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1.  Canadians’ willingness to receive care from physician assistants 
Canadian Family Physician  2012;58(8):e459-e464.
Abstract
Objective
To determine the willingness of Canadians to accept treatment from physician assistants (PAs).
Design
Respondents were asked to be surrogate patients or parents under 1 of 3 conditions selected at random. Two scenarios involved injury to themselves, with the third involving injury to their children. The wait time for a physician was assumed to be 4 hours, whereas to explore the sensitivity of patients’ preferences for a range of times, PA wait times were 30 minutes, 1 hour, and 2 hours.
Setting
Vancouver, BC.
Participants
Two hundred twenty-nine mothers attending a hospital with their children.
Main outcome measures
The main outcome measure was the proportion of individuals in each scenario who were willing to be treated by PAs for at least one of the time trade-off options offered. A secondary outcome was the proportion of individuals who changed their answers when the waiting time to see the PA varied.
Results
Regardless of the scenarios, 99% of participants opted for PAs under the personal circumstances; 96% opted for PAs when the issue involved their children. The choice favouring the PA persisted, albeit at slightly lower proportions, as the difference in wait time between PAs and physicians decreased (85% and 67% for a difference in PA and physician wait time of 3 and 2 hours, respectively).
Conclusion
These findings suggest that British Columbians are willing to be treated by PAs under most circumstances, whether this includes themselves or their children. The high level of willingness to be treated by PAs demonstrates public confidence in PA care, and suggests that the use of PAs in Canadian emergency departments or clinics is a viable policy response to decreasing primary care capacity.
PMCID: PMC3419003  PMID: 22893348
2.  Doctors’ willingness to give honest answers about end-of-life practices: a cross-sectional study 
BMJ Open  2013;3(5):e002598.
Objectives
We aimed to (1) evaluate the extent to which doctors in New Zealand would be willing to answer honestly questions about their care of patients at the end of their lives and (2) identify the assurances that would encourage this. Results were compared with findings from a previous pilot study from the UK.
Design
Survey study involving a mailed questionnaire.
Setting
New Zealand hospital and community-based medical care settings.
Participants
The questionnaire was mailed to a random sample of 800 doctors in New Zealand who were vocationally registered with the Medical Council of New Zealand in disciplines involving caring for patients at the end of their lives.
Primary and secondary outcome measures
Willingness to provide honest answers about various aspects of end-of-life care; assurances that might increase willingness to provide honest answers to questions about end-of-life practices.
Results
Completed questionnaires were returned by 436 doctors. The majority of respondents (59.9–91.5%) indicated willingness to provide honest answers to such questions. However, more than a third of doctors were unwilling to give honest answers to certain questions regarding euthanasia. These results are comparable with the UK data. Complete anonymity was the assurance most likely to encourage honest answering, with most of the respondents preferring the use of anonymous written replies. Respondents were less reassured by survey endorsements from regulatory bodies. Themes in free comments included the deterrent effect of medicolegal consequences, fear of censure from society, peers and the media and concerns about the motivations and potential uses of such research.
Conclusions
Many New Zealand doctors were willing to give honest answers to questions about end-of-life practices, particularly if anonymity was guaranteed; others, however, expressed doubts or indicated that they would not be willing to provide honest answers to questions of this sort.
doi:10.1136/bmjopen-2013-002598
PMCID: PMC3664351  PMID: 23793694
Medical Ethics; Medical Law; Palliative Care
3.  “It’s not just what the doctor tells me:” Factors that influence surrogate decision-makers’ perceptions of prognosis* 
Critical care medicine  2010;38(5):1270-1275.
Objective
Physicians and surrogate decision-makers for seriously ill patients often have different views of patients’ prognoses. We sought to understand what sources of knowledge surrogates rely on when estimating a patient’s prognosis.
Design
Prospective, mixed-methods study using face-to-face, semistructured interviews with surrogate decision-makers.
Setting
Four intensive care units at the University of California, San Francisco Medical Center in 2006 to 2007.
Participants
Participants were 179 surrogate decision-makers for 142 incapacitated, critically ill patients at high risk for death.
Main Results
Less than 2% (3 of 179) of surrogates reported that their beliefs about the patients’ prognoses hinged exclusively on prognostic information provided to them by physicians. The majority cited other factors in addition to physicians’ predictions that also contributed to their beliefs about the patients’ prognoses, including perceptions of the patient’s individual strength of character and will to live; the patient’s unique history of illness and survival; the surrogate’s own observations of the patient’s physical appearance; the surrogate’s belief that their presence at the bedside may improve the prognosis; and the surrogate’s optimism, intuition, and faith. For some surrogates, these other sources of knowledge superseded the importance of the physician’s prognostication. However, most surrogates endeavored to balance their own knowledge of the patient with physicians’ biomedical knowledge.
Conclusions
Surrogates use diverse types of knowledge when estimating their loved ones’ prognoses, including individualized attributes of the patient, such as their strength of character and life history, of which physicians may be unaware. Attention to these considerations may help clinicians identify and overcome disagreements about prognosis.
doi:10.1097/CCM.0b013e3181d8a217
PMCID: PMC3530838  PMID: 20228686
4.  Death with dignity and the right to die: sometimes doctors have a duty to hasten death. 
Journal of Medical Ethics  1987;13(2):81-85.
As the single most important experience in the lives of all people, the process and event of death must be handled carefully by the medical community. Twentieth-century advances in life-sustaining technology impose new areas of concern on those who are responsible for dying persons. Physicians and surrogates alike must be ready and willing to decide not to intervene in the dying process, indeed to hasten it, when they see the autonomy and dignity of patients threatened. In addition, the very ways we talk about death and dying need to come under scrutiny, and it is likely that our technical advances should be parallelled by equally arduous advances in the semantic and rhetorical approaches we take to death.
PMCID: PMC1375428  PMID: 3612699
5.  Impact of the Geriatric Medication Game on Pharmacy Students’ Attitudes Toward Older Adults 
Objective. To examine the impact of participation in the Geriatric Medication Game on pharmacy students’ perceptions of and attitudes toward older adults and familiarity with common disabilities that affect them and the process of seeking health care.
Design. In the game, first-year pharmacy students “became” older adults during a 3-hour pharmacy practice laboratory. They were given aging-related challenges (eg, impaired vision or mobility) and participated as patients in simulated healthcare scenarios, such as a visit to a physician's office and a pharmacy.
Assessment. After playing the game, students completed a 5-question reflection about their experiences and attitudes toward older adults. Content analysis was performed to identify themes from 4 years of student (n = 625) reflections. Predominant themes included: improved attitudes toward older adults, better understanding of patient experiences, and increased willingness to provide assistance.
Conclusions. Incorporating the Geriatric Medication Game into the pharmacy curriculum may facilitate students’ understanding of the challenges that older adults face and improve future interactions.
doi:10.5688/ajpe758158
PMCID: PMC3220339  PMID: 22102748
attitudes; pharmacy education; geriatrics; assessment
6.  The Doctor and the Market: About the Influence of Market Reforms on the Professional Medical Ethics of Surgeons and General Practitioners in The Netherlands 
Health Care Analysis  2011;19(4):388-402.
To explore whether market reforms in a health care system affect medical professional ethics of hospital-based specialists on the one hand and physicians in independent practices on the other. Qualitative interviews with 27 surgeons and 28 general practitioners in The Netherlands, held 2–3 years after a major overhaul of the Dutch health care system involving several market reforms. Surgeons now regularly advertise their work (while this was forbidden in the past) and pay more attention to patients with relatively minor afflictions, thus deviating from codes of ethics that oblige physicians to treat each other as brothers and to treat patients according to medical need. Dutch GPs have abandoned their traditional reticence and their fear of medicalization. They now seem to treat more in accordance with patients’ preferences and less in accordance with medical need. Market reforms do affect medical professional principles, and it is doubtful whether these changes were intended when Dutch policy makers decided to introduce market elements in the health care system. Policy makers in other countries considering similar reforms should pay attention to these results.
doi:10.1007/s10728-011-0166-z
PMCID: PMC3212676  PMID: 21267659
Medical professional ethics; Market reforms; Surgeons; General practitioners
7.  PATIENT RESPONSIBILITY FOR MEDICAL DECISION MAKING AND RISKY TREATMENT OPTIONS 
Arthritis and rheumatism  2009;61(12):1674-1676.
Background:
Some studies have shown that increasing patient participation in decision making decreases utilization of risky procedures. A recent paper demonstrated that risk perception is increased under conditions which emphasize volition, or the act of choosing. The objective of this study was to examine whether emphasizing volition increases patients' risk perception and decreases their willingness to accept risk.
Methods:
Consecutive patients attending outpatient clinic appointments viewed a video in which a physician described the availability of a new medication associated with a rare risk of a serious side effect. Patients' willingness to accept treatment and worry about the risk of the serious side effect were measured under two different conditions: one minimizing patient involvement and the second maximizing patient involvement in the decision making process.
Results:
Subjects' willingness to take the proposed medication was lower (4.2 ± 3.7 versus 5.3 ± 3.7, p<0.001) and their worry about the risk of the adverse event was greater in the high compared to the low involvement condition (6.1 ± 3.7 versus 5.5 ± 3.8, p<0.001).
Conclusions:
Increasing patient responsibility in medical decision making may decrease patients' willingness to accept risky treatment options.
doi:10.1002/art.24947
PMCID: PMC2794915  PMID: 19950320
8.  Moral Controversy, Directive Counsel, and the Doctor’s Role: Findings From a National Survey of Obstetrician–Gynecologists 
Purpose
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.
Method
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.”
Results
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.
Conclusions
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.
doi:10.1097/ACM.0b013e3181eabacc
PMCID: PMC3634119  PMID: 20736675
9.  Installation and Function of COSTAR in a Canadian Doctor's Office 
Canadian Family Physician  1987;33:311-314.
Recently there has been a marked increase in interest in automating the medical office. This paper outlines the steps taken to install COSTAR in a multidisciplinary ambulatory clinic with a wide base of primary-care physicians. Emphasis is placed on the reasons for computerization of the clinic. The registration of patients, scheduling of appointments, billing applications, and the medical record aspects are outlined. The author discusses the reports that can be prepared using Medical Query Language and the electronic transfer of information among the Seymour Clinic, an outside laboratory, and local hospitals.
PMCID: PMC2218350
medical office automation; COSTAR; medical infomatics
10.  Examining Cross-Source Engagement With Cancer-Related Information and Its Impact on Doctor–Patient Relations 
Health communication  2009;24(8):723-734.
Patients may bring unreliable information to the physician, complicating the physician–patient relationship, or outside information seeking may complement physician information provision, reinforcing patients’ responsibility for their health. The current descriptive evidence base is weak and focuses primarily on the Internet's effects on physician–patient relations. This study describes how cancer patients bring information to their physicians from a range of sources and are referred by physicians to these sources; the study also examines explanations for these behaviors. Patients with breast, prostate, and colon cancer diagnosed in 2005 (N = 1,594) were randomly drawn from the Pennsylvania Cancer Registry; participants returned mail surveys in Fall 2006 (response rate = 64%). There is evidence that both bringing information to physicians and being referred to other sources reflects patients’ engagement with health information, preference for control in medical decision making, and seeking and scanning for cancer-related information. There is also evidence that patients who bring information from a source are referred back to that source.
doi:10.1080/10410230903264030
PMCID: PMC2950967  PMID: 20183381
11.  Understanding How Out-of-Pocket Expenses, Treatment Value, and Patient Characteristics Influence Treatment Choices 
The Oncologist  2010;15(6):566-576.
The study used a convenience sample of patients undergoing surveillance following curative treatment for localized cancer who completed a paper survey to estimate the maximum copayment patients are willing to pay for better treatment outcomes. Results suggest that patients may be less willing to pay high copayments for treatments with modest benefit. In addition, sociodemographic factors such as education and employment status were associated with willingness to pay.
Purpose.
Cost sharing, intended to control the “overuse” of health care resources, may also reduce use of necessary services. The influence of cost on the treatment choices of patients with life-threatening illness, such as cancer, is unknown.
Methods.
A convenience sample of patients undergoing surveillance following curative treatment for localized cancer completed a paper survey that included three scenarios to elicit the maximum copayment they would be willing to pay for better treatment outcomes. Scenario A described a treatment for a curable cancer in terms of recurrence risk. Scenarios B and C described treatments for noncurable cancer in terms of the 2-year survival probability and median life expectancy.
Results.
The sample (n = 60) was 78% female, 83% aged <65 years, and 58% college graduates. Thirteen percent reported making financial sacrifices to pay for treatment. Patients were willing to pay higher copayments for more effective treatments (p < .05 for all three scenarios). In scenario B, patients who were employed demonstrated a greater willingness to pay (WTP) (odds ratio [OR], 12.6; 95% confidence interval [CI], 2.0–80.4), when controlling for efficacy. In scenario C, college graduates showed greater WTP (OR, 5.0; 95% CI, 1.2–20.9) and patients who reported previous financial sacrifices showed lower WTP (OR, 0.2; 95% CI, 0.04–0.6).
Conclusion.
This pilot study suggests that patients may be less willing to pay high copayments for treatments with modest benefit. Even among this relatively young, affluent, and educated population, demographic variables were related to WTP. Larger studies in more diverse populations should be conducted to better understand how cost may influence treatment decisions and cancer treatment outcomes.
doi:10.1634/theoncologist.2009-0307
PMCID: PMC2892556  PMID: 20495218
12.  Ineffective disability management by doctors is an obstacle for return-to-work: a cohort study on low back pain patients sicklisted for 3–4 months 
Aims: To determine obstacles for return-to-work in disability management of low back pain patients sicklisted for 3–4 months.
Methods: A cohort of 467 low back pain patients sicklisted for 3–4 months was recruited. A questionnaire was sent to their occupational physicians (OPs) concerning the medical management, obstacles to return-to-work, and the communication with treating physicians.
Results: The OPs of 300 of 467 patients participated in this study. In many cases OPs regarded the clinical waiting period (43%), duration of treatment (41%), and view (25%) of the treating physicians as obstacles for return-to-work. Psychosocial obstacles for return-to-work such as mental blocks, a lack of job motivation, personal problems, and conflicts at work were all mentioned much less frequently by OPs. In only 19% of the patients was there communication between OP and treating physician. Communication almost always entailed an exchange of information, and less frequently an attempt to harmonise the management policy. Surprisingly communication was also limited, when OPs felt that the waiting period (32%), duration of treatment (30%), and view (28%) of treating physicians inhibited return-to-work. Communication was significantly associated with the following obstacles for return-to-work: passivity with regard to return-to-work and clinical waiting period; adjusted odds ratios were 3.35 and 2.23, respectively.
Conclusions: Medical management of treating physicians is often an obstacle for return to work regarding low back pain patients sicklisted for 3–4 months, in the opinion of OPs. Nevertheless communication between OPs and the treating physicians in disability management of these patients is limited. More attention to prevention of absenteeism and bilateral communication is needed in medical courses.
doi:10.1136/oem.59.11.729
PMCID: PMC1740234  PMID: 12409530
13.  Inviting Patients to Read Their Doctors’ Notes: A Quasi-experimental Study and a Look Ahead 
Annals of internal medicine  2012;157(7):461-470.
Background
Little information exists about what primary care physicians (PCPs) and patients experience if patients are invited to read their doctors’ office notes.
Objective
To evaluate the effect on doctors and patients of facilitating patient access to visit notes over secure Internet portals.
Design
Quasi-experimental trial of PCPs and patient volunteers in a year-long program that provided patients with electronic links to their doctors’ notes.
Setting
Primary care practices at Beth Israel Deaconess Medical Center (BIDMC) in Massachusetts, Geisinger Health System (GHS) in Pennsylvania, and Harborview Medical Center (HMC) in Washington.
Participants
105 PCPs and 13 564 of their patients who had at least 1 completed note available during the intervention period.
Measurements
Portal use and electronic messaging by patients and surveys focusing on participants’ perceptions of behaviors, benefits, and negative consequences.
Results
11 797 of 13 564 patients with visit notes available opened at least 1 note (84% at BIDMC, 92% at GHS, and 47% at HMC). Of 5391 patients who opened at least 1 note and completed a postintervention survey, 77% to 87% across the 3 sites reported that open notes helped them feel more in control of their care; 60% to 78% of those taking medications reported increased medication adherence; 26% to 36% had privacy concerns; 1% to 8% reported that the notes caused confusion, worry, or offense; and 20% to 42% reported sharing notes with others. The volume of electronic messages from patients did not change. After the intervention, few doctors reported longer visits (0% to 5%) or more time addressing patients’ questions outside of visits (0% to 8%), with practice size having little effect; 3% to 36% of doctors reported changing documentation content; and 0% to 21% reported taking more time writing notes. Looking ahead, 59% to 62% of patients believed that they should be able to add comments to a doctor’s note. One out of 3 patients believed that they should be able to approve the notes’ contents, but 85% to 96% of doctors did not agree. At the end of the experimental period, 99% of patients wanted open notes to continue and no doctor elected to stop.
Limitations
Only 3 geographic areas were represented, and most participants were experienced in using portals. Doctors volunteering to participate and patients using portals and completing surveys may tend to offer favorable feedback, and the response rate of the patient surveys (41%) may further limit generalizability.
Conclusion
Patients accessed visit notes frequently, a large majority reported clinically relevant benefits and minimal concerns, and virtually all patients wanted the practice to continue. With doctors experiencing no more than a modest effect on their work lives, open notes seem worthy of widespread adoption.
Primary Funding Source
The Robert Wood Johnson Foundation, the Drane Family Fund, the Richard and Florence Koplow Charitable Foundation, and the National Cancer Institute.
doi:10.7326/0003-4819-157-7-201210020-00002
PMCID: PMC3908866  PMID: 23027317
14.  Identifying a Proxy for Health Care as Part of Routine Medical Inquiry 
Journal of General Internal Medicine  2006;21(11):1188-1191.
BACKGROUND
Physician-initiated advance care planning is desirable, effective, and routinely indicated for competent adult patients, but doctors are often reluctant to begin the necessary conversations.
OBJECTIVE
To determine whether patients are willing and able to designate a surrogate for medical decision making, when asked to do so as part of routine medical inquiry.
DESIGN, PATIENTS, MEASUREMENTS
A survey asking patients to name a health care agent was designed and administered in the context of routine clinical care. Participants were drawn from a consecutive sample of 309 competent adult outpatients. Data were analyzed using ordinary descriptive statistics.
RESULTS
Two hundred ninety-eight of 309 patients (response rate, 96%) completed the survey and were willing and able to specify a proxy for health care. One third of married participants did not choose their spouse as proxy.
CONCLUSIONS
Asking patients to identify a surrogate for medical decision making opens the door for ongoing individualized medical care planning in the context of ordinary patient-physician interaction. This approach is applicable to all competent adults. Documenting proxy choice protects a patient's wishes and preferences until more definitive planning is accomplished.
doi:10.1111/j.1525-1497.2006.00570.x
PMCID: PMC1831656  PMID: 16879418
proxy; advance care planning; advance directives; decision making; physician-patient relations
15.  How easy is it to contact the duty medical doctor responsible for acute admissions? 
BMJ : British Medical Journal  1990;301(6751):529-531.
OBJECTIVE--To ascertain ease or difficulty of contacting duty junior doctors responsible for acute medical admissions by telephone. DESIGN--Telephone survey of hospitals in six health regions in England and Wales. SETTING--70 Randomly selected hospitals, 15 of which were excluded because of non-acceptance of acute medical admissions. PARTICIPANTS--71 Duty doctors (duty house physicians, senior house officers, or registrars responsible for acute medical admissions) in 48 hospitals; seven duty doctors in seven hospitals were excluded (four declined to participate and three required a written explanation of the survey). 67 Doctors gave full information to all questions. MAIN OUTCOME MEASURES--Time taken for hospital switchboards and duty doctors to reply to telephone call, diagnoses of patients recently admitted, and on call rotas and hours of sleep of duty doctors. RESULTS--Hospital switchboards responded within 30 seconds in 87 (74%) calls, and in 76 calls (64%) the duty doctor requested was contacted within a further two minutes. Chest pain, possibly due to myocardial infarction, was the most common reason for acute medical admissions. Nearly half (48%) of the duty doctors in larger hospitals reported having 4-5 hours sleep or less on their nights on call. Most (30) were on a one in three rota; two were on a one in two rota. CONCLUSIONS--Despite impressions to the contrary contacting the duty medical team by telephone seemed fairly easy. Although most junior doctors were on a rota of one in three or better, insufficient recognition may be given to their deprivation of sleep during nights on duty.
PMCID: PMC1663802  PMID: 2207424
16.  “Patient-Time,” “Doctor-Time,” and “Institution-Time”: Perceptions and Definitions of Time Among Doctors Who Become Patients 
Patient education and counseling  2006;66(2):147-155.
Objective
To examine views and experiences of conflicts concerning time in healthcare, from the perspective of physicians who have become patients.
Methods
We conducted two in-depth semi-structured two-hour interviews concerning experiences of being health care workers, and becoming a patient, with each of 50 doctors who had serious illnesses.
Results
These doctor-patients often came to realize as they had not before how patients experience time differently, and how “patient-time,” “doctor-time,” and “institution-time” exist and can conflict. Differences arose in both long and short term, regarding historical time (prior eras/decades in medicine), prognosis (months/years), scheduling delays (days/weeks), daily medical events and tasks (hours), and periods in waiting rooms (minutes/hours). Definitions of periods of time (e.g., “fast,” “slow,” “plenty,” and “soon”) also varied widely, and could clash. Professional socialization had heretofore impeded awareness of these differences. Physicians tried to address these conflicts in several ways (e.g., trying to provide test results promptly), though full resolution remained difficult.
Conclusions
Doctors who became patients often now realized how physicians and patients differ in subjective experiences of time. Medical education and research have not adequately considered these issues, which can affect patient satisfaction, doctor-patient relationships and communication, and care.
Practice Implications
Physicians need to be more sensitive to how their definitions, perceptions, and experiences concerning time can differ from those of patients.
doi:10.1016/j.pec.2006.10.005
PMCID: PMC2950119  PMID: 17125956
Doctor-patient relationships; doctor-patient communication; medical education; patient satisfaction; medical ethics; medical socialization; health care delivery
17.  Use of Prescription Drug Samples and Patient Assistance Programs, and the Role of Doctor–Patient Communication 
Journal of General Internal Medicine  2011;26(12):1458-1464.
BACKGROUND
Cost-related underuse of medications is common among older adults, who seldom discuss medication costs with their physicians. Some older adults may use free drug samples or industry-sponsored patient assistance programs (PAP) in hopes of lowering out-of-pocket costs, although the long-term effect of these programs on drug spending is unclear.
OBJECTIVE
To examine older adults’ use of industry-sponsored strategies to reduce out-of-pocket drug costs and the association between doctor–patient communication and use of these programs.
DESIGN
Cross-sectional analysis of a 2006 nationally representative survey of Medicare beneficiaries.
PARTICIPANTS
14,322 community-dwelling Medicare beneficiaries age ≥65.
MAIN MEASURES
We conducted bivariate and multivariate analyses of the association between receipt of free samples and participation in PAPs with sociodemographic characteristics, health status, access to care, drug coverage, medication cost burden, and doctor–patient communication.
KEY RESULTS
51.4% of seniors reported receiving at least one free sample over the last 12 months and 29.2% reported receiving free samples more than once. In contrast, only 1.3% of seniors reported participating in an industry-sponsored PAP. Higher income respondents were more likely to report free sample receipt than low-income respondents (50.8% vs. 43.8%, p < 0.001) and less likely to report participating in a PAP (0.42% vs. 2.2%, p < 0.001). In multivariate analyses, those who reported talking to their doctor about the cost of their medications had more than twice the odds of receiving samples as those who did not (OR 2.17, 95% CI 1.95–2.42).
CONCLUSIONS
In 2006, over half of seniors in Medicare received free samples, but only 1.3% reported receiving any medications from a patient assistance program. Doctor–patient communication is strongly associated with use of these programs, which has important implications for clinical care regardless of whether these programs are viewed as drivers of prescription costs or a remedy for them.
doi:10.1007/s11606-011-1801-y
PMCID: PMC3235606  PMID: 21751052
free drug samples; prescription assistance programs; Medicare; physician–patient communication
18.  The "Medicine in Australia: Balancing Employment and Life (MABEL)" longitudinal survey - Protocol and baseline data for a prospective cohort study of Australian doctors' workforce participation 
Background
While there is considerable research on medical workforce supply trends, there is little research examining the determinants of labour supply decisions for the medical workforce. The "Medicine in Australia: Balancing Employment and Life (MABEL)" study investigates workforce participation patterns and their determinants using a longitudinal survey of Australian doctors. It aims to generate evidence to support developing effective policy responses to workforce issues such as shortages and maldistribution. This paper describes the study protocol and baseline cohort, including an analysis of response rates and response bias.
Methods/Design
MABEL is a prospective cohort study. All Australian doctors undertaking clinical work in 2008 (n = 54,750) were invited to participate, and annual waves of data collections will be undertaken until at least 2011. Data are collected by paper or optional online version of a questionnaire, with content tailored to four sub-groups of clinicians: general practitioners, specialists, specialists in training, and hospital non-specialists. In the baseline wave, data were collected on: job satisfaction, attitudes to work and intentions to quit or change hours worked; a discrete choice experiment examining preferences and trade-offs for different types of jobs; work setting; workload; finances; geographic location; demographics; and family circumstances.
Discussion
The baseline cohort includes 10,498 Australian doctors, representing an overall response rate of 19.36%. This includes 3,906 general practitioners, 4,596 specialists, 1,072 specialists in training, and 924 hospital non-specialists. Respondents were more likely to be younger, female, and to come from non-metropolitan areas, the latter partly reflecting the effect of a financial incentive on response for doctors in remote and rural areas. Specialists and specialists in training were more likely to respond, whilst hospital non-specialists were less likely to respond. The distribution of hours worked was similar between respondents and data from national medical labour force statistics. The MABEL survey provides a large, representative cohort of Australian doctors. It enables investigation of the determinants of doctors' decisions about how much, where and in what circumstances they practice, and of changes in these over time. MABEL is intended to provide an important resource for policy makers and other stakeholders in the Australian medical workforce.
doi:10.1186/1472-6963-10-50
PMCID: PMC2837653  PMID: 20181288
19.  The Doctor–Patient Relationship and HIV-infected Patients' Satisfaction with Primary Care Physicians 
OBJECTIVE
To assess the extent to which perceptions of specific aspects of the doctor–patient relationship are related to overall satisfaction with primary care physicians among HIV-infected patients.
DESIGN
Longitudinal, observational study of HIV-infected persons new to primary HIV care. Data were collected at enrollment and approximately 6 months later by in-person interview.
SETTING
Two urban medical centers in the northeastern United States.
PARTICIPANTS
Patients seeking primary HIV care for the first time.
MEASUREMENTS AND MAIN RESULTS
The primary outcome measure was patient-reported satisfaction with a primary care physician measured 6 months after initiating primary HIV care. Patients who were more comfortable discussing personal issues with their physicians (P = .021), who perceived their primary care physicians as more empathetic (P = .001), and who perceived their primary care physicians as more knowledgeable with respect to HIV (P = .002) were significantly more satisfied with their primary care physicians, adjusted for characteristics of the patient and characteristics of primary care. Collectively, specific aspects of the doctor–patient relationship explained 56% of the variation in overall satisfaction with the primary care physician.
CONCLUSIONS
Patients' perceptions of their primary care physician's HIV knowledge and empathy were highly related to their satisfaction with this physician. Satisfaction among HIV-infected patients was not associated with patients' sociodemographic characteristics, HIV risk characteristics, alcohol and drug use, health status, quality of life, or concordant patient-physician gender and racial matching.
doi:10.1046/j.1525-1497.2000.03359.x
PMCID: PMC1495486  PMID: 10940132
HIV; satisfaction; doctor–patient relationship
20.  Frequent users of ambulatory health care in Quebec: the case of doctor-shoppers. 
OBJECTIVE: To examine the patterns of use of ambulatory care in Quebec in 1991, with special emphasis on patients who received care from more than 20 physicians. DESIGN: Retrospective study of population-based data. SETTING: Province of Quebec. PARTICIPANTS: All 7,154,591 people eligible for coverage under the Régie de l'assurance-maladie du Québec (RAMQ) (Quebec Health Insurance Plan) in 1991, including 3639 people who received ambulatory care from more than 20 physicians. DATA EXTRACTION: The databanks of the RAMQ. OUTCOME MEASURES: Mean number (and standard deviation) of physician visits and services received, place of visit (clinic or private office), mean cost of services, patient's age, diagnosis, type of specialist visited and social assistance status of frequent users. RESULTS: The patients who obtained ambulatory care from more than 20 physicians received 10 times more medical services than the overall patient population (59.6 v. 5.8), and the mean cost per patient for ambulatory care was also 10 times higher ($1379 v. $136). Almost all of the frequent users visited at least one outpatient clinic, as compared with 37.3% of the overall population. A higher proportion of the frequent users than of the overall population obtained care from specialists (98.9% v. 54.7%), mainly general surgeons and psychiatrists. The most frequent diagnoses among the frequent users were anxiety (36.0%), abdominal pain (24.3%), drug or alcohol dependence (22.2%) and depression (16.4%). CONCLUSIONS: A small proportion of the population obtained ambulatory care from a high number of physicians during the year, leading to high expenses. Identifying and understanding this type of frequent user may be useful in developing strategies to promote more effective health-care-seeking behaviours and reduce overuse.
PMCID: PMC1337939  PMID: 7796374
21.  PAMFOnline: Integrating EHealth with an Electronic Medical Record System 
The Institute of Medicine stressed the need for continuous healing relationships, yet the delivery of health care has traditionally been confined to the physician office or hospital. We implemented an eHealth application tightly integrated with our electronic medical record system that provides patients with a convenient, continuously available communication channel to their physician’s office. Patients can view summary data from their medical record, including the results of diagnostic tests, and request medical advice, prescription renewals, appointments, or updates to their demographic information. We have found that patients embrace this new communication channel and are using the service appropriately. Patients especially value electronic messaging with their physicians and timely access to their test results. While initially concerned about an increase in work, physicians have found that use of electronic messaging can be an efficient method for handling non-urgent communication with their patients. Online tools for patients, when integrated with an electronic medical record, can provide patients with better access to health information, improve patient satisfaction, and improve operational efficiency.
PMCID: PMC1479999  PMID: 14728252
22.  Advanced access appointments 
Canadian Family Physician  2010;56(10):e361-e367.
ABSTRACT
OBJECTIVE
To examine the effects of advanced access (same-day physician appointments) on patient and provider satisfaction and to determine its association with other variables such as physician income and patient emergency department use.
DESIGN
Patient satisfaction survey and semistructured interviews with physicians and support staff; analysis of physician medical insurance billings and patient emergency department visits.
SETTING
Cape Breton, NS.
PARTICIPANTS
Patients, physicians, and support staff of 3 comparable family physician practices that had not implemented advanced access and an established advanced access practice.
MAIN OUTCOME MEASURES
Self-reported provider and patient satisfaction, physician office income, and patients’ emergency department use.
RESULTS
The key benefits of implementation of advanced access were an increase in provider and patient satisfaction levels, same or greater physician office income, and fewer less urgent (triage level 4) and nonurgent (triage level 5) emergency department visits by patients.
CONCLUSION
Currently within the Central Cape Breton Region, 33% of patients wait 4 or more days for urgent appointments. Findings from this study can be used to enhance primary care physician practice redesign. This research supports many benefits of transitioning to an advanced access model of patient booking.
PMCID: PMC2954100  PMID: 20944024
23.  Do Patient Preferences Contribute to Racial Differences in Cardiovascular Procedure Use? 
OBJECTIVE
To determine whether patient preferences for the use of coronary revascularization procedures differ between white and black Americans.
DESIGN
Cross-sectional survey.
SETTING
Tertiary care Department of Veterans Affairs hospital.
PATIENTS
Outpatients with and without known coronary artery disease were interviewed while awaiting appointments (n = 272). Inpatients awaiting catheterization were approached the day before the scheduled procedure (n = 80). Overall, 118 blacks and 234 whites were included in the study.
MEASUREMENTS AND MAIN RESULTS
Patient responses to questions regarding (1) willingness to undergo angioplasty or coronary artery bypass surgery if recommended by their physician and (2) whether they would elect bypass surgery if they were in either of two hypothetical scenarios, one in which bypass surgery would improve symptoms but not survival and one in which it would improve both symptoms and survival. Blacks were less likely to say they would undergo revascularization procedures than whites. However, questions dealing with familiarity with the procedure were much stronger predictors of a positive attitude toward procedure use. Patients who were not working or over 65 years of age were also less interested in procedure use. In multivariable analysis race was not a significant predictor of attitudes toward revascularization except for angioplasty recommended by their physician.
CONCLUSIONS
Racial differences in revascularization rates may be due in part to differences in patient preferences. However, preferences were more closely related to questions assessing various aspects of familiarity with the procedure. Patients of all races may benefit from improved communication regarding proposed revascularization. Further research should address this issue in patients contemplating actual revascularization.
doi:10.1046/j.1525-1497.1997.012005267.x
PMCID: PMC1497106  PMID: 9159695
race; coronary artery bypass graft surgery; doctor-patient relationship; percutaneous transluminal coronary angioplasty; survey
24.  Health care professionals' willingness to do mouth-to-mouth resuscitation. 
Western Journal of Medicine  1997;167(6):392-397.
To assess the willingness of physicians and nurses with training in basic cardiac life support to provide mouth-to-mouth resuscitation in both hospital and out-of-hospital settings, we surveyed all attendees at a monthly advanced life support course over a 1-year period. Of 622 attendees, 379 (61%) responded to our survey describing a variety of cardiac arrest scenarios. Less than half of the participants surveyed were willing to do mouth-to-mouth resuscitation on an unknown adult, male or female, who had collapsed in a supermarket. Overall, the group was willing to do mouth-to-mouth resuscitation on victims known to them: their neighbors (84%), children at a pool (88%), spouses (94%), and parents (93%). In the hospital setting, knowing a patient's human immunodeficiency virus (HIV) status greatly influenced the willingness to do mouth-to-mouth rescue. If a patient's HIV status was unknown, only a third of providers would do mouth-to-mouth resuscitation; if the HIV status was known to be negative, two thirds would do mouth-to-mouth resuscitation (P < 0.002), Children in the hospital whose HIV status was unknown would receive mouth-to-mouth resuscitation by 57% of the respondents. Children known to be HIV-negative would be resuscitated by 79% of the respondents. Co-workers were more willing to resuscitate a known physician or nurse than an unknown co-worker, with physicians more willing than nurses to do mouth-to-mouth resuscitation on an unknown co-worker. A third of the group has performed mouth-to-mouth resuscitation previously. Although an increased percentage of this subgroup was willing to provide mouth-to-mouth in all adult hospital scenarios, experienced providers of mouth-to-mouth wanted to receive mouth-to-mouth resuscitation less frequently (75%) than inexperienced providers (84%) (P = 0.02). The self-reported willingness to provide mouth-to-mouth resuscitation is influenced by patient characteristics; as the level of familiarity with the victim decreased, so did the willingness of the health care professional to do mouth-to-mouth.
PMCID: PMC1304717  PMID: 9426477
25.  Doctor-Patient Communication on the Telephone 
Canadian Family Physician  1989;35:123-128.
Since its invention, the telephone has been an important tool in medical practice, particularly for primary care physicians. Approximately half the calls made to a physician's office during regular consulting hours are for clinical problems and most are handled effectively over the phone without an immediate office visit. Telephone encounters are generally very brief, and managing such calls requires a pragmatic approach that is often quite different from the approach taken in the office visit. The telephone encounter should be recognized and recorded as a specific medical interaction in the medical chart for both clinical and legal reasons. Effective telephone encounters depend on good communication skills; decision making regarding disposition is a major goal. The physician's perception of a medical problem may be different from the patient's; patients are frequently seeking advice and reassurance rather than diagnosis and treatment, and may call because of anxiety and psychological stress. For physicians and their families who are not prepared for after-hours telephone encounters, calls that interrupt more “legitimate” activities may result in anger or frustration for the physician and dissatisfaction for the patient.
PMCID: PMC2280438  PMID: 21253275
telephone encounters; primary care physicians; patient management

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