The aim of this thesis is to valuate private medical practice of general practitioner and develop a project that would enable selling this practice in a five-year horizon. For the purpose of valuation I will assess the state of and outlook of the Czech health care system, I will perform financial analysis of the company. Based on information from the financial and strategic analysis I will compile financial plan and final valuation. Project of the sale will address the steps that have an impact on sale in terms of cost, transaction risk, tax perspective, financing and methods of the sale.

In this master thesis I discuss the possibilities how General Practitioners can sell their medical practices. First of all I will mention assumptions relating to the termination of the business as well as the specifics of valuation, legal and tax issues that may General Practitioners meet in the transfer of their medical practices. In the following part I will deal with the effects of taking into account all possibilities mentioned in the theoretical part.

<p>Variations in the rate of use of health care services (a.k.a. medical practice variations) have been described in the literature for over eighty years. The literature suggests three general sources of variation: patients, physicians, and environment. The relative influence of these sources and the specific mechanisms that produce observed variations are not well understood. This thesis presents four studies that identify and examine methodological issues that preclude our ability to understand the variation phenomenon.</p> <p>It is commonly believed that the physician is in part responsible for observed variation in health care services use. However, determining the influence of the physician in this regard is problematic, as it is difficult to isolate the effect of the physician from that of the patient and environment (including available resources). The first study presented in this thesis suggests there is meaningful variation in treatment recommendations between physicians working in a common environment, even after controlling for important patient clinical characteristics. Next, I present an experiment that suggests that factors related to the patient’s unique social context might influence how the physician intends to manage a patient’s care. As variations studies do not measure or adjust for social context, this might indicate an important methodological limitation of those studies if indeed context is an important (and justifiable) determinant of what care the patient will receive.</p> <p>Not all variation is necessarily bad. The third study I present explores how previous researchers discriminate between warranted and unwarranted variation. This study indicates that few researchers explicitly do so, and that a clear, consistent, and functional definition of unwarranted variation is lacking – a feature that potentially limits the interpretation of study results. The final study argues that traditional methods for examining regional variations are inadequate for informing health care managers because they examine variation in health care service use rather than needs.</p> / Doctor of Philosophy (PhD)

This thesis focuses on issues of communication between doctor and patient. After a brief introduction of communication in general, the theoretical part focuses on the specifics of doctor-patient communication. It then deals with different factors that influence communication and selected topics connected to communication. The last chapter summarizes several studies focusing on communication training of doctors and its effect. In the empirical part, the semi-structured interviews were used to explore opinions, attitudes and experiences of doctors concerning their communication with patients. The results suggest, that doctors perceive communication with patients as an important part of their work (even though they differ in the amount of importance they attribute to communication). In accordance with this finding is the fact, that the description of a "good doctor" and "good communication" were quite similar. Almost all respondents considered the undergraduate training in communication as useless, suggesting that the main reason may be the perceived unimportance of this subject at medical school. Some of the communication barriers generally seen by the patients were also seen as important by the doctors (such as time pressure or lack of privacy while consulting with patients), important...

目前在台灣，專科護理師參與醫療處置過程的一部分已經是一個必然的趨勢。雖然目前已針對專科護理師相關的法規做了修正，但是在實務上還是有許多需要克服的問題。修法後雖然對專科護理師的執業範圍包含非侵入性和侵入性醫療行為有了較明確的規範，專科護理師臨床執業面臨的困境還是存在。出現醫療爭議時，醫師、專科護理師、其他醫事人員及醫院的法律責任仍然有許多模糊地帶。專科護理師相關法規修法後，衛生局及醫療機構之因應準備仍有改善的空間。 本研究採用案例分析法依照案例事實、法院見解和爭點問題，討論一個發生在民國95年12月有關專科護理師與醫師的醫療爭議訴訟案件。本醫療糾紛個案是台灣專科護理師正式甄審後，發生的第一件專科護理師被起訴的醫療糾紛案件。 被告因業務過失致死案件，經檢察官提起公訴判決主文如下：主治醫師從事業務之人，因業務上之過失致人於死，處有期徒刑壹年，減為有期徒刑陸月，緩刑貳年。專科護理師從事業務之人，因業務上之過失致人於死，處有期徒刑陸月，減為有期徒刑參月，緩刑貳年。本案例經由臺灣臺北地方法院刑事判決98年度醫訴字第6號，臺灣高等法院刑事判決民國100年度醫上訴字第7號，目前檢察官上訴中。 台灣專科護理師法規未來修正的方向，需更進一步明訂專科護理師的執業範圍以符合法律明確性原則。醫師指示合法化，使醫療輔助行為之定義更明確。建立專科護理師專業能力標準與提升及評估專科護理師執業品質，加強專科護理師的訓練以及訂立專科護理師訓練醫院更完善的認證標準與訓練醫院評鑑制度。有關衛生福利部最近要制定的醫師助理法，其工作範圍與專科護理師有很多重疊之處，引進醫師助理可能造成的衝擊。制定合理的專科護理師的護病比，明定專科護理師是否可以值班?專科護理師是否可以採輪班，以符合勞基法一例一休的規定。我們仍然有很多可以改善的地方，希望有更明確的法律規範，讓合格的專科護理師加入醫療團隊的運作，提高專科護理師的專業能力藉以提升醫療服務品質。不要讓專科護理師面臨或甚至觸法的危險，最終有可能變成密醫，對於台灣的醫療會有很大的衝擊及影響。 / The participation of nurse practitioners in medical practice is a must in Taiwan now. Although amendment of law about the clinical practice for nurse practitioners was made, there are still some issues which should be further evaluated. The scope of medical practice for nurse practitioners includes invasive and non-invasive medical procedures, which were defined more clearly in the revised articles, but some ambiguous situations still persist. The juridical responsibility of doctors and nurse practitioners for medical disputes remains unclear. There is lots of space of improvement which bureau of Health and hospitals can do after the revision of related law for nurse practitioners. The method of this research is a case study including case facts, the decision of the court and the issue of disputes. This is a medical dispute regarding doctors and a nurse practitioner, which occurred in December, 2006.This is the first medical dispute happening in Taiwan after the establishment of official examination for nurse practitioners. The defendants were accused for guilty because of causing death of a patient due to professional negligence. The verdict of the superior criminal court in Taiwan in 2011 after public prosecution was as follows. The attending physician was sentenced for one year, reduced to six months and probated for 2 years because of causing death of a patient due to professional negligence. The nurse practitioner was sentenced for six months, reduced to three months and probated for 2 years because of causing death of a patient due to professional negligence. The future amendment for the law regarding nurse practitioners is as follows: first, to enact the specific scope of medical practice for nurse practitioners according to the law; second, to legalize the directions from doctors; third, to specify the definition of assisted medical practice performed by nurse practitioners; fourth, to establish the standard for evaluating the ability of nurse practitioners; fifth, to elevate and evaluate the quality of medical service from nurse practitioners; sixth, how to strengthen the training programs of nurse practitioners, to build the verification standard of hospitals which can train nurse practitioners and improve the system of accreditation; seventh, to create rational ratio of nurse practitioners to patients; eighth, to clarify whether nurse practitioners can be on duty and in shifts in the hospital according to the law. In addition, the impact for nurse practitioners by introducing physician assistant to medical service suggested by Bureau of Health is high because there is lots of overlap of medical practice between the two professionals. We hope that the participation of verified nurse practitioners under the regulation of specific law can improve the quality of medical service, otherwise, we are afraid that nurse practitioners may break the law, become fake doctors and be sentenced, which will cause great impact and bad influence of medical service in Taiwan.

There is a growing research interest into investigating why NICE (National Institute for Health and Care Excellence) guidelines are not consistently followed in UK mental health services. The current study utilised grounded theory methodology to investigate clinical psychologists’ use of NICE guidelines. Eleven clinical psychologists working in routine practice in the NHS were interviewed. A theoretical framework was produced conceptualising the participants’ beliefs, decision making processes and clinical practices. The overall emerging theme was “considering NICE guidelines to have benefits but to be fraught with dangers”. Participants were concerned that guidelines can create an unhelpful illusion of neatness. They managed the tension between the helpful and unhelpful aspects of guidelines by relating to them in a flexible manner. The participants reported drawing on specialist skills such as idiosyncratic formulation and integration. However, as a result of pressure, and also the rewards that follow from being seen to comply with NICE guidelines, they tended to practice in ways that prevent these skills from being recognised. This led to fears that their professional identity was threatened, which impacted upon perceptions of the guidelines. This is the first theoretical framework that attempts to explain why NICE guidelines are not consistently utilised in UK mental health services. Attention is drawn to the proposed benefits and limitations of guidelines and how these are managed. This study highlights the importance of clinical psychologists articulating and advertising their specialist skills. The findings are integrated with existing theory and research, and clinical and research implications are presented.

La base de la pratique médicale est l’observation : observation clinique du patient, observation épidémiologique d’une population, etc… L’analyse des pratiques observe la pluralité des attitudes adoptées par les praticiens face à une situation clinique. A un fait scientifique reconnu correspond une multitude d’attitudes pratiques. L’analyse de ces pratiques décrit la répartition et les variations de ces pratiques, et tente d’en expliquer les raisons. En France, la pratique clinique quotidienne reste encore un secteur peu étudié. Si les variations ne s’expliquent pas par les caractéristiques des patients, les raisons des variations sont peut-être à rechercher du côté médical. L’un des domaines étudié, où il peut y avoir également des variations de pratiques médicales est la cancérologie. Dans ce domaine les raisons de variations des pratiques peuvent être nombreuses et liées aux médecins, à leur structure ou à la politique d’hospitalisation de la région. Le postulat de départ est que l’harmonisation des prises en charge et des traitements des patients peut influencer leur survie. C’est pourquoi ce travail c’est intéressé à comparer la prise en charge des patients atteints de cancers fréquents (cancer du sein et du colon) à un cancer rare (les sarcomes) dans la région Rhône-Alpes. Nous avons montré, à travers des études prospectives et rétrospectives, le rôle du thesaurus et de son implémentation dans les pratiques médicales et leurs modifications. Nous avons également développé un outil informatique sous forme d’algorithmes décisionnels permettant de montrer le cas échéant si certaines étapes de l’audit clinique pouvaient être automatisées. La comparaison entre l’évaluation des pratiques médicales par un évaluateur et les algorithmes nous ont permis de conclure sur l’importance de la reproductibilité des décisions et sur les apports, de l’informatisation de ces procédés. Nous avons également montré l’importance d’une relecture des blocs de tumeurs par un expert dans une pathologie cancéreuse rare et complexe. Cela nous a permis de spécifier la nouvelle incidence des sarcomes en région Rhône-Alpes / Observation is the basis of medical practice: clinical observation of the patient, epidemiological observation of a population, and so on… the analysis of practices observes the plurality of attitudes physicians take when they face a clinical situation. An acknowledged scientific fact given meets dozen of practical attitudes. The analysis of these practices describes their distribution and variations and try to explain the causes. In France, the daily clinical practice is still a sector on which few studied have been realized. If patients' characteristics can't explain variations, the causes of these variations may be found on the medical side. Medical practice variations can also be found in oncology, one of the studied domains. Causes of variations of practices in this domain can be numerous and linked to physicians, to their structures or to the region hospital care .policy. The postulate is that the harmonization of management and treatment of patients can act up on their survival. That is the reason why this work get interested in comparing the management of patients with frequent cancers (breast and colon) to rare cancers (sarcomas) in the Rhône-Alpes region. We showed, through prospective and retrospective studies, the role of a thesaurus and of its implementation in medical practices and their modifications. We have also developed a computing tool in decision-making algorithm form which could show if need be if some steps of clinical audit could be automated. The comparison between the assessment of medical practice made by an assessor or made thanks to the algorithms allowed us to conclude on the importance of reproducibility of decisions and on the contribution of the computerization of these processes. We also showed the necessity for tumours samples to be reviewed by an expert in a rare and difficult cancerous pathology. We could therefore specify the new incidence of sarcomas in the Rhône-Alpes region

O presente trabalho aborda o problema da variabilidade da prática médica, entendida como as variações sistemáticas na utilização de um procedimento médico ou cirúrgico após terem sido descartadas como causas as diferenças entre as populações e os pacientes. Teoricamente se espera que o comportamento dos médicos seja uniforme, isto é, que frente a uma população fixa, a taxa de encaminhamento dos médicos a procedimentos diagnósticos ou tratamentos hospitalares seja muito parecida, mas na realidade a taxa de encaminhamento segue uma distribuição que da conta dá variabilidade na prática médica. A partir do banco de dados de uma seguradora de saúde colombiana, foi realizada uma vasta análise estatística que permitiu encontrar variáveis importantes para a abordagem do problema. Dentre as variáveis estudadas, mereceram destaque a distribuição de pacientes atendidos pelos médicos (concentração) e a taxa de encaminhamento para cirurgia. O trabalho procura, a partir de simulação computacional, utilizando modelagem baseada em agentes, reproduzir as funções de distribuição empíricas referentes a concentração e a taxa de encaminhamento para procedimentos cirúrgicos. O modelo está baseado na hipótese econômica da renda alvo, teoria da sociologia dos grupos e em dados empíricos. / This study addresses the problem of medical practice variation (MPV), which is the presence of variation in the use of a medical procedure that is not explained by environmental, demographic or epidemiological differences. Theoretically, it is expected that the behavior of physicians were uniform for a fixed population, the rate of remission for diagnostic procedures or hospital treatment must be very similar, but in practice the remission rate follows a distribution that account the variability in medical practice. We used the data base of a Colombian health insurance company. Statistical analysis found important variables to approach the problem as: distribution of patients seen by the physician (concentration) and the rate of referral for surgery.

O presente trabalho aborda o problema da variabilidade da prática médica, entendida como as variações sistemáticas na utilização de um procedimento médico ou cirúrgico após terem sido descartadas como causas as diferenças entre as populações e os pacientes. Teoricamente se espera que o comportamento dos médicos seja uniforme, isto é, que frente a uma população fixa, a taxa de encaminhamento dos médicos a procedimentos diagnósticos ou tratamentos hospitalares seja muito parecida, mas na realidade a taxa de encaminhamento segue uma distribuição que da conta dá variabilidade na prática médica. A partir do banco de dados de uma seguradora de saúde colombiana, foi realizada uma vasta análise estatística que permitiu encontrar variáveis importantes para a abordagem do problema. Dentre as variáveis estudadas, mereceram destaque a distribuição de pacientes atendidos pelos médicos (concentração) e a taxa de encaminhamento para cirurgia. O trabalho procura, a partir de simulação computacional, utilizando modelagem baseada em agentes, reproduzir as funções de distribuição empíricas referentes a concentração e a taxa de encaminhamento para procedimentos cirúrgicos. O modelo está baseado na hipótese econômica da renda alvo, teoria da sociologia dos grupos e em dados empíricos. / This study addresses the problem of medical practice variation (MPV), which is the presence of variation in the use of a medical procedure that is not explained by environmental, demographic or epidemiological differences. Theoretically, it is expected that the behavior of physicians were uniform for a fixed population, the rate of remission for diagnostic procedures or hospital treatment must be very similar, but in practice the remission rate follows a distribution that account the variability in medical practice. We used the data base of a Colombian health insurance company. Statistical analysis found important variables to approach the problem as: distribution of patients seen by the physician (concentration) and the rate of referral for surgery.

Recent trends point toward a decline in solo and small business medical practices, yet, the need and demand still exists for this model of health care. The purpose of this case study was to explore effective approaches to help physicians in solo practice and small medical group primary care practitioners (PCPs) retain their small business medical practices. The study included purposive sampling and face-to-face interviews: 11 physicians, predominately primary care practitioners, in the Baltimore-Washington metropolitan region, were interviewed until data saturation was reached. A component of systems theory (strategic thinking) and the dynamic capabilities concept were used to frame the study. Audio recordings were transcribed and analyzed to identify themes regarding effective competitive approaches to help small medical group physicians retain their practices. Four major themes emerged: need for flexibility and adaptability, need for higher levels of business acumen, need to fully embrace automation, and a focus on pursuing financial stability before pursuing growth and expansion of the medical practice. Results may benefit society by preserving and strengthening a source of patient-centered, effective, affordable health care for communities served by small business medical practices. Implications for social change include presenting methods to enhance stability and organizational sustainability of small business medical practices.