Objectives: There are four primary goals for this research project: <ol><li>To develop an objective index of health care quality which represents, in the best practical way, a comprehensive range of services provided at the health region level. <li>To develop a comparable measure representing physician assessments of health care quality, and compare this measure with the objective index. <li>To develop an understanding of the relationships between physician ratings on the workplace issues of professional autonomy, stress, sense of equity and satisfaction and their views on health care quality.<li>Based on the understanding of this research, provide recommendations to health care policy makers about the use of both physician viewpoints and objective measures of quality.</ol> Background: Health care in Canada has grown and evolved from a relatively simple offering of services, provided primarily by doctors and hospitals, to a complex conglomeration of programs and services, provided by a loose network of both public and private providers. As a result, physicians are under pressure to adapt to these changes and a power struggle which has always pitted physicians against policy makers. In dealing with changes to the health care system the use of statistics and evidence is gaining prominence as the basis for policy decisions, in addition to the less formal tools of rhetoric and politics.<p>Design: Data from the 2004 Canada-wide survey Emerging Issues in the Work of Physicians is compared to a single index score of health care quality based on objective data from the annual Health Indicators Report published by Canadian Institute of Health Information and Statistics Canada (2005). These reports include a number of measures of quality and access to health care by health region and by province, using mandatory standardized data collection and reporting procedures. <p>Measures: Nine reliable measures of health care quality were selected from the Health Indicators Reports for inclusion in the index: 30 day AMI risk; 30 day stroke risk; AMI readmission risk; asthma readmission risk; ACSC rate; hysterectomy readmission rate; prostatectomy rate; in-hospital hip fracture rate; and C-section rate. Index scores were developed for each of the measures, which were then assigned weights based on importance, resulting in a single overall index of health care quality. These scores are compared to a similar index score which is based on physician views on quality, as collected in the national survey.<p>Results: Physician views on health care quality are aligned with the objective data when examined on an aggregate basis. However, there is a high degree of variability in physician responses which results in differences when examining the data on regional or individual bases. In addition, physician views on quality are influenced by factors in their work lives including autonomy, stress, equity and satisfaction. On each of these factors, those reporting high and low levels will generally over and under-rate health care quality as compared to those reporting moderate levels.<p>Discussion: As policy makers make decisions on how to shape the future of health care, they must grapple with conflicting viewpoints of different stakeholder groups, and they must decide on the degree to which they rely on evidence (in the form of objective data) versus influence (as exerted by physicians and/or other stakeholder groups). This research shows that, while physician views on how well the health care system is performing are generally aligned with the objective data, those opinions vary greatly between individuals, and are influenced by work related factors including autonomy, stress, equity and satisfaction.

Objectives: There are four primary goals for this research project: <ol><li>To develop an objective index of health care quality which represents, in the best practical way, a comprehensive range of services provided at the health region level. <li>To develop a comparable measure representing physician assessments of health care quality, and compare this measure with the objective index. <li>To develop an understanding of the relationships between physician ratings on the workplace issues of professional autonomy, stress, sense of equity and satisfaction and their views on health care quality.<li>Based on the understanding of this research, provide recommendations to health care policy makers about the use of both physician viewpoints and objective measures of quality.</ol> Background: Health care in Canada has grown and evolved from a relatively simple offering of services, provided primarily by doctors and hospitals, to a complex conglomeration of programs and services, provided by a loose network of both public and private providers. As a result, physicians are under pressure to adapt to these changes and a power struggle which has always pitted physicians against policy makers. In dealing with changes to the health care system the use of statistics and evidence is gaining prominence as the basis for policy decisions, in addition to the less formal tools of rhetoric and politics.<p>Design: Data from the 2004 Canada-wide survey Emerging Issues in the Work of Physicians is compared to a single index score of health care quality based on objective data from the annual Health Indicators Report published by Canadian Institute of Health Information and Statistics Canada (2005). These reports include a number of measures of quality and access to health care by health region and by province, using mandatory standardized data collection and reporting procedures. <p>Measures: Nine reliable measures of health care quality were selected from the Health Indicators Reports for inclusion in the index: 30 day AMI risk; 30 day stroke risk; AMI readmission risk; asthma readmission risk; ACSC rate; hysterectomy readmission rate; prostatectomy rate; in-hospital hip fracture rate; and C-section rate. Index scores were developed for each of the measures, which were then assigned weights based on importance, resulting in a single overall index of health care quality. These scores are compared to a similar index score which is based on physician views on quality, as collected in the national survey.<p>Results: Physician views on health care quality are aligned with the objective data when examined on an aggregate basis. However, there is a high degree of variability in physician responses which results in differences when examining the data on regional or individual bases. In addition, physician views on quality are influenced by factors in their work lives including autonomy, stress, equity and satisfaction. On each of these factors, those reporting high and low levels will generally over and under-rate health care quality as compared to those reporting moderate levels.<p>Discussion: As policy makers make decisions on how to shape the future of health care, they must grapple with conflicting viewpoints of different stakeholder groups, and they must decide on the degree to which they rely on evidence (in the form of objective data) versus influence (as exerted by physicians and/or other stakeholder groups). This research shows that, while physician views on how well the health care system is performing are generally aligned with the objective data, those opinions vary greatly between individuals, and are influenced by work related factors including autonomy, stress, equity and satisfaction.

Do dying patients have a moral claim to access experimental drugs when all else has failed? This question has been the focus of an active and evolving debate concerning the rights of terminally ill patients, the nature of the drug development process, and the scope of federal regulation, with supporters arguing that seriously ill patients should be able to decide for themselves whether and when to attempt experimental therapies and opponents arguing that the resulting state of affairs would be disastrous for patient safety and for the integrity of the drug development process. This thesis concerns the ethical considerations surrounding the provision of experimental drugs for treatmentoften termed compassionate use or expanded accessand argues that compelling ethical merits on both sides of the debate complicate the formation of satisfactory public policy. Although patient autonomy is often invoked to support liberal access to experimental drugs, the paucity of known information about investigational compounds as well as the unique vulnerability of the terminally ill patient call into question the wisdom of the unfettered exercise of autonomy in this context. Although equitable distribution of experimental drugs is often felt to be a concern, the meaning of equity in this context has not been clearly defined, and in fact several working concepts of equitable access may not be achievable or desirable. Although the financial burden on drug manufacturers is frequently recognized as a barrier to expanded access, the potential for expanded access programs to constitute a marketing strategy should be recognized, and the mixing of profit motives with altruistic ones brought to light. Parsing these and other ethical nuances points to certain ways in which policies governing expanded access can be refined to allow for access while maximizing patient protection and ensuring the generation of scientific knowledge. Physicians, as frequent mediators of requests for experimental drugs, should be knowledgeable of the ethical issues inherent and should help to ensure the judicious use of experimental therapies. Finally, general misconceptions about the benefits of experimental therapy, pervasive in our culture, heighten the contentiousness of this debate. A workable legislative solution should be accompanied by a thoughtful and deliberate effort to educate patients, their advocates, and broader society about the realistic pace of drug development and the limits of modern medicine. This thesis recognizes that individuals who seek expanded access often have valid moral claims to do so, but advocates a cautious attitude toward the dissemination of experimental drugs for treatment and maintains the importance of government and physician participation in adjudicating access.

Background: Weight misperceptions are common in adolescents and doctors’ advice may help clarify these misperceptions. Few studies have examined how common physicians assess various weight-related factors, including physical measurements, lifestyle factors, and obesity-related medical risks, based on adolescents’ reports and patient characteristics that predict such assessments. Physicians’ weight comments were associated with weight perception in overweight patients, however, such association was unclear in non-overweight adolescents. Objectives: The present study aimed to 1) examine how common adolescents received weight-related factors from private practitioners; 2) identify factors associated with these assessments; 3) assess how common adolescents received weight comments from private practitioners; 4) examine the association of body weight comments by private practitioners with weight perception in adolescents, intention to do more non-exercise physical activity (NEPA), and perceived risk of chronic disease for being overweight. Methods: In the Hong Kong Student Obesity Surveillance (HKSOS) project, 33692 students (44.9% boys; mean age 14.8, SD 1.9 years) from 42 randomly selected schools completed an anonymous questionnaire. The students were asked whether in the past 12 months any private practitioner (or their nurses) had assessed their height, weight, waist circumference (WC), blood pressure (BP), body mass index (BMI), diet, and physical activity. Students were also asked to report any weight status comments received from private practitioners. Perceived risk of chronic disease for being overweight and intention to do more NEPA were also reported. Weight status was based on self-reported weight and height. Multiple imputation was used to replace missing values. Logistic (or ordinal logistic) regression was used to assess the association between student characteristics and assessment of each weight-related factor, and the association of weight comments with adolescent weight perception, perceived risk of chronic disease, and intention to do more NEPA. Results: Among 13283 students who had doctor consultations in the past 12 months, 37.9% received physical measurements or lifestyle enquiries, with weight (20.8%), height (16.8%) and blood pressure (11.5%) being the most common, followed by diet (8.1%), BMI (6.3%), WC (4.6%), and physical activity (4.6%). In general, adolescents who were female, older, underweight or overweight/obese, had parents with higher education level, and had actively asked private practitioners for advice about weight were more likely to receive assessments of weight-related factors. Less than one-fifth (16.8%) of adolescents received height and weight or BMI assessments. Nearly 3 in 10 (28.7%) adolescents reported receiving weight status comments from private practitioners, of which 59.8% were correct. Correct weight status comments were associated with correct weight perceptions among adolescents regardless of weight status. Being told by a private practitioner that one is too fat was positively associated with perceiving higher risk of chronic disease for being overweight in normal weight and overweight adolescents, and more intention to do NEPA in all adolescents. Conclusions: Weight-related factors in adolescents were infrequently assessed by private practitioners in Hong Kong. Generally, unhealthy weight, higher parental education and advice-seeking by adolescents predicted these assessments. Receiving correct weight comments predicted correct adolescent weight perceptions. Practitioners should routinely assess and advise adolescents on weight status. / published_or_final_version / Community Medicine / Master / Master of Philosophy

Forming a medical diagnosis is a complicated reasoning process undertaken by physicians. Although there has been much research focusing on clinical reasoning approaches, there is limited empirical evidence in relation to causal attribution in medical diagnosis. The research on which this thesis is based explored and examined the social process of medical diagnosis and provides an explanation of the clinical reasoning and causal attribution used by physicians. The research was undertaken in an Emergency Department within an acute hospital, the data were collected using mixed method approach including one to one semi-structured interviews with individual physicians; observation of their medical assessments of patients and secondary data analysis of the subsequent recorded medical notes. The study involved 202 patients and 26 physicians. The analysis of the physicians’ semi-structured interviews, shows how physicians describe the diagnostic step process and how they blend their clinical reasoning skills and professional judgment with evidence-based medicine. Physicians apply prior learning of taught biomedical and pathophysiological knowledge to question patients using pattern recognition of common signs and symptoms of disease. These findings are portrayed through taped narratives of the physician/patient interaction during the medical diagnostic process, which shows how physicians control the medical encounter. The analysis/interpretation of documentary evidence (recorded medical notes) provides an insight into the way in which physicians used the information gathered during the diagnostic step process. By using SPSS it was possible to cluster the cases (individual patients) into groups. This stage-ordered classification procedure demonstrated commonality amongst individual cases whilst highlighting the uniqueness of any cases. A pattern emerged of two groups of cases: Group 1 - comprised of patients with the presenting complaints of chest pain, shortness of breath, collapse, abdominal pain, per rectal bleed, nausea, vascular and neurological problems and Group 2 - comprised of patients presenting with trauma, mechanical falls, miscarriage/gynaecological problems, allergies/rashes and dental problems. Findings show that the clinical reasoning approaches used varied according to the complexity of the patient’s presenting complaint. The recorded medical notes for the patients in Group 1, were comprehensive and demonstrated a combined approach of hypothetic-deductive and probabilistic reasoning which enabled the physicians to deal with the degree of uncertainty that is inherent in medicine. The recorded process in the medical notes was shortened for the majority of patients in Group 2, and here the clinical reasoning approach used was found to deterministic. It is acknowledged, that this is not always the case. By using crisp set QCA it was possible to explore causal conditions consistent with Group 1. Further analysis led to examination of the link of causal conditions presented in the medical notes with the individual impression/working diagnosis made by physicians.

abstract / toc / Medical Sciences / Master / Master of Medical Sciences

No description available.

A Thesis submitted to The University of Arizona College of Medicine - Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine. / End‐of‐life (EOL) care and decision‐making in pediatrics is a challenging and complex aspect of patient care experienced by residents and physician attendings. Previous studies have evaluated determinants that contribute to physicians’ attitudes towards EOL care as well as preparedness of students and residents in EOL decision‐making. However, the determinants contributing to a physician’s ability to make such decisions and feel confident in addressing EOL issues are dynamic. Recognizing that decision‐making changes over time, identifying when these changes occur may demonstrate the need for educational interventions for medical students and residents early in their career to help prepare them for EOL decision‐making. A longitudinal assessment of changes in attitudes and knowledge of EOL discussions and how they impact EOL decision‐making was not previously evaluated. This preliminary study establishes a baseline for medical student, resident, and attendings for EOL decision‐making and those factors that contribute to their decisions. This preliminary data has demonstrated a difference amongst attendings compared to residents and students. Despite low probability of survival, residents and students are more likely to select more aggressive management options when compared to attendings. Data obtained after completion of future surveys will show when decision‐making changes, which factors contribute to these changes and their significance in making decisions, and when participants are comfortable addressing EOL care.

Because of its perceived ability to predict future health and its relevance for family members, genetic information challenges the traditional justifications for medical confidentiality. This thesis examines the question whether a health care professional should have the discretion or a duty to breach confidentiality in order to inform a patient's relatives of their increased genetic risk. There is currently no exception to the statutory, common law and ethical duties of confidentiality for the non-consensual disclosure of genetic information to relatives. Precedents developed in the context of threats of harm and communicable diseases are of limited value. The law should not recognise the existence of a duty to warn in the context of genetics. As a last resort, health care professionals should be authorized, but not required, to disclose genetic risk information when there is a serious risk of preventable harm and when the potential harm of non-disclosure outweighs that of disclosure.

No description available.