Introduction: E-cigarettes have been marketed as smoking cessation aids and harm reduction strategies. Prior regional surveys found that physicians are recommending them to patients despite the lack of evidence supporting these industry claims. Yet, little is known about physicians’ beliefs regarding e-cigarettes and whether these beliefs are associated with them recommending e-cigarette use in clinical practice. Methods: This three-manuscript dissertation used a mixed-methods approach including both qualitative and quantitative research methods. The aims were to: (1) Uncover the factors associated with primary care physicians’ (PCPs) decisions to recommend e-cigarettes to their patients for tobacco use cessation; (2) Estimate the prevalence of PCPs who recommend e-cigarettes to their patients as a tobacco use cessation aid; (3) Estimate the influence of factors identified in Aim 1 on PCPs’ decisions to recommend e-cigarettes to their patients for tobacco use cessation; (4) Evaluate the conceptual model which demonstrates the factors contributing to PCPs’ decisions to recommend e-cigarettes to their patients for tobacco use cessation. Results: Study 1 found that PCPs expressed a lack of information about e-cigarette safety and efficacy along with skepticism about the role of e-cigarettes in tobacco control in general and in smoking cessation in particular. However, once a patient initiates a discussion with them, PCPs seem to be endorsing patients’ interests in using e-cigarettes, as well as recommending e-cigarettes to particular types of patients who smoke for both smoking cessation and as a harm reduction strategy. Study 2 found that over three-quarters (82.7%, n=220) of PCPs reported previously discussing e-cigarettes with their patients. Overall, 57.8% (n=155) reported previously recommending e-cigarettes to an adult patient who smoked. Among those recommending e-cigarettes, the majority reported recommending them for smoking cessation and harm reduction (71.6%, n=111), 18.8% for smoking cessation only, and 9.6% for harm reduction only. The likelihood of recommending e-cigarettes to patients was associated with considering their patients’ interest in using e-cigarettes, PCP’s belief that e-cigarettes can help in quitting smoking, and PCP’s belief that e-cigarettes limit secondhand smoke exposure for others. Study 3 found that PCPs intend to recommend e-cigarettes for smokers with prior unsuccessful quit attempts (mean=3.63, ±2.1), followed by heavy smokers wanting to quit (3.57, ±2.2), and heavy smokers refusing to quit (mean=3.50, ±2.2). The mean for PCPs’ recommendation intentions was 3.04 (±2.0) for light smokers wanting to quit, and 3.01 (±1.9) for light smokers refusing to quit. Nevertheless, these recommendation intentions were driven by PCPs’ beliefs and perceptions of e-cigarette benefit and harm; however, these intentions varied by patients’ tobacco use profile. Discussion: Findings across the three studies highlight the significance of PCPs’ beliefs in driving their recommendations of e-cigarettes versus evidence based knowledge, as well as, the importance of patients’ factors and interest in using e-cigarettes for PCPs’ recommendations for e-cigarette use.

Prescription drug abuse is a continuing problem in the United States. Educating physicians on issues related to prescription drug abuse is a key factor in preventing and treating this problem. High variability has been found in substance abuse terminology in the literature, textbooks, and FDA-approved product labeling. This dissertation describes a survey study designed to address how the variability in substance abuse terminology, specifically package inserts, affects the prescribing decisions made by physicians.A random sample of 1008 physicians currently licensed and residing in the Commonwealth of Virginia received a letter of explanation, a self-administered questionnaire, and a follow-up reminder and thank you. To increase response rate, a second questionnaire was sent to non-responders. Prescribing decisions made by physicians were measured as three variables: comfort level with a prior physician's choice, likelihood of refilling the prescription, and likelihood of prescribing a drug or drug class as the first physician seeing a particular patient. Physicians were presented with four case scenarios which included package insert information and selected patient characteristics. Other factors affecting physicians' decisions in prescribing controlled substances include ideas about addiction, and characteristics of the physician, patient, disease state, and drug. The patient case scenarios and other items on the questionnaire addressed these covariates. Based on the number of deliverable questionnaires returned and included in analysis, the response rate was 32.3%. More physicians associated abuse, craving, drug-seeking behavior, psychological dependence, and withdrawal with addiction than with drug dependence, while more physicians felt that physical dependence and tolerance were necessary for drug dependence. The most frequently used sources for drug information were the Physicians' Desk Reference (PDR), package inserts, and pharmacists. Four linear regression models were created for physician prescribing decisions. Physician, patient and package insert characteristics were all significant (p

Purpose: The purpose of this study was to determine the knowledge and treatment protocols for physicians in Virginia emergency departments in regards to the emergent treatment of avulsed teeth.Methods: Using a cross sectional survey design, an 8-item questionnaire regarding the treatment of avulsed teeth was emailed to 75 emergency department chairpersons in Virginia. After 30 days, a reminder paper copy of the questionnaire was mailed and an email reminder with the on-line link was sent. After 60 days the study was closed. Comparisons were made using chi-square analysis based on percentages to test for significance. Results: The response rate was 52 % (n = 39). There were no associations between physician knowledge of the treatment of avulsed teeth and whether there was a protocol for treatment, an in-house dental team, or an on-call dentist available. Conclusion: Most of the physicians have some knowledge of the treatment of avulsed teeth; however further training would help ensure appropriate treatment.

OBJECTIVES: To identify the types of patients who talk with their physicians as a result of Direct-to-Consumer (DTC) advertising. METHODS: Data were taken from a national survey, "Public Health Impact of Direct-to-Consumer Advertising of Prescription Drugs, July 2001- January 2002", conducted by researchers from Harvard Medical School. Participants (n = 3000) were interviewed by telephone. We constructed a conceptual framework consisting of outcomes (3 types of physician visits), intervention (DTC experience) and five groups of explanatory factors (health beliefs, demographics, health status, socioeconomic status and market factors). Data were analyzed with three multivariate stepwise logistic regressions. The three dependent variables were whether an advertisement for a prescription drug had ever prompted the patient to: 1) visit to discuss prescription drug, 2) visit to discuss new condition, and 3) visit to discuss treatment change. RESULTS: Out of all independent variables, only six variables consistently showed significant effects on the three dependent variables after adjusting for other variables. They were: 1) taking medication on regular basis, 2) having anxiety, 3) having high advertisement attentiveness, 4) viewing media as the most important source prompting one to talk with physician, 5) believing that DTC advertisements increased awareness of new treatment, and 6) believing that DTC advertisements improved discussion with health professionals. The six variables were the strongest predictors for DTC-prompted physician visits.CONCLUSIONS: Our nationally representative study found multiple factors were associated with different types of physician visits prompted by DTC advertisements. This information could be used to target those patients most likely to talk to their physicians as a result of DTC advertisements.

Abstract This quasi-experimental design study compared two small samples of Emergency medicine residents after one group had an educational intervention on death notification skills and the other did not. Comparisons were made on residents’ confidence in their communication, interpersonal skills and level of compassion fatigue/satisfaction and EM Residents’ level of Secondary Traumatic Stress after an event of patient death and subsequent notification of Secondary Patients. Residents were interviewed to gather recommendations for designing death notification curriculum. Over an eight month period, forty emergency medicine residents at two sites, control and intervention, completed surveys designed to provide quantitative data on self-confidence and stress related to recent patient deaths. Residents who participated in a death notification event completed the Secondary Traumatic Stress Scale. Interviews were conducted to gather information on the impact of the notification and recommend changes in curriculum at the experimental site. The data infer that an educational intervention on death notification skills increased residents’ confidence in their ability to give compassionate death notification to families as compared with the control group. Residents in the intervention and control group had no significant differences in their potential for compassion satisfaction. Residents who had the educational intervention showed less Secondary Traumatic Stress symptoms than their non-intervention counterparts. The intervention group showed less risk for burnout (although it would only be significant at p < 0.10). The overall conclusion is that there is some evidence for a positive effect of the intervention. However, due to the small sample size the conclusion is tentative and more research is needed to evaluate the training.

Background: The current adherence to colorectal cancer screening (CRCS) guidelines is suboptimal. How neighborhood characteristics, e.g., racial residential segregation (RRS), area-level socioeconomic status (SES) and physician composition, affect CRCS adherence are not fully understood. We assessed associations between facility proximity to RRS areas, area-level SES, physician composition, and CRCS adherence. Methods: Data sources included 2013 Minnesota Community Measurement, 2009-2013 American Community Survey, 2012 U.S. and 2012-2013 Washington State Behavioral Risk Factor Surveillance System data, and 2013-2014 Area Health Resource File. Logistic regressions and weighted multilevel logistic regressions were used to assess the association between facility proximity to RRS areas and CRCS adherence, and association between area-level SES, physician composition and CRCS adherence, respectively. Results: Facility proximity to RRS areas was positively associated with low CRCS performance, e.g., facilities located < 2 miles away from Hispanic-segregated areas were 3 times more likely to have low CRCS performance than those at ≥5 miles away (odds ratio (OR): 2.83, 95% confidence interval (CI): 1.29, 6.24). Most area-level SES measures showed negative bivariate associations between deprivation and colonoscopy/overall adherence, and measures such as education had relatively strong associations, although few of fully-adjusted associations remained statistically significant. Further, a one-unit increase in the percentage of gastroenterologists among physicians was associated with 3% increase in the odds of colonoscopy (OR: 1.03, 95% CI: 1.01-1.04) and overall adherence (OR: 1.03, 95% CI: 1.01-1.04) in the rural-metropolitan areas. Conclusions: Developing culturally tailored CRCS programs, increasing percentage of gastroenterologists, and targeting deprived communities may improve CRCS adherence.

Objective—To explore the experience of psychological distress and wellbeing in emergency medicine (EM) consultants. Methods— A qualitative, Interpretative Phenomenological Analysis (IPA) study based on interviews with EM consultants working in emergency departments (EDs) across South West England. 18 EM consultants were interviewed, representing a response rate of 54.55% across 5 EDs. The mean (SD) age of participants was 43.17 (5.8) years. All participants worked full-time as EM consultants, with the average years-in-role being 7.64 (5.76). The personal meanings that participants attached to their experiences were inductively analysed and explored alongside their perceived psychological health. Results— The analysis formed three super-ordinate themes: systemic pressures, physical and mental strain, and managing the challenges. Pressures within the ED and healthcare system contributed to participants feeling undervalued and unsatisfied when working in an increasingly uncontrollable environment. Participants described working intensely to meet systemic demands, which inadvertently contributed to a diminishing sense of achievement and self-worth. Consultants perceived their experience of physical and emotional strain as unsustainable, as it negatively impacted: functioning at work, relationships, personal wellbeing and the EM profession. Sustainability was promoted by the presence of social support and through evolving with the consultant role. Conclusions— EM consultants experience considerable physical and mental strain. This strain is dynamically related to consultants' experiences of diminishing self-worth and satisfaction, alongside current socio-political demands on EM services. Recognising the psychological experience and needs of EM consultants through promoting a sustainable EM consultant role could have wide-reaching benefits for the delivery of emergency care and physician wellbeing.

1 Abstract: The diploma thesis applies sociological perspective on interrelationships of pharmaceutical industry, physicians and patients. Its main focus is on the role of pharmaceutical industry in context of relationships with the two other actors. The first part of the work summarizes available Czech and mainly foreign social science literature referring to the broad network of relations. The transformation of medical profession in current society and the development of international pharmaceutical industry in the Czech Republic are also discussed. The empirical part of the thesis reports the findings of a qualitative interview study undertaken with ambulatory physicians concerning their relationships with pharmaceutical companies. The goal of the research was to explore how and why Czech physicians interact with the pharmaceutical companies, gain insight into their ethical evaluation and assessment of consequences and detect the strategies and rationalizations they use to cope with these relationships. Keywords: pharmaceutical industry, physician, patient, conflict of interest, sociology of medicine

A thesis submitted for the degree of Doctor of Philosophy in the Faculty of Humanities, University of the Witwatersrand, 2017 / This study explores the role of the doctor-patient relationship in the management of diabetes in South Africa. The originality of this study lies in the unique manner in which the topic is approached from an explicit theoretical perspective as well as the context in which it is studied. It takes into account the biomedical aims of diabetes management as well as the socio-cultural context of the environment in which communication occurs. Diabetes Mellitus is a chronic disease of lifestyle (CDL) and one of the most prevalent chronic diseases, both globally and within South Africa. In South Africa, although statistics vary across provinces and within different demographic and socio-economic groups, it is estimated that about 5.5% of the population over the age of 30 years, has diabetes. The disease has a significant impact on morbidity and mortality in the country, as well as on socio-economic development. The need to improve diabetes education and awareness, in addition to the need to address patient adherence to management plans and the prevention of complications, are vital in order to effectively manage this rising epidemic. Current management of diabetes favours an individualised approach to risk reduction. This involves patient adherence to a negotiated (between doctor and patient) management plan, as well as modifications in the patient’s lifestyle behaviours. International literature on adherence to the management plans of all CDLs suggests that there are many challenges. Furthermore, most studies have shown that there are shared common barriers inherent to all chronic diseases, where the complexity and chronicity of treatment are major factors in adherence. Despite the large number of studies and the identification of many influencing factors, few direct and replicable causal links to adherence have been found. Models of adherence from other chronic diseases in South Africa have highlighted the importance of patient motivation to change behaviour as being linked to their perceptions and beliefs, formed by the attitudes of those with whom they interact. A review of the literature on health communication in various fields of medicine identifies the need for a firm perspective and justification of the methodology employed in the study. Various theoretical stances are examined but it is ultimately the interaction between doctor and patient within the sociocultural context of the consultation that is seen to be most relevant. A social constructionist perspective is justified as the basis from which a disease such as diabetes, which requires complex therapeutic manipulation and lifestyle adaptations, can be studied. A brief overview of medical education is also discussed as it pertains particularly to the teaching of communication skills and behaviours. This becomes relevant as it is medical training that ultimately informs clinical practice. In recent years, medical education has been called upon to be more socially relevant and incorporate a multitude of supporting competencies into training. These models are described and interrogated with relevance to the study aims. The research was conducted in the province of KwaZulu-Natal (KZN) in South Africa within the diabetes clinics of two district level public health care institutions; one was located in the eThekwini metropolitan area (Durban) and the second at a rural site in northern KZN. These hospitals were purposively selected because of their contrasting locations, reflecting diverse socio-economic, ethnic, racial and language groups, thus providing a rich set of data. In keeping with the social constructionist perspective of the study, natural consultations at both sites were the primary source of data aimed to focus on the communication between doctor and patient. A total of 24 routine diabetes follow-up consultations provided the data source. Consultations between patients and doctors were audio- and video-recorded and ethnographic observations were made by the researcher, who was an observer in all consultations. All consultations were transcribed, translated into English if necessary, and analysed using elements of conversational analysis transcription conventions. In order to understand the contextual environment of the study, ethnographic observations made by the researcher during the consultations and other site visits are also included in the data set. These observations are presented and contrasted with the experiences of doctors and patients as explored in interviews and focus group discussions at each site. Participants were asked to comment on their experience of their clinical care as well as the interaction with their doctor and their ability to manage their diabetes. By using multiple data sources and contrasting the findings, the study provides a robust framework from where communication in diabetes can be examined. By analysing the data from a socio-constructionist viewpoint it became evident that the relationship between doctor and patient was a strong influential factor on disease management. Furthermore, the manner in which various communication behaviours were interpreted was seen to be able to transcend the superficial socio-cultural environment should other interpersonal factors mitigate the relationship. Not only was the process by which communication content delivered important, but also the underlying attitudes, past experiences and broader context of the consultation. If patients and doctors found themselves in the position to internalise the behaviours experienced in the consultation, their feelings, ideas and beliefs towards one another and diabetes was seen to change. Over time, it was suggested that these new attitudes would feedback either positively or negatively on future interactions. This study also showed how cultural norms cannot be part of a checklist but that they are dynamic over time and are influenced by a multitude of factors, including past experiences and mutual respect, which need to be understood from an interactional and relational perspective. A new model that incorporates existing knowledge coupled with integration of clinical, scientific diabetes management and the art of communication is also described. The findings from this study should be used to guide and inform clinical practice in order to improve health outcomes for those living with diabetes. By extension, they should also be used to inform medical education models where communication is being incorporated into clinical skills training. As was found by observing and analysing clinical practice behaviours for the purpose of this study, the author believes that by internalising experiences, students may be able to forms new ideas and attitudes towards communication which will enhance their clinical practice. The methods utilised in this study have also highlighted the fact that previous methods have not been sensitive enough to the human dynamics that occur in health communication in diabetes and future research should be developed with a strong theoretical perspective that guides an appropriate methodological approach. This study depicts the pivotal role communication plays within each unique consultation and how the manner in which the interaction is perceived and interpreted will have a strong influence on behavioural decisions. However, it is not merely the words that are spoken or the language in which they are spoken but rather the internalisation and adaptation to the context that will ultimately will guide behavioural change. / XL2018

Este estudo teve como proposições: compreender o processo da interação entre profissionais de saúde e usuários estrangeiros nas Unidades Básicas de Saúde (UBS) e Programa Saúde da Família (PSF); conhecer o significado da experiência dos profissionais de saúde ao interagir com os usuários estrangeiros; evidenciar questões bioéticas na experiência de interação entre profissionais e usuários estrangeiros. Utilizou-se como referencial teórico o Interacionismo Simbólico e como referencial metodológico a Teoria Fundamentada nos Dados, até a codificação axial. A análise dos dados, apresentada como ordenamento conceitual, levou à definição de quatro grandes temas: (1) procurando comunicar-se; (2) percebendo limites; (3) percebendo interação como processo; (4) percebendo perspectivas diferentes. O percurso de interação profissional usuário estrangeiro foi desencadeado a partir de uma escolha: atender a todos indiscriminadamente, tornando possível a aproximação. Perceber ou não no usuário estrangeiro sua dignidade de pessoa humana parece ser determinante na abertura do profissional à interação, na sua disposição a buscar estratégias. / This study had the following objectives: to understand the interaction processes among health professionals and foreign users in the Unidades Básicas de Saúde (UBS) and the Program for Family Health (PSF); to get to know the significance of the health professionals experience as they interact with foreign users; to put in evidence bioetiques issues in the experience of professionals and foreign users interaction.It was used as a theorical referential the Symbolic Interacionism and as methodological reference a Grounded Theory up to an axial coding. Data analysis presented as conceptual ordering, lead to the definition of four great issues: (1) trying to communicate; (2) detecting limits; (3) recognizing interaction as a process; (4) recognizing different perspectives. The route of professional foreign users interaction was developed from one choice: attend everyone (indiscriminately) making approximation possible. To recognize or fail to recognize in the foreign user the dignity of human person seems to be the determining factor for the openness of the professional to the interaction, in his disposition to seek strategies.