This thesis contains the findings of a study undertaken in the field of medical decision-making. The Glaserian approach to grounded theory (Glaser and Strauss, 1967; Glaser, 1978) was used in order to build a theoretical representation of this area. Four phases of data collection were used, the first to develop initial theoretical sampling points and obtaining permission to approach medical practitioners. Following this, 12 personal in-depth interviews were performed to collect the primary data. A period of secondary data collection was then performed and finally an appraisal of the draft theory. Trading Off emerged from the constant comparative method as the core category explaining how pharmaceutical decision-making (as a form of medical decisionmaking) is performed. Sub core categories that were integrated within the Trading Off process included Focusing as the initial period of analysis, Self-Referencing and Surrogating reflecting sources and use of information and the Shiftin g that occurs as physicians develop expertise. In order to develop and frame the contribution of this theory within relevant literature, an number of areas of decision-making and medical decision-making research were reviewed. Expertise and its development were also examined. The main conclusions and recommendations of this research are that physicians Trade Off levels of confidence held in behaviours and aspects of the behaviour in order to decide on a course of action. Trading Off can used to direct the efforts of pharmaceutical companies and healthcare providers in order to modify pharmaceutical decision-making and reduce the large volume of prescribing errors. These efforts should be based on an accurate analysis of the individual decision environment and involve a wide view of possible influencing factors. It is recommended that actual patient case studies supplied from clinical trials are used in these efforts and that an opinion leader should perform the delivery where possible.

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Indiana University-Purdue University Indianapolis (IUPUI) / Immigrants are at elevated risk for not having their diabetes treatment appropriately intensified, likely resulting in poorly-controlled diabetes and increased morbidity and mortality. Immigrant status is a powerful sociodemographic cue, yet its influence on providers’ diabetes treatment decisions is unknown. The study objective was to determine the effect of patient immigrant status on providers’ decisions to (1) take no action, (2) add an oral hypoglycemic agent (OHA), (3) add/switch to insulin, or (4) refer the patient to an endocrinologist. Participants were 140 medical students/professionals (‘providers’). Providers viewed profiles (videos + vignettes) for virtual patients differing in immigrant status (born in Mexico or U.S.; other characteristics held constant). Analyses were completed at the group (‘nomothetic’) and individual (‘idiographic’) levels. Nomothetic results indicated providers were less likely to refer foreign-born patients to endocrinology than U.S.-born patients (p=0.03). No differences were detected for the other three treatment likelihood ratings. Idiographic results indicated that about half of provider decisions were influenced by patient immigrant status (i.e., Cohen’s d≥0.50) across all four treatment decisions. Effect size data show an almost even split between higher treatment ratings for foreign-born vs. U.S.-born patients for three decisions (take no action, add an OHA, add/switch to insulin), explaining why group-level differences for these ratings did not emerge (i.e., they were cancelled out). This study found that providers are less likely to refer foreign-born patients to endocrinology, potentially leading to therapeutic inertia. In addition, half of individual-level provider decisions were meaningfully influenced by patient immigrant status. However, traditional group-level analyses mask these important individual-level differences. These systematic differences in treatment based on non-relevant factors could lead to unintended adverse outcomes for the foreign-born population.

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Different people can have different cultural interpretations of the person—atomic versus embedded—and these may affect health care decision-making. This study examines both the ethics of variations in personhood as well as their implications for the doctrine of informed consent and the duty to warn of genetic disease risk. It argues that variations in personhood are consistent with the ethics of the Principle of Autonomy and the Canadian stand on informed consent, though autonomy and consent play out differently in practice on the two models. Also as a result of different interpretations of the person, the duty to warn of hereditary risk is found to be relevant to the atomic conception but unnecessary among embedded individuals. / Graduate / 0422 / 0566 / 0326 / pkdheri@uvic.ca

Purpose - Healthcare (HC) is a globally expensive investment, suffering from service quality, due to medical errors caused by physicians’ poor decisions making (DM). Current published literature: (1) encourages clinical DM research to reduce diagnostic errors and (2) stresses on the dearth of means for practitioners’ knowledge shared DM; this research focuses on knowledge sharing for improving medical DM quality through physicians’ social capital (SC) in a virtual community of practice (VCoP). Physicians join a virtual community (VC) to share clinical practice knowledge to aid medical DM. This study aims to assess the effect of physicians’ SC on medical DM and assess the mediating role of knowledge sharing quality, between physicians’ SC and medical DM quality since research lacks to investigate the impact of knowledge management (KM) tools in a HC context. VCoP is a KM tool and medical DM quality is a HC topic of this study. Design/methodology/approach – This positivist, quantitative research utilizes non-experimental survey to empirically assess its conceptual framework. After attaining an ethical approval, from Brunel Business School Research Ethics Committee, online survey was pre-tested and pilot tested for clarity and validity. 10 non-physician Ph.D. academics voluntarily participated during the survey’s pre-test phase. The survey was amendment for its pilot study phase; conducted in “plastic surgery yahoo group” VC. 31 physician VC members voluntarily participated. Again, the survey was amended and distributed for main data collection from 204 voluntary SurveyMonkey’s VC’s physician members. Findings – Data was analysed using SPSS 20 and LISREL 8.80 by means of confirmatory factor analysis and Structural Equation Modeling. Empirical findings supported this study’s four main hypotheses as well as supported this study’s initially proposed conceptual framework. Originality/value – This study customized the Honeycomb framework to establish a definition of professional physicians; HC VCs followed by identifying 51 VCs from social networking platforms like LinkedIn, Facebook, etc. This study also fulfilled its aim and hence proposed a structurally fit conceptual framework.

This thesis explores the processual nature of agency and constraints in the experience of medicalized conception in a not yet explored locale: Bogota, Colombia. In ten months of ethnographic research at two fertility centers in Bogota, and interview data from over 100 in-depth interviews with women and men undergoing ARTs and clinic staff, a complex ART industry driven by both doctors (qua entrepreneurs) and the couples seeking medicalized conception was explored. This thesis identifies how relationships in the clinic combined with understandings of “the fragmented body” (as a medicalized object under scrutiny) and “the self” (as a conscious agent), to produce intricate dynamics of agency and constraints that co-evolved in a processual manner. Tracing the experiences of women in infertility treatment chronologically, the thesis explores how knowledge was established and renegotiated through productive power fields that relationally incorporated embodied, personal knowledge and authoritative medical expertise. Women adapted to constraints in both active and passive ways to create and assert their ever-transforming agentive capacities. In these processes, they were constantly reflecting on, and renegotiating their position in the treatment process, as well as in their social lives more broadly. Drawing on, and seeking to contribute to, literature on agency in ARTs from across the world, particularly literature that considers agency as a process co-established by the constraints it confronts, this thesis makes two key arguments: First, that agency in Colombian ART clinics is defined as reflection and renegotiation, rather than as something which occurs at a singular moment of reflection and renegotiation. Second, that this negotiated process is constrained, but not contained. In other words, agency is a process that looks both backwards and forwards. Women and couples incorporated different personal histories and embodied knowledge into negotiating the treatment process and constraints they encountered, and adapted their experiences of ART treatments to other aspects of their lives, negotiating constraints that reach beyond the clinical setting.

Recent changes in legislation and access to information, through sources such as the media, may have influenced peoples' expectations for information about their prescribed medication. As a result, health care professionals may perceive an increased pressure to provide information. A case study approach was employed to examine the sources and scope of information patients draw upon when they are prescribed oral steroids for asthma. The aim was to examine the extent to which patients can be said to exercise an `informed choice' when they take prescribed medication. The role and importance of GPs (general practitioners) in informing the choices patients make was also examined. Both qualitative and quantitative methods were employed. Interviews conducted with both patients and GPs indicated `gaps' in understanding. Although the GP was the preferred source of information, patients reported that the choices they made were based on information from a range of sources. General practitioners justified not providing information to patients so as to `protect' patients from knowledge of side effects. However, there was some awareness of the range of sources of information used by patients. A vignette technique was employed to further investigate GPs' recognition and understanding of the range of sources of information patients' use to inform the choices they make. Approximately half of the GPs who responded to the vignette recognised the influences presented. General practitioners who had been practising for a shorter period of time were significantly more likely to recognise these influences. The conclusions draw on the literature of the sociology of the professions. In spite of the way in which the Government has sought to encourage patients to act as consumers, the state has also continued to endorse GPs right to make decisions concerning the level of information to provide. If GPs do not believe it is in the interests of patients to be provided with information to make choices about their medications then the information available to patients may be limited. This will have an impact on the ease with which patients may make `medically' informed choices about their prescribed medication. Only when the communication between patients and GPs improves, will it be possible for a relationship to develop where patients may be assured of gaining information from their GP at the level they feel is appropriate to enable them to make informed choices about their medication.