PMCC PMCC

Search tips
Search criteria

Advanced
Results 1-25 (921786)

Clipboard (0)
None

Related Articles

1.  Doctors as patients: a systematic review of doctors' health access and the barriers they experience 
Background
The need to improve doctors' access to health care by reducing the barriers they experience has been regularly described in the literature, yet the barriers experienced are not well defined, despite the volume of expert opinion in this area.
Aim
To define what is known about doctors' access to health care from the data within the current literature.
Design of study
A systematic review of studies of doctors' health access.
Method
A systematic search of MEDLINE® and CINAHL, supplemented by citation searches and searches of the grey literature, identified both quantitative and qualitative studies. Two reviewers used specific criteria for inclusion of studies and quality assessment. The data were tabulated and analysed.
Results
Twenty-six articles met the inclusion criteria. The paucity of data and the overall poor quality of those data are highlighted. Despite this, many doctors appear to have a GP, but this does not ensure adequate health access. Systemic barriers to healthcare access (long hours and cultural issues) are more significant than individual barriers.
Conclusion
Expert opinion in this field is supported by poor-quality data. The current knowledge reveals important similarities between doctors and the general population in their healthcare access, especially with mental health issues. Understanding this may help the medical profession to respond to these issues of ‘doctors’ health' more effectively.
doi:10.3399/bjgp08X319486
PMCID: PMC2441513  PMID: 18611318
attitude of health personnel; health behaviour; physician health; systematic review
2.  ‘Can he have the test for bipolar, doctor? His dad's got it’: exploring the potential of general practitioners to work with children and young people presenting in primary care with common mental health problems – a clinical initiative 
Mental Health in Family Medicine  2012;9(2):115-123.
Background General practitioners (GPs) play a key role in assessing and managing adult mental health problems, but this input is not seen in their management of child and adolescent mental health. Mental health problems in 5–19-year-olds are common, yet detection rates in primary care are low. The symptoms of most adult diagnoses of mental health problems are present by mid-adolescence, yet the typical time from onset to diagnosis is 5–15 years. The role of general practice in this area has been underexplored.
Aim This pilot study explores the potential of GPs to respond to common mental health problems in children and adolescents.
Design Children and young people who would have ordinarily been referred to Child and Adolescent Mental Health Services (CAMHS) were seen in a GP setting. In a UK general practice surgery serving a disadvantaged population.
Method Children and young people were seen for an initial biopsychosocial assessment and formulation of the presenting concerns. GP-based interventions were offered as appropriate or referred to CAMHS.
Results Data from the first 50 children (2–19 years) are presented. Twenty younger children (10 years and under) and 30 older children (11 years and above) were seen. Eighteen referrals were made to CAMHS. GP interventions included watchful waiting, brief behavioural interventions, non-directive counselling, brief cognitive– behavioural therapy (CBT) and liaison with colleagues in education, CAMHS and the voluntary sector.
Conclusion This clinical pilot demonstrates that with adequate time, access to supervision and practice support, children and young people experiencing emotional and behavioural problems associated with common mental health issues can be helped in primary care.
PMCID: PMC3513704  PMID: 23730336
common child and adolescent mental health problems; early intervention in primary care; GP involvement
3.  A multifaceted strategy using mobile technology to assist rural primary healthcare doctors and frontline health workers in cardiovascular disease risk management: protocol for the SMARTHealth India cluster randomised controlled trial 
Background
Blood Pressure related disease affected 118 million people in India in the year 2000; this figure will double by 2025. Around one in four adults in rural India have hypertension, and of those, only a minority are accessing appropriate care. Health systems in India face substantial challenges to meet these gaps in care, and innovative solutions are needed.
Methods
We hypothesise that a multifaceted intervention involving capacity strengthening of primary healthcare doctors and non-physician healthcare workers through use of a mobile device-based clinical decision support system will result in improved blood pressure control for individuals at high risk of a cardiovascular disease event when compared with usual healthcare. This intervention will be implemented as a stepped wedge, cluster randomised controlled trial in 18 primary health centres and 54 villages in rural Andhra Pradesh involving adults aged ≥40 years at high cardiovascular disease event risk (approximately 15,000 people). Cardiovascular disease event risk will be calculated based on World Health Organisation/International Society of Hypertension’s region-specific risk charts. Cluster randomisation will occur at the level of the primary health centres. Outcome analyses will be conducted blinded to intervention allocation.
Expected outcomes
The primary study outcome is the difference in the proportion of people meeting guideline-recommended blood pressure targets in the intervention period vs. the control period. Secondary outcomes include mean reduction in blood pressure levels; change in other cardiovascular disease risk factors, including body mass index, current smoking, reported healthy eating habits, and reported physical activity levels; self-reported use of blood pressure and other cardiovascular medicines; quality of life (using the EQ-5D); and cardiovascular disease events (using hospitalisation data). Trial outcomes will be accompanied by detailed process and economic evaluations.
Significance
The findings are likely to inform policy on a scalable strategy to overcome entrenched inequities in access to effective healthcare for under-served populations in low and middle income country settings.
Trial registration
Clinical Trial Registry India CTRI/2013/06/003753.
doi:10.1186/1748-5908-8-137
PMCID: PMC4222027  PMID: 24274431
Blood pressure; Capacity strengthening; Clinical decision support system; Healthcare workers; Physicians; India; Implementation
4.  Lifetime Prevalence of Mental Disorders in Lebanon: First Onset, Treatment, and Exposure to War  
PLoS Medicine  2008;5(4):e61.
Background
There are no published data on national lifetime prevalence and treatment of mental disorders in the Arab region. Furthermore, the effect of war on first onset of disorders has not been addressed previously on a national level, especially in the Arab region. Thus, the current study aims at investigating the lifetime prevalence, treatment, age of onset of mental disorders, and their relationship to war in Lebanon.
Methods and Findings
The Lebanese Evaluation of the Burden of Ailments and Needs Of the Nation study was carried out on a nationally representative sample of the Lebanese population (n = 2,857 adults). Respondents were interviewed using the fully structured WHO Composite International Diagnostic Interview 3.0. Lifetime prevalence of any Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) disorder was 25.8%. Anxiety (16.7%) and mood (12.6%) were more common than impulse control (4.4%) and substance (2.2%) disorders. Only a minority of people with any mental disorder ever received professional treatment, with substantial delays (6 to 28 y) between the onset of disorders and onset of treatment. War exposure increased the risk of first onset of anxiety (odds ratio [OR] 5.92, 95% confidence interval [CI] 2.5–14.1), mood (OR 3.32, 95% CI 2.0–5.6), and impulse control disorders (OR 12.72, 95% CI 4.5–35.7).
Conclusions
About one-fourth of the sample (25.8%) met criteria for at least one of the DSM-IV disorders at some point in their lives. There is a substantial unmet need for early identification and treatment. Exposure to war events increases the odds of first onset of mental disorders.
In a survey of 2,857 adults in Lebanon, Elie Karam and colleagues found a lifetime prevalence of any DSM-IV psychiatric disorder of 25.8%.
Editors' Summary
Background.
Mental illnesses—persistent problems with thinking, with feelings, with behavior, and with coping with life—are very common. In the UK about a quarter, and in the US, almost half, of people have a mental illness at some time during their life. Depression, for example, persistently lowers a person's mood and can make them feel hopeless and unmotivated. Anxiety—constant, unrealistic worries about daily life—can cause sleep problems and physical symptoms such as stomach pains. People with impulse-control disorders, have problems with controlling their temper or their impulses which may sometimes lead to hurting themselves or other people. These and other mental illnesses seriously affect the work, relationships, and quality of life of the ill person and of their family. However, most people with mental illnesses can lead fulfilling and productive lives with the help of appropriate medical and nonmedical therapies.
Why Was This Study Done?
Recent epidemiological surveys (studies that investigate the factors that affect the health of populations) have provided important information about the burden of mental disorders in some industrialized countries. However, little is known about the global prevalence of mental disorders (the proportion of people in a population with each disorder at one time) or about how events such as wars affect mental health. This information is needed so that individual countries can provide effective mental-health services for their populations. To provide this information, the World Mental Health (WMH) Survey Initiative is undertaking large-scale psychiatric epidemiological surveys in more than 29 countries. As part of this Initiative, researchers have examined the prevalence and treatment of mental disorders in Lebanon and have asked whether war in this country has affected the risk of becoming mentally ill.
What Did the Researchers Do and Find?
The researchers randomly selected a sample of nearly 3,000 adults living in Lebanon and interviewed them using an Arabic version of the World Health Organization's “Composite International Diagnostic Interview” (CIDI 3.0). This interview tool generates diagnoses of mental disorders in the form of “DSM-IV codes,” the American Psychiatric Association's standard codes for specific mental disorders. The researchers also asked the study participants about their experience of war-related traumatic events such as being a civilian in a war zone or being threatened by a weapon. The researchers found that one in four Lebanese had had one or more DSM-IV disorder at some time during their life. Major depression was the single most common disorder. The researchers also calculated that by the age of 75 years, about one-third of the Lebanese would probably have had one or more DSM-IV disorder. Only half of the Lebanese with a mood disorder ever received professional help; treatment rates for other mental disorders were even lower. The average delay in treatment ranged from 6 years for mood disorders to 28 years for anxiety disorders. Finally, exposure to war-related events increased the risk of developing an anxiety, mood, or impulse-control disorder by about 6-fold, 3-fold, and 13-fold, respectively.
What Do These Findings Mean?
These findings indicate that the prevalence of mental illness in Lebanon is similar to that in the UK and the US, the first time that this information has been available for an Arabic-speaking country. Indeed, the burden of mental illness in Lebanon may actually be higher than these findings suggest, because the taboos associated with mental illness may have stopped some study participants from reporting their problems. The findings also show that in Lebanon exposure to war-related events greatly increases the risk of developing for the first time several mental disorders. Further studies are needed to discover whether this finding is generalizable to other countries. Finally, these findings indicate that many people in Lebanon who develop a mental illness never receive appropriate treatment. There is no shortage of health-care professionals in Lebanon, so the researchers suggest that the best way to improve the diagnosis and treatment of mental disorders in this country might be to increase the awareness of these conditions and to reduce the taboos associated with mental illness, both among the general population and among health-care professionals.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0050061.
Read a related PLoS Medicine Perspective article
IDRAAC has a database that provides access to all published research articles related to mental health in the Arab World
The UK charity Mind provides information on understanding mental illness
The US National Institute of Mental Health provides information on understanding, treating, and preventing mental disorders (mainly in English but some information in Spanish)
MedlinePlus provides a list of useful links to information about mental health
Wikipedia has a page on DSM-IV codes (note that Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
The World Mental Health Survey Initiative and the Lebanese WHM study are described on the organizations' Web pages
doi:10.1371/journal.pmed.0050061
PMCID: PMC2276523  PMID: 18384228
5.  Doctors as patients: postal survey examining consultants and general practitioners adherence to guidelines 
BMJ : British Medical Journal  1999;319(7210):605-608.
Objectives
To examine the adherence by senior NHS medical staff to the BMA guidelines on the ethical responsibilities of doctors towards themselves and their families.
Design
Postal semistructured questionnaire.
Setting
Four randomly selected NHS trusts and three local medical committees in South Thames region.
Subjects
Consultants and principals in general practice.
Main outcome measures
Personal use of health services.
Results
The response rate was 64% (724) for general practitioners and 72% (427) for consultants after three mailings. Most (1106, 96%) respondents were registered with a general practitioner, although little use was made of their services. 159 (26%) general practitioners were registered with a general practitioner in their own practice and 80 (11%) admitted to looking after members of their family. 73 (24%) consultants would never see their general practitioner before obtaining consultant advice. Most consultants and general practitioners admitted to prescribing for themselves and their family. Responses to vignettes for different health problems indicated a general reluctance to take time off, but there were differences between consultants and general practitioners and by sex. Views on improvements needed included the possibility of a “doctor’s doctor,” access to out of area secondary care, an occupational health service for general practitioners, and regular health check ups.
Conclusion
The guidelines are largely not being followed, perhaps because of the difficulties of obtaining access to general practitioners outside working hours. The occupational health service should be expanded and a general practitioner service for NHS staff piloted.
Key messagesSenior doctors are not following the BMA guidelines on looking after their own and their families’ healthThey seem very reluctant to consult their general practitioner They prefer to self treat, carry on working, and consult informallyPotential barriers to access should be removed in order to improve their health
PMCID: PMC28211  PMID: 10473473
6.  What happens when patients know more than their doctors? Experiences of health interactions after diabetes patient education: a qualitative patient-led study 
BMJ Open  2013;3(11):e003583.
Objective
To explore the impact of patient education on the lives of people with diabetes, including the effect on interactions with doctors and other healthcare professionals.
Design
Qualitative user-led study using longitudinal interviews and 146 h of participant observation. Data were analysed using a narrative approach.
Participants
21 patients with type 1 diabetes, those either about to attend a patient education course or those who had completed the course in the previous 10 years.
Setting
Established patient education centres in three UK teaching hospitals teaching the Dose Adjustment for Normal Eating (DAFNE) course.
Results
Both postcourse and several years later, most participants spoke of the experience of taking part in education as life-changingly positive. It helped them understand how to gain control over a very complex disease and freed them from dependence on medical advice and restrictive regimes. However, interactions within the health system following patient education could be fraught. Participants emerged from the course with greater condition-specific knowledge than many of the healthcare professionals they encountered. When these professionals did not understand what their patients were trying to do and were uncomfortable trusting their expertise, there could be serious consequences for these patients' ability to continue effective self-management.
Conclusions
Patients who have in-depth knowledge of their condition encounter problems when their expertise is seen as inappropriate in standard healthcare interactions, and expertise taught to patients in one branch of medicine can be considered non-compliant by those who are not specialists in that field. Although patient education can give people confidence in their own self-management skills, it cannot solve the power imbalance that remains when a generalist healthcare professional, however well meaning, blocks access to medication and supplies needed to manage chronic diseases successfully. There is a role for those involved in primary and hospital care, including those supporting and training healthcare professionals, to recognise these problems and find ways to acknowledge and respect chronic patients' biomedical and practical expertise.
doi:10.1136/bmjopen-2013-003583
PMCID: PMC3831109  PMID: 24231459
Medical Education & Training; Primary Care
7.  Working with the Family Doctor: A Programme for Mental Health 
British Medical Journal  1972;4(5843):781-784.
A new type of assessment for mental health in four Scottish counties has been based on multidisciplinary teams comprising psychiatrists, psychiatric social worker, nursing administrator, and a secretary. Each team collaborated with 15 to 20 family doctors and they established four main patterns of contact: around an outpatient clinic; by informal availability; by administrative and teaching seminars; or by regular consultation sessions. This improved contact was found to help both the team and the family doctors and reduced the number of patients admitted to hospital and the length of their stay and the number of urgent referrals. It emphasizes the need for team work in mental health care and that the hospital needs to remain in touch with the outside community.
Images
PMCID: PMC1787028  PMID: 4646512
8.  The Role of Health Systems Factors in Facilitating Access to Psychotropic Medicines: A Cross-Sectional Analysis of the WHO-AIMS in 63 Low- and Middle-Income Countries 
PLoS Medicine  2012;9(1):e1001166.
In a cross-sectional analysis of WHO-AIMS data, Ryan McBain and colleagues investigate the associations between health system components and access to psychotropic drugs in 63 low and middle income countries.
Background
Neuropsychiatric conditions comprise 14% of the global burden of disease and 30% of all noncommunicable disease. Despite the existence of cost-effective interventions, including administration of psychotropic medicines, the number of persons who remain untreated is as high as 85% in low- and middle-income countries (LAMICs). While access to psychotropic medicines varies substantially across countries, no studies to date have empirically investigated potential health systems factors underlying this issue.
Methods and Findings
This study uses a cross-sectional sample of 63 LAMICs and country regions to identify key health systems components associated with access to psychotropic medicines. Data from countries that completed the World Health Organization Assessment Instrument for Mental Health Systems (WHO-AIMS) were included in multiple regression analyses to investigate the role of five major mental health systems domains in shaping medicine availability and affordability. These domains are: mental health legislation, human rights implementations, mental health care financing, human resources, and the role of advocacy groups. Availability of psychotropic medicines was associated with features of all five mental health systems domains. Most notably, within the domain of mental health legislation, a comprehensive national mental health plan was associated with 15% greater availability; and in terms of advocacy groups, the participation of family-based organizations in the development of mental health legislation was associated with 17% greater availability. Only three measures were related with affordability of medicines to consumers: level of human resources, percentage of countries' health budget dedicated to mental health, and availability of mental health care in prisons. Controlling for country development, as measured by the Human Development Index, health systems features were associated with medicine availability but not affordability.
Conclusions
Results suggest that strengthening particular facets of mental health systems might improve availability of psychotropic medicines and that overall country development is associated with affordability.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Mental disorders—conditions that involve impairment of thinking, emotions, and behavior—are extremely common. Worldwide, mental illness affects about 450 million people and accounts for 13.5% of the global burden of disease. About one in four people will have a mental health problem at some time in their life. For some people, this will be a short period of mild depression, anxiety, or stress. For others, it will be a serious, long-lasting condition such as schizophrenia, bipolar disorder, or major depression. People with mental health problems need help and support from professionals and from their friends and families to help them cope with their illness but are often discriminated against, which can make their illness worse. Treatments include counseling and psychotherapy (talking therapies), and psychotropic medicines—drugs that act mainly on the brain. Left untreated, many people with serious mental illnesses commit suicide.
Why Was This Study Done?
About 80% of people with mental illnesses live in low- and middle-income countries (LAMICs) where up to 85% of patients remain untreated. Access to psychotropic medicines, which constitute an essential and cost-effective component in the treatment of mental illnesses, is particularly poor in many LAMICs. To improve this situation, it is necessary to understand what health systems factors limit the availability and affordability of psychotropic drugs; a health system is the sum of all the organizations, institutions, and resources that act together to improve health. In this cross-sectional study, the researchers look for associations between specific health system components and access to psychotropic medicines by analyzing data collected from LAMICs using the World Health Organization's Assessment Instrument for Mental Health Systems (WHO-AIMS). A cross-sectional study analyzes data collected at a single time. WHO-AIMS, which was created to evaluate mental health systems primarily in LAMICs, is a 155-item survey that Ministries of Health and other country-based agencies can use to collect information on mental health indicators.
What Did the Researchers Do and Find?
The researchers used WHO-AIMS data from 63 countries/country regions and multiple regression analysis to evaluate the role of mental health legislation, human rights implementation, mental health care financing, human resources, and advocacy in shaping medicine availability and affordability. For each of these health systems domains, the researchers developed one or more summary measurements. For example, they measured financing as the percentage of government health expenditure directed toward mental health. Availability of psychotropic medicines was defined as the percentage of mental health facilities in which at least one psychotropic medication for each therapeutic category was always available. Affordability was measured by calculating the percentage of daily minimum wage needed to purchase medicine by the average consumer. The availability of psychotropic medicines was related to features of all five mental health systems domains, report the researchers. Notably, having a national mental health plan (part of the legislation domain) and the participation (advocacy) of family-based organizations in mental health legislation formulation were associated with 15% and 17% greater availability of medicines, respectively. By contrast, only the levels of human resources and financing, and the availability of mental health care in prisons (part of the human rights domain) were associated with the affordability of psychotropic medicines. Once overall country development was taken into account, most of the associations between health systems factors and medicine availability remained significant, while the associations between health systems factors and medicine affordability were no longer significant. In part, this was because country development was more strongly associated with affordability and explained most of the relationships: for example, countries with greater overall development have higher expenditures on mental health and greater medicine affordability compared to availability.
What Do These Findings Mean?
These findings indicate that access to psychotropic medicines in LAMICs is related to key components within the mental health systems of these countries but that availability and affordability are affected to different extents by these components. They also show that country development plays a strong role in determining affordability but has less effect on determining availability. Because cross-sectional data were used in this study, these findings only indicate associations; they do not imply causality. They are also limited by the relatively small number of observations included in this study, by the methods used to collect mental health systems data in many LAMICs, and by the possibility that some countries may have reported biased results. Despite these limitations, these findings suggest that strengthening specific mental health system features may be an important way to facilitate access to psychotropic medicines but also highlight the role that country wealth and development play in promoting the treatment of mental disorders.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/ 10.1371/journal.pmed.1001166.
The US National Institute of Mental Health provides information on all aspects of mental health (in English and Spanish)
The UK National Health Service Choices website provides information on mental health; its Live Well feature provides practical advice on dealing with mental health problems and personal stories
The UK charity Mind provides further information about mental illness, including personal stories
MedlinePlus provides links to many other sources of information on mental health (in English and Spanish)
Information on WHO-AIMS, including versions of the instrument in several languages, and WHO-AIMS country reports are available
doi:10.1371/journal.pmed.1001166
PMCID: PMC3269418  PMID: 22303288
9.  Underperforming doctors: a postal survey of the Northern Deanery 
BMJ : British Medical Journal  1998;316(7146):1705-1708.
Objectives: To discover the perceived size of pool of doctors considered to be underperforming in general practice in the Northern Deanery and to discover whether these perceptions are based on formal assessments.
Design: Postal questionnaire.
Setting: Area covered by the Northern Deanery.
Subjects: Seven health authority directors of primary care, seven secretaries of local medical committees, and 14 chief officers of community health councils.
Results: The response rate was 100% for directors of primary care and secretaries of local medical committees and, after one reminder, 92% for chief officers of community health councils. Numbers of doctors perceived to be underperforming ranged from none to over 15 in different health authority areas. Main areas for concern were communication skills, clinical skills, and management skills. Patients’ representatives were concerned about lack of power of patients and health authorities and doctors’ lack of accountability. Health authorities were concerned about lack of power, identification of underperforming doctors, and doctors’ professional loyalty. Local medical committees were concerned about the problem of identifying underperformance. A number of methods were used for identification, and there was no common method applied.
Conclusions: The number of doctors thought to be underperforming was small. Work still needs to be done on developing tools that can be used in everyday practice to enable doctors to confirm for themselves, their colleagues, and their patients that they are providing an adequate level of care.
Key messages To quantify the problem of underperforming general practitioners in the Northern Deanery, a postal survey was carried out among representatives of healthcare commissioners, doctors, and patients A small but not insignificant number of doctors were identified as providing a poor level of performance Main areas for concern were communication skills, clinical skills, and management skills. Various methods were used for identifying underperforming doctors, but there was no common method applied Perceived problems with the present system of dealing with underperforming doctors included identification, lack of power of patients and health authorities, and doctors’ professional loyalty and lack of accountability
PMCID: PMC28568  PMID: 9614017
10.  Depersonalised doctors: a cross-sectional study of 564 doctors, 760 consultations and 1876 patient reports in UK general practice 
BMJ Open  2012;2(1):e000274.
Objectives
The objectives of this study were to assess burnout in a sample of general practitioners (GPs), to determine factors associated with depersonalisation and to investigate its impact on doctors' consultations with patients.
Design
Cross-sectional, postal survey of GPs using the Maslach Burnout Inventory (MBI). Patient survey and tape-recording of consultations for a subsample of respondents stratified by their MBI scores, gender and duration of General Medical Council registration.
Setting
UK general practice.
Participants
GPs within NHS Essex.
Primary and secondary outcome measures
Scores on MBI subscales (depersonalisation, emotional exhaustion, personal accomplishment); scores on Doctors' Interpersonal Skills Questionnaire and patient-centredness scores attributed to tape-recorded consultations by independent observers.
Results
In the postal survey, 564/789 (71%) GPs completed the MBI. High levels of emotional exhaustion (261/564 doctors, 46%) and depersonalisation (237 doctors, 42%) and low levels of personal accomplishment (190 doctors, 34%) were reported. Depersonalisation scores were related to characteristics of the doctor and the practice. Male doctors reported significantly higher (p<0.001) depersonalisation than female doctors. Doctors registered with the General Medical Council under 20 years had significantly higher (p=0.005) depersonalisation scores than those registered for longer. Doctors in group practices had significantly higher (p=0.001) depersonalisation scores than single-handed practitioners. Thirty-eight doctors agreed to complete the patient survey (n=1876 patients) and audio-record consultations (n=760 consultations). Depersonalised doctors were significantly more likely (p=0.03) to consult with patients who reported seeing their ‘usual doctor’. There were no significant associations between doctors' depersonalisation and their patient-rated interpersonal skills or observed patient-centredness.
Conclusions
This is the largest number of doctors completing the MBI with the highest levels of depersonalisation reported. Despite experiencing substantial depersonalisation, doctors' feelings of burnout were not detected by patients or independent observers. Such levels of burnout are, however, worrying and imply a need for action by doctors themselves, their medical colleagues, professional bodies, healthcare organisations and the Department of Health.
Article summary
Article focus
A cross-sectional survey was designed to assess levels of burnout in a census sample of GPs in Essex, UK, and to determine which doctor- or practice-related variables predicted higher levels of burnout.
In the substudy, patients rated the interpersonal skills of their doctor and independent observers assessed the degree of patient-centredness in a sample of the doctors' audio-taped consultations.
Key messages
High levels of burnout were reported in the census survey—46% doctors reported emotional exhaustion, 42% reported depersonalisation and 34% reported low levels of personal accomplishment.
Doctors' depersonalisation scores could be predicted by a range of variables relating to the individual doctor and their practice, but higher depersonalisation scores were not associated with poorer patient ratings of the doctors' interpersonal skills or a reduction in the patient-centredness of their consultations.
While the professional practice and patient-centredness of consultations of the GPs in this study were not affected by feelings of burnout, there is a need to offer help and support for doctors who are experiencing this.
Strengths and limitations of this study
A high response rate (71%) was achieved in the census sample of GPs completing the MBI and a subsample of 38 doctors who satisfied the predetermined sample stratification consented to further assessment (patient survey and audio-taping of consultations).
The study was, however, limited to one county in the UK and thus cannot be extrapolated to other parts of the UK.
There was a differential response rate by the gender of the participant. Male doctors who were registered with the General Medical Council for >20 years were less likely to respond to the survey than their female counterparts.
doi:10.1136/bmjopen-2011-000274
PMCID: PMC3274717  PMID: 22300669
11.  Prolonged Grief Disorder: Psychometric Validation of Criteria Proposed for DSM-V and ICD-11 
PLoS Medicine  2009;6(8):e1000121.
Holly Prigerson and colleagues tested the psychometric validity of criteria for prolonged grief disorder (PGD) to enhance the detection and care of bereaved individuals at heightened risk of persistent distress and dysfunction.
Background
Bereavement is a universal experience, and its association with excess morbidity and mortality is well established. Nevertheless, grief becomes a serious health concern for a relative few. For such individuals, intense grief persists, is distressing and disabling, and may meet criteria as a distinct mental disorder. At present, grief is not recognized as a mental disorder in the DSM-IV or ICD-10. The goal of this study was to determine the psychometric validity of criteria for prolonged grief disorder (PGD) to enhance the detection and potential treatment of bereaved individuals at heightened risk of persistent distress and dysfunction.
Methods and Findings
A total of 291 bereaved respondents were interviewed three times, grouped as 0–6, 6–12, and 12–24 mo post-loss. Item response theory (IRT) analyses derived the most informative, unbiased PGD symptoms. Combinatoric analyses identified the most sensitive and specific PGD algorithm that was then tested to evaluate its psychometric validity. Criteria require reactions to a significant loss that involve the experience of yearning (e.g., physical or emotional suffering as a result of the desired, but unfulfilled, reunion with the deceased) and at least five of the following nine symptoms experienced at least daily or to a disabling degree: feeling emotionally numb, stunned, or that life is meaningless; experiencing mistrust; bitterness over the loss; difficulty accepting the loss; identity confusion; avoidance of the reality of the loss; or difficulty moving on with life. Symptoms must be present at sufficiently high levels at least six mo from the death and be associated with functional impairment.
Conclusions
The criteria set for PGD appear able to identify bereaved persons at heightened risk for enduring distress and dysfunction. The results support the psychometric validity of the criteria for PGD that we propose for inclusion in DSM-V and ICD-11.
Please see later in the article for Editors' Summary
Editors' Summary
Background
Virtually everyone loses someone they love during their lifetime. Grief is an unavoidable and normal reaction to this loss. After the death of a loved one, bereaved people may feel sadness, anger, guilt, anxiety, and despair. They may think constantly about the deceased person and about the events that led up to the person's death. They often have physical reactions to their loss—problems sleeping, for example—and they may become ill. Socially, they may find it difficult to return to work or to see friends and family. For most people, these painful emotions and thoughts gradually diminish, usually within 6 months or so of the death. But for a few people, the normal grief reaction lingers and becomes increasingly debilitating. Experts call this complicated grief or prolonged grief disorder (PGD). Characteristically, people with PGD have intrusive thoughts and images of the deceased person and a painful yearning for his or her presence. They may also deny their loss, feel desperately lonely and adrift, and want to die themselves.
Why Was This Study Done?
PGD is not currently recognized as a mental disorder although it meets the requirements for one given in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) and in the World Health Organization's International Statistical Classification of Diseases and Related Health Problems, 10thEdition (ICD-10). Before PGD can be recognized as a mental disorder (and included in DSM-V and ICD-11), bereavement and mental-health experts need to agree on standardized criteria for PGD. Such criteria would be useful because they would allow researchers and clinicians to identify risk factors for PGD and to find ways to prevent PGD. They would also help to ensure that people with PGD get appropriate treatments such as psychotherapy to help them change their way of thinking about their loss and re-engage with the world. Recently, a panel of experts agreed on a consensus list of symptoms for PGD. In this study, the researchers undertake a field trial to develop and evaluate algorithms (sets of rules) for diagnosing PGD based on these symptoms.
What Did the Researchers Do and Find?
The researchers used “item response theory” (IRT) to derive the most informative PGD symptoms from structured interviews of nearly 300 people who had recently lost a close family member. These interviews contained questions about the consensus list of symptoms; each participant was interviewed two or three times during the two years after their spouse's death. The researchers then used “combinatoric” analysis to identify the most sensitive and specific algorithm for the diagnosis of PGD. This algorithm specifies that a bereaved person with PGD must experience yearning (physical or emotional suffering because of an unfulfilled desire for reunion with the deceased) and at least five of nine additional symptoms. These symptoms (which include emotional numbness, feeling that life is meaningless, and avoidance of the reality of the loss) must persist for at least 6 months after the bereavement and must be associated with functional impairment. Finally, the researchers show that individuals given a diagnosis of PGD 6–12 months after a death have a higher subsequent risk of mental health and functional impairment than people not diagnosed with PGD.
What Do These Findings Mean?
These findings validate a set of symptoms and a diagnostic algorithm for PGD. Because most of the study participants were elderly women who had lost their husband, further validation is needed to check that these symptoms and algorithm also apply to other types of bereaved people such as individuals who have lost a child. For now, though, these findings support the inclusion of PGD in DSM-V and ICD-11 as a recognized mental disorder. Furthermore, the availability of a standardized way to diagnose PGD will help clinicians identify the minority of people who fail to adjust successfully to the loss of a loved one. Hopefully, by identifying these people and helping them to avoid the onset of PGD (perhaps by providing psychotherapy soon after a death) and/or providing better treatment for PGD, it should now be possible to reduce the considerable personal and societal costs associated with prolonged grief.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000121.
This study is further discussed in a PLoS Medicine Perspective by Stephen Workman
The Dana Farber Cancer Institute has a page describing its Center for Psycho-oncology and Palliative Care Research
The UK Royal College of Psychiatrists has a leaflet on bereavement (in English, Welsh, Urdu, and Chinese)
The US National Cancer Institute also has information about coping with bereavement for patients and health professionals (in English and Spanish)
MedlinePlus has links to other information about bereavement (in English and Spanish)
The Journal of the American Medical Association has a patient page on abnormal grief
Harvard Medical School provides a short family health guide about complicated grief
Information on DSM-IV and ICD-10 is available
doi:10.1371/journal.pmed.1000121
PMCID: PMC2711304  PMID: 19652695
12.  Improving communication between doctor and patient: eHealth in the Netherlands, an established cloud solution 
In the Netherlands, like in many West European countries, demand for healthcare is already sharply increasing, with further acceleration expected soon. All parties involved are convinced that the resulting demand for funding of healthcare will not be met by economic growth. The resulting paradigma shift (live longer healthy, self-care and patient centred care) is a challenge not only for scientists, but for politicians and healthcare-providers as well.
One of the solutions in the paradigma shift is eHealth. eHealth can refer to automated data-exchange between a device and a central database, but also to healthcare practices that use webbased communication. Strengthening patient participation, motivation and self-management is the hope for better therapy outcome. Early deviations need to be recognized, adverse reactions to be understood and appropriate action to be taken. In itself not new, diaries have been around for decades, but appropriate assessment of its content is too time-consuming. Therefore, the challenge is to involve both the patient and the attending professional (-s) and give eHealth solutions a place in the context of regular care. We combined the internet cloud with advanced security-technology to provide an answer to that: Curavista health, a database driven internetplatform for patient@home and doctor@work.
Patient@home replies to webquestionnaires and fill online diaries. The responses are summarized in tables, graphs or automated follow-ups and the patient has immediate insight in the progression achieved. Not only does database technology allow for immediate processing of the responses into summaries; it is also possible to highlight differences, produce alerts or (refer to) educational information.
Doctor@work, using an own account, has access to the responses as well as to the summaries, resulting in early insight. Because the patient@home does not necessarily record only biometrics, but also has the opportunity to add other types of replies, which gives a broader context to the actual situation the patient is in.
Regular care is not only faced with an ageing population but, as a result of new interventions, also with an increased incidence of people with multiple diseases. Curavista health has therefore been designed with the process of chronic care as its cornerstone: the basic architecture for each indication is identical, the content is different. Multiple indications can be attained to one account (doctor or patient) and multiple relations (doctor to patients, patient to professionals) maintained.
Started in 2002, today more than 20 indications are covered using this platform. It is used in both primary care (GPs) as well in out-clinic hospital care: 1000+doctors monitor(-ed) 50,000+patients. The first reports are that face-to-face consultations not only run more effective and more efficient when using the summaries, but also more satisfactorily: the available time can be devoted to the patient need, rather than to the inventory of the patient needs. Is it only a matter of time until timing of face-to-face consultations can be based upon cloud-based eHealth solutions?
PMCID: PMC3571145
eHealth; cloud solution
13.  Duties of a doctor: UK doctors and Good Medical Practice 
Quality in Health Care : QHC  2000;9(1):14-22.
Objective—To assess the responses of UK doctors to the General Medical Council's (GMC) Good Medical Practice and the Duties of a Doctor, and to the GMC's performance procedures for which they provide the professional underpinning.
Design—Questionnaire study of a representative sample of UK doctors.
Subjects—794 UK doctors, stratified by year of qualification, sex, place of qualification (UK v non-UK), and type of practice (hospital v general practice) of whom 591/759 (78%) replied to the questionnaire (35 undelivered).
Main outcome measures—A specially written questionnaire asking about awareness of Good Medical Practice, agreement with Duties of a Doctor, amount heard about the performance procedures, changes in own practice, awareness of cases perhaps requiring performance procedures, and attitudes to the performance procedures. Background measures of stress (General Health Questionnaire, GHQ-12), burnout, responses to uncertainty, and social desirability.
Results—Most doctors were aware of Good Medical Practice, had heard the performance procedures being discussed or had received information about them, and agreed with the stated duties of a doctor, although some items to do with doctor-patient communication and attitudes were more controversial. Nearly half of the doctors had made or were contemplating some change in their practice because of the performance procedures; a third of doctors had come across a case in the previous two years in their own professional practice that they thought might merit the performance procedures. Attitudes towards the performance procedures were variable. On the positive side, 60% or more of doctors saw them as reassuring the general public, making it necessary for doctors to report deficient performance in their colleagues, did not think they would impair morale, were not principally window dressing, and were not only appropriate for problems of technical competence. On the negative side, 60% or more of doctors thought the performance procedures were not well understood by most doctors, were a reason for more defensive practice, and could not be used for problems of attitude. Few differences were found among older and younger doctors, hospital doctors, or general practitioners, or UK and non-UK graduates, although some differences were present.
Conclusions—Most doctors working in the UK are aware of Good Medical Practice and the performance procedures, and are in broad sympathy with Duties of a Doctor. Many attitudes expressed by doctors are not positive, however, and provide areas where the GMC in particular may wish to encourage further discussion and awareness. The present results provide a good baseline for assessing change as the performance procedures become active and cases come before the GMC over the next few years.
(Quality in Health Care 2000;9:14–22)
Key Words: performance procedures; good medical practice; duties; attitudes; knowledge
doi:10.1136/qhc.9.1.14
PMCID: PMC1743494  PMID: 10848365
14.  ‘First we go to the small doctor’: First contact for curative health care sought by rural communities in Andhra Pradesh & Orissa, India 
Background & objectives:
Against the backdrop of insufficient public supply of primary care and reports of informal providers, the present study sought to collect descriptive evidence on 1st contact curative health care seeking choices among rural communities in two States of India - Andhra Pradesh (AP) and Orissa.
Methods:
The cross-sectional study design combined a Household Survey (1,810 households in AP; 5,342 in Orissa), 48 Focus Group Discussions (19 in AP; 29 in Orissa), and 61 Key Informant Interviews with healthcare providers (22 in AP; 39 in Orissa).
Results:
In AP, 69.5 per cent of respondents accessed non-degree allopathic practitioners (NDAPs) practicing in or near their village; in Orissa, 40.2 per cent chose first curative contact with NDAPs and 36.2 per cent with traditional healers. In AP, all NDAPs were private practitioners, in Orissa some pharmacists and nurses employed in health facilities, also practiced privately. Respondents explained their choice by proximity and providers’ readiness to make house-calls when needed. Less than a quarter of respondents chose qualified doctors as their first point of call: mostly private practitioners in AP, and public practitioners in Orissa. Amongst those who chose a qualified practitioner, the most frequent reason was doctors’ quality rather than proximity.
Interpretation & conclusions:
The results of this study show that most rural persons seek first level of curative healthcare close to home, and pay for a composite convenient service of consulting-cum-dispensing of medicines. NDAPs fill a huge demand for primary curative care which the public system does not satisfy, and are the de facto first level access in most cases.
doi:10.4103/0971-5916.90987
PMCID: PMC3249960  PMID: 22199101
First healthcare contact; health seeking; informal; non-degree allopathic providers; primary curative healthcare; rural; traditional healers
15.  Which doctors and with what problems contact a specialist service for doctors? A cross sectional investigation 
BMC Medicine  2007;5:26.
Background
In the United Kingdom, specialist treatment and intervention services for doctors are underdeveloped. The MedNet programme, created in 1997 and funded by the London Deanery, aims to fill this gap by providing a self-referral, face-to-face, psychotherapeutic assessment service for doctors in London and South-East England. MedNet was designed to be a low-threshold service, targeting doctors without formal psychiatric problems. The aim of this study was to delineate the characteristics of doctors utilising the service, to describe their psychological morbidity, and to determine if early intervention is achieved.
Methods
A cross-sectional study including all consecutive self-referred doctors (n = 121, 50% male) presenting in 2002–2004 was conducted. Measures included standardised and bespoke questionnaires both self-report and clinician completed. The multi-dimensional evaluation included: demographics, CORE (CORE-OM, CORE-Workplace and CORE-A) an instrument designed to evaluate the psychological difficulties of patients referred to outpatient services, Brief Symptom Inventory to quantify caseness and formal psychiatric illness, and Maslach Burnout Inventory.
Results
The most prevalent presenting problems included depression, anxiety, interpersonal, self-esteem and work-related issues. However, only 9% of the cohort were identified as severely distressed psychiatrically using this measure. In approximately 50% of the sample, problems first presented in the preceding year. About 25% were on sick leave at the time of consultation, while 50% took little or no leave in the prior 12 months. A total of 42% were considered to be at some risk of suicide, with more than 25% considered to have a moderate to severe risk. There were no significant gender differences in type of morbidity, severity or days off sick.
Conclusion
Doctors displayed high levels of distress as reflected in the significant proportion of those who were at some risk of suicide; however, low rates of severe psychiatric illness were detected. These findings suggest that MedNet clients represent both ends of the spectrum of severity, enabling early clinical engagement for a significant proportion of cases that is of importance both in terms of personal health and protecting patient care, and providing a timely intervention for those who are at risk, a group for whom rapid intervention services are in need and an area that requires further investigation in the UK.
doi:10.1186/1741-7015-5-26
PMCID: PMC2025601  PMID: 17725835
16.  The Effectiveness of a ‘Train the Trainer’ Model of Resuscitation Education for Rural Peripheral Hospital Doctors in Sri Lanka  
PLoS ONE  2013;8(11):e79491.
Background
Sri Lankan rural doctors based in isolated peripheral hospitals routinely resuscitate critically ill patients but have difficulty accessing training. We tested a train-the-trainer model that could be utilised in isolated rural hospitals.
Methods
Eight selected rural hospital non-specialist doctors attended a 2-day instructor course. These “trained trainers” educated their colleagues in advanced cardiac life support at peripheral hospital workshops and we tested their students in resuscitation knowledge and skills pre and post training, and at 6- and 12-weeks. Knowledge was assessed through 30 multiple choice questions (MCQ), and resuscitation skills were assessed by performance in a video recorded simulated scenario of a cardiac arrest using a Resuci Anne Skill Trainer mannequin.
Results/Discussion/Conclusion
Fifty seven doctors were trained. Pre and post training assessment was possible in 51 participants, and 6-week and 12-week follow up was possible for 43, and 38 participants respectively. Mean MCQ scores significantly improved over time (p<0.001), and a significant improvement was noted in “average ventilation volume”, “compression count”, and “compressions with no error”, “adequate depth”, “average depth”, and “compression rate” (p<0.01). The proportion of participants with compression depth ≥40mm increased post intervention (p<0.05) and at 12-week follow up (p<0.05), and proportion of ventilation volumes between 400-1000mls increased post intervention (p<0.001). A significant increase in the proportion of participants who “checked for responsiveness”, “opened the airway”, “performed a breathing check”, who used the “correct compression ratio”, and who used an “appropriate facemask technique” was also noted (p<0.001). A train-the-trainer model of resuscitation education was effective in improving resuscitation knowledge and skills in Sri Lankan rural peripheral hospital doctors. Improvement was sustained to 12 weeks for most components of resuscitation knowledge and skills. Further research is needed to identify which components of training are most effective in leading to sustained improvement in resuscitation.
doi:10.1371/journal.pone.0079491
PMCID: PMC3821851  PMID: 24255702
17.  Holding relationships in primary care: a qualitative exploration of doctors' and patients' perceptions 
The British Journal of General Practice  2011;61(589):e484-e491.
Background
Ongoing doctor-patient relationships are integral to the patient-centred ideals of UK general practice, particularly for patients with chronic conditions or complex health problems. ‘Holding’, a doctor-patient relationship defined as establishing and maintaining a trusting, constant, reliable relationship that is concerned with ongoing support without expectation of cure, has previously been suggested as a management strategy for such patients.
Aim
To explore urban GPs' and patients' experiences of the management of chronic illness, with a particular focus on holding relationships.
Design and setting
A qualitative study in urban and suburban areas of north west England.
Method
Participating GPs recruited registered patients with chronic illness with whom they felt they had established a holding relationship. Data were collected by semi-structured interviews and subjected to constant comparative qualitative analysis.
Results
GP responders considered holding to be a small but routine part of theirwork. Benefits described included providing support to patients but also containing demands on secondary care. Patient responders, all with complex ongoing needs, described the relationship with their GP as a reassuring, positive, and securing partnership. Both GP and patient responders emphasised the importance of pre-existing knowledge of past life-story, and valued holding as a potential tool for changing health-related behaviour. Difficulties with holding work included fears of dependency, and problems of access.
Conclusion
Holding relationships are a routine part of general practice, valued by both GPs and patients. Naming and valuing holding work may legitimise this activity in the management of people with chronic and complex health problems.
doi:10.3399/bjgp11X588457
PMCID: PMC3145532  PMID: 21801542
chronic illness; doctor-patient relations; continuity of care; qualitative research
18.  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
19.  Village doctor-assisted case management of rural patients with schizophrenia: protocol for a cluster randomized control trial 
Background
Strict compliance with prescribed medication is the key to reducing relapses in schizophrenia. As villagers in China lack regular access to psychiatrists to supervise compliance, we propose to train village ‘doctors’ (i.e., villagers with basic medical training and currently operating in villages across China delivering basic clinical and preventive care) to manage rural patients with schizophrenia with respect to compliance and monitoring symptoms. We hypothesize that with the necessary training and proper oversight, village doctors can significantly improve drug compliance of villagers with schizophrenia.
Methods/design
We will conduct a cluster randomized controlled trial in 40 villages in Liuyang, Hunan Province, China, home to approximately 400 patients with schizophrenia. Half of the villages will be randomized into the treatment group (village doctor, or VD model) wherein village doctors who have received training in a schizophrenia case management protocol will manage case records, supervise drug taking, educate patients and families on schizophrenia and its treatment, and monitor patients for signs of relapse in order to arrange prompt referral. The other 20 villages will be assigned to the control group (case as usual, or CAU model) wherein patients will be visited by psychiatrists every two months and receive free antipsychotic medications under an on-going government program, Project 686. These control patients will receive no other management or follow up from health workers. A baseline survey will be conducted before the intervention to gather data on patient’s socio-economic status, drug compliance history, and clinical and health outcome measures. Data will be re-collected 6 and 12 months into the intervention. A difference-in-difference regression model will be used to detect the program effect on drug compliance and other outcome measures. A cost-effectiveness analysis will also be conducted to compare the value of the VD model to that of the CAU group.
Discussion/implications
Lack of specialists is a common problem in resource-scarce areas in China and other developing countries. The results of this experiment will provide high level evidence on the role of health workers with relatively limited medical training in managing severe psychiatric disease and other chronic conditions in developing countries.
Trial registration
ChiCTR-TRC-13003263.
doi:10.1186/1748-5908-9-13
PMCID: PMC3929227  PMID: 24433461
Schizophrenia case management; Village doctor; Community health worker; Cluster randomized controlled trial; Project 686; Rural community health; Drug compliance; Mental health intervention
20.  Evaluating the impact of patients' online access to doctors' visit notes: designing and executing the OpenNotes project 
Background
Providers and policymakers are pursuing strategies to increase patient engagement in health care. Increasingly, online sections of medical records are viewable by patients though seldom are clinicians' visit notes included. We designed a one-year multi-site trial of online patient accessible office visit notes, OpenNotes. We hypothesized that patients and primary care physicians (PCPs) would want it to continue and that OpenNotes would not lead to significant disruptions to doctors' practices.
Methods/Design
Using a mixed methods approach, we designed a quasi-experimental study in 3 diverse healthcare systems in Boston, Pennsylvania, and Seattle. Two sites had existing patient internet portals; the third used an experimental portal. We targeted 3 key areas where we hypothesized the greatest impacts: beliefs and attitudes about OpenNotes, use of the patient internet portals, and patient-doctor communication. PCPs in the 3 sites were invited to participate in the intervention. Patients who were registered portal users of participating PCPs were given access to their PCPs' visit notes for one year. PCPs who declined participation in the intervention and their patients served as the comparison groups for the study. We applied the RE-AIM framework to our design in order to capture as comprehensive a picture as possible of the impact of OpenNotes. We developed pre- and post-intervention surveys for online administration addressing attitudes and experiences based on interviews and focus groups with patients and doctors. In addition, we tracked use of the internet portals before and during the intervention.
Results
PCP participation varied from 19% to 87% across the 3 sites; a total of 114 PCPs enrolled in the intervention with their 22,000 patients who were registered portal users. Approximately 40% of intervention and non-intervention patients at the 3 sites responded to the online survey, yielding a total of approximately 38,000 patient surveys.
Discussion
Many primary care physicians were willing to participate in this "real world" experiment testing the impact of OpenNotes on their patients and their practices. Results from this trial will inform providers, policy makers, and patients who contemplate such changes at a time of exploding interest in transparency, patient safety, and improving the quality of care.
doi:10.1186/1472-6947-12-32
PMCID: PMC3351950  PMID: 22500560
Patient access to records; Electronic health records; Primary care physicians; Internet; Medical records; Medical informatics; Patient participation
21.  Analysis of a survey on young doctors' willingness to work in rural Hungary 
Background
The severe shortage of qualified healthcare staff in Hungary cannot be quickly or easily overcome. There is not only a lack of human resources for health, but significant inequalities are widespread, including in geographical distribution. This disparity results in severe problems regarding access to and performance of health care services. In this context, this report, based on research carried out in 2008, deals with a particularly relevant matter: the willingness of young doctors to work outside Budapest (the capital of Hungary).
Methods
We conducted a survey with voluntary questionnaires and focus group interviews at each of the four Hungarian medical schools, concerning career plans and related incentives among young medical doctors. In all, 524 residents responded to the question concerning their willingness to work in rural areas, and there were seven focus group interviews, with 3-7 participants in each group. The number of residents' places in Hungary were 832, 682, and 785 in 2006/2007, 2007/2008, and 2008/2009, respectively.
Results
The majority of those surveyed would like to work in Budapest or a large town. Fewer than 7% were willing to work in a town with less than 50 000 inhabitants. Most young doctors would like to work in a teaching hospital (i.e. an accredited training site for medical students and postgraduate trainees) or a major regional hospital.
Conclusions
The current system of medical training in Hungary tends to produce doctors who want to live in big cities and work in central hospitals. Rural regions and non-in-patient service alternatives seem either not to be targeted or seen as unattractive work places.
More doctors would be willing to work in smaller towns and villages if in-hospital training was altered and if doctors were offered adequate incentives as part of a comprehensive human resource strategy (high salaries, high professional standards, good working environment, reasonable workload). If these changes do not occur, the existing geographical and structural imbalances will not be improved.
doi:10.1186/1478-4491-8-13
PMCID: PMC2887778  PMID: 20482779
22.  Surgical Resident Doctor's Perspective of Their Training in the Southeast Region of Nigeria 
Background:
There are several problems militating against satisfactory residency training in Nigeria. These problems may not be effectively identified and resolved if the opinion of the trainee doctors is ignored.
Objectives:
To review surgical residents’ perspectives of their training program in South-eastern Nigeria, with the aim of suggesting evidence-based innovative changes to enable the programs meet global trends and standards.
Materials and Methods:
A total of 90 semi-structured and pre-tested questionnaires were evenly distributed (30 per hospital) to the surgical residents at three tertiary healthcare facilities in South-eastern Nigeria. Information sought included sociodemographic variables, level in the residency training, rating of program and different aspects, learning environments/opportunities, and suggestions on ways to improve either part or overall program.
Results:
Analysis of 56 properly completed questionnaires (response rate=62.2%) shows that the respondents were aged 29 to 53 years [mean(SD) = 35.3(1.7)], mostly males (91.1%) and junior residents (75%). A significant majority of residents (47 or 83.8%) rated the surgical residency training in their respective centers as inadequate. Grand rounds were roundly criticized as having misplaced objectives and tending toward fault-finding by Consultants. Suggested interventions for improvement included enhanced supervision/mentoring/teaching by senior colleagues, inclusion of didactic lecture sessions, research trainings, and foreign postings.
Conclusion:
There exist gaps between expectations of surgical residents and the training offered. These create needed support for an evidenced-based review of surgical residency training program to enable it meet the aspirations of trainees and the ever-changing trend in Medicine. More studies on surgical residents covering other regions of Nigeria, and including the trainers (Consultants), will be of immense value.
doi:10.4103/2141-9248.96931
PMCID: PMC3507131  PMID: 23209985
Enugu; Medical; Nigeria; Resident doctors; Surgical training
23.  Underage Binge Drinking Adolescents: Sociodemographic Profile and Utilization of Family Doctors 
ISRN Family Medicine  2013;2013:728730.
Context. Binge drinking (more than five drinks on one occasion) is a major public health problem among teenagers in the US, Canada, and Europe. Negative outcomes to binge drinking include alcohol related injuries and accidental death. Family physicians are the main point of contact between binging adolescents and the health care system. Design and Setting. This study was based on a secondary analysis of 6,607 respondents aged 15–17 from the regionally representative data acquired through the Canadian Community Health Survey 1.1. Results. According to our findings, one in every eight teens aged 15–17 binge drank monthly. The odds of binge drinking were higher among males, Whites, those living away from parents, teens who reported a decline in health status, and those experiencing back problems and depression. Smoking status was strongly associated with the binge drinking behavior. Three-quarters of binge drinking adolescents had seen their family doctor in the past year but only one in ten had spoken with any health professional about a mental health issue. Conclusions. Family physicians need to screen their adolescent patients for binge drinking in order to provide timely and effective interventions. Awareness of the profile of binge drinkers could improve the accuracy of targeting and outreaching strategies.
doi:10.5402/2013/728730
PMCID: PMC4041245  PMID: 24959572
24.  Palliative care for older people – exploring the views of doctors and nurses from different fields in Germany 
Background
Providing appropriate palliative care for older people is a major task for health care systems worldwide, and up to now it has also been one of the most neglected. Focusing on the German health care system, we sought to explore the attitudes of health professionals regarding their understanding of palliative care for older patients and its implementation.
Methods
In a qualitative study design, focus groups were established consisting of general practitioners, geriatricians, palliative care physicians, palliative care nurses and general nurses (a total of 29 participants). The group discussions were recorded, transcribed, coded and analysed using the methodological approach of Qualitative Description.
Results
Deficiencies in teamwork and conflicting role definitions between doctors and nurses and between family practitioners and medical specialists were found to be central problems affecting the provision of appropriate palliative care for older people. It was emphasized that there are great advantages to family doctors playing a leading role, as they usually have the longest contacts to the patients. However, the professional qualifications of family doctors were to some extent criticized. The general practitioners for their part criticized the increasing specialization on the field of palliative care. All groups complained that the German compensation system gives insufficient consideration to the time-consuming care of older patients, and about excessive bureaucracy.
Conclusion
General practitioners are the central health professionals in the delivery of palliative care for older people. They should however be encouraged to involve specialized services such as palliative care teams where necessary. With the German health care reform of 2007, a legal framework has been created that allows for this. As far as its realization is concerned, it must be ensured that the spotlight remains on the needs of the patients and not on policy conflicts and rivalries between health care professionals. Older people might particularly benefit if "talking" medicine and time-consuming care were properly catered for, financially and organizationally, in the health care system.
doi:10.1186/1472-684X-8-7
PMCID: PMC2706814  PMID: 19549336
25.  Why do patients visit their doctors? Assessing the most prevalent conditions in a defined US population 
Objective
To describe the prevalence of non-acute conditions among patients seeking healthcare in a defined US population, emphasizing age, sex, and ethnic differences.
Methods
The Rochester Epidemiology Project (REP) records-linkage system was used to identify all residents of Olmsted County, MN on April 1, 2009 (n=142,377). We then electronically extracted all International Classification of Diseases, ninth revision (ICD-9) codes received by these subjects from any health care provider between January 1, 2005 and December 31, 2009. We grouped ICD-9 codes into Clinical Classification Codes (CCCs), and then into 47 broader disease groups associated with health-related quality of life. Age- and sex-specific prevalence was estimated by dividing the number of individuals within each group by the corresponding age- and sex-specific population. People with multiple codes within a group were counted only once.
Results
We included a total of 142,377 subjects (53% women). Skin disorders (42.7%), osteoarthritis and joint disorders (33.6%), back problems (23.9%), disorders of lipid metabolism (22.4%), and upper respiratory disease (22.1%; excluding asthma) were the most prevalent disease groups in this population. Eight of the 10 most prevalent disease groups were more common in women; however, disorders of lipid metabolism and hypertension were more common in men. Additionally, the prevalence of seven of these 10 groups increased with advancing age. Prevalence varied also across whites, blacks, and Asians.
Conclusion
Our findings suggest areas for focused research that may lead to better care delivery and improved population health.
doi:10.1016/j.mayocp.2012.08.020
PMCID: PMC3564521  PMID: 23274019

Results 1-25 (921786)