Submitted by JAMAL SOBHI AZZAM (jamal@clinicajamal.com.br) on 2018-05-25T17:12:44Z No. of bitstreams: 1 HABILIDADE DE GESTÃO E INICIATIVA EMPREENDEDORA DO MÉDICO BRASILEIRO.pdf: 2390141 bytes, checksum: 4cfa32e796b7110c5a7632f65cc95429 (MD5) / Approved for entry into archive by Simone de Andrade Lopes Pires (simone.lopes@fgv.br) on 2018-05-25T22:10:31Z (GMT) No. of bitstreams: 1 HABILIDADE DE GESTÃO E INICIATIVA EMPREENDEDORA DO MÉDICO BRASILEIRO.pdf: 2390141 bytes, checksum: 4cfa32e796b7110c5a7632f65cc95429 (MD5) / Approved for entry into archive by Suzane Guimarães (suzane.guimaraes@fgv.br) on 2018-05-28T12:38:02Z (GMT) No. of bitstreams: 1 HABILIDADE DE GESTÃO E INICIATIVA EMPREENDEDORA DO MÉDICO BRASILEIRO.pdf: 2390141 bytes, checksum: 4cfa32e796b7110c5a7632f65cc95429 (MD5) / Made available in DSpace on 2018-05-28T12:38:02Z (GMT). No. of bitstreams: 1 HABILIDADE DE GESTÃO E INICIATIVA EMPREENDEDORA DO MÉDICO BRASILEIRO.pdf: 2390141 bytes, checksum: 4cfa32e796b7110c5a7632f65cc95429 (MD5) Previous issue date: 2018-05-25 / O objetivo deste trabalho é conhecer o perfil de habilidade de gestão e iniciativa empreendedora do médico brasileiro. Procuramos entender seu comportamento em relação ao convívio paralelo entre o exercício da Medicina e as práticas administrativas de gestão da sua carreira e do seu ambiente de negócios, bem como as influências que o médico pode ter sofrido, desde o período anterior à formação acadêmica, na sua família, quanto ao longo da sua vida profissional. Este trabalho sugere fortes evidências de que o médico brasileiro tem muito poucas habilidades de gestão e fracas iniciativas empreendedoras. Vários motivos são aventados para a comprovação desta tese, especialmente a forte doutrinação em direção ao sacerdócio ou trabalho de cunho social sofrido na formação acadêmica, a ausência de formação administrativa em gestão, ausência de formação para a gestão da carreira, ausência de educação empreendedora etc. Os resultados sugerem também que o médico brasileiro acredita que os empreendimentos em saúde podem ser fundados por profissionais não médicos, entretanto entende que a gestão destes negócios deve ser predominantemente realizada pelos médicos. Encontramos dados que sugerem que o médico inverte a sequência tradicional de recompensas do empreendedor, colocando em primeiro lugar a satisfação pessoal, seguidas da independência e depois do lucro. / We carried out our Applied Work with the main purpose of knowing the profile of management ability and entrepreneurial initiative of the Brazilian physician. We tried to understand their behavior in relation to the parallel relationship between the practice of Medicine and the administrative practices of managing their career and their business environment, as well as the influences that the doctor may have suffered from the period before the academic training in his family, and throughout his professional life. Our work suggests strong evidence that the Brazilian doctor has very few management skills and weak entrepreneurial initiatives. There are several reasons for this thesis, especially the strong indoctrination towards the priesthood or social work suffered in academic formation, absence of administrative training in management, lack of training for career management, lack of entrepreneurial education, etc. The results also suggest that the Brazilian doctor believes that non-medical professionals can found health care enterprises, however he understands that physicians should predominantly perform the management of these businesses. We found evidence suggesting that the physician reverses the entrepreneur's traditional rewards sequence by placing first personal satisfaction, followed by independence, and then profit.

The Importance and Protection of the Conscience of Physician in the Physician-Patient Relationship In democratic countries all over the world, the protection of the conscience of health workers represents a very relevant problem. Especially the controversial but legal procedures, such as abortion or, in some countries, euthanasia, are often refused by health workers on the basis of their conscience. The society faces a difficult dilemma of balancing the interests of physicians, patients, and health care systems. The thesis approaches the problem primarily from the perspective of Catholic moral theology in the frame of a predominantly secular environment of the contemporary Euro-American civilisation. There are analysed the concept of conscience, the basic principles of moral reasoning, virtue ethics and its importance for modern medicine and, finally, the concept of conscientious objection as a model example of the protection of health worker's conscience. The above mentioned particular topics serve as a basis for the evaluation of the importance of the conscience of health worker and the proposal of possible solutions to the related dilemmas.

<div>This dissertation consists of three chapters. The first chapter, Inertia and Switching in Health Insurance Plans, seeks to examine health insurance choice of families and individuals employed by a large Midwestern public university during the years 2012-2016. A growing number of studies indicate that consumers do not understand the basics of health insurance, make inefficient plan choices, and may hesitate to switch plans even when it is optimal to do so. In this study, I identify what are later defined as unanticipated, exogenous health shocks in the health insurance claims data, in order to examine their effect on families' plan choice and switching behavior. Observing switches into relatively generous plans after a shock is indicative of adverse selection. Adverse retention and inertia, on the other hand, may be present if people remain in the relatively less generous plans after experiencing a shock. The results could help inform the policy-makers about consumer cost-effectiveness in plan choice over time.</div><div> Physicians’ relationships with the pharmaceutical industry have recently come under public scrutiny, particularly in the context of opioid drug prescribing. The second chapter, Pharmaceutical Opioid Marketing and Physician Prescribing Behavior, examines the effect of doctor-industry marketing interactions on subsequent prescribing patterns of opioids using linked Medicare Part D and Open Payments data for the years 2014-2017. Results indicate that both the number and the dollar value of marketing visits increase physicians’ patented opioid claims. Furthermore, direct-to-physician marketing of safer abuse-deterrent formulations of opioids is the primary driver of positive and persistent spillovers on the prescribing of less safe generic opioids - a result that may be driven by insurance coverage policies. These findings suggest that pharmaceutical marketing efforts may have unintended public health implications.</div><div> The third chapter, Accountable Care Organizations and Physician Antibiotic Prescribing Behavior, examines the effects of Accountable Care Organizations (ACOs). Physician accountable care organization affiliation has been found to reduce cost and improve quality across metrics that are directly measured by the ACO shared savings program. However, little is known about potential spillover effects from this program onto non-measured physician behavior such as antibiotic over-prescribing. Using a two-part structural selection model that accounts for selection into treatment (ACO group), and non-treatment (control group), this chapter compares physician/nurse antibiotic prescribing across these groups with adjustment for geographic, physician, patient and institutional characteristics. Heterogeneous treatment responses across specialties are also estimated. The findings indicate that ACO affiliation helps reduce antibiotic prescribing by 23.9 prescriptions (about 19.4 percent) per year. The treatment effects are found to vary with specialty with internal medicine physicians experiencing an average decrease of 19 percent, family and general practice physicians a decrease of 16 percent, and nurse practitioners a reduction of 12.5 percent in their antibiotic prescribing per year. In terms of selection into treatment, the failure to account for selection on physician unobservable characteristics results in an understating of the average treatment effects. In assessing the impact of programs, such as the ACO Shared Savings Program, which act to augment how physicians interact with each other and their patients, it is important to account for spillover effects. As an example of such spillover effect - this study finds that ACO affiliation has had a measurable impact on physician antibiotic prescribing.</div>

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Background: Concerns about burnout, and its consequences, among German physicians are rising. However, data on burnout among German physicians are scarce. Also, a suspected association between burnout and German physicians’ wishes to leave remains to be studied. Therefore, the extent of burnout, and the association between burnout and wishes to leave clinical practice or to go abroad for clinical work was studied in a sample of young physicians in Saxony. Methods: In a cross-sectional survey, all physicians ≤40 years and registered with the State Chamber of Physicians of Saxony, Germany (n = 5956) received a paper-pencil questionnaire inquiring about socio-demographics, job satisfaction, and wishes to leave clinical practice or to go abroad for clinical work. Response rate was 40 % (n = 2357). Burnout was measured with the German version of the Maslach Burnout Inventory - Human Services Survey (MBI) consisting of the subscales emotional exhaustion (feeling emotionally drained), depersonalization (feelings of cynicsm) and personal accomplishment (feelings of personal achievement in job). Variables associated with burnout, and the association between burnout and wishes to leave were assessed in multivariate logistic regression analyses. Results: For emotional exhaustion participants reached a mean of 21.3 [standard deviation = 9.74], for depersonalization a mean of 9.9 [5.92], and for personal accomplishment a mean of 36.3 [6.77]. Men exhibited significantly higher depersonalization than women (11.3 [6.11] versus 9 [5.62], p < 0.001). Eleven percent of participants showed a high degree of burnout on all subscales, while 35 % did not show a high degree of burnout on any subscale. Confirming that one would become a physician again, and higher satisfaction with the components \"work environment\" and \"humaneness\", were associated with a lower chance for a high degree of burnout on all subscales. Higher emotional exhaustion and lower personal accomplishment were associated with an increased chance of wishing to leave clinical practice. Higher emotional exhaustion and higher depersonalization were associated with an increased chance of wishing to go abroad for clinical work. Conclusions: Preventing physician burnout may not only benefit the affected individual. It may also benefit the health care system by potentially preventing physicians from leaving clinical practice or from going abroad for clinical work.

This dissertation is a conversation analytic examination of recurrent practices of interaction in medicalemergency calls. The study expands the analytical focus in past research on emergency calls betweenemergency call operators and callers to pre-hospital emergency care interaction on the phone betweennurses, physicians and callers. The investigation is based on ethnographic fieldwork in a Swedish emergencycontrol centre. The data used for the study consists primarily of audio recordings of medical emergency calls.Fundamental procedures in medical emergency calls examined in the dissertation are: (1) questioning; (2)emotion management; (3) risk management and (4) instruction giving. Emergency call-takers ask questions toelicit descriptions by callers of what is happening and to manage symptoms of patients to help keep them safeuntil ambulance crews arrive. In the questioning practice about acutely ill or injured patients call-takers usemainly yes-no questions and clarify problems by questioning callers making a distinction between defined andundefined problems. The analysis reveals four core types of emotion management practices: (1) call-takerskeep themselves calm when managing callers’ social displays of emotions; (2) promising ambulanceassistance; (3) providing problem solving presentations including emergency response measures to concernsof callers, and (4) emphasising the positive to create hope for callers. Call-takers use seven key procedures tomanage risk in medical emergency calls: (1) risk listening through active listening after actual and possiblerisks; (2) risk questioning; (3) risk identification; (4) risk monitoring; (5) risk assessment; (6) making decisionsabout elicited risk and (7) risk reduction. Instruction giving using directives and recommendations isaccomplished by call-takers in four main ways: (1) acute flow maintaining instruction giving when callers areprocedurally out of line; (2) measure oriented instructions for patient care and emergency responsemanagement; (3) organisational response instructions and (4) summarising instruction giving. Callers routinelyacknowledge risk identifications and follow instructions delivered by call-takers to examine statuses and lifesigns of patients such as breathing, movement and pulse, and perform basic first aid and emergency responsemeasures.The findings generated from this study will be useful in emergency call-taker training in carrying out interactiveprocedures in medical emergency calls and add to the larger research programmes on on-telephoneinteraction between professionals and citizen callers. This is an essential book for pre-hospital emergency careproviders and institutional interaction researchers and students. / <p>At the Faculty of Social Sciences in the subject of Sociology</p>

Bakgrund: Eutanasi är ett ämne som är väl omdebatterat i världen och betyder egentligen hjälp till en smärtfri död, men används idag som synonym till dödshjälp. Aktiv dödshjälp innebär att läkaren förskriver ett läkemedel med syfte att avsluta en patients liv. Läkarassisterat självmord innebär att patienten själv tar läkemedlet medan aktiv dödshjälp innebär att sjukvården hjälper till att avsluta patientens liv. Syfte: Syftet var att beskriva sjuksköterskors inställning till eutanasi och de faktorer som beskrivs ligga bakom dessa inställningar, samt att beskriva undersökningsgrupperna i de valda artiklarna. Metod: Författarna gjorde en deskriptiv litteraturstudie. Artiklar har sökts fram i sökmotorn PubMed med en femårsbegränsning. Totalt 11 artiklar bearbetades och sammanställdes i kategorier för att besvara frågeställningarna. Resultat: Resultatet visade att sjuksköterskors inställning till eutanasi är en komplex fråga som kan vara beroende av olika faktorer som vilket land de arbetar i och vilka patientgrupper de arbetar med. Majoriteten av deltagarna i studierna var kvinnor i olika åldrar med olika lång arbetslivserfarenhet som sjuksköterska. Resultatet i föreliggande litteraturstudie presenteras utifrån tre huvudrubriker med utgångspunkt i frågeställningarna; Sjuksköterskors inställning till eutanasi, Bidragande faktorer till sjuksköterskornas inställning till eutanasi, samt den metodologiska aspekten undersökningsgrupper. Slutsats: Föreliggande litteraturstudie visar att sjuksköterskors inställning till eutanasi kan vara högst individuell och beroende av många faktorer. Att man som sjuksköterska kan komma i kontakt med dessa frågor är ett faktum, oavsett var och med vilka patienter man arbetar. Med mer erfarenhet och kunskap om ämnet kan sjuksköterskan känna sig tryggare i bemötandet med den döende patienten och dennes anhöriga. / Background: Euthanasia is a well-discussed subject all around the world and means help to a painless death. Active euthanasia means that a doctor prescribes a drug intended to end a patients’ life. Physician-assisted suicide means that the patient takes the drug themselves, while active euthanasia involves medical help to end the patient’s life. Aim: The aim of this study was to describe nurses’ attitudes towards euthanasia and the factors described underlie these attitudes, as well as to describe the study groups in the included articles. Method: The authors conducted a descriptive literature review. The articles were found in the search engine PubMed with a five-year limit. A total of 11 articles were processed and summarized into categories to answer the research questions. Findings: The results showed that nurses' attitudes towards euthanasia is a complex issue which may be dependent on several factors such as which country they work in and which patient groups they work with. Most participants in the studies were women of different age and different experience as a nurse. The result of the present literature review form three main headings, based on the issues; nurses' attitudes towards euthanasia, contributing factors to the nurses' attitudes towards euthanasia, as well as the methodological aspect - study groups. Conclusion: The present literature review shows that nurses' attitudes towards euthanasia can be very individual and depend on many factors. It is a fact that nurses may come in contact with these issues, no matter where and with what kind of patients they work. With more experience and knowledge of the subject, the nurse may feel safer in facing the dying patients and their relatives.

L'annonce d'une mauvaise nouvelle en cancérologie constitue un exercice anxiogène pour les médecins. La théorie de la régulation émotionnelle laisse à penser que les médecins vont avoir recours à des stratégies afin de réguler leurs émotions au moment de l'annonce. Nous nous sommes interrogés sur l'impact des stratégies de régulation émotionnelle des médecins confrontés à l'annonce d'une mauvaise nouvelle, sur l'ajustement psychologique de leurs patients. Pour y répondre, quatre études ont été menées. La première visait à analyser l'anxiété des médecins et deux stratégies de régulation émotionnelles ( la réévaluation cognitive et la suppression expressive), à l'annonce d'une mauvaise nouvelle. Dans la seconde étude, les résultats de l'analyse quantitative d'entretiens menés auprès de médecins nous ont permis d'élargir l'éventail des émotions (négatives et positives) et des stratégies de régulation émotionnelle des médecins à l'annonce d'une mauvaise nouvelle. Dans la troisième étude, l'analyse IPA du discours des médecins a fait émerger deux éléments clés de compréhension de l'expérience subjective des médecins face à l'annonce : le sens que les médecins donnent à l'annonce et à leur rôle, et le lien établi avec leurs patients. La dernière étude s'est focalisée sur l'analyse des liens entre l'anxiété, les stratégies de régulation émotionnelle et les compétences relationnelles des médecins au moment de l'annonce, et l'ajustement psychologique de leurs patients quinze jours après l'annonce. Les résultats de ces quatre études apportent de nouveaux éléments de réflexion concernant les formations à l'annonce de mauvaises nouvelles proposées aux médecins. / Breaking bad news in oncology is a difficult task for physicians, generating anxiety. The theory of emotion regulation suggests that physicians are using emotion regulation strategies to influence their emotions when breaking bad news to patients. The literature has led us to question the impact of the emotion regulation strategies of physicians facing giving bad news in oncology, on their patient's psychological adjustment. To address this topic, four studies were carried out. The first one enables us to analyse physicians' anxiety and two emotions regulation strategies (expressive suppression and cognitive reappraisal) at three different stages of the announcement : just before, just after and a week later. In the second study, the results of qualitative analysis from semi-structured interviews with physicians allow us to expand the range of emotions (negative and positive) and physicians' emotion regulation strategies when announcing a bad news. In the third study, the interpretative phenomenological analysis of the physicians' interviews enables us to understand two key elements of the subjective experience of physicians facing the announcement : the importance that physicians give to the announcement and their role, and the relationship established with their patients. Tha last study focusses on the analysis of the link between anxiety, emotion regulation strategies and the physicians' interpersonal skills when breaking bad news in oncology, and the patient's psychological adjustment fifteen days after the announcement. The results of these four studies allow to provide new lines of approach regarding the training in breaking bad news currently available for physicians.

Objetivo: avaliar o grau de empatia dos estudantes de medicina e suas mudanças durante o curso médico de uma Faculdade na cidade de São Paulo, Brasil. Método: Estudo descritivo, comparativo e transversal. Amostra não aleatória de 296 alunos. O estudo foi conduzido de Setembro até Dezembro de 2013. A avaliação da empatia foi realizada usando a escala de empatia médica de Jefferson (JSPE) na versão para estudantes de medicina, e a escala multidimensional de reatividade interpessoal de Davis (EMRI) na versão validade e adaptada no Brasil. Ambas escalas foram aplicadas simultaneamente a cada aluno. A JSPE contém 20 itens que são respondidos de acordo com a variante de escala de Likert de sete pontos (Concordo = 7 / Discordo = 1) .Esta escala avalia atributos cognitivos da empatia. A EMRI contém 21 itens que são respondidos de acordo com a escala de Likert de cinco pontos ( Descreve-me muito bem = 5 / Não me descreve muito bem = 1). Esta escala avalia tanto componentes cognitivos quanto afetivos da empatia. Os alunos foram divididos em três grupos de acordo com o ano da graduação: o grupo básico (1º e 2º ano), grupo clínico (3º e 4º ano ) e o grupo do internato (5 º e 6 º ano), e foram comparados os escores de empatia entre os três grupos. Resultados: Ao aplicar JSPE não houve uma diferença significativa quando comparado o escore entre os 3 grupos. Por outro lado ao aplicar a EMRI foi identificado um escore de empatia significativamente menor no grupo do internato quando avaliado o componente afetivo (p < 0,01). Tanto na JSPE quanto na EMRI, as mulheres obtiveram os melhores escores de empatia (p < 0,01) quando comparada aos homens. Os alunos que pretendiam seguir especialidade clínica obtiveram escore de empatia maior quando comparada com especialidade cirúrgica utilizando tanto a JSPE (p=0,05) quanto a EMRI (p < 0,01). Conclusões: O nível de empatia pode mudar e, neste caso, a dimensão afetiva é a mais afetada durante o curso médico. A identificação desta erosão afetiva mostra a necessidade de elaborar estratégias educacionais efetivas que possam contribuir para uma boa formação do futuro profissional médico / Purpose: This study was designed to examine changes in medical students\' empathy during medical school in São Paulo, Brazil. Method: Descriptive, comparative and cross-sectional study. Not randomized sample of 296 students. The study was conducted from September to December 2013. The empathy evaluation was performed using the Jefferson Scale of Physician Empathy (JSPE), version for medical students, and the Davis\'s multidimensional Interpersonal Reactivity Index (EMRI), both of then being applied simultaneously to each student. The JSPE contains 20 items that are answered according to the scale of Likert variant of seven points (7= completely in agreement / 1= completely in disagreement). It is important to emphasize that this scale assesses cognitive attributes of empathy. The EMRI contains 21 items that are answered according to the scale of Likert variant of five ponts (5= describe me very well /1= not describe me very well). This scale assesses cognitive and affective attributes of empathy. The students were divided into three groups, according to the year of professional career: the Basic Group (1st and 2 nd year), the Clinical Group (3rd and 4th year) and the Clerkship group (5th and 6th year). The score of empathy between the three groups was compared. Results: The JSPE scores were similar among the students from the Basic, Clinical and Clerkship groups (p=0.53). On the other hand, the affective dimension of EMRI revealed a significantly lower score in the Clerkship Group (p < 0.01). Women obtained better scores for empathy compared to men, in both scales (p < 0,01). Students who intended to follow clinical careers had higher empathy scores when compared to those who intended to follow surgical careers so when applied to JSPE (p = 0.05) as the EMRI (p < 0.01). Conclusions: The level of empathy can change and in this case, the affective dimension is most affected during medical school. The identification of affective erosion support the need to develop effective educational strategies that contribute to a good training medical professional future