Thesis (LLD (Public Law))--University of Stellenbosch, 2010. / ENGLISH ABSTRACT: The unique and intimate relationship that exists between a medical practitioner and his/her client is possibly one of the most important relationships that can come into being between any two people. This relationship is characterised and influenced by the qualities and attributes specific to the nature and historical development of medical care, as well as medical science in general. The doctor-patient relationship is also influenced by the social dynamics of a particular community, environmental factors, technological advances and the general social and commercial evolution of the human race. With regard to medical care and health service delivery, the doctor-patient relationship is furthermore vital to the quality of the care provided, as well as to the outcomes and relative success of the specific medical intervention or treatment. One of the distinct characteristics of the doctor-patient relationship is the power imbalance inherent in this relationship. The medical practitioner has expert knowledge and skill, while the patient finds himself or herself in an unusually dependent and vulnerable position. It is because of this important role that the doctor-patient relationship still plays in health service delivery today; the susceptibility of the relationship to a variety of influences, and the characteristic power imbalances inherent in this relationship, that a study of the doctor-patient relationship in South African medical- and health law is necessary. The characteristic power imbalances will be considered from a legal perspective in this dissertation. This study provides a comprehensive source of the doctor-patient relationship from a legal perspective. Where relevant, references are made to theories and principles from other disciplines, including sociology, economy and medical ethnomethodology. The prevalence and consequences of power imbalances in the doctor-patient relationship are identified and discussed with the aim of bringing these to the attention of both the legal fraternity, and medical practitioners. Specific problem areas are identified and solutions are offered, including the following: • The adverse consequences of power imbalances inherent in the doctor-patient relationship on the medical decision-making process are considered from various perspectives. With regard to these adverse consequences, the doctrine of informed consent is analysed and evaluated in great detail. • The influence of paternalistic notions in health service delivery; the business model of health service delivery and the effects of managed care and consumer-directed health care on the doctor-patient relationship and health service delivery in general are also analysed from a legal perspective, and specifically with regard to the power imbalances inherent in this relationship. • The role of autonomy, self-determination and dignity, as well as the principles of beneficence in medical practice, are reconsidered in an attempt to provide a solution for redressing the power imbalances inherent in the doctor-patient relationship. • The fiduciary nature of the doctor-patient relationship and the special role of trust in the relationship are emphasised throughout the dissertation as the focal point of departure in the doctor-patient relationship and the main constituent in any legal endeavor to redress the power imbalances inherent in it. / AFRIKAANS OPSOMMING: Die unieke en intieme verhouding wat bestaan tussen ‘n mediese praktisyn en ‘n pasiënt is wêreldwyd waarskynlik een van die belangrikste verhoudings wat tussen twee persone tot stand kan kom. Hierdie verhouding word gekenmerk en beïnvloed deur kwaliteite en eienskappe eie aan die besonderse aard en historiese ontwikkeling van gesondheidsorg, sowel as die mediese wetenskap in die algemeen. Die dokter-pasiënt verhouding word verder beïnvloed deur die sosiale dinamika van ‘n bepaalde gemeenskap, omgewingsfaktore, tegnologiese vooruitgang en die algemene sosiale en kommersiële ontwikkeling van die mensdom. Op die terrein van gesondheidsorg en mediese dienslewering is die dokter-pasiënt verhouding voorts ook sentraal tot die kwaliteit van die mediese sorg wat verskaf word, sowel as die uitkomste en relatiewe sukses van die spesifieke mediese behandeling. Een van die kenmerkende eienskappe van die dokter-pasiënt verhouding is die magswanbalans wat daar tussen dokter en pasiënt bestaan. Die mediese praktisyn beskik oor deskundige kennis en vaardighede, terwyl die pasiënt hom- of haarself in ‘n ongewone, afhanklike en kwesbare posisie bevind. Dit is dan veral weens die besondere rol wat hierdie verhouding steeds in hedendaagse gesondheidsorg speel, die beïnvloedbaarheid van hierdie verhouding deur ‘n verskeidenheid faktore, sowel as die kenmerkende magswanbalans inherent in die verhouding, dat ‘n ondersoek na die dokter-pasiënt verhouding in die Suid-Afrikaanse mediese reg noodsaaklik is. Hierdie kenmerkende magswanbalans sal vanuit ‘n regsperspektief verder in hierdie proefskrif ondersoek word. Hierdie studie bied ‘n omvattende bron van die dokter-pasiënt verhouding benader vanuit ‘n regsperspektief, terwyl verwysings na teorieë en beginsels van ander dissiplines soos die sosiologie, ekonomie en mediese etnometodologie ook waar nodig ingesluit word. Die voorkoms en gevolge van ‘n magswanbalans in die dokter-pasiënt verhouding word verder geïdentifiseer en bespreek ten einde dit onder die aandag te bring van beide regslui en medici. Spesifieke probleemareas wat geïdentifiseer is en die oplossings wat daarvoor aan die hand gedoen is sluit die volgende in: • Die nadelige gevolge van die bestaan van ‘n magswanbalans in die dokter-pasiënt verhouding op die mediese-besluitnemingsproses word bespreek vanuit verskillende persepktiewe. Met betrekking tot hierdie nadelige gevolge, word die leerstuk van ingeligte toestemming in besonder geanaliseer en geëvalueer. • Die invloed van ‘n paternalistiese benadering tot gesondheidsorg, die besigheids-model van gesondheidsorg, en die effek van bestuurde- en verbruikersgedrewe gesondheidsorg inisiatiewe op die dokter-pasiënt verhouding en die verskaffing van gesondheidsdienste in die algemeen word ook vanuit ‘n regsperspektief ge-analiseer. Spesifieke aandag word in dié verband gegee aan die invloede van hierdie benaderings en perspektiewe op die magswanbalans inherent aan die dokter-pasiënt verhouding. • Die besondere rol van autonomie, selfbeskikking en menswaardigheid, asook die beginsels van weldadigheid in gesondheidsorg, word heroorweeg in ‘n poging om ‘n meer gelyke distribusie van mag in die dokter-pasiënt verhouding te verseker. • Die fidusiêre aard van die dokter-pasiënt verhouding en die besondere rol wat vertroue in hierdie verhouding speel, word in hierdie proefskrif beklemtoon en word voorts as die basis van die dokter-pasiënt verhouding beskou. Vertroue, as ‘n kenmerk van die dokter-pasiënt verhouding, behoort ook die fokuspunt te wees van enige poging om die magswanbalans in die dokter-pasiënt verhouding aan te spreek.

We study inverse treatment planning approaches for stereotactic radiosurgery using Leksell Gamma Knife Perfexion (PFX, Elekta, Stockholm, Sweden) to treat brain cancer and tumour patients. PFX is a dedicated head-and-neck radiation delivery device that is commonly used in clinics. In a PFX treatment, the patient lies on a couch and the radiation beams are emitted from eight banks of radioactive sources around the patient's head that are focused at a single spot, called an isocentre. The radiation delivery in PFX follows a step-and-shoot manner, i.e., the couch is stationary while the radiation is delivered at an isocentre location, and only moves when no beam is being emitted. To find a set of well-positioned isocentres in tumour volumes, we explore fast geometry-based algorithms, including skeletonization and hybrid grassfire and sphere-packing approaches. For the selected set of isocentres, the optimal beam durations to deliver a high prescription dose to the tumour are later found using a penalty-based optimization model. We next extend our grassfire and sphere-packing isocentre selection method to treatments with homogenous dose distributions. Dose homogeneity is required in multi-session plans where a larger volume is treated to account for daily setup errors, and thus large overlaps with surrounding healthy tissue may exist. For multi-session plans, we explicitly consider the healthy tissue overlaps in our algorithms and strategically select many isocentres in adjacent volumes to avoid hotspots. There is also interest in treating patients with continuous couch motion to decrease the total treatment session and increase plan quality. We therefore investigate continuous dose delivery treatment plans for PFX. We present various path selection methods along which the dose is delivered using Hamiltonian paths techniques, and develop mixed-integer and linear approximation models to determine the configuration and duration of the radiation time along the paths. We consider several criteria in our optimization models, including machine speed constraints and movement accuracy, preference for single or multiple paths, and smoothness of movement. Our plans in all proposed approaches are tested on seven clinical cases and can meet or exceed clinical guidelines and usually outperform clinical treatments.

This research examines the experiences of Malaysian Neurosurgeons in managing communications with patients and their families in the aftermath of adverse medical events. These experiences were interpreted from a conflict avoidance and management perspective and the data from the research was analyzed using heuristic methodology. (Douglass and Moustakas 1985) The field of Neurosurgery in Malaysia was chosen firstly as a model of a high-risk medical specialty and secondly because of the researcher’s lived experience with the phenomenon being studied. Participants in the research were eleven Malaysian Neurosurgeons with at least ten years of independent clinical practice as specialists. Qualitative data was obtained through semi-structured in-depth interviews that were subsequently transcribed and analyzed heuristically, looking for different conflict management and patient-physician communication themes. The observations indicate that adverse medical events precipitate a major shift in the focus of tacit conflict management skill sets applied by the participants. The patient-Neurosurgeon relationship is abruptly transformed from one of high trust to one imbued with patient anxiety and suspicion of malpractice or medical error, and physician defensiveness. The observations also indicate that in multicultural Malaysia physician-family relationships were prioritized more than would be expected in a Western context. This may have implications for humanistic and interactive skills training for medical students and residents.

The prevalence of medical misdiagnosis has remained high despite the adoption of diagnostic software. This ongoing controversy about the role of technology in mitigating the problem of misdiagnosis centers on the question of whether diagnostic software does reduce the incidence of misdiagnosis if properly relied upon by physicians. The purpose of this quantitative, cross-sectional study based on planned behavior theory was to measure doctors' opinions of diagnostic technology's medical utility. Recruitment e-mails were sent to 3,100 AMA-accredited physicians through their database that yielded a sample of 99 physicians for the study. One-sample t tests and, where appropriate because of non-normal data, one-sample Wilcoxon signed-rank tests were conducted on the data to address the following key research questions on whether diagnostic software decreases misdiagnosis in healthcare versus unassisted human diagnostic method, if physicians use diagnostic software frequently enough to decrease misdiagnosis in healthcare, and if liability concerns prevent physicians from using diagnostic software. It was found that in the opinion of those surveyed (a) diagnostic software was likely to result in fewer misdiagnoses in healthcare than unassisted human diagnostic methods, (b) when speaking for themselves, physicians thought they used diagnostic software frequently enough to decrease misdiagnoses, and (c) physicians agreed they were not prevented from using diagnostic software because of liability concerns. The study's social significance is the affirmation of diagnostic software's usefulness: Policy and technology stakeholders can use this finding to speed the adoption of diagnostic software, leading to a reduction in the socially costly problem of misdiagnosis.

No description available.