Decision Making About Method of Delivery on the U.S.–Mexico Border

We explored how low-risk, nulliparous pregnant women and their doctors in two contiguous U.S.–Mexico border communities communicate about methods of delivery and how they perceive that the delivery method decision is made. We recruited 18 women through obstetricians in El Paso, Texas (n = 10), and prenatal care providers in Ciudad Juárez, Mexico (n = 8). We observed prenatal care visits, interviewed women prenatally and postpartum, and interviewed the El Paso obstetricians. Qualitative analysis demonstrated that birthing decisions are complex and involve multiple influences, including women's level of knowledge about birth, doctor–patient communication, and women's participation in decision making.     

健康新理念对建立医患关系互动模式的影响

目的探索健康新理念对医患关系互动模式的影响。方法对97位临床医务人员进行一次性问卷调查,内容包括对健康新理念的认知、医患互动模式现状以及对改善医患关系措施的认同度／可行性认可等。结果95．88％的被调查人员了解健康新理念,但仅45．36％能践行良好的医患关系模式。结论尽管健康新理念已被公认多年,但临床指导医患关系仍显不足,需要大力提倡和引导。     

Anomalous patients: the experiences of doctors with an illness

Variations in the distribution of power have been used to account for and to advocate different types of doctor-patient relationship. It might be expected that doctors who become patients would have a ‘mutual’ relationship with their treating doctor. Data from interviews with doctors with a recent illness show that this is not necessarily the case and may not even be doctors’ preferred model of doctor-patient relationship for themselves when they become ill. Doctors constitute anomalous patients since they confound two categories generally held to be separate, ‘doctor’ and ‘patient’. This affects the type of medical encounter they have, raising issues of identity and role performance for both patient and treating doctor. Doctor/patients may be in control of the encounter (through choice or default); they may consciously choose or have explicitly ascribed to them the status of ‘ordinary patient’; some believe that doctors should be treated as extraordinary patients with particular needs dependent on their insider status as much as their pathology. The negotiation of power in the encounter between doctors and medically qualified patients is problematic but the existence of the power differential in the medical encounter emerges as ‘natural’ and largely as desirable, since it is linked to the ability and authority to take charge of the disorder which illness represents.     

建立以人为本的新型知情同意模式构建和谐医患关系

构建和谐医患关系是构建社会主义和谐社会的重要内容，而医患沟通不够、医患之间缺乏信任和理解等是影响医患关系的重要因素。知情同意是加强医患沟通、增强医患相互信任的重要方式。我们应从生物-心理-社会医学模式的要求出发，通过加强医务人员的医德修养，提高沟通技巧；建立和完善知情同意制度，深化知情同意的内涵；设置和完善心理咨询专科，加强人性化的知情沟通；探索新型知情同意模式；建立和完善医患沟通监督机制和投诉处理制度等．让患者作出更自主、更充分的知情选择，构建和谐的医患关系。     

The role of general practitioners in the initial management of women with urinary incontinence in France,Germany, Spain and the UK

Objective: To describe the role of general practitioners (GPs) in the initial management of women with urinary incontinence (UI) in four European countries with different healthcare systems. Methods: Cross-sectional community postal survey of 2953 women with UI in France, Germany, Spain and the UK. Results: Forty-eight per cent of community-dwelling women with UI had discussed their UI with a doctor. More women discussed UI in France and Germany than in the UK and Spain. The patient usually raised the issue during consultations for some other reason. Fear of or actual deterioration in UI was the most important reason for discussing UI. Overall, 52% of incontinent women first discussed their UI with a GP, and almost a third of women reported having all their UI discussions in a GP setting. Twenty-nine per cent of women reported that GPs had either recommended treatment or monitoring of their condition before beginning treatment, and 24% reported that the GP had referred them to another doctor for evaluation and treatment. Most women in the UK first discussed UI with a GP, whereas in Germany most discussed UI with a specialist. In Spain and France, about half the women first discussed their UI with a GP.

Conclusion: GPs are involved to varying degrees in the initial management of UI in France, Germany, Spain and the UK. Even in countries where women have a choice of whether to see a GP or specialist about UI, many choose to have their first contact with a GP.     

基于医生视角的医患知识转移行为模式研究

医患纠纷频发、医患关系紧张等问题已成为社会热点之一。为了解决当前医患关系紧张,寻找医患间信息不对称、医患知识转移行为不匹配的影响因素,本文从医生与患者两方面出发,通过访谈与问卷调查,研究医生知识转移行为的特点,以及医生与患者对于医患知识转移内容认知标准的差异。最终得出医患知识转移行为模式的研究结论：医患双方对于医患知识转移内容的选择、需求标准存在差异;医生知识转移行为显著低于其转移意愿;并提出了基于患者需求的医患知识转移内容偏好匹配矩阵。     

Benefit efficient statistical distributions on patient lists

In this paper, we consider statistical distributions of different types of patients on the patient lists of doctors. In our framework different types of patients have different preferences regarding their preferred choice of doctor. Assuming that the system is benefit efficient in the sense that distributions with larger total utility have higher probability, we can construct unique probability measures describing the statistical distribution of the different types of patients.     

Patient empowerment in the United States: a critical commentary

Whilst there is no consensus amongst analysts regarding how best to define 'patient empowerment', at the very least, this concept entails a re-distribution of power between patients and physicians. Empowered patients attempt to take charge of their own health and their interactions with health care professionals. Empowerment can occur at different levels (micro, meso, and macro) and patients have different ideas about what it means to 'take charge' and 'be empowered'. Some patients simply want to be given information about their conditions whilst others want to have full control over all medical decision-making. Some empirical evidence suggests that active patient participation in health care is associated with better patient outcomes. This field is ripe for future studies which both help to develop theoretical models of patient empowerment and articulate the conditions under which patient empowerment occurs.     

A survey of traditional medical practices used for the treatment of malignant tumors in an East African population

A group of 119 Tanzanians with cancer were interviewed regarding previous traditional medical experiences prior to evaluation for radiation treatment. Forty-nine (49.1%) percent of the females and 40.6% of the males had been treated with traditional medicines. Seventy-four percent of the traditionally-treated patients had consulted a traditional doctor prior to being seen by a Western-trained doctor. The most common given treatment was a combination of several traditional methods. More than half of all traditionally-treated patients reported progression of their diseases after treatment. Only one patient had any subjective improvement. These patients tended to have less formal education and a lower standard of living than untreated patients. Problems associated with the diagnosis of cancer are addressed.     

"I want more time with my doctor": a quantitative study of time and the consultation

BACKGROUND: Although consultations have increased in length, patients still express dissatisfaction with how much time they spend with their doctor. OBJECTIVES: This study aimed to explore aspects of consultation time and to examine the correlates of patients' desire for more time. METHODS: A quantitative cross-sectional design was used. General practice patients from eight UK practices (n = 294) completed a questionnaire following a consultation regarding their satisfaction with the consultation, their beliefs about how long the consultation lasted (perceived time) and how long they would have preferred it to last (preferred time). The actual consultation length (real time) was recorded by the doctor. RESULTS: The majority of patients underestimated how long the consultation took, and a large minority stated that they would have preferred more time. When controlling for both real time and perceived time, a preference for more time was correlated with a dissatisfaction with the emotional aspects of the consultation and a lower intention to comply with the doctors recommendations. It was unrelated to satisfaction with the information giving and examination components of the consultation. CONCLUSION: Patients' dissatisfaction with consultation length could be managed by making consultations longer. Alternatively, it could also be managed by changing how a given time is spent. In particular, a doctor who listens and tries to understand their patient may make the patient feel more satisfied with the consultation length and subsequently more motivated to follow any recommendations for change.     

Health anxiety and patient behavior

Economic models of patient decision-making emphasize the costs of getting medical attention and the improved physical health that results from it. This note builds a model of patient decision-making when fears or anxiety about the future-captured as beliefs about next period's state of health-also enter the patient's utility function. Anxiety can lead the patient to avoid doctor's visits or other easily available information about her health. However, this avoidance cannot take any form: she will never avoid the doctor with small problems, and under regularity conditions she will never go to a bad doctor to limit the information received.     

Postgraduate medical training: getting patients on board

OBJECTIVES: To survey family planning clinic (FPC) patients who may be involved in the Diploma of the Faculty of Family Planning (DFFP) practical training; to obtain their views about the process of giving consent to their involvement; and to compare their views with current practice. METHODS: Questionnaire surveys of 103 female FPC patients and 40 DFFP instructing doctors. Patients were recruited from the waiting room of a community FPC, and DFFP instructing doctors from the North West of England were recruited at an updating meeting. RESULTS: Patients felt strongly that they wanted to know what to expect before deciding whether to agree to be involved in the training. Several items of information were requested. The most important of these were whether the training doctor would be seeing the patient alone; the gender of the training doctor; and the training doctor's level of experience. Patients had not always been given this information. CONCLUSIONS: Clinical experience is an important part of postgraduate medical training and patients need to be able to give fully informed consent to their involvement. The information currently given to patients may be insufficient. A reluctance to see male training doctors may have implications as regards the breadth of experience gained by male training doctors; this needs further investigation. Further research including different patient populations could inform guidelines for patient involvement in training.     

关于医疗事故鉴定中医患双方争议焦点的思考

在医疗事故鉴定中医患双方发生的种种争议，究其原因：①医患双方信息不对称导致患方对医疗行为存在误解；②医方诊治行为确实存在缺陷被患方抓住不放；③患方为经济利益所驱动。要化解医患双方的争议：①必须加强卫生宣教、增进医患沟通，以缩小医惠双方的信息不对称；②必须加强医方内部管理，如遵守有关法律法规，恪守职业道德，严格遵守诊疗常规和操作规程，重视围手术期的处理，妥善保护各种证据，发挥公证制度的作用等等。     

知情同意--临床医疗服务观念的变革

在临床治疗之前征求患者的意见是医生的职责 ,也是临床医学与有关法律条文所规定的患者权益。在临床治疗之前征求患者的意见是一种社会文化价值的反映 ,它体现了对患者权益的尊重以及个人自治权在道德上的重要性。随着社会文化价值观念的变革和伦理道德的逐步规范 ,知情同意 (Inform ed Consent,IC)在临床医疗服务过程中的作用越来越重要。文章阐述了知情同意在临床运用的发展过程及其在临床治疗过程中出现的一些具体问题 ;分析说明了加强医患关系、向患者提供明确的临床信息以及改善医患交流技巧是知情同意的基本要求。     

Consent, dissent, cement

The patient-doctor relationship has two fundamental components. The first is the application of the skill and knowledge of the doctor in the care of the whole patient and family. The second is the right of the individual to have information about his or her illness or treatment, and to be involved in decision making. This relationship is built on trust and comes sharply into focus in the area of consent to take part in clinical trials. The argument is put forward that the use of written information should be seen as an extension of the communication between the doctor and the patient, and not as a legally restrictive device. The concept of an agreement, both on the part of the doctor and of the patient, to take part in a clinical trial is developed.     

Gatekeeping practices of nurses in operating rooms

This paper explores the gatekeeping practices used by operating room nurses to control information flow in their everyday clinical practice. In nursing, gatekeeping appears only sporadically in the literature and usually emerges as a secondary concept rather than being the primary focus of studies. As gatekeeping is a communication practice that has the potential to impact directly on patient safety, a more in-depth exploration of its pervasiveness and effect needs to be undertaken. Accordingly, in this paper we aim to provide an in-depth understanding about gatekeeping practices in operating room nursing by drawing on a ‘network’ model of gatekeeping to highlight the power relationships between stakeholders and how information is controlled. To illustrate our points, we provide four different examples of gatekeeping at an interpersonal level of interaction. Data are drawn from an ethnographic study in Australia that explored nurse–nurse and nurse–doctor communication at three different operating room departments. We explore the impact of gatekeeping on social and professional relationships as well as how it has practical and ethical ramifications for patient care and the organisation of clinical work. The findings show that nurses are selective in their use of gatekeeping, depending on the perceived impact on patient care and the benefit that is accrued to nurses themselves.     

上海剖宫产率影响因素研究

目的:探讨妇女在怀孕不同时期选择分娩方式的影响因素。方法:用自填问卷方式对分娩后42天内的300例妇女进行调查,用Pearson卡方、配对卡方检验和logistic回归进行统计分析。结果:在上海市妇产科医院分娩妇女的剖宫产率为57.4%;影响妇女在怀孕初期选择分娩方式的因素主要是孕妇对分娩方式的认知;影响妇女在怀孕中后期对分娩方式选择的因素主要有产检医生、周围亲戚朋友的建议及孕妇运动情况;影响妇女最终采取的分娩方式的因素是年龄、怀孕初期选择的分娩方式、产检医生的建议、住院分娩期间周围孕产妇的分娩方式以及产科医生的建议。结论:孕妇分娩方式的选择在怀孕早期和中期主要受妇女和亲戚朋友因素影响;而住院分娩期主要受医生的建议和周围孕产妇选择的分娩方式的影响。     

Patient choice in general practice: the implications of patient satisfaction surveys

OBJECTIVES: To identify factors that explain patient satisfaction with general practice physicians and hence that may drive patients' choice of practice. METHODS: Logistic regression analysis of English National Health Service national patient survey data is used to identify the aspects of general practice care that are associated with high levels of overall satisfaction among patients. RESULTS: Confidence and trust in the doctor is the most important factor in explaining the variation in overall patient satisfaction (predicting 82% of satisfaction levels accurately). The seven variables relating to the relationship between patient and doctor have stronger explanatory power than other aspects of the general practitioner (GP) experience. The variables with the lowest overall predictive power are whether the patient was told how long they would have to wait in the surgery (72%), the length of time they had to wait after their appointment time (74%) and ability to get through to the surgery on the phone (74%). CONCLUSIONS: Patients value the quality of their relationship with their doctor more than the appearance of the surgery, accessibility of appointments and their experience in the waiting room. This suggests that, if current restrictions on choice of GP were removed, we would in theory expect a patient's choice to be driven by the quality of the doctor-patient relationship. Once a patient establishes a good relationship with a GP, however, we might expect them to be loyal and therefore unlikely to change practice unless the relationship with the doctor breaks down. Although relationship factors are important to the satisfaction of patients, it is not clear that they will lead large numbers of people to change their GP.     

Assertiveness with physicians: does it predict mammography use?

In a prior study we found that women's self-reported assertiveness with their healthcare providers was associated with their use of mammography in a population-based cross-sectional sample of women. Women who reported being more assertive, by repeating information if they felt their doctor didn't hear them, asking their doctor to explain information they didn't understand, or reminding their doctor about screening tests, were more likely to have received a mammogram recently than those who reported being less assertive. Here we examined how women's self-reports of assertiveness predicted their use of mammography three years later. We examined this using a population-based sample of 781 women living in rural Washington State who were participating in a trial of mammography promotion. We found that assertive women were younger on average than less assertive women, but that even after controlling for age, education, income, and marital status, women who reported being assertive with their doctor in 1994 were more likely to receive regular mammograms in the next three years than those who did not (OR 2.1; CI 1.5, 2.9). If future studies also suggest that assertiveness predicts use of mammography or other preventive healthcare services, it would be valuable to examine the promotion of assertiveness as a means of improving public health.     

The application of the heuristic-systematic processing model to treatment decision making about prostate cancer.

The study investigated the utility of the Heuristic-Systematic Processing Model as a framework for the investigation of patient decision making. A total of 111 men recently diagnosed with localized prostate cancer were assessed using Verbal Protocol Analysis and self-report measures. Study variables included men's use of nonsystematic and systematic information processing, desire for involvement in decision making, and the individual differences of health locus of control, tolerance of ambiguity, and decision-related uncertainty. Most men (68%) preferred that decision making be shared equally between them and their doctor. Men's use of the expert opinion heuristic was related to men's verbal reports of decisional uncertainty and having a positive orientation to their doctor and medical care; a desire for greater involvement in decision making was predicted by a high internal locus of health control. Trends were observed for systematic information processing to increase when the heuristic strategy used was negatively affect laden and when men were uncertain about the probabilities for cure and side effects. There was a trend for decreased systematic processing when the expert opinion heuristic was used. Findings were consistent with the Heuristic-Systematic Processing Model and suggest that this model has utility for future research in applied decision making about health.