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1.  Clinical essentialising: a qualitative study of doctors’ medical and moral practice 
While certain substantial moral dilemmas in health care have been given much attention, like abortion, euthanasia or gene testing, doctors rarely reflect on the moral implications of their daily clinical work. Yet, with its aim to help patients and relieve suffering, medicine is replete with moral decisions. In this qualitative study we analyse how doctors handle the moral aspects of everyday clinical practice. About one hundred consultations were observed, and interviews conducted with fifteen clinical doctors from different practices. It turned out that the doctors’ approach to clinical cases followed a rather strict pattern across specialities, which implied transforming patients’ diverse concerns into specific medical questions through a process of ‘essentialising’: Doctors broke the patient’s story down, concretised the patient’s complaints and categorised the symptoms into a medical sense. Patients’ existential meanings were removed, and the focus placed on the patients’ functioning. By essentialising, doctors were able to handle a complex and ambiguous reality, and establish a medically relevant problem. However, the process involved a moral as well as a practical simplification. Overlooking existential meanings and focusing on purely functional aspects of patients was an integral part of clinical practice and not an individual flaw. The study thus questions the value of addressing doctors’ conscious moral evaluations. Yet doctors should be aware that their daily clinical work systematically emphasises beneficence at the expense of others—that might be more important to the patient.
doi:10.1007/s11019-009-9193-z
PMCID: PMC2848348  PMID: 20336384
Beneficence; Clinical decision-making; Dehumanising; Empirical research; Grounded theory; Medical ethics; Moral practice; Professional values; Qualitative
2.  What Do Patients Choose to Tell Their Doctors? Qualitative Analysis of Potential Barriers to Reattributing Medically Unexplained Symptoms 
BACKGROUND
Despite both parties often expressing dissatisfaction with consultations, patients with medically unexplained symptoms (MUS) prefer to consult their general practitioners (GPs) rather than any other health professional. Training GPs to explain how symptoms can relate to psychosocial problems (reattribution) improves the quality of doctor–patient communication, though not necessarily patient health.
OBJECTIVE
To examine patient experiences of GPs’ attempts to reattribute MUS in order to identify potential barriers to primary care management of MUS and improvement in outcome.
DESIGN
Qualitative study.
PARTICIPANTS
Patients consulting with MUS whose GPs had been trained in reattribution. A secondary sample of patients of control GPs was also interviewed to ascertain if barriers identified were specific to reattribution or common to consultations about MUS in general.
APPROACH
Thematic analysis of in-depth interviews.
RESULTS
Potential barriers include the complexity of patients’ problems and patients’ judgements about how to manage their presentation of this complexity. Many did not trust doctors with discussion of emotional aspects of their problems and chose not to present them. The same barriers were seen amongst patients whose GPs were not trained, suggesting the barriers are not particular to reattribution.
CONCLUSIONS
Improving GP explanation of unexplained symptoms is insufficient to reduce patients’ concerns. GPs need to (1) help patients to make sense of the complex nature of their presenting problems, (2) communicate that attention to psychosocial factors will not preclude vigilance to physical disease and (3) ensure a quality of doctor–patient relationship in which patients can perceive psychosocial enquiry as appropriate.
doi:10.1007/s11606-008-0872-x
PMCID: PMC2659146  PMID: 19089505
doctor–patient communication; medically unexplained symptoms; reattribution
3.  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
4.  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
5.  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
6.  The cultural context of patient’s autonomy and doctor’s duty: passive euthanasia and advance directives in Germany and Israel 
The moral discourse surrounding end-of-life (EoL) decisions is highly complex, and a comparison of Germany and Israel can highlight the impact of cultural factors. The comparison shows interesting differences in how patient’s autonomy and doctor’s duties are morally and legally related to each other with respect to the withholding and withdrawing of medical treatment in EoL situations. Taking the statements of two national expert ethics committees on EoL in Israel and Germany (and their legal outcome) as an example of this discourse, we describe the similarity of their recommendations and then focus on the differences, including the balancing of ethical principles, what is identified as a problem, what social role professionals play, and the influence of history and religion. The comparison seems to show that Israel is more restrictive in relation to Germany, in contrast with previous bioethical studies in the context of the moral and legal discourse regarding the beginning of life, in which Germany was characterized as far more restrictive. We reflect on the ambivalence of the cultural reasons for this difference and its expression in various dissenting views on passive euthanasia and advance directives, and conclude with a comment on the difficulty in classifying either stance as more or less restrictive.
doi:10.1007/s11019-010-9262-3
PMCID: PMC2949555  PMID: 20680469
Culture; End of life; Expert ethics committees; Doctors’ duties; German law; Living will; Israeli Law; Patients’ rights; Religion
7.  “Doctor, please tell me it’s nothing serious”: an exploration of patients’ worrying and reassuring cognitions using stimulated recall interviews 
BMC Family Practice  2014;15:73.
Background
Many patients who consult their GP are worried about their health, but there is little empirical data on strategies for effective reassurance. To gain a better understanding of mechanisms for effective patient reassurance, we explored cognitions underlying patients’ worries, cognitions underlying reassurance and factors supporting patients’ reassuring cognitions.
Methods
In a qualitative study, we conducted stimulated recall interviews with 21 patients of 12 different GPs shortly after their consultation. We selected consultations in which the GPs aimed to reassure worried patients and used their videotaped consultation as a stimulus for the interview. The interviews were analysed with thematic coding and by writing interpretive summaries.
Results
Patients expressed four different core cognitions underlying their concerns: ‘I have a serious illness’, ‘my health problem will have adverse physical effects’, ‘my treatment will have adverse effects’ and ‘my health problem will negatively impact my life’. Patients mentioned a range of person-specific and context-specific cognitions as reasons for these core cognitions. Patients described five core reassuring cognitions: ‘I trust my doctor’s expertise’, ‘I have a trusting and supporting relationship with my doctor’, ‘I do not have a serious disease’, ‘my health problem is harmless’ and ‘my health problem will disappear.’ Factors expressed as reasons for these reassuring cognitions were GPs’ actions during the consultation as well as patients’ pre-existing cognitions about their GP, the doctor-patient relationship and previous events. Patients’ worrying cognitions were counterbalanced by specific reassuring cognitions, i.e. worrying and reassuring cognitions seemed to be interrelated.
Conclusions
Patients described a wide range of worrying cognitions, some of which were not expressed during the consultation. Gaining a thorough understanding of the specific cognitions and tailoring reassuring strategies to them should be an effective way of achieving reassurance. The identified reassuring cognitions can guide doctors in applying these strategies in their daily practice.
doi:10.1186/1471-2296-15-73
PMCID: PMC4008437  PMID: 24762333
8.  GP recruitment and retention: a qualitative analysis of doctors' comments about training for and working in general practice. 
BACKGROUND AND AIMS: General practice in the UK is experiencing difficulty with medical staff recruitment and retention, with reduced numbers choosing careers in general practice or entering principalships, and increases in less-than-full-time working, career breaks, early retirement and locum employment. Information is scarce about the reasons for these changes and factors that could increase recruitment and retention. The UK Medical Careers Research Group (UKMCRG) regularly surveys cohorts of UK medical graduates to determine their career choices and progression. We also invite written comments from respondents about their careers and the factors that influence them. Most respondents report high levels of job satisfaction. A noteworthy minority, however, make critical comments about general practice. Although their views may not represent those of all general practitioners (GPs), they nonetheless indicate a range of concerns that deserve to be understood. This paper reports on respondents' comments about general practice. ANALYSIS OF DOCTORS' COMMENTS: Training Greater exposure to general practice at undergraduate level could help to promote general practice careers and better inform career decisions. Postgraduate general practice training in hospital-based posts was seen as poor quality, irrelevant and run as if it were of secondary importance to service commitments. In contrast, general practice-based postgraduate training was widely praised for good formal teaching that met educational needs. The quality of vocational training was dependent upon the skills and enthusiasm of individual trainers. Recruitment problems Perceived deterrents to choosing general practice were its portrayal, by some hospital-based teachers, as a second class career compared to hospital medicine, and a perception of low morale amongst current GPs. The choice of a career in general practice was commonly made for lifestyle reasons rather than professional aspirations. Some GPs had encountered difficulties in obtaining posts in general practice suited to their needs, while others perceived discrimination. Newly qualified GPs often sought work as non-principals because they felt too inexperienced for partnership or because their domestic situation prevented them from settling in a particular area. Changes to general practice The 1990 National Health Service (NHS) reforms were largely viewed unfavourably, partly because they had led to a substantial increase in GPs' workloads that was compounded by growing public expectations, and partly because the two-tier system of fund-holding was considered unfair. Fund-holding and, more recently, GP commissioning threatened the GP's role as patient advocate by shifting the responsibility for rationing of health care from government to GPs. Some concerns were also expressed about the introduction of primary care groups (PCGs) and trusts (PCTs). Together, increased workload and the continual process of change had, for some, resulted in work-related stress, low morale, reduced job satisfaction and quality of life. These problems had been partially alleviated by the formation of GP co-operatives. Retention difficulties Loss of GPs' time from the NHS workforce occurs in four ways: reduced working hours, temporary career breaks, leaving the NHS to work elsewhere and early retirement. Child rearing and a desire to pursue interests outside medicine were cited as reasons for seeking shorter working hours or career breaks. A desire to reduce pressure of work was a common reason for seeking shorter working hours, taking career breaks, early retirement or leaving NHS general practice. Other reasons for leaving NHS general practice, temporarily or permanently, were difficulty in finding a GP post suited to individual needs and a desire to work abroad. CONCLUSIONS: A cultural change amongst medical educationalists is needed to promote general practice as a career choice that is equally attractive as hospital practice. The introduction of Pre-Registration House Officer (PRHO) placements in general practice and improved flexibility of GP vocational training schemes, together with plans to improve the quality of Senior House Officer (SHO) training in the future, are welcome developments and should address some of the concerns about poor quality GP training raised by our respondents. The reluctance of newly qualified GPs to enter principalships, and the increasing demand from experienced GPs for less-than-full-time work, indicates a need for a greater variety of contractual arrangements to reflect doctors' desires for more flexible patterns of working in general practice.
PMCID: PMC2560447  PMID: 12049026
9.  Computer-based quality of life questionnaires may contribute to doctor–patient interactions in oncology 
British Journal of Cancer  2002;86(1):51-59.
It is well recognized that oncologists should consider patients' quality of life and functioning when planning and delivering anticancer treatment, but a comprehensive assessment of how a patient feels requires a thorough inquiry. A standardized measurement of patients' quality of life may support clinicians in identifying important problems for discussion during the limited time of the medical consultations. The aim of this study was to assess the feasibility of computer-administered individual quality of life measurements in oncology clinics with immediate feedback of results to clinicians and to examine the impact of the information on consultations. The study employed a prospective non-randomized design with pre-test post-test within subjects comparisons and involved three medical oncologists and 28 cancer patients receiving chemotherapy. The intervention consisted of completion of quality of life questionnaires before the consultations and informing clinicians of the results. The main outcome measures were patients' perceptions of the content of baseline and intervention consultations and satisfaction with communication. A qualitative analysis of clinicians' interviews was performed. When clinicians had the quality of life results they enquired more often about daily activities (Z=−2.71, P=0.007), emotional problems (Z=−2.11, P=0.035) and work related issues (Z=−1.89, P=0.058). There was an increase in the number of issues discussed during the intervention consultation (Z=−1.89, P=0.059). Patients were highly satisfied with both consultations. The computer measurement was well accepted by patients who felt that the questionnaires were a useful tool to tell the doctors about their problems. The clinicians perceived that the quality of life data broadened the range of the clinical inquiry and helped them identify issues for discussion. Having symptoms and functional problems expressed quantitatively on a scale was useful for detection of change over time.
British Journal of Cancer (2002) 86, 51–59. DOI: 10.1038/sj/bjc/6600001 www.bjcancer.com
© 2002 The Cancer Research Campaign
doi:10.1038/sj.bjc.6600001
PMCID: PMC2746549  PMID: 11857011
quality of life; individual; cancer; computer; communication
10.  Doctors' emotional reactions to recent death of a patient: cross sectional study of hospital doctors 
BMJ : British Medical Journal  2003;327(7408):185.
Objectives: To describe doctors' emotional reactions to the recent death of an “average” patient and to explore the effects of level of training on doctors' reactions.
Design: Cross sectional study using quantitative and qualitative data.
Setting: Two academic teaching hospitals in the United States.
Participants: 188 doctors (attending physicians (equivalent to UK consultants), residents (equivalent to UK senior house officers), and interns (equivalent to UK junior house officers)) who cared for 68 patients who died in the hospital.
Main outcome measures: Doctors' experiences in providing care, their emotional reactions to the patient's death, and their use of coping and social resources to manage their emotions.
Results: Most doctors (139/188, 74%) reported satisfying experiences in caring for a dying patient. Doctors reported moderate levels of emotional impact (mean 4.7 (SD 2.4) on a 0-10 scale) from the death. Women and those doctors who had cared for the patient for a longer time experienced stronger emotional reactions. Level of training was not related to emotional reactions, but interns reported needing significantly more emotional support than attending physicians. Although most junior doctors discussed the patient's death with an attending physician, less than a quarter of interns and residents found senior teaching staff (attending physicians) to be the most helpful source of support.
Conclusions: Doctors who spend a longer time caring for their patients get to know them better but this also makes them more vulnerable to feelings of loss when these patients die. Medical teams may benefit from debriefing within the department to give junior doctors an opportunity to share emotional responses and reflect on the patient's death.
PMCID: PMC166122  PMID: 12881257
11.  Concerns over confidentiality may deter adolescents from consulting their doctors. A qualitative exploration 
Journal of Medical Ethics  2006;32(3):133-137.
Objectives
Young people who are concerned that consultations may not remain confidential are reluctant to consult their doctors, especially about sensitive issues. This study sought to identify issues and concerns of adolescents, and their parents, in relation to confidentiality and teenagers' personal health information.
Setting
Recruitment was conducted in paediatric dermatology and general surgery outpatient clinics, and on general surgery paediatric wards. Interviews were conducted in subjects' own homes.
Methods
Semistructured interviews were used for this exploratory qualitative study. Interviews were carried out with 11 young women and nine young men aged 14–17. Parents of 18 of the young people were interviewed separately. Transcripts of tape recorded interviews provided the basis for a framework analysis.
Results
Young women were more concerned than young men, and older teenagers more concerned than younger teenagers, about people other than their general practitioner (GP) having access to their health information. Young people with little experience of the healthcare system were less happy than those with greater knowledge of the National Health Service (NHS) for non‐medical staff to access their health information. As they grow older, adolescents become increasingly concerned that their health information should remain confidential.
Conclusion
Young people's willingness to be open in consultations could be enhanced by doctors taking time to explain to them that their discussion is completely confidential. Alternatively, if for any reason confidentiality cannot be assured, doctors should explain why.
doi:10.1136/jme.2004.011262
PMCID: PMC2564464  PMID: 16507655
confidentiality; medical records; young people; rights of children; parental view
12.  Being lesbian – does the doctor need to know? 
Background
A lesbian woman will have to choose whether to disclose or not in every new encounter, including when consulting her general practitioner (GP). She may fear a negative reaction in the doctor, based on knowledge of marginalization and prejudice of homosexuals throughout history.
Objectives
To explore patients’ experiences concerning disclosure of their lesbian orientation to general practitioners (GPs), focusing on why they find it important, and what GPs can do to promote disclosure.
Methods
One group interview was conducted, audiotaped, and transcribed verbatim. Qualitative analysis was conducted by systematic text condensation inspired by Giorgi's phenomenological approach. Six women aged 28–59 years, who self-identified as lesbian, were recruited through a web-based, publicly accessible network for research on homosexuality.
Main outcome measures
Accounts of experiences where the patient thought that information of a lesbian sexual orientation was of importance in the consultation with a GP.
Results
Disclosure can imply information of medical relevance, explain circumstances, and generate a feeling of being seen as one's true self. The intentional use of common consultation techniques may facilitate disclosure.
Conclusion
Lesbian patients may want to disclose their sexual orientation to the general practitioner but they experience certain barriers. These can be overcome when the GP provides an open and permissive context. GPs can benefit from knowledge concerning sexual orientation in their work with lesbian patients.
doi:10.1080/02813430601086178
PMCID: PMC3389455  PMID: 17354161
Communication; family practice; female; homosexuality; truth disclosure
13.  How should doctors approach patients? A Confucian reflection on personhood 
Journal of Medical Ethics  2001;27(1):44-50.
The modern doctor-patient relationship displays a patient-centred, mutual-participation characteristic rather than the former active-passive or guidance-cooperation models in terms of medical decision making. Respecting the wishes of patients, amounting to more than mere concern for their welfare, has become the feature central to certain modern bioethics theories. A group of ethical principles such as respect for autonomy, beneficence, non-maleficence, and justice has been proposed by bioethicists and widely adopted by many medical societies as an ethical guide to how doctors, in their daily practice, should treat their patients. However, seeing patients as persons who are rational, self-conscious beings capable of valuing their own lives, and who are consequently entitled to the liberty and rights to choose for themselves, is in general the backbone of Western bioethical principles.
Since Confucian philosophy has long been a representative of the East-Asia cultural tradition and Confucian bioethics has recently been developed as a theory of applied ethics, examining Confucius's idea of "persons" may shed some light on the current bioethical debates. Confucius's concept of persons, which is best interpreted via his theories of "chun-tze", (the morally ideal person) encapsulating a two-dimensional approach, (the "autonomous person" and the "relational person"), provides a more comprehensive model regarding what a person is and how he/she should be treated. This two-dimensional approach sees a person not only as a rational, autonomous agent but also as a relational, altruistic identity whose self actualisation involves incessant participating in and promoting of the welfare of his fellow persons. Hence this may balance the current bioethical trend whereby "respect for autonomy" often triumphs.
Key Words: Personhood • autonomy • Confucian ethics • physician-patient relationship • principle-oriented bioethics
doi:10.1136/jme.27.1.44
PMCID: PMC1733353  PMID: 11233378
14.  Changes in the quality of doctor–patient communication between 1982 and 2001: an observational study on hypertension care as perceived by patients and general practitioners 
BMJ Open  2011;1(1):e000203.
Background
The rise of evidence-based medicine may have implications for the doctor–patient interaction. In recent decades, a shift towards a more task-oriented approach in general practice indicates a development towards more standardised healthcare.
Objective
To examine whether this shift is accompanied by changes in perceived quality of doctor–patient communication.
Design
GP observers and patient observers performed quality assessments of Dutch General Practice consultations on hypertension videotaped in 1982–1984 and 2000–2001. In the first cohort (1982–1984) 81 patients were recorded by 23 GPs and in the second cohort (2000–2001) 108 patients were recorded by 108 GPs. The GP observers and patient observers rated the consultations on a scale from 1 to 10 on three quality dimensions: medical technical quality, psychosocial quality and quality of interpersonal behaviour. Multilevel regression analyses were used to test whether a change occurred over time.
Results
The findings showed a significant improvement over time on all three dimensions. There was no difference between the quality assessments of GP observers and patient observers. The three different dimensions were moderately to highly correlated and the assessments of GP observers showed less variability in the second cohort.
Conclusions
Hypertension consultations in general practice in the Netherlands received higher quality assessments by general practitioners and patients on medical technical quality, psychosocial quality and the quality of interpersonal behaviour in 2000–2001 as compared with the 1980s. The shift towards a more task-oriented approach in hypertension consultations does not seem to detract from individual attention for the patient. In addition, there is less variation between general practitioners in the quality assessments of more recent consultations. The next step in this line of research is to unravel the factors that determine patients' quality assessments of doctor–patient communication.
Article summary
Article focus
Doctor–patient communication in hypertension consultations has become more business-like and task-oriented in the past few decades.
Shifts in communication styles in general practice may have produced changes in quality assessments of doctor–patient communication by general practitioners and patients.
Key messages
Compared with 20 years earlier (1982–1984), hypertension consultations recorded in 2000–2001 received higher quality assessments by GP observers and patient observers on three distinct quality dimensions: medical technical quality, psychosocial quality and the quality of interpersonal behaviour.
There was less variation between general practitioners in the quality assessments of more recent consultations.
Strengths and limitations of this study
Videotaped real-life general practice consultations from two distinct periods were analysed, which means that the findings refer to actual behaviour in general practice.
The quality assessments were made according to the same protocol in both periods.
Assessments of the GPs were executed by contemporary peers, while the assessments of patients were performed retrospectively. However, the concurrence of assessments of patient observers and GP observers in their different contexts reinforces our conclusions.
The generalisability of the findings is restricted to hypertension consultations, which involve a high proportion of repeat visits.
doi:10.1136/bmjopen-2011-000203
PMCID: PMC3191582  PMID: 22021787
15.  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
16.  "Seeing a doctor is just like having a date": a qualitative study on doctor shopping among overactive bladder patients in Hong Kong 
BMC Family Practice  2014;15:27.
Background
Although having a regular primary care provider is noted to be beneficial to health, doctor shopping has been documented as a common treatment seeking behavior among chronically ill patients in different countries. However, little research has been conducted into the reasons behind doctor shopping behavior among patients with overactive bladder, and even less into how this behavior relates to these patients’ illness and social experiences, perceptions, and cultural practices. Therefore, this study examines overactive bladder patients to investigate the reasons behind doctor shopping behavior.
Methods
My study takes a qualitative approach, conducting 30 semi-structured individual interviews, with 30 overactive bladder patients in Hong Kong.
Results
My study found six primary themes that influenced doctor shopping behavior: lack of perceived need, convenience, work-provided medical insurance, unpleasant experiences with doctors, searching for a match doctor, and switching between biomedicine and traditional Chinese medicine. Besides the perceptual factors, participants’ social environment, illness experiences, personal cultural preference, and cultural beliefs also intertwined to generate their doctor shopping behavior. Due to the low perceived need for a regular personal primary care physician, environmental factors such as time, locational convenience, and work-provided medical insurance became decisive in doctor shopping behavior. Patients’ unpleasant illness experiences, stemming from a lack of understanding among many primary care doctors about overactive bladder, contributed to participants’ sense of mismatch with these doctors, which induced them to shop for another doctor.
Conclusions
Overactive bladder is a chronic bladder condition with very limited treatment outcome. Although patients with overactive bladder often require specialty urology treatment, it is usually beneficial for the patients to receive continuous, coordinated, comprehensive, and patient-centered support from their primary care providers. Primary care doctors’ understanding on patients with overactive bladder with empathetic attitudes is important to reduce the motivations of doctor shopping behavior among these patients.
doi:10.1186/1471-2296-15-27
PMCID: PMC3936809  PMID: 24502367
Hong Kong; Doctor shopping; Perceptions; Social environment; Illness and treatment experiences; Personal cultural preference; Cultural beliefs; Overactive bladder patients
17.  Consultation skills of young doctors: II--Most young doctors are bad at giving information. 
Forty young doctors, half of whom had had feedback training in interviewing as students, were assessed five years later. Each interviewed three patients and after being given results of examination, investigations, and diagnosis and prognosis returned to discuss them with each patient for 10 minutes. These discussions were filmed on videotape and evaluated. There was no difference between the scores of interview trained and control doctors. Though most gave simple information on diagnosis and treatment, few mentioned investigations, aetiology, or prognosis. Very few obtained and took any account of patients' views or expectations of these matters. Some young doctors do discover for themselves how best to give patients information and advice, but most remain extremely incompetent. This is presumably because they get no training as students in this important aspect of clinical practice. This deficiency should be corrected, and competence tested before qualification to practise.
PMCID: PMC1340569  PMID: 3087523
18.  'It gives you an understanding you can't get from any book.' The relationship between medical students' and doctors' personal illness experiences and their performance: a qualitative and quantitative study 
Background
Anecdotes abound about doctors' personal illness experiences and the effect they have on their empathy and care of patients. We formally investigated the relationship between doctors' and medical students' personal illness experiences, their examination results, preparedness for clinical practice, learning and professional attitudes and behaviour towards patients.
Methods
Newly-qualified UK doctors in 2005 (n = 2062/4784), and two cohorts of students at one London medical school (n = 640/749) participated in the quantitative arm of the study. 37 Consultants, 1 Specialist Registrar, 2 Clinical Skills Tutors and 25 newly-qualified doctors participated in the qualitative arm. Newly-qualified doctors and medical students reported their personal illness experiences in a questionnaire. Doctors' experiences were correlated with self-reported preparedness for their new clinical jobs. Students' experiences were correlated with their examination results, and self-reported anxiety and depression. Interviews with clinical teachers, newly-qualified doctors and senior doctors qualitatively investigated how personal illness experiences affect learning, professional attitudes, and behaviour.
Results
85.5% of newly-qualified doctors and 54.4% of medical students reported personal illness experiences. Newly-qualified doctors who had been ill felt less prepared for starting work (p < 0.001), but those who had only experienced illness in a relative or friend felt more prepared (p = 0.02). Clinical medical students who had been ill were more anxious (p = 0.01) and had lower examination scores (p = 0.006). Doctors felt their personal illness experiences helped them empathise and communicate with patients. Medical students with more life experience were perceived as more mature, empathetic, and better learners; but illness at medical school was recognised to impede learning.
Conclusion
The majority of the medical students and newly qualified doctors we studied reported personal illness experiences, and these experiences were associated with lower undergraduate examination results, higher anxiety, and lower preparedness. However reflection on such experiences may have improved professional attitudes such as empathy and compassion for patients. Future research is warranted in this area.
doi:10.1186/1472-6920-7-50
PMCID: PMC2211477  PMID: 18053231
19.  The patient–doctor relationship: a synthesis of the qualitative literature on patients' perspectives 
The British Journal of General Practice  2009;59(561):e116-e133.
Background
The patient–doctor relationship is an important but poorly defined topic. In order to comprehensively assess its significance for patient care, a clearer understanding of the concept is required.
Aim
To derive a conceptual framework of the factors that define patient–doctor relationships from the perspective of patients.
Design of study
Systematic review and thematic synthesis of qualitative studies.
Method
Medline, EMBASE, PsychINFO and Web of Science databases were searched. Studies were screened for relevance and appraised for quality. The findings were synthesised using a thematic approach.
Results
From 1985 abstracts, 11 studies from four countries were included in the final synthesis. They examined the patient–doctor relationship generally (n = 3), or in terms of loyalty (n = 3), personal care (n = 2), trust (n = 2), and continuity (n = 1). Longitudinal care (seeing the same doctor) and consultation experiences (patients' encounters with the doctor) were found to be the main processes by which patient–doctor relationships are promoted. The resulting depth of patient–doctor relationship comprises four main elements: knowledge, trust, loyalty, and regard. These elements have doctor and patient aspects to them, which may be reciprocally related.
Conclusion
A framework is proposed that distinguishes between dynamic factors that develop or maintain the relationship, and characteristics that constitute an ongoing depth of relationship. Having identified the different elements involved, future research should examine for associations between longitudinal care, consultation experiences, and depth of patient–doctor relationship, and, in turn, their significance for patient care.
doi:10.3399/bjgp09X420248
PMCID: PMC2662123  PMID: 19341547
communication; continuity of patient care; physician–patient relations; qualitative research
20.  English language usage pattern in China mainland doctors: AME survey-001 initial analysis results 
Purpose
English is the most widely used language in medical community worldwide. Till now there is no study yet on how English language is being used among mainland Chinese doctors. The present survey aimed to address this question.
Methods
An online cross-sectional survey was carried out during the period of 23 Oct 2014 to 13 November 2014, totaling 22 days. This survey was conducted on the platform provided by DXY (www.dxy.cn), which is the largest medical and paramedical related website in China with registered medical doctor users of slightly more than one million. E-mails were sent to all DXY registered users to invite them to participate the survey which lasts approximately five-minute. The questionnaire included three major aspects: (I) the demographic characteristics of participants; (II) English reading pattern; and (III) paper publishing experience in international journals. To accommodate the complexity of relationships among variables, structural equation modeling (SEM) was employed to build the model.
Results
In total 1,663 DXY users completed the survey, which counted for ≈1% of the total registered medical doctor users. There were more participants from relatively economically developed eastern coast areas. The age of participants was 33.6±7.4 years. There were 910 respondents from teaching hospitals (54.72%), followed by tertiary care hospitals (class-III hospital, 22.37%). Mainland Chinese doctors were more likely to consult medical materials in Chinese (63.5%) when they encounter clinical difficulties. Participants who were able to list English journals of their own specialty up to four were 44.02% for 0, 13.77% for one journal, 13.89% for two journals, 9.26% for three journals, and 19.06% for four journals. Most participants (82.86%) have read at least one English paper or one professional book in English, while 17.14% responded they never read a single English paper or professorial book in English. About 30.42% participants published at least one paper in English journals, and approximately half of them require professional English editing service.
Conclusions
This limited survey shows Mainland Chinese doctors are more likely to use Chinese medical materials. Overall their familiarity with international English journals is relatively low. Improving English education at the undergraduate and post-graduate levels is recommended.
doi:10.3978/j.issn.2223-4292.2014.12.05
PMCID: PMC4312298
English language; China; survey; medical education; structural equation modeling (SEM)
21.  Training community resource center and clinic personnel to prompt patients in listing questions for doctors: Follow-up interviews about barriers and facilitators to the implementation of consultation planning 
Background
Visit preparation interventions help patients prepare to meet with a medical provider. Systematic reviews have found some positive effects, but there are no reports describing implementation experiences. Consultation Planning (CP) is a visit preparation technique in which a trained coach or facilitator elicits and documents patient questions for an upcoming medical appointment. We integrated CP into a university breast cancer clinic beginning in 1998. Representatives of other organizations expressed interest in CP, so we invited them to training workshops in 2000, 2001, and 2002.
Objectives
In order to learn from experience and generate hypotheses, we asked: 1) How many trainees implemented CP? 2) What facilitated implementation? 3) How have trainees, patients, physicians, and administrative leaders of implementing organizations reacted to CP? 4) What were the barriers to implementation?
Methods
We attempted to contact 32 trainees and scheduled follow-up, semi-structured, audio-recorded telephone interviews with 18. We analyzed quantitative data by tabulating frequencies and qualitative data by coding transcripts and identifying themes.
Results
Trainees came from two different types of organizations, clinics (which provide medical care) versus resource centers (which provide patient support services but not medical care). We found that: 1) Fourteen of 21 respondents, from five of eight resource centers, implemented CP. Four of the five implementing resource centers were rural. 2) Implementers identified the championing of CP by an internal staff member as a critical success factor. 3) Implementers reported that modified CP has been productive. 4) Four respondents, from two resource centers and two clinics, did not implement CP, reporting resource limitations or conflicting priorities as the critical barriers.
Conclusion
CP training workshops have been associated with subsequent CP implementations at resource centers but not clinics. We hypothesize that CP workshops combined with an internal champion and adequate program resources may be sufficient for some patient support organizations to implement CP.
doi:10.1186/1748-5908-3-6
PMCID: PMC2270865  PMID: 18237380
22.  Measuring morale--does practice area deprivation affect doctors' well-being? 
BACKGROUND: Morale is a perennial concern in general practice and, over the years, a variety of tools have been used to examine doctors' mental well-being in a range of psychological and sociological studies. Despite perceived associations between low morale and practice area deprivation, this has not been investigated previously. AIM: To devise and apply a measure of mental well-being in general practitioners, and to use this to investigate the effect of practice area deprivation. METHOD: A questionnaire was devised and piloted, then used in an anonymous postal survey of a random sample of 500 London general practitioners, with questions on demography, workload, practice characteristics, patient centredness, and practice area deprivation. RESULTS: A total of 334 (68%) doctors replied to the questionnaire. Of these, 45% often feel exhausted, 46% are often frustrated by trivial consultations, and a third are seriously disenchanted with work. The resulting well-being score had a normal distribution, was reproducible (test-retest reliability = 0.91), and was internally consistent (Cronbach's alpha = 0.76). Comments from respondents suggested good face validity. Low well-being was not associated with practice area deprivation, but was associated with time stress, small practices and primary care teams, and lack of patient centredness. CONCLUSION: The instrument provided a useful tool for examining doctors' well-being and the associations thereof. Well-being was not associated with practice area deprivation. Help for small primary care teams and measures to reduce time stress should help to improve morale.
PMCID: PMC1313102  PMID: 9406487
23.  Questionnaire severity measures for depression: a threat to the doctor–patient relationship? 
Background
Since 2006 the Quality Outcomes Framework (QOF) has rewarded GPs for carrying out standardised assessments of the severity of symptoms of depression in newly diagnosed patients.
Aim
To gain understanding of GPs' opinions and perceived impact on practice of the routine introduction of standardised questionnaire measures of severity of depression through the UK general practice contract QOF.
Design of study
Semi-structured qualitative interview study, with purposive sampling and constant comparative analysis.
Setting
Thirty-four GPs from among 38 study general practices in three sites in England, UK: Southampton, Liverpool, and Norfolk.
Method
GPs were interviewed at a time convenient to them by trained interviewers. Interviews were audiorecorded and transcribed verbatim in preparation for thematic analysis, to identify key views.
Results
Analysis of the interviews suggested that the use of severity questionnaires posed an intrusion into the consultation. GPs discursively polarised two technologies: formal assessment versus personal enquiry, emphasising the need to ensure the scores are used sensitively and as an aid to clinical judgement rather than as a substitute. Importantly, these challenges implicitly served a function of preserving GPs' identities as professionals with expertise, constructed as integral to the process of diagnosis.
Conclusion
GP accounts indicated concern about threats to patient care. Contention between using severity questionnaires and delivering individualised patient care is significantly motivated by GP concerns to preserve professional expertise and identity. It is important to learn from GP concerns to help establish how best to optimise the use of severity questionnaires in depression.
doi:10.3399/bjgp11X556236
PMCID: PMC3026150  PMID: 21276338
depression; diagnosis; general practice
24.  Shifts in doctor-patient communication between 1986 and 2002: a study of videotaped General Practice consultations with hypertension patients 
BMC Family Practice  2006;7:62.
Background
Departing from the hypotheses that over the past decades patients have become more active participants and physicians have become more task-oriented, this study tries to identify shifts in GP and patient communication patterns between 1986 and 2002.
Methods
A repeated cross-sectional observation study was carried out in 1986 and 2002, using the same methodology. From two existing datasets of videotaped routine General Practice consultations, a selection was made of consultations with hypertension patients (102 in 1986; 108 in 2002). GP and patient communication was coded with RIAS (Roter Interaction Analysis System). The data were analysed, using multilevel techniques.
Results
No gender or age differences were found between the patient groups in either study period. Contrary to expectations, patients were less active in recent consultations, talking less, asking fewer questions and showing less concerns or worries. GPs provided more medical information, but expressed also less often their concern about the patients' medical conditions. In addition, they were less involved in process-oriented behaviour and partnership building. Overall, these results suggest that consultations in 2002 were more task-oriented and businesslike than sixteen years earlier.
Conclusion
The existence of a more equal relationship in General Practice, with patients as active and critical consumers, is not reflected in this sample of hypertension patients. The most important shift that could be observed over the years was a shift towards a more businesslike, task-oriented GP communication pattern, reflecting the recent emphasis on evidence-based medicine and protocolized care. The entrance of the computer in the consultation room could play a role. Some concerns may be raised about the effectiveness of modern medicine in helping patients to voice their worries.
doi:10.1186/1471-2296-7-62
PMCID: PMC1630692  PMID: 17064407
25.  Meanings of existential uncertainty and certainty for people diagnosed with cancer and receiving palliative treatment: a life-world phenomenological study 
BMC Palliative Care  2014;13:28.
Background
Many people around the world are getting cancer and living longer with the disease. Thanks to improved treatment options in healthcare, patients diagnosed with advanced gastrointestinal cancer can increasingly live for longer. Living with cancer creates existential uncertainty, but what does this situation mean for the individual? The purpose of the study is to interpret meanings of existential uncertainty and certainty for people diagnosed with advanced gastrointestinal cancer and receiving palliative treatment.
Methods
This study is part of a larger project in which 7 men and 7 women aged between 49 and 79 participated in a study of information and communication for people with advanced gastrointestinal cancer. A total of 66 interviews were conducted with participants who were followed up over time. The narrative interviews were transcribed verbatim and the texts were analysed in three steps: naive reading, structural analysis and interpreted whole by utilizing a phenomenological life-world approach.
Results
This study has identified different spheres in which people diagnosed with advanced gastrointestinal cancer vacillate between existential uncertainty and certainty: bodily changes, everyday situations, companionship with others, healthcare situations and the natural environment. Existing in the move between existential uncertainty and certainty appears to change people’s lives in a decisive manner. The interview transcripts reveal aspects that both create existential certainty and counteract uncertainty. They also reveal that participants appear to start reflecting on how the new and uncertain aspects of their lives will manifest themselves –a new experience that lays the foundation for development of knowledge, personal learning and growth.
Conclusions
People diagnosed with advanced gastrointestinal cancer and receiving palliative care expressed thoughts about personal learning initiated by the struggle of living with an uncertain future despite their efforts to live in the present. Their personal learning was experienced through a changed life for themselves and having to confront their own pending death and develop self-insight regarding finality of life. Healthcare professionals can try to support people receiving palliative treatment for cancer by diversifying avenues for their personal growth, thus helping them manage their existential uncertainty and gravitate towards greater existential certainty.
doi:10.1186/1472-684X-13-28
PMCID: PMC4059734  PMID: 24936149
Existential uncertainty and existential certainty; Life-world phenomenology; Nursing; Palliative care; Personal growth; Qualitative research; Spirituality

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