<p>There is no stronger or more enduring prohibition in medicine than the rule against the killing of patients by doctors. This prohibition is rooted in some medical codes and principles. Out standing among the principles surrounding these prohibitions are the principles of beneficence and non-maleficience. The contents of these principles in a way mark the professional integrity of the physician. But the modern approach to health care services pulls a demand for the respect of the individual right of self-determination. This demand is now glaring in almost all the practices pertaining to health care services. In end of life decisions, this modern demand is found much in practices like physician- assisted suicide and euthanasia. It demands that the physician ought to respect the wish and choice of the patient, and so, must assist the patient in bringing about his or her death when requested. In such manner, this views the principle of autonomy as absolute and should not be overridden in any circumstance.</p><p>However, the physician on his part is part of the medical profession that has integrity to protect. This integrity in medical profession which demands that the physician works only towards the health care of the patient and to what reduces diseases and deaths often go contrary to this respect for individual autonomy. Thus faced with such requests by patients, the physician always sees his integrity in conflict with his demand to respect the autonomous choice of the patient and so has a dilemma in responding to such requests. This is the focus of this work,"Professional Integrity and the Dilemma in Physician- Assisted Suicide"</p><p>However, the centre of my argument in this work is not merely though necessary to develop general arguments for or against the general justification of PAS, but to critically view the role played by the physicians in assisting the death of their patients as it comes in conflict with the medical obligation and integrity. Is it morally right, out rightly wrong or in certain situation permissible that physicians respond positively to the request of the patients for PAS? This is the overarching moral problem in the morality of physician- assisted suicide, and this work will consider this in line with the main problem in the work “the dilemma of professional physicians in the assistance of suicide.</p>

<p>Sjuksköterskeyrket är det äldsta traditionellt, professionella kvinnliga yrket inom vården. Sjuksköterskan kan bidra till en bra samverkan genom sin omvårdnadskunskap och yrkeskompetens. Syftet med studien var att belysa faktorer av betydelse för samarbetet mellan sjuksköterska och läkare som kan inverka på en välfungerande samverkan mellan de båda professionerna. Metoden är utförd som en litteraturstudie där sammanställning av forskning inom aktuellt område har genomförts genom systematiska sökningar i olika databaser. I resultatet framkom fem kategorier av viktiga faktorer för samverkan mellan läkare och sjuksköterskor, dessa var traditionella hierarkiska strukturer, respekt och jämställdhet, kunskap, kommunikation, samt strategier för förbättrad samverkan. Sjuksköterskor upplevde sig underordnade under läkare beroende på ojämlikheter som uppstår genom bristande respekt och dåliga kunskaper om andra professioners ansvarsområden. Kommunikation framhölls som en avgörande faktor för en positiv samverkan mellan sjuksköterskor och läkare. Sjuksköterskans kunskaper i att informera, planera, organisera och kommunicera verbalt och skriftligt visade sig ha stor betydelse för hur relationen utvecklade sig mellan olika professioner. Grunden för en bra relation mellan sjuksköterska och läkare är att kunna kommunicera och använda sig av olika strategier för att främja samverkan positivt. Sjuksköterskan kan bidra till att förbättra olika faktorer i samverkan professionerna.</p> / <p>Nursing profession is the oldest traditional female occupation in medical care. The nurse can contribute to a good collaboration by her nursing knowledge and professional competence. The aim of this study was to illuminate factors of meaning between nurse and physician that has impact on collaboration between those professions. The method was a literature study where research was compiled within the topical area and conducted by systematical searches in different databases. The result shows different categories that appeared to be important factors for collaboration between nurses and physicians. Categories shown were traditional hierarchical structures, respect and equality, knowledge, communication and different strategies for improved collaboration. Several nurses experienced that subordination of nurses depended on inequalities that comes from lack of respect and bad knowledge about each others professional occupations. Communication was pointed out as a conclusive factor that contributed to a positive collaboration between the nurse and the physician. Nurses knowledge about informing, planning, organizing, and communicating both in oral and in writing was of importance for developing collaboration between different professions. The foundation for a good relationship between nurse and physician is to be able to communicate and to use different strategies in order to promote collaboration in a positive manner. Nurses have the ability to improve different factors of collaboration between the professions.</p>

<p>The study aimed to investigate the acute medical chain consisting of SOS operator, ambulance nurse, emergency nurse and emergency physician with regard to the assessment and prioritization of the victim.</p><p>The design of this journal study is retrospective with descriptive approach. Data were collected from all ambulance missions carried out in Uppsala county 2009-01-01 between the hours 00:00 to 12:00. Sample period was chosen because the prerequisite for high frequency on the ambulance mission was supposed to be good. In order to be able to systematize the compilation of data a protocol were prepared and used. Applicable data were collected from three databases SOS Alarms, ambulance operations, and the University Hospital in Uppsala. The study was divided into three stages and record documents usefulness was assessed individually based on inclusion criteria's. During the measurement period the SOS operator assessed need of an ambulance at 62 occasions in Uppsala County. Of these 62 ambulance missions there were 18 that could be followed during the whole acute medical chain.</p><p>The results showed that the participants of the acute medical chain most of the time did the same assessment of the victim main problem/symptom and thus the criterion. Without considering the priority it appeared that the criteria were the same in 83% of all 18 included ambulance missions. SOS operator assessed ambulance mission as a priority one in 39% (7/18), and the ambulance nurse judged that priority one on the way to the hospital was justified in 17% (3/18). Of the 18 victims who were transported by ambulance to the emergency department at the University Hospital in Uppsala 72% (13/18) went home the same day.</p> / <p>Studiens syfte var att undersöka den akutmedicinska vårdkedjan bestående av SOS operatör, ambulanssjuksköterska, akutsjuksköterska och akutläkare med avseende på bedömning och prioritering av drabbad.</p><p>Designen på denna journalstudie är retrospektiv med deskriptiv ansats. Data insamlades från samtliga ambulansuppdrag som genomfördes i Uppsala län 2009-01-01 mellan klockan 00:00 - 12:00. Urvalsperioden valdes därför att förutsättningen för hög frekvens på ambulansuppdrag förmodades vara goda. För att systematisera sammanställningen av data utarbetades och användes ett protokoll. Tillämpbara uppgifter inhämtades från tre databaser SOS Alarms, ambulansverksamhetens och Akademiska sjukhusets. Studien delades upp i tre steg och journalhandlingarnas användbarhet bedömdes var för sig utifrån inklusionskriterier. Under mätperioden bedömde SOS operatören behov av ambulans vid 62 tillfällen i Uppsala län. Av dessa 62 ambulansuppdrag gick 18 att följa under hela vårdkedjan.</p><p>Resultatet visade att aktörerna i akutmedicinska vårdkedjan för det mesta gjorde samma bedömning av den drabbades huvudproblem/symtom och därmed kriteriet. Utan hänsyn taget till prioritet så visade det sig att kriterierna övrrensstämde vid 83% av alla 18 inkluderade ambulansuppdrag. SOS operatören bedömde ambulansuppdraget som prioritet ett i 39% (7/18) och ambulanssjuksköterskan bedömde att prioritet ett på väg till sjukhus var motiverat i 17% (3/18). Av de18 drabbade som transporterats med ambulans till akutmottagningen på Akademiska sjukhuset fick 72% (13/18) åka hem samma dag.</p>

The feminist beliefs of abortion service providers and the effects of these beliefs on the delivery of health care to patients is examined by the author who is herself a feminist and member of an abortion clinic staff. Discussion includes abortion rates, abortion safety, characteristics of patients, and accessibility of abortion, particularly as affected by legislation and anti-abortion activism. The research consists of the author's personal experiences as a counselor and patient advocate, conducting patient health history interviews, supporting patients in the operating room, and attending patients during recovery. The data is presented in a personal narrative including autobiographical material, a methodological style supported by feminist theories which question the supposed objectivity and neutrality of conventional scientific methods. Three means by which feminist beliefs are expressed in the delivery of abortion services to patients are identified: the language used to refer to abortion and abortion-related services, the choice of abortion related topics addressed during clinic visits, and the reconfiguration of the conventional provider/patient relationship. / Graduation date: 1999

The aim of this thesis is to study (1) the impact of physicians' locus of control (LOC) on their communication styles in interviews with cancer patients as well as (1) the impact of physicians' LOC on their acquisition of effective communication skills in a communication skills training program. LOC is a generalised belief regarding the extent to which life outcomes are controlled by an individual's actions (“internal” LOC) or by external forces such as luck, fate or other individuals (“external” LOC). (1) Although is it widely recognised that physicians' characteristics could influence their communication styles and may thus interfere with a patient-centred communication, no empirical evidence is currently available. No studies are available on the impact of physicians' LOC on their communication skills. It was hypothesised that physicians with an “external” LOC have a different communication style than physicians with an “internal” LOC. Eighty-one voluntary physicians with a practice in oncology were recorded performing an actual and a simulated interview with a cancer patient as wall as an actual and a simulated interview with a cancer patient and a relative. Physicians' communication skills were assessed using the Cancer Research Campaign Workshop Evaluation Manual. Physicians' LOC was assessed using the Rotter I-E scale. Communication skills of the upper and lower quartiles of physicians in respect of their scores on this scale were compared using Student's t-test. Results show that physicians with “external” LOC give more appropriate information than physicians with “internal” LOC in simulated interviews with a cancer patient (P=0.011) and less premature information than physicians with “internal” LOC in clinical interviews with a cancer patient (P=0.015). Moreover, in actual interviews with a cancer patient and a relative, physicians with an “external” LOC talked more to the relative (P=0.017) and used more utterances with an assessment function (P=0.010) than physicians with an “internal” LOC. In simulated interviews with a cancer patient and a relative, physicians with an “external” LOC used less utterances giving premature information (P=0.031) and used more utterances with a supportive function such as empathy and reassurance (P=0.029) than physicians with an “internal” LOC. (2) Although it is widely recognised that educational interventions may be more effective for people with an “internal” LOC compared to people with an “external” LOC, no study has yet assessed the influence of physicians' LOC on communication skills learning. This study aims to test the hypothesis that, in a communication skills training program, physicians with an “internal” LOC would demonstrate communication skills acquisition to a greater degree than those with an “external” LOC. A non-randomised longitudinal intervention study was conducted between January 1999 and April 2001. Sixty-seven volunteer physicians from private and institutional practice in Belgium participated to a learner-centred, skills-focused, practice-oriented communication skills training program. Communication skills changes were assessed in 2 standardised simulated interviews before and after training (one two-person and one three-person interview). Communication skills were assessed using the Cancer Research Campaign Workshop Evaluation Manual. Physicians' LOC was assessed using the Rotter I-E scale. Communication skills changes of the upper and lower third of physicians in respect of their scores on this scale were compared using group by time repeated measures of variance. In the two-person and three-person interviews, the increase in open directive questions was more important among physicians with an “internal” LOC compared to physicians with an “external” LOC (P=0.066 and P=0.004 respectively). In the three-person interview, the increase in directive questions (P=0.001), in assessing functions (P=0.002) and in the use of moderate feelings stated explicitly (P=0.011) was more important among physicians with an “internal” LOC compared to physicians with an “external” LOC. Conclusion. These results provide evidence that physicians' LOC can influence their communication styles as well as the efficacy of a communication skills training program. Physicians' awareness of first results constitutes a step towards a tailoring of their communication skills to every patient's and relative's concerns and needs and thus towards a patient-centred communication. The second results support the idea that a psychological characteristic such as "internal" LOC may facilitate communication skills acquisition through physicians' belief that communication with patients may be controlled by physicians themselves.

Long waitlists and growing numbers of unattached patients are indicative of a Canadian healthcare system which is unable to address the demands of a growing and aging population. Health information technology is one solution offering respite, but brings its own issues. Health information technology includes primary care physician office systems, telehealth and jurisdictional EHRs integrated through interoperability standards to share data across care providers. This dissertation explores effects that health information technology has on primary care. Literature reviews provided context of health information systems adoption. Surveys and semi-structured interviews gathered information from health system actors. Workflow analysis illustrated how technology could change physician office workflow. Exam room observations illustrated how technology affects proxemics and haptics in the patient encounter. This research derived change management models which quantified substantial change management costs related to adoption of physician office systems. We found that physicians have concerns over how health information technology will affect efficiency, financial, quality, liability, safety and other factors. Physicians in smaller suburban physician offices take little time to select a system for their needs. Urban, academic and hospital physicians spend more time networking with colleagues and devote funds to project management and training. Our studies showed that stronger professional networks, more complete training, a managed approach to implementation and in-house technical support are more influential in facilitating adoption than remuneration models. Telemedicine can improve quality of care, the referral process for family physicians and access to services for patients. Teledermatology was shown to make significant improvements in access to services for patients, but referring physicians are concerned about their liability if they follow the recommendations of a dermatologist who has not seen their patient face-to-face. Certification organizations mitigate liability, procurement and financial risk to qualifying family physicians by pre-qualifying vendor solutions, coaching physicians through procurement and reimbursing family physicians for purchasing an approved system. We found that centralization plays a key role in adoption of health information systems at the jurisdictional and primary care level. Online scheduling can reduce human resource requirements used in scheduling, if the system is well implemented, well documented and easy to use. / Engineering Management

In Sweden and elsewhere there is evidence of poorer cancer survival for patients of low socioeconomic status (SES), and in some settings differences in treatment by SES have been shown. The aim of this thesis was to explore factors which influence cancer treatment decisions, such as knowledge reaped from clinical trials, patient-related factors, and physician-related factors. In a register study of colorectal cancer, all stages, patients were stratified for SES-factors. Differences were seen with regards to clinical investigation, surgical and oncological treatment and survival, with the highly educated group being favored. Survival was better for highly educated patients in stages I, II and III but not in stage IV. In a Scandinavian cohort of newly metastasized colorectal cancer patients, recruitment to clinical trials was studied. Patients entering clinical trials had better performance status and fewer cancer symptoms than those who were treated with chemotherapy outside of a clinical trial. Median survival was 21.3 months for trial-patients and 15.2 months for those treated with chemotherapy outside a  trial. Those not treated with chemotherapy had a median survival of just 2.1 months. Patients in clinical trials are highly selected and conclusions drawn from studies cannot be applied to all patients. In the same cohort, treatment and survival were stratified for education, smoking and indicators of social structure. Highly educated patients did not have a survival advantage. Patients who lived alone were offered less combination chemotherapy and surgery of metastases than other patients and had 4 months shorter survival than those who lived with a spouse or child. In a fourth study, 20 Swedish gastrointestinal oncologists were interviewed on which factors they considered when deciding on oncological treatment. Oncologists feared chemotherapy complications due to lack of social support, and ordered less combination chemotherapy for patients living alone. Highly educated patients were seen as well-read and demanding, and giving in to these patients’ requests for treatment was regarded as a way of pleasing patients and relatives and of avoiding conflict.

There is no common understanding on what constitutes good sick-listing, a frequent and problematic task for many physicians, especially general practitioners (GPs) and orthopaedic surgeons. Aiming to achieve a deeper understanding of sick-listing practices, 19 GPs (I, III) and 18 orthopaedic surgeons (II) in four counties were interviewed, and data analysed qualitatively for views on good sickness certification and barriers to desired practice. Data from a survey of all 7665 physicians in two counties on emotionally straining problems in sickness certification (IV) was analysed quantitatively. Some GPs exposed narrow views of sick-listing, where their responsibility was limited to issuing a certificate, while GPs with the most inclusive view had a perspective of the patient’s total life-situation and aimed to help patients shoulder their own responsibility (I). The orthopaedic surgeons´ perceptions of good sick-listing were mainly related to their views on their role in the health-care system. Some perceived their responsibility as confined to the orthopaedic clinic only, while others had the ultimate goal of helping the patient to become well functioning in life with regained work capacity – by means of surgery and proper management of sick-listing (II). Difficulty handling conflicting opinions was a barrier to good sickness certification for GPs (III), and problematic for about 50% of all physicians and about 80% of GPs (IV). Orthopaedic surgeons’ handling of such situations varied from being directed by the patient, via compromising, to being directed by professional judgement (II). Other barriers included poor stakeholder collaboration (III). GPs with a workplace-policy on sickness certification reported fewer conflicts and less worry of getting reported to the disciplinary board in relation to sick-listing (IV). Understanding physicians’ underlying views on and barriers to practicing “good sick-listing” can inform efforts to change physician practice. Communications skills training in handling sick-listing situations with conflicting opinions is recommended.

One of the most critical elements in empowering the patient, and ensuring concordance, is communication of the possible benefits and harms of different actions in health care. Risk assessment is a complex task due both to the different interpretations of the concept of risk, and the common lack of hard facts. Hormone, or hormone replacement, therapy (HT) is used by many women in, and after, the menopause. The benefits and possible harms associated with short and long term treatment with HT have been extensively discussed the last decade and the use of HT has decreased dramatically internationally the last few years. The aims of this thesis were to study the interaction between patient and physician when discussing risks and benefits of different treatment alternatives, and to suggest strategies to improve risk communication in clinical practice. The studies have focused on how risks and benefits with HT were communicated between women and physicians during firsttime consultations in 1999- 2000 on this subject (20 women, 5 gynaecologists), and through questionnaires how attitudes towards HT have changed between 1999 (n=1,760) and 2003 (n=1,733) among women entering the menopause (53-54 years). Through a qualitative analysis of the risk communication in the consultations a system was constructed to classify how risk is communicated in relation to benefits. This was used to assess and present differences in risk communication in the consultations. Different rhetorical strategies by the physicians were identified and the dominating tendency was a move from the woman’s current problems to the long-term effects of HT. The questionnaires showed a marked difference in attitudes towards HT between the years. In 2003 women perceived HT to be associated with higher risk and less benefits than in 1999. This correlated to a drastic reduction in the use of HT over the same period. Media was the most frequent source of information about HT during the last twelve months before the questionnaire in 2003. Possible explanations for the different attitudes towards HT between women entering the menopause and gynaecologist; how this difference might have influenced the results; and how they may have implications for future communication strategies are discussed. This thesis illustrates the importance of a deeper understanding in health care of the concept of risk in order to achieve an adequate communication of risk. This is important both in consultations and in campaigns to educate and inform the public. / Reprinted figure 1 on page 32 with permission from Science Ref # 05-17260-Revised. Copyright 2006 AAAS.

Degenerative disease of the lumbar spine (DDLS) is a common condition for which surgery is beneficial in selected patients. Wide variation in surgical referral and rates of surgery has been observed contributing to unequal access to care. Our objectives were to examine (1) the variation in preferences for referral and surgery among surgeons, family physicians (FPs) and patients, (2) how FP referral practices compare with preferences and guideline recommendations, and (3) how the ‘enthusiasm’ of patients and physicians influence regional variation in surgical rates. We used conjoint analysis in a mailed survey to elicit preferences based on clinical vignettes from surgeons, FPs and patients. A Delphi expert panel provided consensus guideline recommendations for surgical referral to compare with actual FP referral practices. Rates of surgery for DDLS, obtained from Ontario hospital discharge data, were used to quantify regional variation and regression models assessed the relationship with patient and physician enthusiasm. We identified significant differences in preferences for referral and surgery between patients, FPs and surgeons. Surgeons placed high importance on leg-dominant symptoms while patients had high importance for quality of life symptoms (i.e. severity, duration, walking tolerance). Surgical referral practices were poorly predicted by individual FP preferences and guideline recommendations based on clinical factors alone. Variation in Ontario surgical rates was higher than that of hip or knee replacements and was highly associated with the enthusiasm of surgeons (p<0.008), rather than FPs or patients. By appreciating the variation in preferences between patients and physicians, and exploring other non-clinical factors that influence referrals, we may be able to improve the efficiency of referrals and enhance the shared decision making process. With an understanding of the influence that surgeons have in driving variation in surgical rates, further research may allow us to direct strategies to improve access and allow for a more equitable delivery of care for patients suffering from DDLS.