Quality matters: junior doctors' perceptions

Presents the results of an empirical study of junior doctors' views on quality and clinical audit in health care. Claims that the requirement for annual efficiency gains and rising patient expectations, together with the realization that the "costs of quality" can consume between 30 and 50 per cent of costs, has brought quality in health care to the forefront. In this context, and because much of the medical care is delivered by junior doctors, studies their perceptions on dimension of quality in health care, their knowledge of, and participation in, clinical audit and the obstacles to providing quality care. Makes a striking finding--the low priority given to patient satisfaction--a perspective which is out of alignment with the priorities of government policy, and the whole philosophy of "quality in service". Asserts that the role, significance and outcome of clinical audit as a quality improvement tool is cast into doubt by these consultants of tomorrow.     

Junior doctors' hours: what do they really think?

Junior doctors' hours are one of the most controversial topics under debate in the health service today. We undertook a detailed postal questionnaire of hospital doctors in training within a major teaching unit in order to assess the awareness and perceived implications of the incipient changes and to elucidate how it was felt these changes would affect both the doctors and patients. The questionnaire focused specifically on the effect of the changes on quality and continuity of patient care, junior training and socio-economic factors relating to the medical staff. The questionnaire was entirely anonymous and carried only the first author name but provision was made to determine current grade, specialty, age, sex and career plans of the respondents. Importantly, space was included at the end for pertinent comments. All junior staff in training in all specialties in the Cardiff area were circulated. Three hundred and twenty-six questionnaires were sent out and 202 were returned of which 192 were properly completed (59%). Almost everyone was au fait with the proposed changes. There was a surprisingly high level of support for changes among non-surgical trainees, and half felt that quality of care would improve, though the more senior the trainee, the less enthusiastic they were in all aspects. Many felt that far too little consultation with junior staff had taken place and there was generalized criticism of general practitioner trainees by their specializing counterparts, partly because of a perceived lack of commitment and partly because of blame of this group for the inception of the changes.(ABSTRACT TRUNCATED AT 250 WORDS)     

Professional values and reported behaviours of doctors in the USA and UK: quantitative survey

BACKGROUND The authors aimed to determine US and UK doctors' professional values and reported behaviours, and the extent to which these vary with the context of care. METHOD 1891 US and 1078 UK doctors completed the survey (64.4% and 40.3% response rate respectively). Multivariate logistic regression was used to compare responses to identical questions in the two surveys. RESULTS UK doctors were more likely to have developed practice guidelines (82.8% UK vs 49.6% US, p<0.001) and to have taken part in a formal medical error-reduction programme (70.9% UK vs 55.7% US, p<0.001). US doctors were more likely to agree about the need for periodic recertification (completely agree 23.4% UK vs 53.9% US, p<0.001). Nearly a fifth of doctors had direct experience of an impaired or incompetent colleague in the previous 3 years. Where the doctor had not reported the colleague to relevant authorities, reasons included thinking that someone else was taking care of the problem, believing that nothing would happen as a result, or fear of retribution. UK doctors were more likely than US doctors to agree that significant medical errors should always be disclosed to patients. More US doctors reported that they had not disclosed an error to a patient because they were afraid of being sued. DISCUSSION The context of care may influence both how professional values are expressed and the extent to which behaviours are in line with stated values. Doctors have an important responsibility to develop their healthcare systems in ways which will support good professional behaviour.     

Implementing U.S. federal health reform: learning from the Israeli experience

The purpose of the Federal Health Care Reform signed into law in the United States in March 2010 was to create a fundamental change in the configuration of national health care and to bring about significant improvements in health care quality and costs. Interpretation and implementation of the laws and regulations enacted will have a direct bearing on the reform's potential success. However, it is not always possible to predict eventual developments. This paper demonstrates some possible unanticipated implications of the health care reform, based on the Israeli experience. While the US reform is yet in its initial stages, it is suggested that health care policy makers and implementers learn from the Israeli experience and embrace its lessons.     

江苏省乡村医生签约服务试点经验及启示

本文简述了江苏乡村医生签约服务的实施背景、主要做法、推进措施,并从强化基本公共卫生服务公益性,提高乡村医生积极性,增加乡村医生收入待遇,均衡签约双方供需关系,引导建立农村分级诊疗制度和对新农合基金的影响等方面,对签约服务实施效果进行了分析。得出启示:以签约服务为切入点,重塑医患信任关系,改善乡村医生执业环境;围绕服务对象需求设计供给,明确基层首诊负责,建立合理就医秩序,有效提高资金使用效率;以健康管理为出发点,回归初级卫生保健本源,提升农村人群健康素质。     

Education and the working patterns of junior doctors in the UK: a review of the literature

OBJECTIVE: To identify and review UK research relating to the effects of patterns of work on the education of junior doctors, describe the trends in the research, contextualise the progress of the UK in reducing the number of hours worked by junior doctors alongside that of other countries and identify areas for future research. METHOD: A total of 77 research studies, mostly written after 1995, were identified as relevant from approximately 900 references generated by searching Medline and using a 'snowball' technique. The articles identified were qualitatively reviewed to identify their key research conclusions and/or the main points of argument. These were collated and presented in a qualitative review. RESULTS: Research in the UK is contradictory regarding the effects of working patterns and the views of doctors towards them. Further research is needed to examine in depth the differences in the effects of working patterns on education between hard-pressed and non hard-pressed specialties, hospitals and regions. When viewed in an international context, the UK ranks among a number of countries with similar medical systems that are moving towards reducing the hours worked by doctors in training, all of which are at different points in the process. CONCLUSION: The literature review has helped to identify the popular wisdom surrounding the debate on junior doctors' hours, the progress of the UK when compared to that of other countries and gaps in research. Further research is needed to refine understanding of this area.     

Separating doctors' homes and doctors' offices: San Francisco, 1881-1941

The urban medical delivery system includes not only the technological and scientific skills and apparatus used by health care practitioners but also those economic and social arrangements made by doctors that affect their ability to provide medical care. Among the most important of these is the location of health care facilities, especially doctors' offices. This paper traces the changing locations of doctors' offices in San Francisco between 1881 and 1941. Most specifically, it focuses on the separation of office from residence and the location of offices in the city. Changes in location began to occur during the urban transformation that occurred late in the nineteenth century. At that time, changes in the division of labor, the role of the family, and transportation and communications technology interacted with changes in science, medical technology and professional organization to alter the nature and location of the settings used to provide medical care. The health care delivery system is thus interpreted as the product of the overall dynamics of urbanization rather than the outcome simply of scientific discovery, medical technology and the influence of key medical practitioners and professional organizations.     

Advanced nurse practitioners and physician assistants: what is the difference? Comparing the USA and UK

With the reduction in junior doctors' hours and fewer doctors being trained in the UK, there is a need for other types of health-care practitioners to fill the gap. This article describes some of the background to the present situation and delineates two types of roles, the advanced nurse practitioner and the physician assistant, for consideration as alternatives to address the present and growing shortage of doctors.     

Evidence-based medicine: UK doctors' attitudes and understanding

The aim of this paper is to understand UK doctors' attitudes towards evidence-based medicine (EBM) and their self-perceived understanding of specified EBM terms. An online questionnaire was emailed to doctor's emails (identified from the Internet) and the questionnaire URL was promoted on certain websites and electronic newsletters. This article focuses on the EBM questions posed on this research instrument. Respondents were generally positive towards the practice of EBM; for example, 72.3% of UK doctors agreed that EBM improves patient outcomes. Over 85% of respondents were either able to explain (or had some understanding) all the specified EBM terms. Respondents who had graduated from medical school most recently were more positive towards EBM and had a stronger self-perceived understanding of the EBM terms. This research found that doctors were generally in favour of EBM and their understanding of specialist terms was higher than previous published research.     

Further challenges to medical dominance? The case of nurse and pharmacist supplementary prescribing

Doctors have traditionally been viewed as the dominant healthcare profession, with the authority to prescribe medicines, but recent non-medical prescribing initiatives have been viewed as possible challenges to such dominance. Using the example of the introduction of supplementary prescribing in the UK, this study sought to explore whether such initiatives represent a challenge to medical authority. Ten case study sites in England involving primary and secondary care and a range of clinical areas were used to undertake a total of 77 observations of supplementary prescribing consultations and interviews with 28 patients, 11 doctors and nurse and pharmacist prescribers at each site. Supplementary prescribing was viewed positively by all participants but several doctors and patients appeared to lack awareness and understanding of supplementary prescribing. Continued medical authority was supported empirically in five areas: patients' and supplementary prescribers' perception of doctors as being hierarchically superior; doctors legitimation of nurses' and pharmacists' prescribing initially; doctors' belief that they could control (particularly nurses') access to prescribing training; supplementary prescribers' frequent recourse to use doctors' advice, coupled with doctors' encouragement of such 'knock on door' prescribing advice policies; doctors' denigration of most routine prescribing but claims that diagnosis was more skilled and key to medicine. Supplementary prescribing appeared to be successfully accomplished in practice in a range of clinical settings and was acceptable to all involved but did not ultimately challenge medical dominance. However, more recent nurse and pharmacist independent prescribing (involving diagnosis) may represent a more significant threat.     

论增设乡村全科执业助理医师资格考试的必要性及可行性

乡村全科执业助理医师资格考试的增设符合乡村医生合法行医的需要,有利于加快乡村医生队伍执业医师化的进程,并提高其素质,同时在规范乡村医生队伍管理和稳定乡村医生队伍方面具有重要意义。乡镇执业助理医师资格考试的增设、现行相关法律政策提供的法律依据以及政策实施的客体——乡村医生群体的强烈诉求和居民支持使得乡村全科执业助理医师资格考试的增设具备了可行性。为保障乡村医生的执业医师化进程,还需完善现行法律法规和政策、加强针对乡村医生参加执业医师资格考试的医学专业培训及全科医师培训、建立合理的乡村全科执业助理医师补偿、养老等社会保障机制。     

山西省乡村医生现状分析

本研究源于世界银行贷款《中国农村卫生人力开发》项目。对山西省翼城和汾阳两县的基线调查数据分析表明：乡村医生年龄偏大,结构不合理;男女乡医比例失调,女乡医严重不足;乡村医生素质低,文化程度以初中为主,专业程度以短期培训为主,乡村医生报酬主要依靠业务投入,而业务收入的90％是药品收入。由于报酬结构不合理,乡村医生的行医行为发生扭曲,农民看病经济负担加重,造成有限卫生资源的浪费。因此,合理的报酬结构是提高乡村医生医疗保健服务质量的重要保证。建议对乡村医生实行“工资加奖金”的报酬模式,按乡村医生的技术职务、医龄、岗位工作效率等实行有层次的结构工资制,以医疗预防保健工作质量作为分发奖金的依据。最终建立以调整乡村医生报酬结构、保证基本报酬和调控激励报酬的干预措施,使乡村医生的行医行为由单纯医疗型逐步向医疗预防保健型转变。     

Abortion discourse in Bolivian hospital contexts: doctors' repertoire conflicts and the Saving Women device

The author proposes going Beyond attitudes (Potter and Wetherell 1987) to a more nuanced assessment of doctors' discursive variations. Through an application of Gilbert and Mulkay's (1984) interpretative repertoires, she defined three voices--technical, normative and pragmatic--in which Bolivian doctors spoke of abortion. In State and social security hospital contexts, doctors hastened to express compliance with government policy and institutional norms regulating abortion and postabortion care. Technical and pragmatic considerations, however, often entered into conflict with established rules. When contradictions became apparent in their own discourse, doctors regularly drew on the Saving Women device. This accounting strategy enabled them to save face as up-to-date professionals through justifying temporary deviance from norms in terms of benefit to women treated. The author describes her development of the repertoires, their validation with different medical audiences, and doctors' critical appropriation of the model to explain their own discursive variations.     

''We''d like to have a family''--young women doctors'' opinions of maternity leave and part-time training.

Maternity leave and part-time training should facilitate the integration of the family and professional lives of young women doctors - whom the NHS cannot afford to lose as their numbers rise to half the number of the graduates of UK medical schools. Women doctors' planned professional activity is high, but to what extent do the maternity leave and part-time training arrangements assist them in fulfilling their plans? One hundred and forty-five young women doctors reported their experiences of and views on maternity leave and part-time training. Most had children between 6 and 10 years after qualification, to fit with career development. Seventy-one per cent of the confinements had qualified for maternity leave and pay, but there were complaints about the working of the regulations, particularly in relation to junior hospital doctors' short contracts. When asked to comment about part-time training, most (77%) expressed themselves as broadly in favour - only three actively opposing it. It was perceived as difficult to organize by 20% of respondents, as difficult to undertake by 29%, and as being of low status by 15%. This study concludes that the arrangements for maternity leave need to be improved and that the availability and status of part-time training need enhancing - especially to encourage women doctors to enter careers in hospital medicine.     

The influence of patient and doctor gender on diagnosing coronary heart disease

Using novel methods, this paper explores sources of uncertainty and gender bias in primary care doctors' diagnostic decision-making about coronary heart disease (CHD). Claims about gendered consultation styles and quality of care are re-examined, along with the adequacy of CHD models for women. Randomly selected doctors in the UK and the US (n=112, 56 per country, stratified by gender) were shown standardised videotaped vignettes of actors portraying patients with CHD. Patients' age, gender, ethnicity and social class were varied systematically. During interviews, doctors gave free-recall accounts of their decision-making, which were analysed to determine patient and doctor gender effects. We found differences in male and female doctors' responses to different types of patient information. Female doctors recall more patient cues overall, particularly about history presentation, and particularly amongst women. Male doctors appear less affected by patient gender but both male and especially female doctors take more account of male patients' age, and consider more age-related disease possibilities for men than women. Findings highlight the need for better integration of knowledge about female presentations within accepted CHD risk models, and do not support the contention that women receive better-quality care from female doctors.     

互联网医疗推动医师多点执业的思考

国家“十三五”深化医药卫生体制改革规划明确将分级诊疗作为重点工作任务,医师多点执业作为推进分级诊疗的重要措施近年来虽然备受关注,但其实施却困难重重,互联网医疗的快速发展有望为医师多点执业带来新的改变。文章在深入分析当前医师多点执业发展现状与挑战的基础上,系统梳理出了互联网医疗背景下医师多点执业呈现出的新形势以及存在的新问题,并从行业监管、机制设计、平台建设和服务模式等方面提出了对策建议,力求为医师多点执业的规范实施提供参考,加快推进分级诊疗政策落地。     

Attending doctors' perspectives on how residents learn

CONTEXT: Graduate medical education is currently facing major educational reforms. There is a lack of empirical evidence in the literature about the learning processes of residents in the clinical workplace. This qualitative study uses a 'grounded theory' approach to continue the development of a theoretical framework of learning in the clinical workplace by adding the perspective of attending doctors. METHODS: A total of 21 Dutch attending doctors involved in the training of residents in obstetrics and gynaecology participated in 1 of 3 focus group sessions. They discussed their perceptions of how residents learn and what factors influence residents' learning. A grounded theory approach was used to analyse the transcribed discussions. RESULTS: Three related themes emerged. The first concerned the central role of participation in work-related activities: according to attending doctors, residents learn by tackling the everyday challenges of clinical work. The second involved the ways in which attending doctors influence what residents learn from work-related activities. The final theme focused on attending doctors' views of the essential characteristics of residents and their development during residency. CONCLUSIONS: Attending doctors' perspectives complement current insights derived from similar research among residents and from related literature. As part of an ongoing effort to further develop understanding of how residents learn, this study adds several ways in which attending doctors strive to combine guidance in both patient care and resident training. Furthermore, attending doctors' perspectives draw attention to other aspects of learning in the clinical workplace, such as the role of confidence and the balance between supervision and independence.     

Knowledge of junior doctors regarding the New Deal

Junior doctors' knowledge of the content and local implementation of the New Deal for junior doctors was surveyed in one English region. Data were analysed from 254 replies (response rate 60%); a majority (86%) knew that the initiative was intended to reduce their working hours, but detailed knowledge was lacking. Less than half could identify the correct limits on contracted hours for full or partial shift working patterns, while 73% knew that they should not be contracted for more than 72 hours per week for an on-call pattern, the most common and traditional pattern worked. Only 20% knew that hours actually worked should not exceed 56 per week. Only 13 of 114 doctors who believed their posts conformed to the New Deal knew the correct hours limits. Only 11% knew any member of the hospital local implementation group for the New Deal. The results of the survey indicate that junior doctors are not well informed about the details of the New Deal, or its local implementation-four years into the New Deal, this situation needs to be improved, especially as junior doctors are now to be asked to validate the progress of the initiative.     

Do junior doctors feel they are prepared for hospital practice? A study of graduates from traditional and non-traditional medical schools

A valid and reliable questionnaire was developed which assesses eight subscales relating to key areas of medical hospital-based work. This was used to evaluate junior doctors' perceptions of the adequacy of their undergraduate medical training to prepare them for hospital practice. Data from 139 (60%) first-year doctors (interns) showed that graduates from the problem-based medical school rated their undergraduate preparation more highly than traditional medical school graduates in preparing them for practice in the areas of interpersonal skills, confidence, collaboration with other health care workers, preventive care, holistic care and self-directed learning. These findings persisted when ratings were adjusted for the effects of age and gender. There were no differences between the intern groups for patient management and understanding science. This research suggests that educational experiences in different undergraduate medical courses are important in preparing doctors for their early working life.