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1.  Moral Controversy, Directive Counsel, and the Doctor’s Role: Findings From a National Survey of Obstetrician–Gynecologists 
To explore physicians’ attitudes toward providing directive counsel when dealing with morally controversial medical decisions, and to examine associations between physicians’ opinions and their demographic and religious characteristics.
In 2008–2009, the authors mailed a survey to a stratified, random sample of 1,800 U.S. obstetrician–gynecologists. They asked participants whether, when dealing with either typical or morally controversial medical decisions, “a physician should encourage patients to make the decision that the physician believes is best.”
Among eligible physicians, the response rate was 66%. Fifty-four percent of respondents rejected the use of directive counsel for typical medical decisions; 78% did so for morally controversial medical decisions. Physicians were less likely to refrain from directive counsel for typical medical decisions if they were older and foreign-born but more likely to refrain from directive counsel if they were more theologically pluralistic. Theological pluralism was the only characteristic significantly associated with refraining from directive counsel for morally controversial medical decisions.
Providing nondirective counsel to their patients appears to have become the norm among certain obstetrician–gynecologists in the United States, particularly when dealing with morally controversial medical decisions. These physicians tend to be female, younger, U.S.-born, and more theologically pluralistic. Shifts toward refraining from directive counsel seem to relate to shifts in physicians’ demographic, cultural, and religious characteristics.
PMCID: PMC3634119  PMID: 20736675
2.  Should doctors inform terminally ill patients? The opinions of nationals and doctors in the United Arab Emirates. 
Journal of Medical Ethics  1997;23(2):101-107.
OBJECTIVES: To study the opinions of nationals (Emiratis) and doctors practising in the United Arab Emirates (UAE) with regard to informing terminally ill patients. DESIGN: Structured questionnaires administered during January 1995. SETTING: The UAE, a federation of small, rich, developing Arabian Gulf states. PARTICIPANTS: Convenience samples of 100 Emiratis (minimum age 15 years) and of 50 doctors practising in government hospitals and clinics. RESULTS: Doctors emerged as consistently less in favour of informing than the Emiratis were, whether the patient was described as almost certain to die during the next six months or as having a 50% chance of surviving, and even when it was specified that the patient was requesting information. In the latter situation, a third of doctors maintained that the patient should not be told. Increasing survival odds reduced the number of doctors selecting to inform; but it had no significant impact on Emiratis' choices. When Emiratis were asked whether they would personally want to be informed if they had only a short time to live, less than half responded in the way they had done to the in principle question. CONCLUSIONS: The doctors' responses are of concern because of the lack of reference to ethical principles or dilemmas, the disregard of patients' wishes and dependency on survival odds. The heterogeneity of Emiratis' responses calls into question the usefulness of invoking norms to explain inter-society differences. In the current study, people's in principle choices did not provide a useful guide to how they said they would personally wish to be treated.
PMCID: PMC1377210  PMID: 9134491
3.  Patients Do not Know the Level of Training of Their Doctors Because Doctors Do not Tell Them 
Although patients should know the level of training of the physician providing their care in teaching hospitals, many do not.
The objective of this study is to determine whether the manner by which physicians introduce themselves to patients is associated with patients’ misperception of the level of training of their physician.
This was an observational study of 100 patient–physician interactions in a teaching emergency department.
Measurements and Main Results
Residents introduced themselves as a doctor 82% of the time but identified themselves as a resident only 7% of the time. While attending physicians introduced themselves as a “doctor” 64% of the time, only 6% identified themselves as the supervising physician. Patients felt it was very important to know their physicians’ level of training, but most did not.
Physicians in our sample were rarely specific about their level of training and role in patient care when introducing themselves to patients. This lack of communication may contribute to patients’ lack of knowledge regarding who is caring for them in a teaching hospital.
PMCID: PMC2324138  PMID: 18097726
physician–patient relations; graduate medical education; teaching hospitals
4.  Disciplined doctors: Does the sex of a doctor matter? A cross-sectional study examining the association between a doctor's sex and receiving sanctions against their medical registration 
BMJ Open  2014;4(8):e005405.
To examine the association between doctors’ sex and receiving sanctions on their medical registration, while controlling for other potentially confounding variables.
Cross-sectional study.
The General Medical Council (GMC)'s List of Registered Medical Practitioners (LRMP) database of doctors practising in the UK.
All doctors on the GMC's LRMP on 29 May 2013. The database included all doctors who are or have been registered to practise medicine in the UK since October 2005. The exposure of interest was doctor's sex. Confounding variables included years since primary medical qualification, world region of primary medical qualification and specialty.
Outcome measures
Sanctions on a doctor's medical registration. Sanction types included warnings, undertakings, conditions, suspension or erasure from the register. Binary logistic regression modelling, controlling for confounders, described the association between the doctor's sex and sanctions on a doctor's medical registration.
Of the 329 542 doctors on the LRMP, 2697 (0.8%) had sanctions against their registration, 516 (19.1%) of whom were female. In the fully adjusted model, female doctors had nearly a third of the odds (OR: 0.37, 95% CI: 0.33 to 0.41) of having sanctions compared to male doctors. There was evidence that the association varies with specialty, with female doctors who had specialised as general practitioners being the least likely to receive sanctions compared with their male colleagues (OR: 0.26, 95% CI: 0.22 to 0.31).
Female doctors have reduced odds of receiving sanctions on their medical registration when compared with their male colleagues. This association remained after adjustment for the confounding factors. These results are representative of all doctors registered to practise in the UK. Further exploration of why doctors’ sex may impact their professional performance is underway.
PMCID: PMC4127941  PMID: 25104057
5.  Comparison of estimates and calculations of risk of coronary heart disease by doctors and nurses using different calculation tools in general practice: cross sectional study 
BMJ : British Medical Journal  2002;324(7335):459-464.
To assess the effect of using different risk calculation tools on how general practitioners and practice nurses evaluate the risk of coronary heart disease with clinical data routinely available in patients' records.
Subjective estimates of the risk of coronary heart disease and results of four different methods of calculation of risk were compared with each other and a reference standard that had been calculated with the Framingham equation; calculations were based on a sample of patients' records, randomly selected from groups at risk of coronary heart disease.
General practices in central England.
18 general practitioners and 18 practice nurses.
Main outcome measures
Agreement of results of risk estimation and risk calculation with reference calculation; agreement of general practitioners with practice nurses; sensitivity and specificity of the different methods of risk calculation to detect patients at high or low risk of coronary heart disease.
Only a minority of patients' records contained all of the risk factors required for the formal calculation of the risk of coronary heart disease (concentrations of high density lipoprotein (HDL) cholesterol were present in only 21%). Agreement of risk calculations with the reference standard was moderate (κ=0.33-0.65 for practice nurses and 0.33 to 0.65 for general practitioners, depending on calculation tool), showing a trend for underestimation of risk. Moderate agreement was seen between the risks calculated by general practitioners and practice nurses for the same patients (κ=0.47 to 0.58). The British charts gave the most sensitive results for risk of coronary heart disease (practice nurses 79%, general practitioners 80%), and it also gave the most specific results for practice nurses (100%), whereas the Sheffield table was the most specific method for general practitioners (89%).
Routine calculation of the risk of coronary heart disease in primary care is hampered by poor availability of data on risk factors. General practitioners and practice nurses are able to evaluate the risk of coronary heart disease with only moderate accuracy. Data about risk factors need to be collected systematically, to allow the use of the most appropriate calculation tools.
What is already known on this topicRecent guidelines have recommended determining the risk of coronary heart disease for targeting patients at high risk for primary preventionEstimates of risk have been shown to be inaccurateGeneral practitioners and practice nurses can use risk calculation tools accurately when given patient data in the form of scenariosWhat this study addsMany patients do not have adequate information in their records to allow the risk of coronary heart disease to be calculatedWhen data about risk factors were available, risk calculations made by general practitioners and practice nurses were moderately accurate compared to a reference calculationWhen adequate information about risk factors is not available, subjective estimates are a reasonable alternative to calculating risk
PMCID: PMC65668  PMID: 11859049
6.  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
7.  The patient’s anxiety before seeing a doctor and her/his hospital choice behavior in China 
BMC Public Health  2012;12:1121.
The patient’s anxiety before seeing a doctor may influence her/his hospital choice behavior through various ways. In order to explore why high level hospitals were overused by patients and why low level hospitals were not fully used by patients in China, this study was set up to test whether and to what extent the patient’s anxiety before seeing a doctor influenced her/his hospital choice behavior in China.
This study commissioned a large-scale 2009–2010 national resident household survey (N=4,853) in China, and in this survey the Self-Rating Anxiety Scale (SAS) was employed to help patients assess their anxiety before seeing a doctor. Specified ordered probit models were established to analyze the survey dataset.
When the patient had high level of anxiety before seeing a doctor, her/his level of anxiety could not only predict that she/he was more likely to choose the high level hospital, but also accurately predict which level of hospital she/he would choose; when the patient had low level of anxiety before seeing a doctor, her/his level of anxiety could only predict that she/he was more likely to choose the low level hospital, but it couldn’t clearly predict which level of hospital she/he would choose.
The patient with high level of anxiety had the strong consistent bias when she/he chose a hospital (she/he always preferred the high level hospital), while the patient with low level of anxiety didn’t have such consistent bias.
PMCID: PMC3536590  PMID: 23270526
8.  Does awareness of being video recorded affect doctors' consultation behaviour? 
Four general practitioners, two of whom had no previous experience of video recording in the consultation, took part in a study to assess the effect of awareness of video recording on their consultation behaviour. A video camera was sited unobtrusively in each consulting room for a month during which five randomly selected surgeries were recorded with the doctors being informed at the time, and five without their being informed. The video recorded consultations were analysed using TIMER, a tool designed to measure objectively behaviour in terms of physical, verbal and secondary activities in consultations. The proportions of time spent on the 27 consultation parameters were compared when doctors were aware and unaware of the recording, using analysis of variance. This demonstrated only one significant difference, in the low frequency parameter of the doctor's exploration of the patients' concepts (P less than 0.05). In a secondary analysis of the first four consultations in each surgery, where any effect of the presence of the video camera would be expected to be most marked, there was again only one significant difference in the 27 parameters (in patient preparation; P = 0.01). No significant difference owing to awareness of video recording was found in consultation length, the number of problems dealt with, or previous inexperience of video recording. When surgeries at the start of the month were compared with those at the end, four significant differences (P less than 0.05) out of 108 areas were demonstrated both when the doctor was aware and unaware of video recording, and there was no consistency in the direction of the differences.(ABSTRACT TRUNCATED AT 250 WORDS)
PMCID: PMC1371415  PMID: 2271278
9.  Acute referral of patients from general practitioners: should the hospital doctor or a nurse receive the call? 
Surprisingly little is known about the most efficient organization of admissions to an emergency hospital. It is important to know, who should be in front when the GP requests an acute admission. The aim of the study was to analyse how experienced ED nurses perform when assessing requests for admissions, compared with hospital physicians.
Before- and after ED nurse assessment study, in which two cohorts of patients were followed from the time of request for admission until one month later. The first cohort of patients was included by the physicians on duty in October 2008. The admitting physicians were employed in the one of the specialized departments and only received request for admission within their speciality. The second cohort of patients was included by the ED in May 2009. They received all request from the GPs for admission, independent of the speciality in question.
A total of 944 requests for admission were recorded. There was a non-significant trend towards the nurses admitting a smaller fraction of patients than the physicians (68 versus 74%). While the nurses almost never rejected an admission, the physicians did this in 7% of the requests. The nurses redirected 8% of the patients to another hospital, significantly more than the physicians with only 1%. (p < 0.0001). The nurses referred significantly more patients to the correct hospital than the doctors (78% vs. 70% p: 0.03). There were no differences in the frequency of unnecessary admissions between the groups. The self-reported use of time for assessment was twice as long for the physicians as for the nurses. (p < 0.0001).
We found no differences in the frequency of admitted patients or unnecessary admissions, but the nurses redirected significantly more patients to the right hospital according to the catchment area, and used only half the time for the assessment. We find, that nurses, trained for the assignment, are able to handle referrals for emergency admissions, but also advise the subject to be explored in further studies including other assessment models and GP satisfaction.
PMCID: PMC3170607  PMID: 21831325
10.  What doctors tell patients with breast cancer about diagnosis and treatment: findings from a study in general hospitals. GIVIO (Interdisciplinary Group for Cancer Care Evaluation) Italy. 
British Journal of Cancer  1986;54(2):319-326.
In a study aimed at assessing whether and how patients with breast cancer are informed on their diagnosis and treatment a large group of physicians participating in a quality of care evaluation program were asked to report what they told patients about diagnosis and treatment. The completeness of such communication was then assessed using an explicit protocol designed to measure precision and lack of ambiguity of reported phrases. By this measure 39% patients received 'thorough' information on diagnosis and 11% 'detailed' information on surgery. These proportions become 48% and 14%, respectively, when only cases for whom answers were available are considered. Physicians, however, considered this communication 'thorough' for 69% of patients. Among patient-related characteristics, age, education and stage of disease were independent predictors of quality of information. Setting-dependent features more than individual provider attitudes seemed to account for at least part of the quality of information sharing behaviour as both hospital size (comparing centres larger than 500 beds and smaller ones) and degree of hospital organization (comparing centres adhering to the Italian Breast Cancer Task Force, FONCaM and those not) were - simultaneously - significant predictors of quality of communication, independently from patients' case-mix. Physicians' judgement - measured assuming the explicit protocol as standard - proved to be of acceptable sensitivity only when information was 'Thorough' by the protocol. However, its specificity and predictive values were consistently low in all three categories defined by the protocol, leading to high misclassification rates. The implications of these findings for studies aimed at assessing the quality of patients-providers communication are discussed.
PMCID: PMC2001524  PMID: 3741767
11.  Don’t Forget the Doctor: Gastroenterologists’ Preferences on the Development of mHealth Tools for Inflammatory Bowel Disease 
JMIR mHealth and uHealth  2015;3(1):e5.
Inflammatory bowel disease (IBD) encompasses a number of disorders of the gastrointestinal tract. Treatment for IBD is lifelong and complex, and the majority of IBD patients seek information on the Internet. However, research has found existing digital resources to be of questionable quality and that patients find content lacking. Gastroenterologists are frontline sources of information for North American IBD patients, but their opinions and preferences for digital content, design, and utility have not been investigated. The purpose of this study is to systematically explore gastroenterologists’ perceptions of, and design preferences for, mHealth tools.
Our goal was to critically assess these issues and elicit expert feedback by seeking consensus with Canadian gastroenterologists.
Using a qualitative approach, a closed meeting with 7 gastroenterologists was audio recorded and field notes taken. To synthesize results, an anonymous questionnaire was collected at the end of the session. Participant-led discussion themes included methodological approaches to non-adherence, concordance, patient-centricity, and attributes of digital tools that would be actively supported and promoted.
Survey results indicated that 4 of the 7 gastroenterologists had experienced patients bringing digital resources to a visit, but 5 found digital patient resources to be inaccurate or irrelevant. All participants agreed that digital tools were of increasing importance and could be leveraged to aid in consultations and save time. When asked to assess digital attributes that they would be confident to refer patients to, all seven indicated that the inclusion of evidence-based facts were of greatest importance. Patient peer-support networks were deemed an asset but only if closely monitored by experts. When asked about interventions, nearly all (6/7) preferred tools that addressed a mix of compliance and concordance, and only one supported the development of tools that focused on compliance. Participants confirmed that they would actively refer patients and other physicians to digital resources. However, while a number of digital IBD tools exist, gastroenterologists would be reluctant to endorse them.
Gastroenterologists appear eager to use digital resources that they believe benefit the physician-patient relationship, but despite the trend of patient-centric tools that focus on concordance (shared decision making and enlightened communication between patients and their health care providers), they would prefer digital tools that highlight compliance (patient following orders). This concordance gap highlights an issue of disparity in digital health: patients may not use tools that physicians promote, and physicians may not endorse tools that patients will use. Further research investigating the concordance gap, and tensions between physician preferences and patient needs, is required.
PMCID: PMC4319145  PMID: 25608628
mHealth; adherence; concordance; compliance; shared decision making; therapeutic alliance; gastroenterology; IBD; ulcerative colitis
12.  Wearing facemasks when performing lumbar punctures: a snapshot of current practice amongst trainee doctors 
Infective complications of lumbar puncture are not common, but are a significant source of mortality. Causative pathogens have been traced to the oropharynx of the operator, and it is likely that wearing facemasks will minimize the risk of iatrogenic meningitis. The aim of this survey was to assess whether doctors currently wear facemasks when performing lumbar punctures.
We constructed an anonymous survey asking about the use of a facemask when performing lumbar punctures. This was distributed to trainee doctors in medical specialties at the West Midlands and Severn Deaneries in the UK.
The response rate was 72% (72/100). Responders had performed, on average, a total of 15 (range 3–22) lumbar punctures. Only 27 of the doctors (37.5%) wore a facemask when performing lumbar punctures. CT 1–2 doctors were five times more likely than registrars to wear a facemask (53% versus 10%). Similarly, the likelihood of wearing a facemask decreased with the number of times the procedure had been performed.
There are varying practices regarding the use of facemasks for lumbar punctures amongst doctors, with significant differences according to grade and level of experience. Facemasks should be used as part of a “maximal sterile precautions” approach to reduce the risk of infective complications.
PMCID: PMC3417960  PMID: 22915881
infection control; iatrogenic meningitis; facemasks
13.  Does smoking status affect the likelihood of consulting a doctor about respiratory symptoms? A pilot survey in Western Australia 
BMC Family Practice  2009;10:16.
Smokers attribute respiratory symptoms, even when severe, to everyday causes and not as indicative of ill-health warranting medical attention. The aim of this pilot study was to conduct a structured vignette survey of people attending general practice to determine when they would advise a person with respiratory symptoms to consult a medical practitioner. Particular reference was made to smoking status and lung cancer.
Participants were recruited from two general practices in Western Australia. Respondents were invited to complete self-administered questionnaires containing nine vignettes chosen at random from a pool of sixty four vignettes, based on six clinical variables. Twenty eight vignettes described cases with at least 5% risk of cancer. For analysis these were dubbed 'cancer vignettes'. Respondents were asked if they would advise a significant other to consult a doctor with their respiratory symptoms. Logistic regression and non-parametric tests were used to analyse the data.
Three hundred questionnaires were distributed and one hundred and forty completed responses were collected over six weeks. The majority (70.3%) of respondents were female aged forty and older. A history of six weeks' of symptoms, weight loss, cough and breathlessness independently increased the odds of recommending a consultation with a medical practitioner by a factor of 11.8, 2.11, 1.40 and 4.77 respectively. A history of smoking independently increased the odds of the person being thought 'likely' or 'very likely' to have cancer by a factor of 2.46. However only 32% of cancer vignettes with a history of cigarette smoking were recognised as presentations of possible cancer.
Even though a history of cigarette smoking was more likely to lead to the suggestion that a symptomatic person may have cancer we did not confirm that smokers would be more likely to be advised to consult a doctor, even when presenting with common symptoms of lung cancer.
PMCID: PMC2652431  PMID: 19220917
14.  Pitfalls in computer housekeeping by doctors and nurses in KwaZulu-Natal: No malicious intent 
BMC Medical Ethics  2013;14(Suppl 1):S8.
Information and communication technologies are becoming an integral part of medical practice, research and administration and their use will grow as telemedicine and electronic medical record use become part of routine practice. Security in maintaining patient data is important and there is a statuary obligation to do so, but few health professionals have been trained on how to achieve this. There is no information on the use of computers and email by doctors and nurses in South Africa in the workplace and at home, and whether their current computer practices meets legal and ethical requirements. The aims of this study were to determine the use of computers by healthcare practitioners in the workplace and home; the use and approach to data storage, encryption and security of patient data and patient email; and the use of informed consent to transmit data by email.
A self-administered questionnaire was administered to 400 health care providers from the state and private health care sectors. The questionnaire covered computer use in the workplace and at home, sharing of computers, data encryption and storage, email use, encryption of emails and storage, and the use of informed consent for email communication.
193 doctors and 207 nurses in the private and public sectors completed the questionnaire. Forty (10%) of participants do not use a computer. A third of health professionals were the only users of computers at work or at home. One hundred and ninety-eight respondents (55%) did not know if the data on the computers were encrypted, 132 (36.7%) knew that the data were not encrypted and 30 (8.3%) individuals knew that the data on the computers they were using were encrypted. Few doctors, 58 (16%), received emails from patients, with doctors more likely to receive emails from patients than nurses (p = 0.0025). Thirty-one percent of individuals did not respond to the emails. Emails were saved by 40 (69%) recipients but only 5 (12.5%) doctors encrypted the messages, 19 (47.5%) individuals knowingly did not encrypt and 16 (40.0%) did not know if they encrypted the data. While 20% of health professionals have emailed patient data, but only 41.7% gained consent to do so.
Most health professionals as sampled in South Africa are not compliant with the National Health Act or the Electronic Communications Transactions Act of South Africa or guidelines from regulatory bodies when managing patient data on computers. Many appear ignorant or lack the ability to comply with simple data security procedures.
PMCID: PMC3878337  PMID: 24565043
15.  Should doctors wear white coats? 
Postgraduate Medical Journal  2004;80(943):284-286.
Objective: To compare the views of doctors and patients on whether doctors should wear white coats and to determine what shapes their views.
Methods: A questionnaire study of 400 patients and 86 doctors was performed.
Results: All 86 of the doctors' questionnaires were included in the analysis but only 276 of the patients were able to complete a questionnaire. Significantly more patients (56%) compared with their doctors (24%) felt that doctors should wear white coats (p<0.001). Only age (>70 years) (p<0.001) and those patients whose doctors actually wore white coats (p<0.001) were predictive of whether patients favoured white coats. The most common reason given by patients was for easy identification (54%). Less than 1% of patients believed that white coats spread infection.
Only 13% of doctors wore white coats as they were felt to be an infection risk (70%) or uncomfortable (60%). There was no significant difference between doctor subgroups when age, sex, grade, and specialty were analysed.
Conclusion: In contrast to doctors, who view white coats as an infection risk, most patients, and especially those older than 70 years, feel that doctors should wear them for easy identification. Further studies are needed to assess whether this affects patients' perceived quality of care and whether patient education will alter this view.
PMCID: PMC1743003  PMID: 15138319
16.  Intravenous fluid prescribing practices by foundation year one doctors – a questionnaire study 
JRSM Short Reports  2012;3(9):64.
Foundation Year Ones (FY1s) are the most junior doctors in the UK who are often required to prescribe intravenous fluid to patients not under their regular care, during on-call or out-of-hours ward cover. This study aimed to investigate FY1s’ practice and decision-making process of intravenous fluid prescribing to these patients.
Questionnaire survey.
Survey on Practices during on-calls and out-of-hours ward covers.
FY1s of five National Health Service (NHS) hospitals in England and Scotland.
All 149 FY1s responded to survey. Eighty-six percent have been taught intravenous fluid prescribing during medical school, compared with only 48% in FY1 induction. More than half always/often checked the patient's urea and electrolytes (U&Es) (72%), read the fluid balance (58%) and observation charts (80%), discussed the case with nursing staff (75%), enquired about oral status (82%), identified the main diagnosis/operation (75%) and indication for intravenous fluid (72%) of the patient when prescribing intravenous fluid. However, less than half often/always read the medical notes (43%) or performed clinical examinations on patients (16%). Most FY1s (94%) always/often checked patient's U&Es when prescribing potassium.
The questionnaire study demonstrated variations among FY1s in the practice and decision-making process of intravenous fluid prescribing to patients unknown to them, during on-calls or out-of-hours ward covers. Such variations in practice should be addressed especially by medical and foundation schools, and NHS hospitals to improve patient care.
PMCID: PMC3545346  PMID: 23323204
17.  Patients, their doctors, nonsteroidal anti-inflammatory drugs and the perception of risk 
This article is about risk. Risk is probably the most misunderstood component in determining therapeutic intervention; however, it is probably the most relevant issue to consider in the context of expected benefit. The rarity of quantitative risk–benefit assessment and the lack of comparative risk–benefit when alternative therapies exist for a given condition leads to inadequate decisions. Without some quantitation of the risks associated with specific therapies, doctors and patients cannot make optimal risk–benefit calculations. Patients may abandon effective therapies for which benefits may still outweigh risks, or opt for therapies with less well-publicized potential adverse events of even greater frequency or severity. When only small incremental benefits accrue to patients from the use of a given therapy, on the other hand, even very rare serious events may play a role in decision-making by patients, by their health care providers and by regulatory authorities.
PMCID: PMC1526603  PMID: 16542490
18.  Sleep deprivation and junior doctors' performance and confidence 
Postgraduate Medical Journal  2002;78(916):85-87.
Purpose of study: To determine whether sleep deprivation affects not only junior doctors' performance in answering medical questions but whether their ability to judge their own performance is also affected by lack of sleep.
Methods: A questionnaire based follow up study in two district general hospitals of the Carmarthenshire NHS Trust. Eleven house officers and 15 senior house officers (SHOs) within the medical directorate participating in the on-call rota were recruited between July 1999 and May 2000.
Results: SHOs answered significantly more questions correctly (p=0.04) and were more confident than house officers when they were either correct or incorrect (p<0.001). Length of unbroken or continuous sleep is associated with more correct answers (p=0.03) and higher energy (p=0.09) and confidence (p=0.07) scores self rated by the profile of mood states. Length of continuous sleep was not related to the appropriateness of confidence, as measured by the "within-subject confidence-accuracy correlation" (p=0.919).
Conclusions: SHOs performed better than house officers even allowing for sleep loss. Sleep deprivation had adverse effects on mood and performance but junior doctors can still monitor their performance and retain insight into their own ability when sleep deprived.
PMCID: PMC1742284  PMID: 11807189
19.  Norfolk general practice: a comparison of rural and urban doctors 
A postal questionnaire was sent to all Norfolk practitioners, allowing a comparison to be made between rural general practice and urban practice in Norwich and Great Yarmouth. However, when Norfolk town and country doctors were compared, little difference was found in their personal or practice characteristics. In respect of their workload rural doctors, as expected, carried out more procedures overall but, somewhat surprisingly, did not make more home visits. Both sets of doctors had similar views on their present and future role in general practice.
When Norfolk doctors collectively were compared with general practitioners nationally their service appeared to be of a high standard. The only uncertainty surrounded the effects of the greater clustering of Norfolk surgeries, together with the levels of home visiting and their attendant effects on patient accessibility.
PMCID: PMC1711366  PMID: 3255815
20.  Junior doctor titles following implementation of Modernising Medical Careers in the UK 
JRSM Short Reports  2011;2(3):22.
Recent changes in postgraduate medical training in the UK collectively organized under the auspices of Modernising Medical Careers (MMC) have created new labels for junior doctors in training. It would appear that many nurses and other health workers do not understand the new terminology. We aimed to investigate the knowledge of nursing staff about new junior doctor titles in a district general hospital. As far as we are aware, this is the first survey to determine the views and knowledge of the new terms among staff working in the NHS.
Questionnaire study.
District general hospital, West Midlands, UK.
Fifty-five randomly selected staff nurses working in the surgical directorate.
Main outcome measure
Questions were asked about their views and knowledge of the current nomenclature. To objectively assess knowledge of the new titles respondents were asked to match equivalent positions with those based on the old system.
Only 22% (n = 12) of respondents felt that they fully understand current terms in usage. Seventy-six percent (n = 42) felt that it was ‘very important’ that titles accurately convey role and seniority of the doctor. The most common titles correctly matched were FY1 and House Officer (n = 45, 81%) and FY2 and First Year Senior House Officer (n = 35, 64%). Only 9% (n = 5) of staff nurses correctly matched ST3 to Junior Registrar and 13% (n = 7) correctly matched ST7 to Senior Registrar. Ward-based staff nurses demonstrated greater familiarity with titles when compared to nurses who work mainly in the outpatient clinic and theatre setting (p = 0.017). We did not identify a statistically significant association with demographic characteristics (age, gender, experience) and knowledge of the new terms (p > 0.05). Approximately 98% (n = 54) of the staff surveyed felt that terms are confusing to nurses and need to be simplified.
Our survey revealed that nursing staff lacked knowledge of the current terminology to describe doctors in training. This may have implications for staff expectations regarding specific role of junior doctor in terms of clinical decision-making, working relationships and communication between team members, and ultimately patient care.
PMCID: PMC3086326  PMID: 21541090
21.  MedEval — A Swedish medical test collection with doctors and patients user groups 
Journal of Biomedical Semantics  2011;2(Suppl 3):S4.
Test collections for information retrieval are scarce. Domain specific test collections even more so, and medical test collections in the Swedish language non-existent prior to the making of the MedEval test collection. Most research in information retrieval has been performed in the English language, thus most test collections contain English documents. However, English is morphologically poor compared to many other European languages and a number of interesting and important aspects have not been investigated. Building a medical test collection in Swedish opens new research opportunities.
This article describes the making of and potential uses of MedEval, a Swedish medical test collection with assessments, not only for topical relevance, but also for target reader group: Doctors or Patients. A user of the test collection may choose if she wishes to search in the Doctors or the Patients scenario where the topical relevance assessments have been adjusted with consideration to user group, or to search in a scenario which regards only topical relevance.
In addition to having three user groups, MedEval, in its present form, has two indexes, one where the terms are lemmatized and one where the terms are lemmatized and the compounds split and the constituents indexed together with the whole compound.
Differences discovered between the documents written for medical professionals and documents written for laypersons are presented. These differences may be utilized in further studies of retrieval of documents aimed at certain groups of readers. Differences between the groups of documents are, for example, that professional documents have a higher ratio of compounds, have a greater average word length and contain more multi-word expressions.
An experiment is described where the user scenarios have been utilized, searching with expert terms and lay terms, separately and in combination in the different scenarios. The tendency discovered is that the medical expert gets best results using expert terms and the lay person best results using lay terms, but also quite good results using expert terms or lay and expert terms in combination.
The many features of MedEval gives a variety of research possibilities, such as comparing the effectiveness of search terms when it comes to retrieving documents aimed at the different user groups or to study the effect of compound decomposition in retrieval of documents. As Swedish, the language of MedEval, is a morphologically more complex language than English, it is possible to study additional aspects of the effect of natural language processing in information retrieval, for example utilizing different inflectional word forms in the retrieval of expert vs lay documents. MedEval is the first Swedish test collection of the medical domain.
The Department of Swedish at the University of Gothenburg is in the process of making the MedEval test collection available to academic researchers.
PMCID: PMC3194176  PMID: 21992659
22.  Evaluation of standardized doctor's orders as an educational tool for undergraduate medical students: a prospective cohort study 
BMC Medical Education  2013;13:97.
Standardized doctor’s orders are replacing traditional order writing in teaching hospitals. The impact of this shift in practice on medical education is unknown. It is possible that preprinted orders interfere with knowledge acquisition and retention by not requiring active decision-making. The objective of the study was to evaluate the impact of standardized admission orders on disease-specific knowledge among undergraduate medical trainees.
This prospective cohort study enrolled Year 3 (n = 121) and Year 4 (n = 54) medical students at two academic hospitals in Toronto (Ontario, Canada) during their general internal medicine rotation. We used standardized orders for patient admissions for alcohol withdrawal (AW) and for acute exacerbations of chronic obstructive pulmonary disease (AECOPD) as the intervention and manual order writing as the control. Educational outcomes were assessed through end-of-rotation questionnaires assessing disease-specific knowledge of AW and AECOPD.
Results and discussions
Of 175 students, 105 had exposure to patients with alcohol withdrawal during their rotation, and 68 students wrote admission orders. Among these 68 students, 48 used standardized orders (intervention, n = 48) and 20 used manual order writing (control, n = 20). Only 3 students used standardized orders for AECOPD, precluding analysis. There was no significant difference found in mean total score of questionnaires between those who used AW standardized orders and those who did not (11.8 vs. 11.0, p = 0.4). Students who had direct clinical experience had significantly higher mean total scores (11.6 vs. 9.0, p < 0.0001 for AW; 13.8 vs. 12.6, p = 0.02 for AECOPD) compared to students who did not. When corrected for overall knowledge, this difference only persisted for AW.
No significant differences were found in total scores between students who used standardized admission orders and traditional manual order writing. Clinical exposure was associated with increase in disease-specific knowledge.
PMCID: PMC3710495  PMID: 23842504
23.  A survey on doctors’ knowledge and attitude of treating chronic pain in three tertiary hospitals in Nigeria 
Chronic non-cancer pain (CP) is one of the most common complaints that bring patients to the hospital. When pain persists, people move from doctor-to-doctor seeking for help, thus the burden of CP is huge. This study, therefore was aimed at assessing attitude and knowledge of doctors in three teaching hospitals in Nigeria to CP.
Materials and Methods:
Structured questionnaire was administered to doctors practicing at the University of Ilorin Teaching Hospital, Usmanu Danfodio University Teaching Hospital and University of Maiduguri Teaching Hospital. Responses were graded on maximum scale of five.
Of the 410 doctors who participated in study, 79.7% were men. Their years of practice varied from 1 year to 20 years (mean SD = 4.5 ± 1.7 years). Close to 58% of participants were resident doctors, 36.4% medical officers and 8.6% consultants. Only 23.3% of participants had basic medical or postgraduate training on pain management. The physicians’ mean goal of treating CP in patients was 3.7 ± 1.1, compared to 4.0 ± 1.1 in close relative and 4.1 ± 0.9 for doctors’-self pain. Only 9.5% of doctors use opioids for CP compared to 73% who use Nonsteroidal anti-inflammatory drugs (NSAIDs). Few doctors (23%) use ≥2 drugs to treat CP. Doctors were indifferent on the appropriateness of patients with CP to request for additional analgesics (mean score = 3.1 + 1.4). Doctors’ self-rated knowledge of CP was 1.8 ± 0.7 compared to 4.1 ± 0.9 for acute and 0.8 ± 0.3 for cancer pains (P = 0. 003).
Incorporation of pain management into continuing medical education could help improve observed deficiency in doctors’ knowledge of pain treatment which resulted from lack of basic medical education on pain.
PMCID: PMC4003710  PMID: 24791041
Attitude; chronic pain; doctors; knowledge; treatment
24.  How Doctors View and Use Social Media: A National Survey 
Doctors are uncertain of their ethical and legal obligations when communicating with patients online. Professional guidelines for patient-doctor interaction online have been written with limited quantitative data about doctors’ current usage and attitudes toward the medium. Further research into these trends will help to inform more focused policy and guidelines for doctors communicating with patients online.
The intent of the study was to provide the first national profile of Australian doctors’ attitudes toward and use of online social media.
The study involved a quantitative, cross-sectional online survey of Australian doctors using a random sample from a large representative database.
Of the 1500 doctors approached, 187 participated (12.47%). Most participants used social media privately, with only one-quarter not using any social media websites at all (48/187, 25.7%). One in five participants (30/155, 19.4%) had received a “friend request” from a patient. There was limited use of online communication in clinical practice: only 30.5% (57/187) had communicated with a patient through email and fewer than half (89/185, 48.1%) could offer their patients electronic forms of information if that were the patients’ preference. Three in five participants (110/181, 60.8%) reported not being uncomfortable about interacting with patients who had accessed personal information about them online, prior to the consultation. Most of the participants (119/181, 65.8%) were hesitant to immerse themselves more fully in social media and online communication due to worries about public access and legal concerns.
Doctors have different practices and views regarding whether or how to communicate appropriately with patients on the Internet, despite online and social media becoming an increasingly common feature of clinical practice. Additional training would assist doctors in protecting their personal information online, integrating online communication in patient care, and guidance on the best approach in ethically difficult online situations.
PMCID: PMC4275505  PMID: 25470407
social media; Internet; professional practice; health communication; ethics; health policy; patient-physician relations
25.  Should doctors intentionally do less than the best? 
Journal of Medical Ethics  1999;25(2):121-126.
The papers of Burley and Harris, and Draper and Chadwick, in this issue, raise a problem: what should doctors do when patients request an option which is not the best available? This commentary argues that doctors have a duty to offer that option which will result in the individual affected by that choice enjoying the highest level of wellbeing. Doctors can deviate from this duty and submaximise--bring about an outcome that is less than the best--only if there are good reasons to do so. The desire to have a child which is genetically related provides little, if any, reason to submaximise. The implication for cloning, preimplantation diagnosis and embryo transfer is that doctors should only produce a clone or transfer embryos expected to enjoy a level of wellbeing which is less than that enjoyed by other children the couple could have, if there is a good reason to employ that technology. This paper sketches what might constitute a good reason to submaximise.
PMCID: PMC479195  PMID: 10226916

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