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Objectives 1. To determine drug misusers' views about their primary health care and their relationship with general practitioners. 2. To undertake a controlled evaluation of small group education of general practitioners in the management of drug misusers. Method 1. Drug misusers attending five treatment services in north east London - a general practice with a special interest in managing drug misuse; a private drug clinic; a community drug team; a drug dependence unit and a street agency - were interviewed using a semi-structured interview and the Social Functioning Questionnaire. 2. All general practitioners who practised within the former North East Thames Regional Health Authority were approached to take part in small group teaching about drug misuse. This was conducted over two consecutive afternoons in a general practice, with four follow-up seminars. The trained doctors were compared with two groups of untrained general practitioners. Outcome measures included: Drug Training Questionnaire responses at the outset and 9 months after training; evaluation of the training appraised on a ten point Likert scale; Home Office Addicts Index and North Thames Regional Drug Misuse Database figures for notification of newly presenting subjects, for each of the three groups of general practitioners, 8 months prior to training and 8 and 16 months after training. Results Ninety percent of the drug misusers were registered with a non-specialist general practitioner and 88% of these doctors were aware of their patients' drug use. Half of the non-specialist general practitioners aware of their patient's drug use were reported as prescribing substitute medication. Sixty percent of misusers attending the non-specialist doctors perceived their general practitioners to hold negative or neutral views about them. Doctors in the specialist general practice were more likely to prescribe, compared to the other four centres, and 97% of their patients believed these doctors had a positive view of drug misusers. The specialist general practice was more active in providing counselling and/or education about drug misuse. 2. Forty doctors attended the teaching programme. Twenty-eight doctors comprised comparison group one (interested but unable to attend the teaching) and 30 formed comparison group two(not interested in training but completed questionnaires). The about to be trained group were seeing and treating more drug misusers compared to the comparison groups. The overall ratings for the teaching programme were high (7.9 for usefulness and 8.0 for interest - maximum score 10). Doctors in the trained group were found to be notifying significantly more drug misusers to the Home Office and prescribing methadone more frequent1y 16 months after the teaching, than doctors in the comparison groups. Over 9 months, the Drug Training Questionnaires demonstrated no significant changes. The cost of the course per doctor was £127. Conclusions 1. The majority of drug misusers attending treatment centres are registered with general practitioners and regarded them as an important health resource in managing both their drug use and wider medical issues, despite the reluctance of non-specialist general practitioners to be involved in prescribing and a high prevalence of unfavourable attitudes towards drug misusers. 2. The participating doctors assessed the teaching programme positively and it was relatively cheap to run. The self-report questionnaires as a single determinant of outcome revealed no significant change in attitudes, knowledge or behaviour but when assessed by more objective means, demonstrated a rise in notification rates and methadone prescribing by the trained doctors.

Medical confidentiality is widely recognised as a concept worth protecting. Problems arise, however, when medical confidentiality conflicts with interests that are equally regarded as important, such as the interests of justice; the interest in criminal prosecution; the interest in crime prevention; or defence rights. In order to develop convincing and workable criteria to balance the competing interests in case of a conflict, the different interests at stake must be clearly defined, and their respective importance assessed. Different ethical approaches to the balancing process will be introduced, followed by an analysis of the law of four legal systems, France, Germany, the UK and the u.s. AIl four legal systems protect medical confidentiality by the means of private law, but only Germany and the U.S. protect medical confidentiality as part of the constitutional right to privacy. In France and Germany, a breach of medical confidentiality by a physician amounts to a criminal offence. Regardless of these differences, all systems agree that medical confidentiality serves both the privacy interests of the patient, and the public interest in protecting public health. Fundamental differences materialise with regard to the recognition of medical privilege, which is recognised in France, Germany, and some States in the U.S., but is rejected by other States in the U.S. and by the UK. While in the U.S., defence rights are regarded as more important than medical confidentiality, the same is not true for France and Germany. All systems agree that medical confidentiality can be outweighed by the interest in preventing a crime that might cause serious harm to a third party, but the criteria according to which the competing interests are balanced, differ. Based on a comparison of the different approaches, criteria for a consistent and morally justified resolution of the conflicts between medical confidentiality and the competing interests will be suggested.

Introduction: Newly qualified doctors are frequently first to the scene in managing acutely unwell in-patients. Failures in clinical assessment, basic management and early escalation of care lead to avoidable patient morbidity and mortality. Analyses of adverse events have highlighted the importance of non-technical skills training to improve patient safety. These are a combination of cognitive (such as decision making) and social skills (such as team working), which complement knowledge and technical ability, and contribute to safe and effective care. In order to train and assess junior doctors in these skills, we must first have an accurate understanding of what they involve. This research project was designed to identify the critical non-technical skills required by junior doctors to manage acutely unwell patients safely and effectively. It aimed to develop a tool to observe these skills that could be used in training, assessment and research. Method: A literature review was used to develop an initial framework to categorise the non-technical skills required in this domain. Twenty-nine in depth semi-structured interviews were then completed with junior doctors. A critical incident technique was utilised: Junior doctors were asked to recall a challenging case in which they managed an acute medical emergency. Interviews were transcribed and coded using template analysis. A panel of subject matter experts were then consulted in order to refine this framework and develop an assessment tool for observing these skills. This involved two focus groups and an iterative process, returning to the original data to verify any changes. Results: Four categories of critical non-technical skills were identified: Situation awareness, decision-making, task management and teamwork. Each of these had between three and four sub-categories. Descriptors, exemplar behaviours and an assessment scale were developed to allow these non-technical skills to be observed and rated using a behavioural marker system. During the development of this tool, exploration of the data revealed the influence of factors such as hierarchy and culture on the behaviour of junior doctors. Conclusions: The performance of newly qualified doctors in acute care is influenced by the complex clinical environments in which they work. This can have profound implications for patient outcomes. The framework developed by this research allows us to be explicit about the types of behaviours that are required to keep patients safe. If this tool can be integrated into clinical training, then it could be used by clinicians to support the development of safe and effective skills and reduce the current level of avoidable patient harm.

While there is extensive research on medical doctors and their mental health, little is known about the specific barriers which prevent them from accessing psychological services. Numerous studies have shown that rather than asking for help from other professionals such as counselling psychologists and therapists, doctors would rather turn to drugs and alcohol to cope with their psychological distress. Junior Doctors (JDs) specifically are at particular risk of mental ill-health but feel prevented by their profession from seeking psychological treatment. Little research has been conducted on this particular subject area focusing specifically on JDs. This study readdresses the empirical evidence available for the issue and informs more clearly how counselling psychology and related professions can provide a more effective service to this client group. A constructivist grounded theory approach using eight participants allowed for a detailed examination of the participants’ subjective experiences of the research phenomenon and the generation of new theory on the barriers which prevent JDs from accessing psychological help. Of the eight participants, seven were from an Asian background and one was of Caucasian origin. Further, seven were male with the remaining one participant being female. A core category was uncovered from the analysis of the data which apply to the research participants: psychosocial barriers to accessing psychological services by JDs. This core category was informed by three main themes: 1) medical identity 2) the development of coping strategies in the British medical culture, and 3) the unacceptability of difference. This core category and its themes make up the grounded theory of the research. In light of the findings it may be suitable to adapt the usual process of therapy and negotiate a more appropriate method of delivering psychological support to reduce barriers and to promote credibility and effectiveness of counselling psychology among this client group.

Introduction: As many recently qualified South African doctors pursue specialisation and sub-specialisation, projections indicate that the critical mass of medical practitioners required to support primary healthcare will continue to dwindle, with wholly inadequate numbers to sustain the country's proposed National Health Insurance plan. Little is known, however, about what newly qualified doctors on the verge of making career choices think of the speciality of Family Medicine (FM) and how these young doctors actually decide on what career options to pursue. Objectives: This study describes the career intentions of newly qualified doctors working in the four southern districts of Gauteng Province, the factors that influence their career aspirations, and their views on FM as a specialty. Methods: This is a descriptive cross sectional study using a self-administered questionnaire, which targeted 502 participants (interns N=396 and community service doctors N=106) in 2013. Results: Out of 368 questionnaires returned, 342 were eligible for analysis. More than two thirds (68%) of the respondents graduated from medical schools located in Gauteng Province. Only 5.3% were working in primary healthcare (PHC) facilities. The most chosen specialties were: surgical (32.2%), internal medicine (14.3%), and paediatrics (12.9%). FM was the least chosen specialty by only eight respondents (2.3%). Only 44% had ever considered FM as a career. Of these, 77% agreed that they were not well enough informed about the FM registrar-training programme to select this discipline. Only 16.8% thought they would be job satisfied working in a PHC facility, while 53.4% believed that FM would not be financially rewarding. Conclusions: A serious human resource shortage looms large in primary healthcare if most newly qualified doctors have no desire to enter general medical practice or work in PHC settings. This study highlights the need to urgently address current undergraduate, internship and registrar training programmes in South Africa with a view to marketing FM and making generalism attractive. / AC 2016

Tongue diagnosis is a unique method of diagnosis practiced in traditional Chinese medicine and an important tool in diagnosing diseases before determining proper methods of cures and treatment. In the traditional clinical practice, tongue diagnosis depends solely on the personal knowledge and experience of the practitioner, thereby lacking in objectivity and quantification. Consequently, an automatic tongue diagnosis system (ATDS) has been developed to provide practitioners with objective data and assist them in reaching diagnoses. To prove the system¡¦s stability in clinical application, this study employs 20 sets of tongue images, taken 10 minutes apart from 20 patients with possible variations in lighting, and the length, shape and angle of extruding tongue. The features extracted by the ATDS for each set of tongue images are compared to investigate the intra-agreement of ATDS, and two sessions of tongue diagnosis questionnaires to investigate the intra-agreement of doctors with consensus (DC) and doctors without consensus(DWC),and the inter-agreement between ATDS, DC and DWC, and the inter- agreement among DC and DWC. And this study also investigate the improvement of agreement by DWC after a training process.

Research Doctorate - Doctor of Philosophy (PhD) / Background Due to an ongoing shortage of rural medical professionals both in Australia and internationally, the recruitment and retention of rural doctors has been extensively researched. Mostly the research used quantitative methods to focus on factors associated with rural medical workforce recruitment and retention issues, and until now, limited work has investigated inter-relationships between these factors. Although a few qualitative studies have used thematic analysis to develop models to better understand these issues, none have specifically considered the attitudes of medical students, and female rural doctors. This Thesis responds to this need by using qualitative research methods to develop a model which incorporates feminisation of the medical workforce and generational change in the 21st century. Data were collected from Australian medical students and female rural general practitioners (GPs) as study participants. Aims The broad aims were to develop a model for understanding recruitment and retention of rural doctors in Australia, incorporating concepts of place, gender, and professional identity. Research Questions How are Australian medical students' and female general practitioners' perceptions of entering and remaining in a rural health career influenced by the constructs of place, gender and professional identity? Does this perception change as doctors progress through their careers from students to practising general practitioners? Methods A case series of three qualitative studies were used to develop a model for understanding rural GP recruitment and retention. Data, collected using focus groups and interviews, were analysed thematically by domains describing participants’ lives, and the interaction between the domains was explored to better understand influences on location choice. Results The ����Landscape of fulfilment��� model which is integral to this research, incorporates the domains of self, place, work, significant others, recreation, and significant others’ work as the domains of life which influence location choice. Most participants sought balance within their lives, and maximum fulfilment in all domains, but at times they faced conflict between domains. Individuals’ gender, professional, and place identities were related to how they viewed the domains and how the domains interacted. Conclusion This model provides a way of understanding the complex interaction between aspects of life which affect a doctor’s location choice. There is important potential to use the model to inform the development of rural medical recruitment and retention strategies, and as a basis for further rural health workforce research. The model has already been used by General Practice Education and Training (GPET) in developing post graduate general practice training research, and also by the Sustainable Practice Working Group of the Rural Faculty of the Royal Australian College of General Practitioners (RACGP) in developing strategies for sustainable rural general practice.

Research Doctorate - Doctor of Philosophy (PhD) / Background Due to an ongoing shortage of rural medical professionals both in Australia and internationally, the recruitment and retention of rural doctors has been extensively researched. Mostly the research used quantitative methods to focus on factors associated with rural medical workforce recruitment and retention issues, and until now, limited work has investigated inter-relationships between these factors. Although a few qualitative studies have used thematic analysis to develop models to better understand these issues, none have specifically considered the attitudes of medical students, and female rural doctors. This Thesis responds to this need by using qualitative research methods to develop a model which incorporates feminisation of the medical workforce and generational change in the 21st century. Data were collected from Australian medical students and female rural general practitioners (GPs) as study participants. Aims The broad aims were to develop a model for understanding recruitment and retention of rural doctors in Australia, incorporating concepts of place, gender, and professional identity. Research Questions How are Australian medical students' and female general practitioners' perceptions of entering and remaining in a rural health career influenced by the constructs of place, gender and professional identity? Does this perception change as doctors progress through their careers from students to practising general practitioners? Methods A case series of three qualitative studies were used to develop a model for understanding rural GP recruitment and retention. Data, collected using focus groups and interviews, were analysed thematically by domains describing participants’ lives, and the interaction between the domains was explored to better understand influences on location choice. Results The ����Landscape of fulfilment��� model which is integral to this research, incorporates the domains of self, place, work, significant others, recreation, and significant others’ work as the domains of life which influence location choice. Most participants sought balance within their lives, and maximum fulfilment in all domains, but at times they faced conflict between domains. Individuals’ gender, professional, and place identities were related to how they viewed the domains and how the domains interacted. Conclusion This model provides a way of understanding the complex interaction between aspects of life which affect a doctor’s location choice. There is important potential to use the model to inform the development of rural medical recruitment and retention strategies, and as a basis for further rural health workforce research. The model has already been used by General Practice Education and Training (GPET) in developing post graduate general practice training research, and also by the Sustainable Practice Working Group of the Rural Faculty of the Royal Australian College of General Practitioners (RACGP) in developing strategies for sustainable rural general practice.

The main objective of this thesis is the comparison of the position of the healthcare personnel on the labor market and migration in selected countries - Czech Republic, Germany, France and the United Kingdom. In the theoretical introduction it describes concepts such as brain drain, remittances, emigration and others subjects associated with the migration of the workforce. It analyzes the differences in labor market of healthcare personnel in selected countries and the activities of doctors for change of working conditions. The practical part presents and analyzes data from publicly available statistical sources (OECD, Eurostat, IHIS CR etc.) regarding the number of healthcare personnel, the number of migrating doctors and nurses and their destination countries, salary and wage conditions of health professionals. Expenses on health and quality of the health care are compared between selected countries. Finally, recommendations for Czech Republic, that could help prevent excessive drain of medical personnel abroad, are given - an increase in wages and health expenditures, increasing the number of medical personnel and reduction of administrative burdens.