Straight talk. Doctor-driven systems tell how they've gained physician allies

Convincing physicians to join integrated health care networks often requires them to make a real leap of faith. But such conversions are becoming necessary in the currently evolving health care market. Success, say physician leaders who have achieved it, comes out of working out both compensation and trust issues to the mutual satisfaction of all parties involved.     

Gallstones and isoflurane hepatitis

OBJECTIVES: To assess the level of satisfaction of physicians in provincial psychiatric hospitals with Review Boards (RBs) regarding Civil Commitment Certificates (CCCs), Certificates of Incompetence (COIs), and Treatment Orders (TOs). METHOD: A total of 200 survey questionnaires were distributed to physicians in provincial psychiatric hospitals. Ninety surveys (completed by 25 females, 45 males, and 20 unknown gender) were returned, representing a 45% return rate. Because of their assignments (for example, outpatient department), not all physicians were involved with RBs, and the return rate is likely to have been influenced by this factor. RESULTS: Physician satisfaction rates of 58.2% for CCCs, 66.7% for COIs, and 70.0% for TOs were obtained. Stepwise multiple regression analysis showed that the level of physician satisfaction with RBs for CCCs was predicted best (44.7% of variance) by physician level of comfort with certification and years of institutional affiliation. Qualitative physician responses revealed 3 major themes: patient-related issues, physician-related issues, and RB structure- and process-related issues. CONCLUSIONS: Strategies that increase physician comfort level with RBs and changes in the medicolegal structure and process are discussed. A similar survey of patients and RB members is recommended.     

Using health status surveys in medical consultations

The goal of this research was to identify patients' preferences for physician inquiry into various aspects of health status and to examine whether the preconsultation availability of health status data (collected from the SF-36 Health Status Questionnaire) influenced the physician's conduct during the consultation. Results from 58 prenatal patient visits yielded the following findings. First, patients expressed strong preferences for physicians to ask about the patient's perceptions of health in general and about physical dimensions of health status such as pain, vitality, and role limitations due to physical functioning. Patients also were more satisfied when doctors were perceived as having asked about these issues. Second, patients varied considerably in their preferences for physician inquiries into psychosocial issues such as social functioning, mental health, and role limitations due to emotional problems. Approximately half the patients wanted these matters discussed, whereas the remainder either did not care or preferred that doctors not ask about these topics. Third, the preconsultation availability of health status information had little effect on the degree to which physicians asked about the patient's health-related quality of life. Clinical implications are discussed.     

Health care research and policy studies

Health economic studies in rheumatology have never been of greater policy importance, but unfortunately there are only a small number of researchers examining issues in this area. This paper reviews studies relating to economics and rheumatology as well as some important methodologic issues relating to conducting such studies. The topics covered include cost-identification analysis, physician variation, specialty versus subspecialty care, utility assessment, decision analysis, quality of life, time preferences and discounting, and sensitivity analysis. More than ever, now is the time to provide policy makers with evidence that rheumatologists provide medical care that is not only the finest from a medical perspective but the most cost effective from society's perspective.     

Foot asymmetry in healthy adults: elliptic fourier analysis of standardized footprints

Issues regarding the deaths of patients in the ED arise on a regular basis for emergency physicians. These issues include physician discomfort with death notification, the approach to families after ED deaths, autopsies, donation of organs and tissues, and procedures on the newly dead. If physicians were more comfortable with death notification, not only would families be better served but benefits to society could be realized through the increased use of autopsy and organ/tissue donation. The controversial topic of physician education through practice of medical procedures on the newly dead weighs the benefits to society against the rights of the individual. Improved physician education, including the need for a death notification plan and enlistment of the support of nursing personnel, social workers, and clergy, may improve the experience of events surrounding ED deaths for physicians, families, and society. We review the literature and give recommendations on approaches to deal with these issues.     

The emotional aftermath of adoption

Adopted children are emotionally vulnerable. Adoptive parents must cope with more complex problems than biologic parents. The family physician can provide valuable counseling. Preadoption counseling focuses on motivation and ambivalence. After adoption, however, serious, sometimes predictable, issues arise, such as: how and when to tell the child he is adopted; the child's search for knowledge; the problem of subsequent divorce; the birth of a natural sibling, and the involvement of other family members. New concepts include "open adoption" and "single parent adoption."     

Care of the renal transplant recipient: a field guide for the generalist

More than 60,000 kidney transplant recipients currently live in the United States. It is not uncommon for these persons to receive medical care through a primary care physician. The widely held belief that only physicians and surgeons with "special knowledge" can care for these patients is clearly not the case. In addition to considering the immediate posttransplantation problems, this section attempts to demystify the care of kidney transplant recipients beyond the first few months of recovery after surgery. It also serves as a guide to help determine which problems can be handled by a primary care physician and which indicate referral back to the transplant center. Common infectious problems, both bacterial and viral, are discussed. This section also considers metabolic abnormalities such as hypertension, increased lipids, gout, calcium/bone diseases, and hematologic issues. Common conditions that cause real or perceived decreases in function but are not related to graft rejection are also explained.     

Inhibition of TNFalpha attenuates infarct volume and ICAM-1 expression in ischemic mouse brain

The family physician occupies a front-line position in the detection and treatment of emotional problems and psychiatric illnesses. The practice pattern of the family physician necessitates an efficient, effective model of psychotherapy The BATHE technique is a brief psychotherapeutic method that addresses the patient's background issues, affect and most troubling problem. The emphasis of the interview then shifts to how the patient is handling the problem and a demonstration of empathy by the physician. Some of the challenges in psychotherapy are presented, and cases in which the BATHE technique was used are described.     

Health and environment. Between certainty and uncertainty, the emergence of environmental medicine

The evaluation of environmental risks for the human health implies a complex process where a great number of parameters has to be considered. The complexity and the multiplicity of the problem brings on many uncertainties. However several leads exist to guide our reflection with more assurance. Toxicology, ecotoxicoly, occupational medicine, analyse of ecological disasters, epidemiological studies on environmental health issues are such elements the physician can refer to when confronted with a environmental health problem. In looking for solutions, it will be necessary to search and deal with other competences from social life and economics and to take technical feasibility as well as architectural reality and urban development policy into account.     

Legal issues for nurse managers

In addition to their leadership responsibilities, nurse managers must have a solid understanding of current legal trends as they relate to patient care and staff. An overview is given on links between morality, ethics, and law; legal issues related to patient falls, documentation and physician communication; and legal issues related to managing of human resources.     

Psychosocial aspects of hand injuries and diseases

More than 50% of patients with a diagnosable psychiatric disorder initially present with somatic symptoms, which often effectively distract the physician from the true illness. Moreover, the occupational setting is ripe for the emergence of psychosocial issues.     

Practice guidelines for community-based parenteral anti-infective therapy

Practice guidelines for community-based parenteral anti-infective therapy (CoPAT) have recently been formulated in several countries. These guidelines emphasize the importance of teamwork and the interdisciplinary nature of CoPAT, and they use similar criteria for patient selection and evaluation, anti-infective agent selection and administration, and clinical monitoring. There are now guidelines or standards addressing the roles and responsibilities of the physician, nurse, and pharmacist in the delivery of CoPAT, and home care standards that address issues such as drug storage and preparation, treatment planning, and monitoring of ongoing care.     

Treatment of progressive metastatic prostate cancer

The optimal therapy for metastatic prostate cancer that has failed initial hormonal therapy poses a significant dilemma for the attending physician. No salvage therapy has proven to be clearly superior. Currently accepted treatment options range from supportive care alone to highly investigational regimens. Recent encouraging results have been reported with investigational agents such as suramin and R. 75251 (Liarozole), and with novel combinations such as estramustine (Emcyt) plus vinblastine. However, there is still no proof that salvage therapy prolongs survival. In a patient population that is older and frequently debilitated, with an expected median survival of 6 months, determinants of therapy should include drug toxicity profiles, frequency of treatment and follow-up studies, and necessity for hospitalization. For patients with good performance status and organ function, participation in clinical trials should be advocated. Quality-of-life issues should be integrated into all clinical trials involving hormone-refractory metastatic prostate cancer.     

Teaching negotiating skills in the family medicine center

Teaching residents how to come to terms with their patients over issues such as "what is wrong" and "what needs to be done" is one of the daily challenges of precepting in family medicine. Difficulties inherent in any two-person negotiation are discussed and related specifically to the physician-patient relationship. A methodology for teaching negotiating skills is suggested. The method involves the preceptor asking the resident a number of questions that mimic a successfully negotiated physician-patient interaction. The technique allows the preceptor to identify weaknesses in the resident's abilities at the negotiating process and exposes the resident to statements that make for successful negotiating between physician and patient. Examples of weaknesses in residents' negotiating styles are described and specific recommendations for preceptors are provided.     

Legal issues surrounding privately funded research cause furore in Toronto

Toronto physician Miriam Shuchman has spent the last 4 months tracking the research issues surrounding a controversial clinical trial conducted in Toronto. Much of the information appearing in this article was gathered while she was preparing a segment for the CBC Radio program Quirks and Quarks. Earlier, she had reported on similar issues in the US for the Annals of Internal Medicine.     

Aims and objectives of medical training at the University of Valparaíso

The Medical School of the University of Valparaíso was founded thirty years ago aiming to produce a physician considering the health needs of the population and with a solid humanitarian training. The epidemiological, demographic and scientific changes of the last decades prompted the introduction of modifications in the curriculum such as using problem oriented active learning, incorporation of new subjects such as geriatrics, labour medicine and trauma and training in communication skills. The curricular mesh will be modified to allow an efficient vertical integration of educational contents, which will be delivered sequentially during the different years of the career. The internship, as a crucial part of the career, has incorporated outpatient clinical practice, has emphasized preventive medicine and has stimulated active learning through research projects and active reviews of specific issues. These changes will require cultural changes of professors and students and more resources that are difficult to obtain.     

Grass roots participation in health care reform

Concerned citizens have responded to the health care crisis by developing the health decisions movement. American Health Decisions, a national consortium of 21 state organizations, leads a grass roots discussion network of community meetings committed to education and consensus on the ethical, technologic, legal, and economic issues (the tough issues) of health policy. The movement (with its stages of development, structure, process, and accomplishments) is described, and potential roles for physician cooperation and participation in forging functional, community-based health policy are delineated.     

Completing advance directives for health care decisions: Getting to yes.

The concept of advance directives for health care decision making has been judicially condoned, legislatively promoted, and systematically implemented by health care institutions, yet the execution rate of advance directives remains low. Physicians should discuss with their patients advance care planning generally and end-of-life issues specifically, preferably when patients are in good health and not when they face an acute medical crisis. The physician–hospital relationship poses particular challenges for the optimal implementation of advance directives that must be addressed. Hospital administrators must improve education of patients and physicians on the value of such documents as well as internal mechanisms to ensure better implementation of directives. Health insurance plans may be better able to ensure optimal gathering and implementation of directives. Patients must become more familiar and more comfortable with advance care planning and the reality of death and dying issues. Full acceptance of the value of directives ultimately rests on achieving full participation of all involved—providers, patients, families, and payors—in this most profound process. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Hepatocyte growth factor and fibroblast growth factor 2 are overexpressed after cerulein-induced acute pancreatitis

Competency assessments are a growing function of the consultation-liaison (C-L) psychiatrist. Such consultation requests often mask a variety of psychosocial issues that are a source of frustration to the referring physician responding to the pressures of the changing health care delivery system in the acute care setting. This study identifies the issues and the outcome of psychiatric consultation in these patients. The implications of this burgeoning role for the C-L psychiatrist are also explored.