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1.  Doctors accessing mental-health services: an exploratory study 
BMJ Open  2011;1(1):e000017.
Objective
To develop a more in-depth understanding of how doctors do and do not access mental healthcare from the perspectives of doctors themselves and people they have contact with through the process.
Design
Qualitative methodology was used with semistructured interviews transcribed and analysed using Grounded Theory. Participants were 11 doctors with experience as patients of psychiatrists, four doctor and four non-doctor personal contacts (friends, family and colleagues) and eight treating psychiatrists.
Results
Participants described experiencing unrealistic expectations and a harsh work environment with poor self care and denial and minimisation of signs of mental health difficulties. Doctor contacts described particular difficulty in responding effectively to doctor friends, family and colleagues in need of mental healthcare. In contrast, non-doctor personal contacts were more able to identify and speak about concerns but not necessarily to enable accessing adequate mental-health services.
Conclusions
Three areas with potential to address in supporting doctors' accessing of appropriate healthcare have been identified: (1) processes to enable doctors to maintain high standards of functioning with less use of minimisation and denial; (2) improving the quality and effectiveness of informal doctor-to-doctor conversations about mental-health issues among themselves; (3) role of non-doctor support people in identifying doctors' mental-health needs and enabling their access to mental healthcare. Further research in all these areas has the potential to contribute to improving doctors' access to appropriate mental healthcare and may be of value for the general population.
Article summary
Article focus
Doctors' accessment of adequate mental healthcare is less than optimal.
Family and community contacts have an important role in accessing mental healthcare.
Our understanding of the processes related to doctors accessing mental healthcare can be improved by exploring perspectives of doctor patients, their support people and treating psychiatrists.
Key messages
Doctors' unrealistic expectations of themselves and associated minimisation and denial of a range of self care needs may function as a barrier to accessing mental healthcare.
Addressing how doctors respond to other doctors in informal conversations indicating mental healthcare needs may be helpful in improving access to care.
Non-doctor support people may have a valuable role in enabling doctors to access appropriate mental healthcare.
All these areas need further research.
Strengths and limitations of this study
This is the first study of its kind and generates new insights in an important area.
Because of challenges in recruiting doctors with experience as patients of psychiatrists, a hard-to-reach group, the sample is small and not broadly representative.
doi:10.1136/bmjopen-2010-000017
PMCID: PMC3191385  PMID: 22021726
Child & adolescent psychiatry; adult psychiatry; physicians' health; accessing healthcare; impaired physician; mental health
2.  Doctors' perceptions of palliative care for heart failure: focus group study 
BMJ : British Medical Journal  2002;325(7364):581-585.
Objectives
To identify doctors' perceptions of the need for palliative care for heart failure and barriers to change.
Design
Qualitative study with focus groups.
Setting
North west England.
Participants
General practitioners and consultants in cardiology, geriatrics, palliative care, and general medicine.
Results
Doctors supported the development of palliative care for patients with heart failure with the general practitioner as a central figure. They were reluctant to endorse expansion of specialist palliative care services. Barriers to developing approaches to palliative care in heart failure related to three main areas: the organisation of health care, the unpredictable course of heart failure, and the doctors' understanding of roles. The health system was thought to work against provision of holistic care, exacerbated by issues of professional rivalry and control. The priorities identified for the future were developing the role of the nurse, better community support for primary care, and enhanced communication between all the health professionals involved in the care of patients with heart failure.
Conclusions
Greater consideration should be given to the care of patients dying with heart failure, clarifying the roles of doctors and nurses in different specialties, and reshaping the services provided for them. Many of the organisational and professional issues are not peculiar to patients dying with heart failure, and addressing such concerns as the lack of coordination and continuity in medical care would benefit all patients.
What is already known on this topicPatients with heart failure have unmet needs for health care at the end of lifeSpecialist palliative care services see few patients with heart failureThe national service framework for coronary heart disease endorses the provision of palliative care for heart failureLittle evidence exists on how this care should be provided, and doctors' views are not knownWhat this study addsBarriers to adopting a palliative care approach in heart failure care relate to the current organisation of health services, the difficulties of prognostication, and doctors' understanding of roles and responsibilitiesDoctors believe that the general practitioner should be the central figure in palliative care for heart failure, supported by specialistsDoctors' future priorities are developing the role of nurses, increasing essential community services, such as district nursing, and improving communication with colleagues
PMCID: PMC124557  PMID: 12228136
3.  Barriers to referral in patients with angina: qualitative study 
BMJ : British Medical Journal  1999;319(7207):418-421.
Objectives
To explore barriers to patients being referred for possible revascularisation.
Design
Qualitative study using semi-structured interviews.
Participants
16 patients aged under 75 years with stable angina and their doctors.
Setting
General practice in Toxteth, Liverpool.
Results
Fear of both hospitals and medical tests was common and largely hidden from the doctors. Patients felt they were old, had low expectations of treatment, viewed angina as a chronic illness, and knew little about new developments in angina treatment. Patients and doctors had difficulty in recognising angina symptoms that were not textbook definitions amid multiple comorbidity. Patients saw doctors as busy and did not want to bother them with their condition. Cultural gaps and communication difficulties existed despite all but one patient having English as their first language.
Conclusions
Listening to patients is vital to address inequitable access to health services: how patients are treated by doctors today affects acceptability of referral tomorrow. Primary care groups in deprived areas should work with communities to address local fears. This will involve collaboration between primary, secondary, and tertiary care. Cultural gaps exist between patients and doctors in deprived areas, and diagnostic confusion can occur particularly in the presence of other psychological and physical morbidity. Adequate time and resources—for example, education for doctors and patients and provision of interpreters—need to be provided if inequitable access to revascularisation procedures is to be addressed.
Key messagesIn different communities and patient groups different myths and fears operate and need to be addressed, as experiences of hospital can profoundly affect patients’ confidencePatients in deprived areas with high mortality rates perceive themselves as “old” at a young age, and expectations of treatment are limitedAngina symptoms in inner city primary care may not be the same as those in a textbook, and this has implications for care of patientsCultural gaps exist even between committed doctors and their patients in deprived areas—time and resources are needed to address these gapsQualitative studies are necessary to understand quantitative evidence of inequitable access to specialist health services
PMCID: PMC28197  PMID: 10445924
4.  Understanding the 'four directions of travel': qualitative research into the factors affecting recruitment and retention of doctors in rural Vietnam 
Background
Motivation and retention of health workers, particularly in rural areas, is a question of considerable interest to policy-makers internationally. Many countries, including Vietnam, are debating the right mix of interventions to motivate doctors in particular to work in remote areas. The objective of this study was to understand the dynamics of the health labour market in Vietnam, and what might encourage doctors to accept posts and remain in-post in rural areas.
Methods
This study forms part of a labour market survey which was conducted in Vietnam in November 2009 to February 2010. The study had three stages. This article describes the findings of the first stage - the qualitative research and literature review, which fed into the design of a structured survey (second stage) and contingent valuation (third stage). For the qualitative research, three tools were used - key informant interviews at national and provincial level (6 respondents); in-depth interviews of doctors at district and commune levels (11 respondents); and focus group discussions with medical students (15 participants).
Results
The study reports on the perception of the problem by national level stakeholders; the motivation for joining the profession by doctors; their views on the different factors affecting their willingness to work in rural areas (including different income streams, working conditions, workload, equipment, support and supervision, relationships with colleagues, career development, training, and living conditions). It presents findings on their overall satisfaction, their ranking of different attributes, and willingness to accept different kinds of work. Finally, it discusses recent and possible policy interventions to address the distribution problem.
Conclusions
Four typical 'directions of travel' are identified for Vietnamese doctors - from lower to higher levels of the system, from rural to urban areas, from preventive to curative health and from public to private practice. Substantial differences in income from formal and informal sources all reinforce these preferences. While non-financial attributes are also important for Vietnamese doctors, the scale of the difference of opportunities presents a considerable policy challenge. Significant salary increases for doctors in hard-to-staff areas are likely to have some impact. However, addressing the differentials is likely to require broader market reforms and regulatory measures.
doi:10.1186/1478-4491-9-20
PMCID: PMC3169448  PMID: 21849045
5.  Professional Uncertainty and Disempowerment Responding to Ethnic Diversity in Health Care: A Qualitative Study 
PLoS Medicine  2007;4(11):e323.
Background
While ethnic disparities in health and health care are increasing, evidence on how to enhance quality of care and reduce inequalities remains limited. Despite growth in the scope and application of guidelines on “cultural competence,” remarkably little is known about how practising health professionals experience and perceive their work with patients from diverse ethnic communities. Using cancer care as a clinical context, we aimed to explore this with a range of health professionals to inform interventions to enhance quality of care.
Methods and Findings
We conducted a qualitative study involving 18 focus groups with a purposeful sample of 106 health professionals of differing disciplines, in primary and secondary care settings, working with patient populations of varying ethnic diversity in the Midlands of the UK. Data were analysed by constant comparison and we undertook processes for validation of analysis. We found that, as they sought to offer appropriate care, health professionals wrestled with considerable uncertainty and apprehension in responding to the needs of patients of ethnicities different from their own. They emphasised their perceived ignorance about cultural difference and were anxious about being culturally inappropriate, causing affront, or appearing discriminatory or racist. Professionals' ability to think and act flexibly or creatively faltered. Although trying to do their best, professionals' uncertainty was disempowering, creating a disabling hesitancy and inertia in their practice. Most professionals sought and applied a knowledge-based cultural expertise approach to patients, though some identified the risk of engendering stereotypical expectations of patients. Professionals' uncertainty and disempowerment had the potential to perpetuate each other, to the detriment of patient care.
Conclusions
This study suggests potential mechanisms by which health professionals may inadvertently contribute to ethnic disparities in health care. It identifies critical opportunities to empower health professionals to respond more effectively. Interventions should help professionals acknowledge their uncertainty and its potential to create inertia in their practice. A shift away from a cultural expertise model toward a greater focus on each patient as an individual may help.
From a qualitative study, Joe Kai and colleagues have identified opportunities to empower health professionals to respond more effectively to challenges in their work with patients from diverse ethnic communities.
Editors' Summary
Background.
Communities are increasingly diverse in terms of ethnicity (belonging to a group of people defined by social characteristics such as cultural tradition or national origin) and race (belonging to a group identified by inherited physical characteristics). Although health professionals and governments are striving to ensure that everybody has the same access to health care, there is increasing evidence of ethnic inequalities in health-care outcomes. Some of these inequalities reflect intrinsic differences between groups of people—Ashkenazi Jews, for example, often carry an altered gene that increases their chance of developing aggressive breast cancer. Often, however, these differences reflect inequalities in the health care received by different ethnic groups. To improve this situation, “cultural competence” has been promoted over recent years. Cultural competence is the development of skills by individuals and organizations that allow them to work effectively with people from different cultures. Health professionals are now taught about ethnic differences in health beliefs and practices, religion, and communication styles to help them provide the best service to all their patients.
Why Was This Study Done?
Numerous guidelines aim to improve cultural competency but little is known about how health professionals experience and perceive their work with patients from diverse ethnic groups. Is their behavior influenced by ethnicity in ways that might contribute to health care disparities? For example, do doctors sometimes avoid medical examinations for fear of causing offence because of cultural differences? If more were known about how health professionals handle ethnic diversity (a term used here to include both ethnicity and race) it might be possible to reduce ethnic inequalities in health care. In this qualitative study, the researchers have explored how health professionals involved in cancer care are affected by working with ethnically diverse patients. A qualitative study is one that collects nonquantitative data such as how doctors “feel” about treating people of different ethnic backgrounds; a quantitative study might compare clinical outcomes in different ethnic groups.
What Did the Researchers Do and Find?
The researchers enrolled 106 doctors, nurses, and other health-related professionals from different health-service settings in the Midlands, an ethnically diverse region of the UK. They organized 18 focus groups in which the health professionals described their experiences of caring for people from ethnic minority backgrounds. The participants were encouraged to recall actual cases and to identify what they saw as problems and strengths in their interactions with these patients. The researchers found that the health professionals wrestled with many challenges when providing health care for patients from diverse ethnic backgrounds. These challenges included problems with language and with general communication (for example, deciding when it was acceptable to touch a patient to show empathy). Health professionals also worried they did not know enough about cultural differences. As a result, they said they often felt uncertain of their ability to avoid causing affront or appearing racist. This uncertainty, the researchers report, disempowered the health professionals, sometimes making them hesitate or fail to do what was best for their patient.
What Do These Findings Mean?
These findings reveal that health professionals often experience considerable uncertainty when caring for ethnically diverse patients, even after training in cultural competency. They also show that this uncertainty can lead to hesitancy and inertia, which might contribute to ethnic health care inequalities. Because the study participants were probably already interested in ethnic diversity and health care, interviews with other health professionals (and investigations of patient experiences) are needed to confirm these findings. Nevertheless, the researchers suggest several interventions that might reduce health care inequalities caused by ethnic diversity. For example, health professionals should be encouraged to recognize their uncertainty and should have access to more information and training about ethnic differences. In addition, there should be a shift in emphasis away from relying on knowledge-based cultural information towards taking an “ethnographic” approach. In other words, health professionals should be helped to feel able to ask their patients about what matters most to them as individuals about their illness and treatment.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0040323.
Information on cultural competence and health care is available from the US National Center for Cultural Competence (in English and Spanish) and DiversityRx
PROCEED (Professionals Responding to Cancer in Ethnic Diversity) is a multimedia training tool for educators within the health and allied professions developed from the results of this study; a press release on PROCEED is available from the University of Nottingham
Transcultural Health Care Practice: An educational resource for nurses and health care practitioners is available on the web site of the UK Royal College of Nursing
doi:10.1371/journal.pmed.0040323
PMCID: PMC2071935  PMID: 18001148
6.  Reasons for Consulting a Doctor on the Internet: Web Survey of Users of an Ask the Doctor Service 
Background
In 1998 the Swedish noncommercial public health service Infomedica opened an Ask the Doctor service on its Internet portal. At no charge, anyone with Internet access can use this service to ask questions about personal health-related and disease-related matters.
Objective
To study why individuals choose to consult previously-unknown doctors on the Internet.
Methods
Between November 1, 2001, and January 31, 2002 a Web survey of the 3622 Ask the Doctor service users, 1036 men (29%) and 2586 (71%) women, was conducted. We excluded 186 queries from users. The results are based on quantitative and qualitative analysis of the answers to the question "Why did you choose to ask a question at Infomedica's 'Ask the Doctor' service?"
Results
1223 surveys were completed (response rate 34%). Of the participants in the survey 322 (26%) were male and 901 (74%) female. As major reasons for choosing to consult previously-unknown doctors on the Internet participants indicated: convenience (52%), anonymity (36%), "doctors too busy" (21%), difficult to find time to visit a doctor (16%), difficulty to get an appointment (13%), feeling uncomfortable when seeing a doctor (9%), and not being able to afford a doctors' visit (3%). Further motives elicited through a qualitative analysis of free-text answers were: seeking a second opinion, discontent with previous doctors and a wish for a primary evaluation of a medical problem, asking embarrassing or sensitive questions, seeking information on behalf of relatives, preferring written communication, and (from responses by expatriates, travelers, and others) living far away from regular health care.
Conclusions
We found that an Internet based Ask the Doctor service is primarily consulted because it is convenient, but it may also be of value for individuals with needs that regular health care services have not been able to meet.
doi:10.2196/jmir.5.4.e26
PMCID: PMC1550573  PMID: 14713654
Internet; remote consultation; physician-patient relations; access to information; information services; anonyms and pseudonyms
7.  Human Resource and Funding Constraints for Essential Surgery in District Hospitals in Africa: A Retrospective Cross-Sectional Survey 
PLoS Medicine  2010;7(3):e1000242.
In the second of two papers investigating surgical provision in eight district hospitals in Saharan African countries, Margaret Kruk and colleagues describe the range of providers of surgical care and anesthesia and estimate the related costs.
Background
There is a growing recognition that the provision of surgical services in low-income countries is inadequate to the need. While constrained health budgets and health worker shortages have been blamed for the low rates of surgery, there has been little empirical data on the providers of surgery and cost of surgical services in Africa. This study described the range of providers of surgical care and anesthesia and estimated the resources dedicated to surgery at district hospitals in three African countries.
Methods and Findings
We conducted a retrospective cross-sectional survey of data from eight district hospitals in Mozambique, Tanzania, and Uganda. There were no specialist surgeons or anesthetists in any of the hospitals. Most of the health workers were nurses (77.5%), followed by mid-level providers (MLPs) not trained to provide surgical care (7.8%), and MLPs trained to perform surgical procedures (3.8%). There were one to six medical doctors per hospital (4.2% of clinical staff). Most major surgical procedures were performed by doctors (54.6%), however over one-third (35.9%) were done by MLPs. Anesthesia was mainly provided by nurses (39.4%). Most of the hospital expenditure was related to staffing. Of the total operating costs, only 7% to 14% was allocated to surgical care, the majority of which was for obstetric surgery. These costs represent a per capita expenditure on surgery ranging from US$0.05 to US$0.14 between the eight hospitals.
Conclusion
African countries have adopted different policies to ensure the provision of surgical care in their respective district hospitals. Overall, the surgical output per capita was very low, reflecting low staffing ratios and limited expenditures for surgery. We found that most surgical and anesthesia services in the three countries in the study were provided by generalist doctors, MLPs, and nurses. Although more information is needed to estimate unmet need for surgery, increasing the funds allocated to surgery, and, in the absence of trained doctors and surgeons, formalizing the training of MLPs appears to be a pragmatic and cost-effective way to make basic surgical services available in underserved areas.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Infectious diseases remain the major killers in developing countries, but traumatic injuries, complications of childbirth, and other conditions that need surgery are important contributors to the overall burden of disease in these countries. Unfortunately, the provision of surgical services in low- and middle-income countries is often insufficient. There are many fewer operations per a head of population in developing countries than in developed countries, essential operations such as cesarean sections for complicated deliveries are not always available, and elective operations such as male and female sterilization can be difficult to obtain. Lack of funding for surgical procedures and shortages of trained health workers have often been blamed for the low rates of surgery in developing countries. For example, anesthesiologists (doctors who are trained to give anesthetics and other pain-relieving agents) and trained anesthetists (usually nurses and technicians) are rare in many African countries, as are surgeons and obstetricians (doctors who look after women during pregnancy and childbirth). To make matters worse, these specialists often work in tertiary referral hospitals in large cities. In district hospitals, which provide most of the primary health care needs of rural populations, basic surgical care is usually provided by “mid-level health care providers” (MLPs)—individuals with a level of training between that of nurses and physicians.
Why Was This Study Done?
Various organizations are currently working to improve emergency and essential surgical care in developing countries. For example, the Bellagio Essential Surgery Group (BESG) seeks to define, quantify, and address the problem of unmet surgical needs in sub-Saharan Africa. Importantly, however, before any programs can be introduced to improve access to surgical services in developing countries, better baseline data on existing surgical services needs to be collected—most of the available information on these services is anecdotal. In this study, the researchers (most of whom are members of the BESG) investigate the provision of surgical procedures and anesthesia in district hospitals in three sub-Saharan African countries and estimate the costs of surgery performed in the same hospitals.
What Did the Researchers Do and Find?
The researchers collected recent data on the number of doctors, MLPs, and nurses in two district hospitals in Tanzania and in Mozambique, and from four district hospitals in Uganda and information on each hospital's expenditure. Most of the health workers in these hospitals (which care for 3 million people between them) were nurses (77.5%), followed by MLPs not trained to provide surgical care (7.8%), and MLPs trained to provide surgical care (3.8%). The hospitals had between one and six medical doctors each (28 across all the hospitals), but there were no trained surgeons or anesthesiologists posted at any of the hospitals. About half of the major surgical procedures undertaken at these hospitals were performed by doctors but more than a third were done by MLPs although the exact pattern of personnel involved in surgery varied among the three countries. Anesthesia was mostly provided by nurses and doctors; again the pattern of anesthesia provision varied among countries and hospitals. Only 7%–14% of overall hospital expenditure was allocated to surgical care and most of this allocation was used for obstetric services. Finally, the researchers estimate that, on the basis of district populations, the district hospitals spent between US$0.05 and US$0.14 per head on surgical services.
What Do These Findings Mean?
These findings indicate that, in the district hospitals investigated in this study, physicians, MLPs, and nurses provide most of the surgical care. Furthermore, although all the hospitals in the study provide some surgical care, it accounts for a small part of the hospitals' overall operating costs. These findings may not be generalizable to other district hospitals in sub-Saharan Africa and provide no information about the unmet needs for surgical care. Nevertheless, these findings and those of a separate paper that investigates the range and volume of surgical procedures undertaken in the same district hospitals provide a valuable baseline for planning the expansion of health care services in Africa. They also suggest that increasing the funds allocated to surgery and formalizing the training of MLPs might be a cost-effective way of increasing access to surgical care in sub-Saharan Africa and other developing regions.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000242.
The range and volume of surgery in the same hospitals is investigated in a PLoS Medicine Research Article by Moses Galukande et al.
Information on the Bellagio Essential Surgery Group is available
WHO's Global initiative for Emergency and Essential Surgical Care plans to take essential emergency, basic surgery and anesthesia skills to health care staff in low- and middle-income countries around the world; WHO also has a page describing the importance of emergency and essential surgery in primary health care
doi:10.1371/journal.pmed.1000242
PMCID: PMC2834706  PMID: 20231869
8.  Experiences of Living and Dying With COPD 
Executive Summary
In July 2010, the Medical Advisory Secretariat (MAS) began work on a Chronic Obstructive Pulmonary Disease (COPD) evidentiary framework, an evidence-based review of the literature surrounding treatment strategies for patients with COPD. This project emerged from a request by the Health System Strategy Division of the Ministry of Health and Long-Term Care that MAS provide them with an evidentiary platform on the effectiveness and cost-effectiveness of COPD interventions.
After an initial review of health technology assessments and systematic reviews of COPD literature, and consultation with experts, MAS identified the following topics for analysis: vaccinations (influenza and pneumococcal), smoking cessation, multidisciplinary care, pulmonary rehabilitation, long-term oxygen therapy, noninvasive positive pressure ventilation for acute and chronic respiratory failure, hospital-at-home for acute exacerbations of COPD, and telehealth (including telemonitoring and telephone support). Evidence-based analyses were prepared for each of these topics. For each technology, an economic analysis was also completed where appropriate. In addition, a review of the qualitative literature on patient, caregiver, and provider perspectives on living and dying with COPD was conducted, as were reviews of the qualitative literature on each of the technologies included in these analyses.
The Chronic Obstructive Pulmonary Disease Mega-Analysis series is made up of the following reports, which can be publicly accessed at the MAS website at: http://www.hqontario.ca/en/mas/mas_ohtas_mn.html.
Chronic Obstructive Pulmonary Disease (COPD) Evidentiary Framework
Influenza and Pneumococcal Vaccinations for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Smoking Cessation for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Community-Based Multidisciplinary Care for Patients With Stable Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Pulmonary Rehabilitation for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Long-Term Oxygen Therapy for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Noninvasive Positive Pressure Ventilation for Acute Respiratory Failure Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Noninvasive Positive Pressure Ventilation for Chronic Respiratory Failure Patients With Stable Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Hospital-at-Home Programs for Patients With Acute Exacerbations of Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Home Telehealth for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Cost-Effectiveness of Interventions for Chronic Obstructive Pulmonary Disease Using an Ontario Policy Model
Experiences of Living and Dying With COPD: A Systematic Review and Synthesis of the Qualitative Empirical Literature
For more information on the qualitative review, please contact Mita Giacomini at: http://fhs.mcmaster.ca/ceb/faculty_member_giacomini.htm.
For more information on the economic analysis, please visit the PATH website: http://www.path-hta.ca/About-Us/Contact-Us.aspx.
The Toronto Health Economics and Technology Assessment (THETA) collaborative has produced an associated report on patient preference for mechanical ventilation. For more information, please visit the THETA website: http://theta.utoronto.ca/static/contact.
Objective of Analysis
The objective of this analysis was to review empirical qualitative research on the experiences of patients with chronic obstructive pulmonary disease (COPD), informal caregivers (“carers”), and health care providers—from the point of diagnosis, through daily living and exacerbation episodes, to the end of life.
Clinical Need and Target Population
Qualitative empirical studies (from social sciences, clinical, and related fields) can offer important information about how patients experience their condition. This exploration of the qualitative literature offers insights into patients’ perspectives on COPD, their needs, and how interventions might affect their experiences. The experiences of caregivers are also explored.
Research Question
What do patients with COPD, their informal caregivers (“carers”), and health care providers experience over the course of COPD?
Research Methods
Literature Search
Search Strategy
Literature searches for studies published from January 1, 2000, to November 2010 were performed on November 29, 2010, using OVID MEDLINE; on November 26, 2010, using ISI Web of Science; and on November 28, 2010, using EBSCO Cumulative Index to Nursing and Allied Health Literature (CINAHL). Titles and abstracts were reviewed by a single reviewer and, for those studies meeting the eligibility criteria, full-text articles were obtained. One additional report, highly relevant to the synthesis, appeared in early 2011 during the drafting of this analysis and was included post hoc.
Inclusion Criteria
English-language full reports
studies published between January 1, 2000, and November 2010
primary qualitative empirical research (using any descriptive or interpretive qualitative methodology, including the qualitative component of mixed-methods studies) and secondary syntheses of primary qualitative empirical research
studies addressing any aspect of the experiences of living or dying with COPD from the perspective of persons at risk, patients, health care providers, or informal carers; studies addressing multiple conditions were included if COPD was addressed explicitly
Exclusion Criteria
studies addressing topics other than the experiences of living or dying with COPD from the perspective of persons at risk, patients, health care providers, or informal carers
studies labelled “qualitative” but not using a qualitative descriptive or interpretive methodology (e.g., case studies, experiments, or observational analysis using qualitative categorical variables)
quantitative research (i.e., using statistical hypothesis testing, using primarily quantitative data or analyses, or expressing results in quantitative or statistical terms)
studies that did not pose an empirical research objective or question, or involve the primary or secondary analysis of empirical data
Outcomes of Interest
qualitative descriptions and interpretations (narrative or theoretical) of personal and social experiences of COPD
Summary of Findings
Experiences at Diagnosis
Patients typically seek initial treatment for an acute episode rather than for chronic early symptoms of COPD.
Many patients initially misunderstand terms such as COPD, chronic obstructive pulmonary disease, or exacerbation.
Patients may not realize that COPD is incurable and fatal; some physicians themselves do not consider early COPD to be a fatal disease.
Smokers may not readily understand or agree with the idea that smoking caused or worsens their COPD. Those who believe there is a causal link may feel regret or shame.
Experiences of Living Day to Day
COPD patients experience alternating good days and bad days. A roller-coaster pattern of ups and downs becomes apparent, and COPD becomes a way of life.
Patients use many means (social, psychological, medical, organizational) to control what they can, and to cope with what they cannot. Economic hardship, comorbidities, language barriers, and low health literacy can make coping more difficult.
Increasing vulnerability and unpredictable setbacks make patients dependent on others for practical assistance, but functional limitations, institutional living or self-consciousness can isolate patients from the people they need.
For smokers, medical advice to quit can conflict with increased desire to smoke as a coping strategy.
Many of the factors that isolate COPD patients from social contact also isolate them from health care.
Experiences of Exacerbations
Patients may not always attribute repeated exacerbations to advancing disease, instead seeing them as temporary setbacks caused by activities, environmental factors, faltering self-management, or infection.
Lack of confidence in community-based services leads some patients to seek hospital admission, but patients also feel vulnerable when hospitalized. They may feel dependent on others for care or traumatized by hospital care routines.
Upon hospital discharge following an exacerbation, patients may face new levels of uncertainty about their illness, prognosis, care providers, and supports.
Experiences of the End of Life
Patients tend to be poorly informed about the long-term prognosis of COPD and what to expect toward the end of life; this lack of understanding impairs quality of life as the disease progresses.
As the end of life approaches, COPD patients face the usual challenges of daily living, but in a context of increasing exacerbations and deepening dependency. Activities and mobility decrease, and life may become confined.
Some clinicians have difficulty identifying the beginning of “the end of life,” given the unpredictable course of COPD. Long-term physician-patient relationships, familiarity and understanding, trust, good communication skills, sensitivity, and secure discussion settings can help facilitate end-of-life discussions.
Divergent meanings and goals of palliative care in COPD lead to confusion about whether such services are the responsibility of home care, primary care, specialty care, or even critical care. Palliative end-of-life care may not be anticipated prior to referral for such care. A palliative care referral can convey the demoralizing message that providers have “given up.”
Experiences of Carers
Carers’ challenges often echo patients’ challenges, and include anxiety, uncertainty about the future, helplessness, powerlessness, depression, difficulties maintaining employment, loss of mobility and freedoms, strained relationships, and growing social isolation.
Carers feel pressured by their many roles, struggling to maintain patience when they feel overwhelmed, and often feeling guilty about not doing enough.
Carers often face their own health problems and may have difficulty sustaining employment.
Synthesis: A Disease Trajectory Reflecting Patient Experiences
The flux of needs in COPD calls for service continuity and flexibility to allow both health care providers and patients to respond to the unpredictable yet increasing demands of the disease over time.
PMCID: PMC3384365  PMID: 23074423
9.  The present state and future direction of primary care: a qualitative study of GPs' views 
Background
Over the past decade there has been a sharp increase in the number of non-profit-sharing salaried doctors employed by practices. This has been accompanied by the introduction of mechanisms to facilitate the entry of other providers into the primary care market.
Aim
To explore the views of GP principals and salaried doctors on current working practices and the future direction of primary care in England.
Design of study
Qualitative study using semi-structured interviews.
Setting
Twenty-two nationally representative practices across England, between February and August 2007.
Method
Interviews were conducted with 22 principals and seven salaried doctors. A topic guide included questions on motivations for working in primary care, descriptions of working lives, the way in which clinical time was spent, and predictions for future working conditions.
Results
Significant changes to GP working arrangements were identified, including increasing pursuit of specialist clinical interests by GP principals and increasing employment of salaried GPs. These developments were reported as improving the working lives of principals but also creating a hierarchical structure at practice level that led to resentment among salaried doctors. Many of the salaried GPs felt disenfranchised and disillusioned by the difference in status and autonomy in decision making and the type of work they performed in the practice. Almost all GPs felt uncertain about the future of primary care and were concerned about the potential threat of private providers delivering primary care within the NHS through a largely salaried workforce.
Conclusion
By failing to recognise the problems of employing an increasingly disenfranchised salaried labour force, GP principals may be undermining the very ethos of general practice they otherwise advocate and recreating smaller versions of the private provider organisations they suggest threaten to corrode NHS primary care.
doi:10.3399/bjgp09X473060
PMCID: PMC2784528  PMID: 19889257
primary care; salaried GP; workforce
10.  Qualitative study of patients’ perceptions of doctors’ advice to quit smoking: implications for opportunistic health promotion 
BMJ : British Medical Journal  1998;316(7148):1878-1881.
Objectives: To determine the effectiveness and acceptability of general practitioners’opportunistic antismoking interventions by examining detailed accounts of smokers’ experiences of these.
Design: Qualitative semistructured interview study.
Setting: South Wales.
Subjects: 42 participants in the Welsh smoking intervention study were asked about initial smoking, attempts to quit, thoughts about future smoking, past experiences with the health services, and the most appropriate way for health services to help them and other smokers.
Results: Main emerging themes were that subjects already made their own evaluations about smoking, did not believe doctors’ words could influence their smoking, believed that quitting was down to the individual, and felt that doctors who took the opportunity to talk about smoking should focus on the individual patient. Smokers anticipated that they would be given antismoking advice by doctors when attending for health care; they reacted by shrugging this off, feeling guilty, or becoming annoyed. These reactions affected the help seeking behaviour of some respondents. Smokers were categorised as “contrary,” “matter of fact,” and “self blaming,” depending on their reported reaction to antismoking advice.
Conclusions: Doctor-patient relationships can be damaged if doctors routinely advise all smokers to quit. Where doctors intervene, a patient centred approach—one that considers how individual patients view themselves as smokers and how they are likely to react to different styles of intervention—is the most acceptable.
Key messages Many patients who smoke are sceptical about the power of doctors’ words to influence smoking since most know about the dangers, make their own evaluations, and feel that quitting is down to the individual Opportunistic antismoking interventions should be sympathetic, not preaching, and centred on the patient as an individual Repeated ritualistic intervention on the part of doctors may deter patients from seeking medical help when they need it Smokers can be categorised as “contrary,” “matter of fact,” or “self blaming” in their reaction to antismoking advice Doctors can tailor their approach according to the type of patient
PMCID: PMC28587  PMID: 9632409
11.  The Effect of Alternative Graphical Displays Used to Present the Benefits of Antibiotics for Sore Throat on Decisions about Whether to Seek Treatment: A Randomized Trial 
PLoS Medicine  2009;6(8):e1000140.
In a randomized trial, Cheryl Carling and colleagues evaluate how people respond to different statistical presentations regarding the consequences of taking antibiotic treatment for sore throat.
Background
We conducted an Internet-based randomized trial comparing four graphical displays of the benefits of antibiotics for people with sore throat who must decide whether to go to the doctor to seek treatment. Our objective was to determine which display resulted in choices most consistent with participants' values.
Methods and Findings
This was the first of a series of televised trials undertaken in cooperation with the Norwegian Broadcasting Company. We recruited adult volunteers in Norway through a nationally televised weekly health program. Participants went to our Web site and rated the relative importance of the consequences of treatment using visual analogue scales (VAS). They viewed the graphical display (or no information) to which they were randomized and were asked to decide whether to go to the doctor for an antibiotic prescription. We compared four presentations: face icons (happy/sad) or a bar graph showing the proportion of people with symptoms on day three with and without treatment, a bar graph of the average duration of symptoms, and a bar graph of proportion with symptoms on both days three and seven. Before completing the study, all participants were shown all the displays and detailed patient information about the treatment of sore throat and were asked to decide again. We calculated a relative importance score (RIS) by subtracting the VAS scores for the undesirable consequences of antibiotics from the VAS score for the benefit of symptom relief. We used logistic regression to determine the association between participants' RIS and their choice. 1,760 participants completed the study. There were statistically significant differences in the likelihood of choosing to go to the doctor in relation to different values (RIS). Of the four presentations, the bar graph of duration of symptoms resulted in decisions that were most consistent with the more fully informed second decision. Most participants also preferred this presentation (38%) and found it easiest to understand (37%). Participants shown the other three presentations were more likely to decide to go to the doctor based on their first decision than everyone based on the second decision. Participants preferred the graph using faces the least (14.4%).
Conclusions
For decisions about going to the doctor to get antibiotics for sore throat, treatment effects presented by a bar graph showing the duration of symptoms helped people make decisions more consistent with their values than treatment effects presented as graphical displays of proportions of people with sore throat following treatment.
Clinical Trials Registration
ISRCTN58507086
Please see later in the article for the Editors' Summary
Editors' Summary
Background
In the past, patients usually believed that their doctor knew what was best for them and that they had little say in deciding what treatment they would receive. But many modern interventions have complex trade-offs. Patients' opinions about the relative desirability of the possible outcomes of health care interventions depend on their lifestyle and expectations, and these “values” need to be considered when making decisions about medical treatments. Consequently, shared decision-making is increasingly superseding the traditional, paternalistic approach to medical decision-making. In shared decision-making, health care professionals talk to their patients about the risks and benefits of the various treatment options, and patients tell the health care professionals what they expect and/or require from their treatment.
Why Was This Study Done?
Shared decision-making can only succeed if patients know about the treatment options that are available for their medical condition and understand the consequences of each option. But how does the presentation of information about treatment options to patients affect their decisions? In 2002, a series of internet-based randomized trials (studies in which participants are randomly allocated to different “treatment” groups) called the Health Information Project: Presentation Online (HIPPO) was initiated to answer this question. Here, the researchers describe HIPPO 3, a trial that investigates how alternative graphical displays of the benefits of antibiotics for the treatment of sore throat affect whether people decide to seek treatment. In particular, the researchers ask which display results in people making a treatment decision most consistent with their values, i.e., in terms of the relative importance to them of the treatment's desirable and undesirable outcomes.
What Did the Researchers Do and Find?
Adult Norwegians recruited through a television health program numerically rated the importance of symptom relief and of several negative consequences (for example, side effects) of antibiotic treatment for sore throat on the trial's Web site. Relative importance scores (which indicate the participants' values) were calculated for each participant by subtracting their ratings for the importance of the negative consequences of seeking antibiotic treatment from his or her rating for the importance of symptom relief. The participants were then asked to decide whether to visit a doctor for antibiotics without receiving any further information or after being shown one of four graphical displays illustrating the benefits of antibiotic treatment. Two bar charts and one display of happy- and sad-face icons showed the proportion of people with symptoms at specific times after sore throat onset with and without treatment. A third bar chart indicated symptom duration with and without antibiotics. Finally, all the participants were shown all the displays and other information about sore throat and were asked to decide again about seeking treatment. The researchers found a clear association between the participants' values and the likelihood of their deciding to go to the doctor, and this likelihood depended on which graphical display the participants saw. People shown information on the proportion of patients with symptoms were more likely to decide to visit a doctor than those shown information on symptom duration. Furthermore, first decisions reached after being given information on symptom duration or no information were more consistent with the fully informed second decision than first decisions reached after seeing the other displays.
What Do These Findings Mean?
These findings suggest that, for people considering whether to seek antibiotic treatment for sore throat, a bar graph showing the duration of symptoms is more likely to help them make a decision that is consistent with their own values than a bar chart showing the proportions of people with sore throat following treatment. The researchers also found that the bar chart showing symptom duration was preferred by more of the participants than any of the other representations. Whether these results can be applied to other health care decisions or in other settings is not known. However, the researchers suggest that these findings may be most relevant to treatments that, like antibiotic treatment of sore throat, have a short-lived benefit and relatively important downsides.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000140.
A PLoS Medicine Editorial discusses this trial and the results of another HIPPO trial that are presented in a separate PLoS Medicine Research Article by Carling et al.; details of a pilot HIPPO trial are also available
The Foundation for Informed Medical Decision Making (a US-based nonprofit organization) provides information on many aspects of medical decision making
The Dartmouth-Hitchcock Medical Center provides information to help people make health care decisions through its Center for Shared Decision Making
The Ottawa Hospital Research Institute provides information on patient decision aids, including an inventory of decision aids available on the Web (in English and French)
MedlinePlus provides links to information and advice about sore throat (in English and Spanish)
doi:10.1371/journal.pmed.1000140
PMCID: PMC2726763  PMID: 19707579
12.  Shame! Self-stigmatisation as an obstacle to sick doctors returning to work: a qualitative study 
BMJ Open  2012;2(5):e001776.
Objective
To explore the views of sick doctors on the obstacles preventing them returning to work.
Design
Qualitative study.
Setting
Single participating centre recruiting doctors from all over the UK.
Participants
Doctors who had been away from work for at least 6 months with physical or mental health problems, drug or alcohol problems, General Medical Council involvement or any combination of these, were eligible. Eligible doctors were recruited in conjunction with the Royal Medical Benevolent Fund, the General Medical Council and the Practitioner Health Programme. These organisations approached 77 doctors; 19 participated. Each doctor completed an in-depth semistructured interview. We used a constant comparison method to identify and agree on the coding of the data and the identification of a number of central themes.
Results
The doctors described that being away from work left them isolated and sad. Many experienced negative reactions from their family and some deliberately concealed their problems. Doctors described a lack of support from colleagues and feared a negative response when returning to work. Self-stigmatisation was central to the participants’ accounts; several described themselves as failures and appeared to have internalised the negative views of others.
Conclusions
Self-stigmatising views, which possibly emerge from the belief that ‘doctors are invincible’, represent a major obstacle to doctors returning to work. From medical school onwards cultural change is necessary to allow doctors to recognise their vulnerabilities so they can more easily generate strategies to manage if they become unwell.
doi:10.1136/bmjopen-2012-001776
PMCID: PMC3488732  PMID: 23069770
Mental Health; Occupational & Industrial Medicine; Qualitative Research
13.  Inviting Patients to Read Their Doctors’ Notes: A Quasi-experimental Study and a Look Ahead 
Annals of internal medicine  2012;157(7):461-470.
Background
Little information exists about what primary care physicians (PCPs) and patients experience if patients are invited to read their doctors’ office notes.
Objective
To evaluate the effect on doctors and patients of facilitating patient access to visit notes over secure Internet portals.
Design
Quasi-experimental trial of PCPs and patient volunteers in a year-long program that provided patients with electronic links to their doctors’ notes.
Setting
Primary care practices at Beth Israel Deaconess Medical Center (BIDMC) in Massachusetts, Geisinger Health System (GHS) in Pennsylvania, and Harborview Medical Center (HMC) in Washington.
Participants
105 PCPs and 13 564 of their patients who had at least 1 completed note available during the intervention period.
Measurements
Portal use and electronic messaging by patients and surveys focusing on participants’ perceptions of behaviors, benefits, and negative consequences.
Results
11 797 of 13 564 patients with visit notes available opened at least 1 note (84% at BIDMC, 92% at GHS, and 47% at HMC). Of 5391 patients who opened at least 1 note and completed a postintervention survey, 77% to 87% across the 3 sites reported that open notes helped them feel more in control of their care; 60% to 78% of those taking medications reported increased medication adherence; 26% to 36% had privacy concerns; 1% to 8% reported that the notes caused confusion, worry, or offense; and 20% to 42% reported sharing notes with others. The volume of electronic messages from patients did not change. After the intervention, few doctors reported longer visits (0% to 5%) or more time addressing patients’ questions outside of visits (0% to 8%), with practice size having little effect; 3% to 36% of doctors reported changing documentation content; and 0% to 21% reported taking more time writing notes. Looking ahead, 59% to 62% of patients believed that they should be able to add comments to a doctor’s note. One out of 3 patients believed that they should be able to approve the notes’ contents, but 85% to 96% of doctors did not agree. At the end of the experimental period, 99% of patients wanted open notes to continue and no doctor elected to stop.
Limitations
Only 3 geographic areas were represented, and most participants were experienced in using portals. Doctors volunteering to participate and patients using portals and completing surveys may tend to offer favorable feedback, and the response rate of the patient surveys (41%) may further limit generalizability.
Conclusion
Patients accessed visit notes frequently, a large majority reported clinically relevant benefits and minimal concerns, and virtually all patients wanted the practice to continue. With doctors experiencing no more than a modest effect on their work lives, open notes seem worthy of widespread adoption.
Primary Funding Source
The Robert Wood Johnson Foundation, the Drane Family Fund, the Richard and Florence Koplow Charitable Foundation, and the National Cancer Institute.
doi:10.7326/0003-4819-157-7-201210020-00002
PMCID: PMC3908866  PMID: 23027317
14.  What E-patients Want From the Doctor-Patient Relationship: Content Analysis of Posts on Discussion Boards 
Background
People with long-term conditions are encouraged to take control and ownership of managing their condition. Interactions between health care staff and patients become partnerships with sharing of expertise. This has changed the doctor-patient relationship and the division of roles and responsibilities that traditionally existed, but what each party expects from the other may not always be clear. Information that people with long-term conditions share on Internet discussion boards can provide useful insights into their expectations of health care staff. This paper reports on a small study about the expectations that people with a long-term condition (diabetes) have of their doctors using information gleaned from Internet discussion boards.
Objective
The aim of this study was to ascertain what people with diabetes who use Internet discussion forums want from their doctors. The study objectives were to identify what people with diabetes (1) consider their role in condition management, (2) consider their doctor’s role in managing their condition, (3) see as positive elements of their interactions with medical staff, and (4) find problematic in their interactions with medical staff.
Methods
The study used qualitative methodology to explore the experiences, views, and perceptions of individuals participating on 4 Internet message boards. Posts made on the discussion boards were analyzed using the principles of qualitative content analysis. The meanings of sections of data were noted using codes that were developed inductively; those with similar codes were merged into subcategories and related subcategories were combined to form categories.
Results
The key themes identified in the study were ownership of condition management, power issues between people with long-term conditions and doctors, and ways in which people seek to manage their doctors.
Conclusions
People with diabetes valued doctors who showed respect for them and their knowledge, and were willing to listen and openly discuss their options. Patients felt that they could and should take responsibility for and control of their day-to-day disease management. They saw doctors as having a role in this process, but when this was lacking, many people felt able to use alternative means to achieve their goal, although the doctor’s function in terms of gatekeeping resources could create difficulties for them in this respect.
doi:10.2196/jmir.2068
PMCID: PMC3510709  PMID: 23137788
Physician-patient relations; consumer health informatics; eHealth; participatory medicine
15.  Psychosocial Factors That Shape Patient and Carer Experiences of Dementia Diagnosis and Treatment: A Systematic Review of Qualitative Studies 
PLoS Medicine  2012;9(10):e1001331.
A systematic review of qualitative studies conducted by Frances Bunn and colleagues identifies and describes the experiences of patients and caregivers on receiving and adapting to a diagnosis of dementia.
Background
Early diagnosis and intervention for people with dementia is increasingly considered a priority, but practitioners are concerned with the effects of earlier diagnosis and interventions on patients and caregivers. This systematic review evaluates the qualitative evidence about how people accommodate and adapt to the diagnosis of dementia and its immediate consequences, to guide practice.
Methods and Findings
We systematically reviewed qualitative studies exploring experiences of community-dwelling individuals with dementia, and their carers, around diagnosis and the transition to becoming a person with dementia. We searched PubMed, PsychINFO, Embase, CINAHL, and the British Nursing Index (all searched in May 2010 with no date restrictions; PubMed search updated in February 2012), checked reference lists, and undertook citation searches in PubMed and Google Scholar (ongoing to September 2011). We used thematic synthesis to identify key themes, commonalities, barriers to earlier diagnosis, and support identified as helpful. We identified 126 papers reporting 102 studies including a total of 3,095 participants. Three overarching themes emerged from our analysis: (1) pathways through diagnosis, including its impact on identity, roles, and relationships; (2) resolving conflicts to accommodate a diagnosis, including the acceptability of support, focusing on the present or the future, and the use or avoidance of knowledge; and (3) strategies and support to minimise the impact of dementia. Consistent barriers to diagnosis include stigma, normalisation of symptoms, and lack of knowledge. Studies report a lack of specialist support particularly post-diagnosis.
Conclusions
There is an extensive body of qualitative literature on the experiences of community-dwelling individuals with dementia on receiving and adapting to a diagnosis of dementia. We present a thematic analysis that could be useful to professionals working with people with dementia. We suggest that research emphasis should shift towards the development and evaluation of interventions, particularly those providing support after diagnosis.
Please see later in the article for the Editors' Summary.
Editors' Summary
Background
Dementia is a decline in mental ability severe enough to interfere with daily life. Alzheimer disease is the most common type of dementia. People with dementia usually have problems with two or more cognitive functions—thinking, language, memory, understanding, and judgment. Dementia is rare before the age of 65, but about a quarter of people over 85 have dementia. Because more people live longer these days, the number of patients with dementia is increasing. It is estimated that today between 40 and 50 million people live with dementia worldwide. By 2050, this number is expected to triple.
One way to study what dementia means to patients and their carers (most often spouses or other family members) is through qualitative research. Qualitative research aims to develop an in-depth understanding of individuals' experiences and behavior, as well as the reasons for their feelings and actions. In qualitative studies, researchers interview patients, their families, and doctors. When the studies are published, they usually contain direct quotations from interviews as well as summaries by the scientists who designed the interviews and analyzed the responses.
Why Was This Study Done?
This study was done to better understand the experiences and attitudes of patients and their carers surrounding dementia diagnosis. It focused on patients who lived and were cared for within the community (as opposed to people living in senior care facilities or other institutions). Most cases of dementia are progressive, meaning symptoms get worse over time. Diagnosis often happens at an advanced stage of the disease, and some patients never receive a formal diagnosis. This could have many possible reasons, including unawareness or denial of symptoms by patients and people close to them. The study was also trying to understand barriers to early diagnosis and what type of support is useful for newly diagnosed patients and carers.
What Did the Researchers Do and Find?
The researchers conducted a systematic search for published qualitative research studies that reported on the experience, beliefs, feelings, and attitudes surrounding dementia diagnosis. They identified and reviewed 102 such studies. Among the quotations and summaries of the individual studies, they looked for prominent and recurring themes. They also compared and contrasted the respective experiences of patients and carers.
Overall, they found that the complexity and variety of responses to a diagnosis of dementia means that making the diagnosis and conveying it to patients and carers is challenging. Negative connotations associated with dementia, inconsistent symptoms, and not knowing enough about the signs and symptoms were commonly reported barriers to early dementia diagnosis. It was often the carer who initiated the search for help from a doctor, and among patients, willingness and readiness to receive a diagnosis varied. Being told one had dementia had a big impact on a patient's identity and often caused feelings of loss, anger, fear, and frustration. Spouses had to adjust to increasingly unequal relationships and the transition to a role as carer. The strain associated with this often caused health problems in the carers as well. On the other hand, studies examining the experience of couples often reported that they found ways to continue working together as a team.
Adjusting to a dementia diagnosis is a complex process. Initially, most patients and carers experienced conflicts, for example, between autonomy and safety, between recognizing the need for help but reluctance to accept it, or between living in the present and dealing with anxiety about and preparing for the future. As these were resolved and as the disease progressed, the attitudes of patients and carers towards dementia often became more balanced and accepting. Many patients and their families adopted strategies to cope with the impact of dementia on their lives in order to manage the disease and maintain some sort of normal life. These included practical strategies involving reminders, social strategies such as relying on family support, and emotional strategies such as using humor. At some point many patients and carers reported that they were able to adopt positive mindsets and incorporate dementia in their lives.
The studies also pointed to an urgent need for support from outside the family, both right after diagnosis and subsequently. General practitioners and family physicians have important roles in helping patients and carers to get access to information, social and psychological support, and community care. The need for information was reported to be ongoing and varied, and meeting it required a variety of sources and formats. Key needs for patients and carers mentioned in the studies include information on financial aids and entitlements early on, and continued access to supportive professionals and specialists.
What Do These Findings Mean?
Qualitative studies to date on how patients and carers respond to a diagnosis of dementia provide a fairly detailed picture of their experiences. The summary provided here should help professionals to understand better the challenges patients and carers face around the time of diagnosis as well as their immediate and evolving needs. The results also suggest that future research should focus on the development and evaluation of ways to meet those needs.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001331.
Wikipedia has pages on dementia and qualitative research (note that Wikipedia is a free online encyclopedia that anyone can edit)
Alzheimer Europe, an umbrella organization of 34 Alzheimer associations from 30 countries across Europe, has a page on the different approaches to research
The UK Department of Health has pages on dementia, including guidelines for carers of people with dementia
MedlinePlus also has information about dementia
doi:10.1371/journal.pmed.1001331
PMCID: PMC3484131  PMID: 23118618
16.  Postgraduate career intentions of medical students and recent graduates in Malawi: a qualitative interview study 
BMC Medical Education  2012;12:87.
Background
In 2004, the Malawian Ministry of Health declared a human resource crisis and launched a six year Emergency Human Resources Programme. This included salary supplements for key health workers and a tripling of doctors in training. By 2010, the number of medical graduates had doubled and significantly more doctors were working in rural district hospitals. Yet there has been little research into the views of this next generation of doctors in Malawi, who are crucial to the continuing success of the programme. The aim of this study was to explore the factors influencing the career plans of medical students and recent graduates with regard to four policy-relevant aspects: emigration outside Malawi; working at district level; private sector employment and postgraduate specialisation.
Methods
Twelve semi-structured interviews were conducted with fourth year medical students and first year graduates, recruited through purposive and snowball sampling. Key informant interviews were also carried out with medical school faculty. Recordings were transcribed and analysed using a framework approach.
Results
Opportunities for postgraduate training emerged as the most important factor in participants’ career choices, with specialisation seen as vital to career progression. All participants intended to work in Malawi in the long term, after a period of time outside the country. For nearly all participants, this was in the pursuit of postgraduate study rather than higher salaries. In general, medical students and young doctors were enthusiastic about working at district level, although this is curtailed by their desire for specialist training and frustration with resource shortages. There is currently little intention to move into the private sector.
Conclusions
Future resourcing of postgraduate training opportunities is crucial to preventing emigration as graduate numbers increase. The lesser importance put on salary by younger doctors may be an indicator of the success of salary supplements. In order to retain doctors at district levels for longer, consideration should be given to the introduction of general practice/family medicine as a specialty. Returning specialists should be encouraged to engage with younger colleagues as role models and mentors.
doi:10.1186/1472-6920-12-87
PMCID: PMC3480922  PMID: 22978475
Doctors; Medical students; Postgraduate education; Specialisation; Malawi; Rural health; Brain drain; Emigration
17.  At the coalface and the cutting edge: general practitioners’ accounts of the rewards of engaging with HIV medicine 
BMC Family Practice  2013;14:39.
Background
HIV has become a chronic manageable infection in the developed world, and early and lifelong treatment has the potential to significantly reduce transmission rates in the community. A skilled and motivated HIV medical workforce will be required to achieve these health management and prevention outcomes, but concerns have been noted in a number of settings about the challenges of recruiting a new generation of clinicians to HIV medicine.
Methods
As part of a larger qualitative study of the HIV general practice workforce in Australia, in-depth interviews were conducted with 31 general practitioners accredited to prescribe HIV medications in community settings. A thematic analysis was conducted of the de-identified transcripts, and this paper describes and interprets accounts of the rewards of pursuing and sustaining an engagement with HIV medicine in general practice settings.
Results
The rewards of initially becoming involved in providing care to people living with HIV were described as interest and inspiration, community calling and right place, right time. The rewards which then supported and sustained that engagement over time were described as challenge and change, making a difference and enhanced professional identity. Participants viewed the role of primary care doctor with special expertise in HIV as occupying an ideal interface between the ‘coalface’ and the ‘cutting edge’, and offering a unique opportunity for general practitioners to feel intimately connected to both community needs and scientific change.
Conclusions
Approaches to recruiting and retaining the HIV medical workforce should build upon the intellectual and social rewards of this work, as well as the sense of professional belonging and connection which is imbued between both doctors and patients and across the global and national networks of HIV clinicians. Insights regarding the rewards of engaging with HIV medicine may also be useful in enhancing the prospect of general practice as a career, and strengthening retention and job satisfaction among the existing general practice workforce.
doi:10.1186/1471-2296-14-39
PMCID: PMC3610239  PMID: 23517462
HIV; General practice; Workforce issues; Rewards; Australia
18.  Patient Perspectives on Online Health Information and Communication With Doctors: A Qualitative Study of Patients 50 Years Old and Over 
Background
As health care systems around the world shift toward models that emphasize self-care management, there is increasing pressure for patients to obtain health information online. It is critical that patients are able to identify potential problems with using the Internet to diagnose and treat a health issue and that they feel comfortable communicating with their doctor about the health information they acquire from the Internet.
Objective
Our aim was to examine patient-identified (1) problems with using the Internet to identify and treat a health issue, (2) barriers to communication with a doctor about online health information seeking, and (3) facilitators of communication with a doctor about patient searches for health information on the Internet.
Methods
For this qualitative exploratory study, semistructured interviews were conducted with a sample of 56 adults age 50 years old and over. General concerns regarding use of the Internet to diagnose and treat a health issue were examined separately for participants based on whether they had ever discussed health information obtained through the Internet with a doctor. Discussions about barriers to and facilitators of communication about patient searches for health information on the Internet with a doctor were analyzed using thematic analysis.
Results
Six higher-level general concerns emerged: (1) limitations in own ability, (2) credibility/limitations of online information, (3) anxiety, (4) time consumption, (5) conflict, and (6) non-physical harm. The most prevalent concern raised by participants who communicated with a doctor about their online health information seeking related to the credibility or limitations in online information. Participants who had never communicated with a doctor about their online health information seeking most commonly reported concerns about non-physical harm. Four barriers to communication emerged: (1) concerns about embarrassment, (2) concerns that the doctor doesn’t want to hear about it, (3) belief that there is no need to bring it up, and (4) forgetting to bring it up. Facilitators of communication included: (1) having a family member present at doctor visits, (2) doctor-initiated inquiries, and (3) encountering an advertisement that suggested talking with a doctor.
Conclusions
Overall, participants displayed awareness of potential problems related to online health information seeking. Findings from this study point to a set of barriers as well as facilitators of communication about online health information seeking between patients and doctors. This study highlights the need for enhanced patient communication skills, eHealth literacy assessments that are accompanied by targeted resources pointing individuals to high-quality credible online health information, and the need to remind patients of the importance of consulting a medical professional when they use online health resources to diagnose and treat a health issue.
doi:10.2196/jmir.3588
PMCID: PMC4319073  PMID: 25586865
health communication; Internet; online health information seeking; barriers to patient-doctor communication; adults 50 years old and over; qualitative research
19.  Impact on patients of expanded, general practice based, student teaching: observational and qualitative study 
BMJ : British Medical Journal  2005;331(7508):89.
Objectives To compare patients' enablement and satisfaction after teaching and non-teaching consultations. To explore patients' views about the possible impact that increased community based teaching of student doctors in their practice may have on the delivery of service and their attitudes towards direct involvement with students.
Design Observational study using validated survey instruments (patient enablement index—PEI, and consultation satisfaction questionnaire—CSQ) administered after teaching consultations and non-teaching consultations. Ten focus groups (two from each practice), comprising five with patients participating in prearranged teaching sessions and five with patients not participating in these.
Setting Five general practices in west Suffolk and southern Norfolk, England, that teach student doctors on the Cambridge graduate medical course.
Participants 240 patients attending teaching consultations (response rate 82%, 196 patients) and 409 patients attending non-teaching consultations (response rate 72%, 294 patients) received survey instruments. Ten focus groups with a total of 34 patients participating in prearranged teaching sessions and 20 patients not participating in these.
Main outcome measures Scores on the patient enablement index and consultation satisfaction questionnaire, analysed at the level of all patients, allowing for age, sex, general practitioner, and practice, and at the level of the individual general practitioner teacher. Qualitative analysis of focus group data.
Results Patients' enablement or satisfaction was not reduced after teaching consultations compared with non-teaching consultations (mean difference in scores on the patient enablement index and consultation satisfaction questionnaire with adjustment for confounders 2.24% and 1.70%, respectively). This held true for analysis by all patients and by general practitioner teacher. Qualitative data showed that patients generally supported the teaching of student doctors in their practice. However, this support was conditional on receiving sufficient information about reasons for doctors' absence, the characteristics of students, and the nature of teaching planned. Many patients viewed their general practice as different from hospital and expected greater control over students' presence during their consultations.
Conclusions Patients' enablement and satisfaction are not impaired by students' participation in consultations. Patients generally support the teaching of student doctors in their general practice but expect to be provided with sufficient information and to have a choice about participation, so they can give informed consent. Recognising this when organising general practice based teaching is important.
doi:10.1136/bmj.38492.599606.8F
PMCID: PMC558616  PMID: 15996965
20.  Physician Awareness of Drug Cost: A Systematic Review 
PLoS Medicine  2007;4(9):e283.
Background
Pharmaceutical costs are the fastest-growing health-care expense in most developed countries. Higher drug costs have been shown to negatively impact patient outcomes. Studies suggest that doctors have a poor understanding of pharmaceutical costs, but the data are variable and there is no consistent pattern in awareness. We designed this systematic review to investigate doctors' knowledge of the relative and absolute costs of medications and to determine the factors that influence awareness.
Methods and Findings
Our search strategy included The Cochrane Library, EconoLit, EMBASE, and MEDLINE as well as reference lists and contact with authors who had published two or more articles on the topic or who had published within 10 y of the commencement of our review. Studies were included if: either doctors, trainees (interns or residents), or medical students were surveyed; there were more than ten survey respondents; cost of pharmaceuticals was estimated; results were expressed quantitatively; there was a clear description of how authors defined “accurate estimates”; and there was a description of how the true cost was determined. Two authors reviewed each article for eligibility and extracted data independently. Cost accuracy outcomes were summarized, but data were not combined in meta-analysis because of extensive heterogeneity. Qualitative data related to physicians and drug costs were also extracted. The final analysis included 24 articles. Cost accuracy was low; 31% of estimates were within 20% or 25% of the true cost, and fewer than 50% were accurate by any definition of cost accuracy. Methodological weaknesses were common, and studies of low methodological quality showed better cost awareness. The most important factor influencing the pattern and accuracy of estimation was the true cost of therapy. High-cost drugs were estimated more accurately than inexpensive ones (74% versus 31%, Chi-square p < 0.001). Doctors consistently overestimated the cost of inexpensive products and underestimated the cost of expensive ones (binomial test, 89/101, p < 0.001). When asked, doctors indicated that they want cost information and feel it would improve their prescribing but that it is not accessible.
Conclusions
Doctors' ignorance of costs, combined with their tendency to underestimate the price of expensive drugs and overestimate the price of inexpensive ones, demonstrate a lack of appreciation of the large difference in cost between inexpensive and expensive drugs. This discrepancy in turn could have profound implications for overall drug expenditures. Much more focus is required in the education of physicians about costs and the access to cost information. Future research should focus on the accessibility and reliability of medical cost information and whether the provision of this information is used by doctors and makes a difference to physician prescribing. Additionally, future work should strive for higher methodological standards to avoid the biases we found in the current literature, including attention to the method of assessing accuracy that allows larger absolute estimation ranges for expensive drugs.
From a review of data from 24 studies, Michael Allan and colleagues conclude that doctors often underestimate the price of expensive drugs and overestimate the price of those that are inexpensive.
Editors' Summary
Background.
Many medicines are extremely expensive, and the cost of buying them is a major (and increasing) proportion of the total cost of health care. Governments and health-care organizations try to find ways of keeping down costs without reducing the effectiveness of the health care they provide, but their efforts to control what is spent on medicines have not been very successful. There are often two or more equally effective drugs available for treating the same condition, and it would obviously help keep costs down if, when a doctor prescribes a medicine, he or she chose the cheapest of the effective drugs available. This choice could result in savings for whoever is paying for the drugs, be it the government, the patient, or a medical insurance organization.
Why Was This Study Done?
Doctors who prescribe drugs cannot be expected to know the exact cost of each drug on the market, but it would he helpful if they had some impression of the cost of a treatment and how the various alternatives compare in price. However, systems deciding how drugs are priced are often very complex. (This is particularly the case in the US.) The researchers wanted to find out how aware doctors are regarding drug costs and the difference between the alternatives. They also wanted to know what factors affected their awareness.
What Did the Researchers Do and Find?
They decided to do a systematic review of all the research already conducted that addressed this issue so that the evidence from all of them could be considered together. In order to do such a review they had to specify precise requirements for the type of study that they would include and then comprehensively search the medical literature for such studies. They found 24 studies that met their requirements. From these studies, they concluded that doctors were usually not accurate when asked to estimate the cost of drugs; doctors came up with estimates that were within 25% of the true cost less than one-third of the time. In particular doctors tended to underestimate the cost of expensive drugs and overestimate the cost of the cheaper alternatives. A further analysis of the studies showed that many doctors said they would appreciate more accurate information on costs to help them choose which drugs to prescribe but that such information was not readily available.
What Do These Findings Mean?
The researchers concluded that their systematic review demonstrates a lack of appreciation by prescribing doctors of the large difference in cost between inexpensive and expensive drugs, and that this finding has serious implications for overall spending on drugs. They call for more education and information to be provided to doctors on the cost of medicines together with better processes to help doctors in making such decisions.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0040283.
A brief guide to systematic reviews has been published by the BMJ (British Medical Journal)
The Web site of the Cochrane Collaboration is a more detailed source of information on systematic reviews; in particular there is a newcomers' guide and information for health-care consumers
The Kaiser Family Foundation, a nonprofit, private operating foundation focusing on the major health care issues in the US, has a section on prescription drugs and their costs
doi:10.1371/journal.pmed.0040283
PMCID: PMC1989748  PMID: 17896856
21.  Task Shifting for Scale-up of HIV Care: Evaluation of Nurse-Centered Antiretroviral Treatment at Rural Health Centers in Rwanda 
PLoS Medicine  2009;6(10):e1000163.
Fabienne Shumbusho and colleagues evaluate a task-shifting model of nurse-centered antiretroviral treatment prescribing in rural primary health centers in Rwanda and find that nurses can effectively and safely prescribe ART when given adequate training, mentoring, and support.
Background
The shortage of human resources for health, and in particular physicians, is one of the major barriers to achieve universal access to HIV care and treatment. In September 2005, a pilot program of nurse-centered antiretroviral treatment (ART) prescription was launched in three rural primary health centers in Rwanda. We retrospectively evaluated the feasibility and effectiveness of this task-shifting model using descriptive data.
Methods and Findings
Medical records of 1,076 patients enrolled in HIV care and treatment services from September 2005 to March 2008 were reviewed to assess: (i) compliance with national guidelines for ART eligibility and prescription, and patient monitoring and (ii) key outcomes, such as retention, body weight, and CD4 cell count change at 6, 12, 18, and 24 mo after ART initiation. Of these, no ineligible patients were started on ART and only one patient received an inappropriate ART prescription. Of the 435 patients who initiated ART, the vast majority had adherence and side effects assessed at each clinic visit (89% and 84%, respectively). By March 2008, 390 (90%) patients were alive on ART, 29 (7%) had died, one (<1%) was lost to follow-up, and none had stopped treatment. Patient retention was about 92% by 12 mo and 91% by 24 mo. Depending on initial stage of disease, mean CD4 cell count increased between 97 and 128 cells/µl in the first 6 mo after treatment initiation and between 79 and 129 cells/µl from 6 to 24 mo of treatment. Mean weight increased significantly in the first 6 mo, between 1.8 and 4.3 kg, with no significant increases from 6 to 24 mo.
Conclusions
Patient outcomes in our pilot program compared favorably with other ART cohorts in sub-Saharan Africa and with those from a recent evaluation of the national ART program in Rwanda. These findings suggest that nurses can effectively and safely prescribe ART when given adequate training, mentoring, and support.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Infection with the human immunodeficiency virus (HIV) is a serious health problem in sub-Saharan Africa. The virus attacks white blood cells that protect against infection, most commonly a type of white blood cell called CD4. When a person has been infected with HIV for a long time, the number of CD4 cells they have goes down, resulting in acquired immune deficiency syndrome (AIDS), in which the person's immune system no longer functions effectively.
The World Health Organization (WHO) has divided the disease into four stages as it progresses, according to symptoms including weight loss and so-called opportunistic infections. These are known as clinical stage I, II, III, or IV but were revised and renamed 1, 2, 3, and 4 in September 2005. HIV infection and AIDS cannot be cured but they can be managed with antiretroviral treatment (ART). The WHO currently recommends that ART is begun when the CD4 count falls below 350.
Rwanda is a country situated in the central Africa with a population of around 9 million inhabitants; over 3% of the rural population and 7% of the urban population are infected with HIV. In 2007, the WHO estimated that 220,000 Rwandan children had lost one or both parents to AIDS.
Why Was This Study Done?
The WHO estimates that 9.7 million people with HIV in low- to middle-income countries need ART but at the end of 2007, only 30% of these, including in Rwanda, had access to treatment. In many low-income countries a major factor in this is a lack of doctors. Rwanda, for example, has one doctor per 50,000 inhabitants and one nurse per 3,900 inhabitants.
This situation has led the WHO to recommend “task shifting,” i.e., that the task of prescribing ART should be shifted from doctors to nurses so that more patients can be treated. This type of reorganization is well studied in high-income countries, but the researchers wanted to help develop a system for treating AIDS that would be effective and timely in a predominantly rural, low-income setting such as Rwanda.
What Did the Researchers Do and Find?
In conjunction with the Rwandan Ministry of Health, the researchers developed and piloted a task-shifting program, in which one nurse in each of three rural Rwandan primary health centers (PHCs) was trained to examine HIV patients and prescribe ART in simple cases. Nurses had to complete more than 50 consultations observed by the doctor before being permitted to consult patients independently. More complex cases were referred to a doctor. The authors developed standard checklists, instructions, and evaluation forms to guide nurses and the doctors who supervised them once a week.
The authors evaluated the pilot program by reviewing the records of 1,076 patients who enrolled on it between September 2005 and March 2008. They looked to see whether the nurses had followed guidelines and monitored the patients correctly. They also considered health outcomes for the patients, such as their death rate, their body weight, their CD4 cell count, and whether they maintained contact with caregivers.
They found that by March 2008, 451 patients had been eligible for ART. 435 received treatment and none of the patients were prescribed ART when they should not have been. Only one prescription did not follow national guidelines.
At every visit, nurses were supposed to assess whether patients were taking their drugs and to monitor side effects. They did this and maintained records correctly for the vast majority of the 435 patients who were prescribed ART. 390 patients (over 90%) of the 435 prescribed receiving ART continued to take it and maintain contact with the pilot PHC's program. 29 patients died. Only one was lost to follow up and the others transferred to another ART site. The majority gained weight in the first six months and their CD4 cell counts rose. Outcomes, including death rate, were similar to those treated on the (doctor-led) Rwandan national ART program and other sub-Saharan African national (doctor-led) programs.
What Do These Findings Mean?
The study suggests that nurses are able to prescribe ART safely and effectively in a rural sub-Saharan setting, given sufficient training, mentoring, and support. Nurse-led prescribing of ART could mean that timely, appropriate treatment reaches many more HIV patients. It would reduce the burden of HIV care for doctors, freeing their time for other duties, and the study is already being used by the Rwandan Ministry of Health as a basis for plans to adopt a task-shifting strategy for the national ART program.
The study does have some limitations. The pilot program was funded and designed as a health project to deliver ART in rural areas, rather than a research project to compare nurse-led and doctor-led ART programs. There was no group of equivalent patients treated by doctors rather than nurses for direct comparison, although the authors did compare outcomes with those achieved nationally for doctor-led ART. The most promising sites, nurses, and patients were selected for the pilot and careful monitoring may have been an additional motivation for the nurses and doctors taking part. Health professionals in a scaled-up program may not be as committed as those in the pilot, who were carefully monitored. In addition, the nature of the pilot, which lasted for under three years and recruited new patients throughout, meant that patients were followed up for relatively short periods.
The authors also warn that they did not consider in this study the changes task shifting will make to doctors' roles and the skills required of both doctors and nurses. They recommend that task shifting should be implemented as part of a wider investment in health systems, human resources, training, adapted medical records, tools, and protocols.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000163.
PLoS Medicine includes a page collecting together its recent articles on HIV infection and AIDS that includes research articles, perspectives, editorials, and policy forums
SciDev.net provides news, views, and information about science, technology, and the developing world, including a section specific to HIV/AIDs
The World Health Organization (WHO) has published a downloadable booklet Task Shifting to Tackle Health Worker Shortages
The WHO offers information on HIV and AIDS (in Arabic, Chinese, English, French, Russian, and Spanish) as well as health information and fact sheets on individual countries, including on Rwanda
The UNAIDS/WHO working group on HIV/AIDS and Sexually Transmitted Infections (STI) Surveillance gathers and publishes data on the prevalence of HIV and AIDS in individual countries, including on Rwanda
AIDS.ORG provides information to help prevent HIV infections and to improve the lives of those affected by HIV and AIDS. Factsheets on many aspects of HIV and AIDS are available. It is the official online publisher of AIDS Treatment News
doi:10.1371/journal.pmed.1000163
PMCID: PMC2752160  PMID: 19823569
22.  Quality in general practice consultations; a qualitative study of the views of patients living in an area of high socio-economic deprivation in Scotland 
BMC Family Practice  2007;8:22.
Background
Inequality in health and health care services is an important policy issue internationally as well as in the UK, and is closely linked to socio-economic deprivation, which in Scotland is concentrated in and around Glasgow. Patients views on primary care in deprived areas are not well documented. In the present study we explore the views of patients living in a high deprivation area on the quality of consultations in general practice.
Methods
Qualitative focus group study set in an area of high socio-economic deprivation in a large peripheral housing estate in Glasgow, Scotland. 11 focus groups were conducted; 8 with local community groups and 3 with other local residents. In total 72 patients took part. Grounded theory was used to analyse the data.
Results
Patients' perceptions of the quality of the consultation with GPs consisted of two broad, inter-relating themes; (1) the GPs' competence, and (2) the GPs empathy or ' caring'. Competence was often assumed but many factors coloured this assumption, in particular whether patients had experienced (directly or indirectly with a close family member) 'successful' outcomes with that doctor previously or not. 'Caring' related to patients feeling (a) listened to by the doctor and being able to talk; (b) valued as an individual by the doctor (c) that the doctor understood 'the bigger picture', and (d) the doctors' explanations were clear and understandable.
Relational continuity of care (being able to see the same GP and having a good relationship), and having sufficient time in the consultation were closely linked with perceptions of consultation quality.
Conclusion
Patients from deprived areas want holistic GPs who understand the realities of life in such areas and whom they can trust as both competent and genuinely caring. Without this, they may judge doctors as socially distant and emotionally detached. Relational continuity, empathy and sufficient time in consultations are key factors in achieving this.
doi:10.1186/1471-2296-8-22
PMCID: PMC1857696  PMID: 17442123
23.  Junior doctor titles following implementation of Modernising Medical Careers in the UK 
JRSM Short Reports  2011;2(3):22.
Objective
Recent changes in postgraduate medical training in the UK collectively organized under the auspices of Modernising Medical Careers (MMC) have created new labels for junior doctors in training. It would appear that many nurses and other health workers do not understand the new terminology. We aimed to investigate the knowledge of nursing staff about new junior doctor titles in a district general hospital. As far as we are aware, this is the first survey to determine the views and knowledge of the new terms among staff working in the NHS.
Design
Questionnaire study.
Setting
District general hospital, West Midlands, UK.
Participants
Fifty-five randomly selected staff nurses working in the surgical directorate.
Main outcome measure
Questions were asked about their views and knowledge of the current nomenclature. To objectively assess knowledge of the new titles respondents were asked to match equivalent positions with those based on the old system.
Results
Only 22% (n = 12) of respondents felt that they fully understand current terms in usage. Seventy-six percent (n = 42) felt that it was ‘very important’ that titles accurately convey role and seniority of the doctor. The most common titles correctly matched were FY1 and House Officer (n = 45, 81%) and FY2 and First Year Senior House Officer (n = 35, 64%). Only 9% (n = 5) of staff nurses correctly matched ST3 to Junior Registrar and 13% (n = 7) correctly matched ST7 to Senior Registrar. Ward-based staff nurses demonstrated greater familiarity with titles when compared to nurses who work mainly in the outpatient clinic and theatre setting (p = 0.017). We did not identify a statistically significant association with demographic characteristics (age, gender, experience) and knowledge of the new terms (p > 0.05). Approximately 98% (n = 54) of the staff surveyed felt that terms are confusing to nurses and need to be simplified.
Conclusions
Our survey revealed that nursing staff lacked knowledge of the current terminology to describe doctors in training. This may have implications for staff expectations regarding specific role of junior doctor in terms of clinical decision-making, working relationships and communication between team members, and ultimately patient care.
doi:10.1258/shorts.2011.010110
PMCID: PMC3086326  PMID: 21541090
24.  Evaluation of Current Knowledge, Awareness and Practice of Spirometry among Hospital -based Nigerian Doctors 
Background
Spirometry is a cost-effective diagnostic tool for evaluation of lung function and for case-finding in a resource-limited setting. The acceptance of this test depends on the awareness of its indications and the ability to interpret the results. No studies have assessed the knowledge of spirometry among Nigerian doctors. The aim of this study was to evaluate the current knowledge, awareness and practice of spirometry among hospital-based Nigerian doctors.
Methods
We carried out a cross-sectional survey among 321 doctors working in Nigerian hospitals between March 2008 and June 2008. Information on knowledge, awareness, practice of and barriers to spirometry were obtained using a pre-tested, self-administered structured questionnaire and the data were then analysed.
Results
Of the 321 doctors that participated, 108 (33.6%) reported that they have good knowledge of spirometry. One hundred and ninety-five (60.7%) were aware of the importance of spirometry in aiding the diagnosis of respiratory diseases; 213(66.4%) were aware of the importance of spirometry in determining the severity of diseases. Medical school was the most common source of knowledge on spirometry (64.5%). Eighty-one (25.2%) doctors reported having a spirometer in their hospitals. Doctors having access to a spirometer used it more frequently for aiding the diagnosis of COPD (40.7% vs.27.5%) and for monitoring of asthma (18.5% vs.11.3%) than those without access to a spirometer. The doctors working in University Teaching Hospitals and Federal Medical Centres (FMC) (22.4% vs. 4.5%) and those having access to a spirometer (40.7 vs.11.3%) were very confident of interpreting spirometry results compared to those working in District and General Hospitals and without access to a spirometer. Irrespective of access to a spirometer or the type of hospital they were employed in, doctors reported that unavailability of a spirometer was the greatest barrier to its use (62.5%) followed by lack of awareness about its usefulness (17.2%).
Conclusion
The knowledge and practice of spirometry were poor among hospital-based Nigerian doctors because of unavailability of spirometers in most hospitals. These findings have implications for further evaluation, planning and management of patient care in respiratory disease. Spirometers should be made available in all hospitals, and the knowledge of spirometry should be improved among doctors.
doi:10.1186/1471-2466-9-50
PMCID: PMC2803443  PMID: 20003446
25.  Doctors’ views about training and future careers expressed one year after graduation by UK-trained doctors: questionnaire surveys undertaken in 2009 and 2010 
BMC Medical Education  2014;14(1):270.
Background
The UK medical graduates of 2008 and 2009 were among the first to experience a fully implemented, new, UK training programme, called the Foundation Training Programme, for junior doctors. We report doctors’ views of the first Foundation year, based on comments made as part of a questionnaire survey covering career choices, plans, and experiences.
Methods
Postal and email based questionnaires about career intentions, destinations and views were sent in 2009 and 2010 to all UK medical graduates of 2008 and 2009. This paper is a qualitative study of ‘free-text’ comments made by first-year doctors when invited to comment, if they wished, on any aspect of their work, education, training, and future.
Results
The response rate to the surveys was 48% (6220/12952); and 1616 doctors volunteered comments. Of these, 61% wrote about their first year of training, 35% about the working conditions they had experienced, 33% about how well their medical school had prepared them for work, 29% about their future career, 25% about support from peers and colleagues, 22% about working in medicine, and 15% about lifestyle issues. When concerns were expressed, they were commonly about the balance between service provision, administrative work, and training and education, with the latter often suffering when it conflicted with the needs of medical service provision. They also wrote that the quality of a training post often depended on the commitment of an individual senior doctor. Service support from seniors was variable and some respondents complained of a lack of team work and team ethic. Excessive hours and the lack of time for reflection and career planning before choices about the future had to be made were also mentioned. Some doctors wrote that their views were not sought by their hospital and that NHS management structures did not lend themselves to efficiency. UK graduates from non-UK homes felt insecure about their future career prospects in the UK. There were positive comments about opportunities to train flexibly.
Conclusions
Although reported problems should be considered in the wider context, in which the majority held favourable overall views, many who commented had been disappointed by aspects of their first year of work. We hope that the concerns raised by our respondents will prompt trainers, locally, to determine, by interaction with junior staff, whether or not these are concerns in their own training programme.
Electronic supplementary material
The online version of this article (doi:10.1186/s12909-014-0270-5) contains supplementary material, which is available to authorized users.
doi:10.1186/s12909-014-0270-5
PMCID: PMC4302441  PMID: 25528260
Medical careers; Junior doctors; Medical education; Foundation training

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