Thesis (M. A. (Clinical Psychology)) --University of the North, 2002 / Refer to the document

Primary care physicians (PCPPs) have been slow to implement electronic health records (EHRs), even though there is a U.S. federal requirement to implement EHRs. The purpose of this phenomenological study was to determine why PCPPs have been slow to adopt electronic health record (EHR) systems despite the potential to increase efficiency and quality of health care. The complex adaptive systems theory (CAS) served as the conceptual framework for this study. Twenty-six PCPPs were interviewed from primary care practices (PCPs) based in southwestern Ohio. The data were collected through a semistructured interview format and analyzed using a modified van Kaam method. Several themes emerged as barriers to EHR implementation, including staff training on the new EHR system, the decrease in productivity experienced by primary care practice (PCP) staff adapting to the new EHR system, and system usability and technical support after adoption. The findings may contribute to the body of knowledge regarding EHR system implementation and assist healthcare providers who are slow to adopt EHRs. Additionally, findings could contribute to social change by reducing healthcare costs, increasing patient access to care, and improving the efficacy of patient diagnosis and treatment.

Changes in American healthcare over the last half century have created social and economic crises, presenting challenges for doctors and patients. The recently-implemented Patient Protection and Affordable Care Act is an incremental reform that does little to change the complex multi-payer financing characterizing American healthcare. There have been growing demands for more equitable financing arrangements, notably, a single-payer healthcare system in which medical care is financed through a single, non-profit payer and in which medical care is treated as a public good and medically-necessary care is available to everyone. Nationally-representative surveys have demonstrated widespread physician support for single-payer legislation. Yet, very little scholarship has examined physician activism and virtually no studies have examined physician activism for single-payer healthcare. It is important to examine physician activism for single-payer because their participation is considered fundamental to achieving the goals of the movement. If the movement is successful in implementing single-payer financing , more efficient use of healthcare resources will ensure that all residents have access to needed medical care without being saddled by financial burdens from their care. Oregon is one of several US states with a growing grassroots movement to enact single-payer healthcare at the state level. This study seeks to examine the determinants of collective action for physicians in the Oregon movement for single-payer healthcare by answering two research questions. First, what accounts for differences in activism among physicians who support single-payer healthcare system? And second, for those physicians who are active, what activities do they do and what shapes those choices of activities? Data includes 21 semi-structured interviews with physicians around the state of Oregon supplemented with participant observation data. The interview data was analyzed using techniques from grounded theory and thematic analysis. I find that among collective action theories, collective identity theory best accounts for whether or not a physician engages in single-payer activism. A strength of collective identity theory is that it brings to light the importance of subjective interpretations of structural conditions by movement actors. The findings suggest that differences in interpretation shape the influence of motivators for and barriers to an individual's decision to engage in activism. Physicians that become active are primed to engage in single-payer activism because of their moral value sets and frustrating work experiences. They seek out groups of like-minded physicians who then are part of the process of socially-constructing a collective identity. This collective identity is emotionally-laden, is a reaction to state policies, serves to distinguish insiders from outsiders, and facilitates activism. Activist physicians engaging in the process of collective identity come to believe that altering financing is the only way to solve healthcare system issues. The activists view the political and cultural barriers to single-payer as surmountable by their activism. In contrast, non-activists interpret structural conditions like American politics and American culture as immutable barriers that will prevent the attainment of single-payer at the national or state level. In addition, non-activists lack the collective identity activists share because their beliefs contradict key beliefs of activists. The combination of the lack of collective identity and the perception of immutable barriers results in their non-participation.

The undertreatment of chronic pain and the prevention of drug abuse and diversion of pain medications (i.e., opioids) have been identified as public health issues in the United States. In this domain, the Drug Enforcement Administration (D.E.A.) faces challenges when enforcing the Controlled Substance Act because it is tasked with regulating the dispensing of opioids by physicians in the treatment of chronic pain, while also attempting to prevent their abuse and diversion. Thus, the D.E.A. must use discretion in how it enforces the C.S.A. because intentional actions to prevent opioid abuse and diversion could also unintentionally affect the willingness of primary care physicians to prescribe them in the treatment of chronic pain. As an initial step in clarifying the boundaries between the D.E.A. and the medical profession, it was necessary to assess physician perceptions about the D.E.A. 's use of enforcement discretion. A total of 205 Oregon primary care physicians completed a web-based survey examining three domains: concern about D.E.A. enforcement discretion; autonomy related to use of opioids in the treatment of chronic pain; and prescribing of opioids in the treatment of chronic pain. Results indicated that some physicians perceive a concern about D.E.A. enforcement discretion, and those who have concern are more likely to perceive having reduced autonomy related to the use of opioids in the treatment of chronic pain. The results do not support previous research that showed that such concerns directly affects physician prescribing of opioids. Instead, results reveal that concern about D.E.A. enforcement discretion is associated with reduced perceived autonomy, and reduced perceived autonomy is associated with less willingness to prescribe opioids in the treatment of chronic pain. This research takes the study on this topic one step further in identifying physician perceptions about D.E.A. enforcement discretion, and how these perceptions were associated with physician autonomy and prescribing of opioids in the treatment of chronic pain. In doing so, this research provides important scholarly contributions to the enforcement discretion literature, specific to the D.E.A., and medical professionalism as it pertains to physician autonomy related to the use of opioids in the treatment of chronic pain.

The prevalence of chronic Lyme disease (CLD) remains relatively unknown in Connecticut because there is not an agreement on what CLD is and how it should be diagnosed in addition to which pathological agent causes CLD. The aim of this quantitative study was to assess whether there were significant differences between two groups of primary care physicians (PCP) working in Connecticut from two different points in time regarding their knowledge in the diagnosis, treatment, and management of CLD. A knowledge, attitude, and practice model was used as the underlying theoretical framework for this study. A random cross-sectional survey was mailed out to the 1,726 PCPs found in the list of certified medical doctors in Connecticut of 2015. One hundred and forty-five PCPs responses (11.9% response rate) were received and compared to responses from previous data (a 2010 study) of 285 PCPs (39.1% response rate) from the list of certified medical doctors in 2006. The PCP estimated mean number of patients diagnosed and treated for CLD was not significantly different between 2006 and 2015. However, a significantly higher number of PCPs in 2015 reported knowing Lyme disease (LD) symptoms but not feeling comfortable diagnosing LD (χ� = 536.83, p < 0.001), and significantly more PCPs in 2015 reported knowing LD symptoms and feeling comfortable diagnosing CLD (χ� = 265.41, p < 0.001). This study can promote social change by encouraging Connecticut PCPs to recognize CLD as a diagnosis to enable the development of registries and case-control assessments. The findings of this study may also inspire future studies.

Orientador: Eliana Goldfarb Cyrino / Resumo: Introdução: A Organização Mundial de Saúde recomenda uma razão de um médico para cada mil habitantes para que a população tenha um adequado acesso à saúde. Apesar de o Brasil possuir um número absoluto satisfatório de médicos, há no país uma distribuição desigual destes profissionais, com carência de médicos em comunidades remotas e vulneráveis, causando um grande impacto no bem-estar da população que ali se encontra e dificultando a universalização da saúde, como prevê os princípios do Sistema Único de Saúde. Diante disso, o Governo Federal criou, em 2013, o Programa Mais Médicos (PMM), com o intuito de suprir de forma emergencial a carência de médicos em regiões de difícil fixação dos mesmos. A literatura considera que o principal fator que leva um trabalhador a deixar uma organização é seu nível de insatisfação com a função que desempenha, o que também se faz verdadeiro na área da saúde. Sendo assim, podemos inferir que a insatisfação laboral do médico da Atenção Básica é um dos motivos da dificuldade de recrutá-los e fixá-los por um período mais longo. Objetivo: Este estudo se propõe a avaliar as satisfações e insatisfações no trabalho de médicos integrantes do PMM no município de Botucatu – SP, cidade universitária com elevado IDH e com razão médico-paciente de 6,25. Metodologia: Trata-se de pesquisa qualitativa, na qual foram feitas oito entrevistas semiestruturadas com médicos do PMM e uma entrevista com gestores da AB no município, as quais foram analisadas e categori... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Introduction: The World Health Organization recommends a ratio of one doctor per thousand inhabitants so that the population has adequate access to health. Although Brazil has a satisfactory absolute number of doctors, there is an unequal distribution of these professionals in the country, with a shortage of physicians in remote and vulnerable communities, causing a great impact on the well-being of the population that lives there and making it difficult to make health accessible for everyone, as foreseen by the principles of the Sistema Único de Saúde. Due to that, the Federal Government created in 2013 the More Doctors Program (PMM), with the aim of urgently supplying the shortage of doctors in regions that are difficult to set them down. The literature considers that the main factor that leads a worker to leave an organization is their level of dissatisfaction with the role they play, which is also true in the health field. Thus, we can infer that the dissatisfaction at work of the primary care physician is one of the reasons for the difficulty of recruiting them and fixing them for a longer period. Objective: This study aims to evaluate the satisfactions and dissatisfactions in the work of physicians of the PMM in the city of Botucatu - SP, a city with a renowned University, a high HDI and a physician-patient ratio of 6.25. Methodology: This is a qualitative research, in which eight semi-structured interviews were conducted with PMM physicians and one interview with healt... (Complete abstract click electronic access below) / Mestre

The New South Wales Medical Board established a Health Programme for the assessment and rehabilitation of doctors whose clinical performance was impaired by alcohol or psychoactive substance use, mental or physical illness. This programme was developed to be individualized to the needs of each registrant. The present study has three aims: 1. To describe those doctors who participated in the Board???s Health Programme. 2. To chart the duration of involvement of these doctors through the programme. 3. To examine the outcomes associated with this programme. The study is based on the prospective cohort of all 181 impaired doctors who participated in the Health Programme between July 1st 1993 and April 30th 2001. Information on each registrant was collected at the time of the initial assessment and at each review conducted as part of the programme. Additional qualitative data was also collected and supplemented by a file audit conducted in August and September 2001. One hundred and eighty-one doctors were prospectively monitored as part of this study. The largest source of impairment was psychiatric illness (45.3%), 77% of the doctors were male. The average age of the cohort was 41.6 (sd 11.1) years. Impaired doctors were more likely to be working in emergency medicine or psychiatry and be based in a rural area. Of those who had finished their involvement in the programme, successful graduates participated for a mean of 38.2 (sd 22.3) months. In general outcomes of involvement were positive, 64 of 113 (56.6%) of doctors successfully graduated from the programme. One hundred and ten of 168 (65.5%) improved during the period of their involvement and 111 of 126 (88.1%) were working in medicine. Five, 2.8% of the participants died during the period of this study. Measures of registrant insight and support tended to increase during the period of involvement with the Health Programme. Future studies will need to establish evidence for the most appropriate interventions with impaired doctors. This process would be strengthened by the collection of standardized data across intervention programmes, supplemented with functional assessments and the collection of qualitative data.

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Adverse drug reactions (ADRs) constitute a major problem in society and in drug therapy. They are a common cause of short-term hospitalization, prolonged hospitalization and death. Spontaneous reporting of ADRs remains one the most effective methods for detecting new and serious drug reactions. In Sweden physicians are legally required to report fatal and serious ADRs. We know from previous studies that there is a substantial degree of under-reporting of ADRs also in Sweden. Attitudes towards reporting of ADRs among physicians in the northern region of Sweden were investigated using a questionnaire. The most important factor for not reporting ADRs among physicians and general practioners in our region was that the reaction was considered to be well known. However, their attitudes could also allow for a considerable rate of under-reporting. The effect on the reporting rate when nurses received instruction and were encouraged to report ADRs was studied. During a 12-month study period, 18 ADR reports with a total number of 22 ADRs were sent in by the nurses participating in the study to test nurses as reporters of ADRs. Using the Swedish ADR database, we calculated the risk of agranulocytosis associated with the use of metamizole by using consumption data from the case records of scrutinized patients’ and stored prescriptions. Over the period from 1996 to 1999, ten cases of agranulocytosis during treatment with metamizole were reported to SADRAC. Metamizole was prescribed to 666 (19%) inpatients during the 3-month study period and 112 prescriptions were identified at the participating pharmacies. Thirty-eight percent of them indicated treatment for more than 15 days. Making certain assumptions, the calculated risk of agranulocytosis was one out of every 31 000 inpatients and one out of every 1400 outpatients. The degree of under-reporting of serious ADRs was studied in five hospitals. More than 1300 case records were scrutinized and among these we found 107 cases that according to current rules for ADR reporting, should have been reported. Only fifteen of these were found in the SADRAC database, indicating a under-reporting rate of 86%.The effect on the reporting rate of ADRs was studied in an intervention study in which a small economical inducement was given to those who reported ADRs. The effect of a small economical stimulation to increase the reporting rate was studied. From the intervention area we received 62 suspected ADRs compared with 50 from the control area. The increase in the number of reports was 59% compared with an unchanged reporting rate from the control area. The physicians in northern Sweden have a relatively good knowledge of the existing rules for ADR reporting. Nurses could play an important role in detecting and reporting suspected ADRs. The risk of developing an metamizole induced agranulocytosis is considerably increased if metamizole is given to patients for a longer time than recommended. The rate of reported ADRs is very low, also for serious and fatal reactions. An increase in the reporting rate of suspected ADRs was observed during study period.

Political liberalization and increased public costs have placed new demands on the Swedish public sector. Two ways of meeting these novel requirements have been to corporatize and privatize organizations. With these two organizational changes, however, comes a risk of increased insecurity and higher demands on employees; the ability to handle these changes is likely dependent on their social status within an organization. The general aim of the thesis is to contribute to the understanding of how corporatization and privatization might affect employees’ work climate, work attitudes and ill-health. Special importance is placed on whether outcomes may differ depending on the employees’ social status in the form of hierarchic level and gender. Questionnaire data from Swedish acute care hospitals were used in three empirical studies. Study I showed that physicians at corporatized and privatized hospitals reported more positive experiences of their work climate compared with physicians at a public administration hospital. Study II showed that privatization had more negative ramifications for a middle hierarchic level (i.e., registered nurses) who reported deterioration of work attitudes, while there were no major consequences for employees at high (physicians) or low (assistant nurses) hierarchic levels. Study III found that although the work situation for women and men physicians were somewhat comparable (i.e., the same occupation, the same organization), all of the differences that remained between the genders were to the detriment of women. The results of this thesis suggest that corporatizations and privatizations do not necessarily imply negative consequence for employees. However, the consequences appear to differ between groups with different social status. Employees whose immediate work situation is affected but who do not have sufficient resources to handle the requirements associated with an organizational change may perceive the most negative consequences. / At the time of the doctoral defense, the following papers were unpublished and had a status as follows: Paper 3: Manuscript.