively. Approval for cost saving was greater than guideline adherence (58.0% versus 41.0%, P<0.001) and safety concerns (58.0% versus 44.4%, P=0.005). Approval among primary care physicians (PCP) compared to specialty physicians was greater for both cost saving (60.6% versus 50.7%, P=0.046) and guideline adherence (43.2% versus 36.2%, P=0.045) interventions. Conclusions: Results of this investigation provide evidence that there are differences in the types of MTM interventions that physicians will approve. In an effort to improve patient outcomes, this finding suggests a potential to increase overall physician approval of pharmacist-initiated MTM interventions in the areas of guideline adherence and safety concerns. Results further suggest that lower approval by specialists compared to PCPs may call for alternative methods to better reach these providers.

The role played by medical doctors and the employment positions they hold in South Africa and in the world today has shifted from being clinical only to include management. They were once only responsible for patient care, now are responsible for their organization's management. Physician managers have difficult tasks for which medical school provides no preparation. Doctors in an assortment of roles take on management responsibilities to varying degrees: these may be a single-handed private practitioner or lead a small clinical team; or a clinical or medical director or a chief executive; or hold senior management positions in National or Regional Legislature. Some are also managing and supervising colleagues in public or private hospitals and are responsible for managing budgets, allocation of resources; developing policies and making other management decisions. These roles require knowledge and competence of managerial skills in order to facilitate and lead in an effective and efficient manner. This study revealed that medical doctors, as business owners, in Mercantile Hospital are running their businesses, the medical private practices, without any managerial skills’ training. There was a general consensus that there is a need for managerial skills in any business and the respondents confirmed that managerial skills are important and necessary for the successful achievement of goals in a medical private practice.

Performance of Emergency Department (ED) physicians (MDs) is multi-faceted since it impacts multiple dimensions such as health outcomes of patients, utilization of resources, throughput of patients and timeliness of care. Therefore, the assessment of their performance demands the use of a tool that allows considering multiple evaluation criteria. However, commonly used multi-criteria evaluation methods often require assigning weights to dimensions in order to define their relative importance on a final performance score. This feature introduces subjectivity in the development of weights and has the potential to produce biased results. The purpose of this thesis research is to develop a multi-dimensional evaluation tool for evaluating performance of ED MDs. The proposed evaluation tool relies on a mathematical programming model known as Data Envelopment Analysis (DEA). The use of DEA does not ask for subjective weighting assignments for each dimension that describe the ED MDs’ performance. It is capable of considering multiple heterogeneous performance measures to identify benchmark practice and the individual improvements leading to best practice of each evaluated unit. The DEA model described here was developed from real data to assess the performance of 20 PED MDs from the Children’s Hospital of Eastern Ontario (CHEO). Multiple evaluations were run on stratified data in order to identify benchmark practice in each of seven categories of patients’ complaints and to determine the impact of accompanying MD trainees on PED MDs’ performance. For each PED MD, performance scores and improvements in each category of patients’ complaints (i.e. respiratory, trauma, abdominal, fever, gastroenterology, allergy and Ear-Nose-Throat complaints) were determined. This helped identifying the required improvements that would lead PED MDs to achieve benchmark performance. Regarding the influence of MD trainees on PED MDs’ performance, results show that most PED MDs (15 out of 20) perform better when they are not accompanied by a trainee which motivates further research to assess trade-offs between teaching and clinical performance. In summary, DEA proved to be an appropriate tool for performance evaluation of PED MDs because it helped to identify benchmark performers and provided information for performance improvements under a multi dimensional performance evaluation framework.

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The flipped classroom structure is a new concept designed to accommodate current students in place of the traditional classroom structure. Instead of in-class lectures, students do the majority of learning outside of class and use in-class time to participate in interactive activities with peers and with educators. Most out-of-class learning materials involve use of lecture videos, online games, or lecture notes. Recent studies found success with flipped classrooms in a variety of settings and students. However, there are no studies regarding whether current students better retain information when providing lectures in digital media as opposed to traditional media. This study compares the mean difference of pretest and post classroom scores for pharmacology using NBME exams of PA students given study materials in digital form and those given study materials in traditional paper form. We hope the study can contribute to effective teaching for future students.

Background: In South Africa, tuberculosis (TB) is the leading cause of death, and Cape Town is among the three cities in the country with the highest TB burden. Despite implementation of Directly Observed Treatment Short-Course (DOTS), and improvements in the organisation and delivery of TB care, poor treatment adherence challenges treatment outcomes and the health system's ability to reach international targets. TB requires long-term care, where the relationship with healthcare providers is one of the important influences on decisions to seek care and adhere to treatment. This study sought to explore and deepen insight into how trust is built and experienced between patients and healthcare providers for TB treatment in primary care settings from a gender perspective. Methods: The research was located in three local government-managed clinics in the City of Cape Town's Metropole health district, similar in TB patient load and performance indicators, but differing in level of TB-HIV integrated services. A case study design employing qualitative data collection approaches (non-participant observations in clinics, focus group discussions and in-depth interviews with patients and providers) was applied. Findings: Trust plays a central role for both patients and providers in treatment for TB. On the part of patients, many expressed a deep desire and motivation to complete their treatment. However, patient vulnerability, a complex outcome of intersecting factors at all levels (personal, community and health service level), across which gender was an underlying influence, emerged as a critical influence over patient trust in providers and the health system, with consequences for a range of outcomes including treatment adherence. The ability of providers and the health system as an institution to recognise and respond to patient vulnerability and needs beyond the illness, including to access socio-economic and psycho-social support for the patient, was critical for building trust and enabling adherence. On the part of healthcare providers, vulnerability was a consequence of a range of factors, including professional status and gender, with implications for how trust was built in patients and managers and its outcomes. Patient trustworthiness was based on judgements of competency, integrity and recognition. The ability of managers to mitigate the challenges healthcare providers faced, through providing a supportive and enabling work environment, had implications for providers' experiences and judgements of institutional trustworthiness. Conclusion: Reflecting on the findings within broader national, provincial and global health policy reforms, specific strategies for building patient and provider trust in each other, and in the health system, are proposed. Recommended strategies addressing both patient and provider vulnerabilities rooted in the personal, community and health facility environment are considered. While many of the recommendations are specific to the TB and TB/HIV model of care, they have wider relevance for building mutual trust between patients and providers and enhancing the responsiveness of the health system as a whole. This is important in the context of South Africa, where the vision espoused under proposed National Health Insurance reforms towards universal coverage is transformative, even revolutionary, but its implementation and ultimate achievements are likely to be dogged by challenges of patient and provider trust in the health system, unless themselves addressed. Globally, the study's conclusions also offer important insights about patient-provider trust relevant to health system development, as well as ideas for future, related research.

Research on medical interpreters (MIs) in recent years has informed us of the visible and active participating roles that MIs play in the doctor-interpreter-patient triadic encounter. The use of multi-faceted, authentic data has also allowed both verbal and nonverbal nuances to be studied. However, while empirical studies have shown that physician empathy in medical communication is beneficial to the patient's healthcare outcomes, empathy in medical interpreting, especially the one that is expressed nonverbally, is rarely examined in medical interpreting research, even though MI is the key communication facilitator and in principle shares a communicative goal with the doctor. This study aims to acquire a deeper understanding of how an MI's empathy is constructed nonverbally and perceived by service users, and how it affects interlocutors and the communication process. This research argues that MI empathy in communication is desired and should be incorporated in the training, assessment, and most importantly, in the interpreting practice. Three sets of research questions are thus formed: 1) How do Mis communicate empathy, if any, for and to the patient? 2) How do the other medical interview participants (doctor and patient) and observers (video observers) perceive the empathic performance of the interpreters? Is there any discrepancy? Why? and 3) How do internal and external factors such as an MI's nonverbal sensitivity and personality traits influence empathic performance? The findings are expected to inform medical interpreting training and assessment and to enhance doctors' awareness of the roles of MIs so that a more patient-centred and empathic communication environment can be nurtured.