Medical malpractice experience of physicians. Predictable or haphazard?

This study uses a large malpractice database from Florida to assess the concentration of losses among physicians, predictability of claims experience, characteristics of physicians with favorable vs unfavorable experience, and effects of claims experience on physicians' practice decisions and on actions taken by the state's licensing board. Most payments by insurers involved a comparatively small number of physicians. Physicians with relatively prestigious credentials had no better, and on some indicators, worse claims experience. If anything, physicians with adverse claims experience were less likely to make subsequent changes in their practice, such as quitting practice or moving to another state. Physicians with very poor claims histories were more likely to have complaints filed against them with the Florida licensing board, but the sanctions against physicians with either poor or excellent histories were not severe. Physicians with adverse claims experience from incidents that arose between 1975 and 1980 had appreciably worse claims experience from incidents that arose during 1981 to 1983.     

Republished original viewpoint: complaints, shame and defensive medicine

While the complaints process is intended to improve healthcare, some doctors appear to practise defensive medicine after receiving a complaint. This response occurs in countries that use a tort-based medicolegal system as well as in countries with less professional liability. Defensive medicine is based on avoiding malpractice liability rather than considering a risk-benefit analysis for both investigations and treatment. There is also evidence that this style of practice is low quality in terms of decision-making, cost and patient outcomes. Western medical practice is based on biomedicine: determining medical failure using the underlying, taken-for-granted assumptions of biomedicine can potentially contribute to a response of shame after an adverse outcome or a complaint. Shame is implicated in the observable changes in practising behaviour after receipt of a complaint. Identifying and responding to shame is required if doctors are to respond to a complaint with an overall improvement in clinical practice. This will eventually improve the outcomes of the complaints process.     

Guideline on training and credentialing in endoscopic retrograde cholangiopancreatography

The aim of the Endoscopic Retrograde Cholangiopancreatography (ERCP) Working Group was to examine the issues of training, credentialing and quality control in ERCP in Singapore. Published guidelines and clinical trials concerning issues of training, complications and quality control in ERCP have been reviewed. The Working Group recommended that a trainee reach a minimum threshold of 200 cases before the assessment of competency. The target for achievement of competency was set at an 85 percent successful cannulation rate for native papilla. To perform advanced ERCP, endoscopists should have undergone dedicated training either in a recognised training centre or in conjunction with and under the guidance of a more experienced colleague, until technical competency is achieved. Precut should only be performed by endoscopists with experience and expertise in performing Levels II and III ERCP, who have been formally proctored. An audit of ERCP should examine parameters such as appropriate indication, success rates of selective cannulation, technical success rate of commonly performed procedures and procedure-related complications. To maintain technical competency, an individual should be performing ERCP on a regular basis. In conclusion, the innate risks of ERCP necessitate that all ERCP practitioners should be appropriately trained, practise within their expertise level and maintain regular practice in order to minimise risks and improve patient outcome.     

农村某中学高中生慢性病相关行为危险因素调查

目的:了解象山县农村高中生慢性病相关危险因素的分布状况,为制定有效的干预策略提供依据.方法:采用整群随机抽样方法进行问卷调查.结果:15.12%的学生近1年内有过伤害自己的想法,18.85%的学生曾吸过烟,29.71%的学生近30天内饮过酒,94.46%的学生近30天内不吃早餐,68.58%的学生近30天内中重度体育锻炼次数少于5次.结论:象山县农村高中生普遍存在慢性病行为危险因素.     

Patients' complaints about medical practice.

OBJECTIVES: To survey complainants' experience and the outcome of lodging a complaint about medical treatment. DESIGN AND SETTING: Random sample survey. A 32-item questionnaire was sent to 500 complainants by the New South Wales Health Care Complaints Commission (HCCC), and responses were returned reply-paid to the university. PARTICIPANTS: 290 people with complaints finalised by the HCCC between February 1996 and August 1997. OUTCOME MEASURES: Profile of complainants and doctor involved; type and place of incident; complainants' emotions at the time of the incident and at the conclusion of the complaints process; outcome of complaint, and satisfaction with outcome and intention to take further action. RESULTS: After excluding non-medical complaints, 290 of 314 questionnaires returned were analysed, giving a response rate of 63% (314/500): 64% of complaints were about clinical care, and the remainder related to rudeness or poor communication (22%), and unethical or improper behaviour (14%); 70% of complainants were women, and 44% of complaints were on behalf of another person; Complainants had a high socioeconomic status, and 60% were currently in paid employment; More than half the incidents occurred in doctors' consulting rooms; 87% of the doctors involved were men, and over half were general practitioners. 37% of complaints were dismissed; 21% of complainants did not know the outcome of their complaint, and 40% believed that the doctor had been disciplined. Most complainants were dissatisfied with the outcome; a quarter stated that they would sue, but 70% would do nothing further. All but two complainants would never consult the doctor involved again. CONCLUSIONS: Most of the respondents were not satisfied with either the process or the outcome. Typically they wanted stronger measures taken. Only a few wanted compensation; more wanted acknowledgement of harm done; and most wanted the doctor punished.     

Postmortem procedures in the emergency department: using the recently dead to practise and teach.

In generations past, it was common practice for doctors to learn lifesaving technical skills on patients who had recently died. But this practice has lately been criticised on religious, legal, and ethical grounds, and has fallen into disuse in many hospitals and emergency departments. This paper uses four questions to resolve whether doctors in emergency departments should practise and teach non-invasive and minimally invasive procedures on the newly dead: Is it ethically and legally permissible to practise and teach non-invasive and minimally invasive procedures on the newly dead emergency-department patient? What are the alternatives or possible consequences of not practising non-invasive and minimally invasive procedures on newly dead patients? Is consent from relatives required? Should doctors in emergency departments allow or even encourage this use of newly dead patients?     

General practice placements for pre-registration junior doctors: adding value to intern education and training

OBJECTIVE: To examine pre-registration junior doctors' perceptions of the value of a general practice term in their training program. DESIGN, SETTING AND PARTICIPANTS: Semi-structured interviews, in five teaching hospitals in South Australia in 2005, with 20 pre-registration junior doctors (interns) who had completed a general practice term and at least one core term of intern training. MAIN OUTCOME MEASURE: Comparisons between general practice and teaching hospital core training terms with respect to the domains of junior doctor education. RESULTS: Interns perceived general practice and teaching hospital terms to be complementary in their overall training program. The general practice term provided them with knowledge and skills they would not have acquired in the teaching hospital terms alone. One-on-one consulting, initiating patient management, and the opportunity to practise a range of practical and procedural skills were seen to be of particular value. CONCLUSIONS: The general practice and teaching hospital terms both contribute to the training of interns, offering contrasting environments and experiences which enhance interns' professional and personal growth. General practice terms should be considered for inclusion in intern training programs across Australia.     

Attitudes of Ontario psychiatrists towards health insurance.

In 1979 the opinions of Ontario psychiatrists were sought regarding the influence of the Ontario Health Insurance Plan (OHIP) on the practice of their specialty. Full replies to a 44-item questionnaire were received from more than half the certified psychiatrists in Ontario, half of whom had been in practice before the introduction of OHIP. Both satisfaction and uneasiness were expressed about most aspects of health insurance. Many of the 416 psychiatrists stated that OHIP had improved access to psychiatric care, providing a more socially diverse practice, especially with respect to psychotherapy. Only one quarter believed that OHIP constituted a major intrusion on the doctor-patient relationship, and the majority reported that OHIP had been beneficial to themselves as psychiatrists (70%) and to their patients (86%). Almost half reported having raised their concern about the confidentiality of OHIP records with their patients; the patients less often brought up the issue. Although most psychiatrists in practice before the introduction of OHIP reported no change in their conduct of psychotherapy, a minority reported a decrease in the duration of treatment and an increase in the frequency of missed appointments. Also noted was an increase in the number of referrals for consultation, which led at times to overutilization of these specialists' services.     

A questionnaire survey of stress and bullying in doctors undertaking research

Background: Research is an increasingly important aspect of higher medical training for many doctors. Studies investigating sources of stress, isolation, and workplace bullying have not previously sought information in this setting. Methods: An internet based questionnaire survey of doctors undertaking research (n = 259) was conducted to examine stressors and levels of job satisfaction in this potentially vulnerable group. In order to assess overall levels of satisfaction, we asked whether doctors would recommend their research post to a colleague. Results: There was a statistically significant association between those who would not recommend their post to a colleague and those who had difficulties in arranging funding and in writing up (p<0.001). Further significant correlations were found between dissatisfaction with the post and lack of help, support, and advice from supervisors and colleagues, wanting to change supervisors, experience of the major categories of workplace bullying, and having an inadequate clinical commitment (p<0.001). When the significant variables were entered into a multivariate analysis, the results showed that dissatisfaction was associated with wanting to change supervisors and with a threat to professional status. Conclusions: Stress and bullying are common in doctors undertaking research. These findings have important implications for medical training and for doctors choosing research projects. Setting up systems of support may have important benefits.     

癌症患者自杀事件影响肿瘤科护士心理应激状况的调查分析

目的：调查肿瘤患者自杀事件对病区护士的心理影响,探讨有针对性的干预措施。方法采用 Zung 氏焦虑自评量表（SAS）和自制的问卷调查表对肿瘤科41名护士进行调查,对所得数据进行分析。结果患者自杀事件发生后的前3 d ,肿瘤科直接面对自杀事件的护士 SAS 评分为（63．30±9．21）分,与国内健康人群常模及国内护士常模 SAS 均分比较差异有统计学意义（P＜0．05）;自杀事件发生后的4周内,护士群体的个人生活和工作状态受到明显影响,精神应激体验严重。结论护理管理层应充分认识自杀事件发生对一线护士可能造成的心理影响,建立针对性强的心理干预机制,尽早对护士（特别是直接面对自杀事件的护士）实施心理干预,使护士身心处于最佳状态,保证护理队伍的稳定性。     

HIV risk behaviour among injecting drug users in Perth: the Australian National AIDS and Injecting Drug Use Study.

OBJECTIVE: This study was carried out in 1989 to examine behaviour involving risk of human immunodeficiency virus (HIV) infection and to measure the prevalence of HIV antibodies in a sample of injecting drug users (IDUs) in Perth. DESIGN: The study was a cross-sectional survey with a sample of convenience of 196 IDUs drawn from drug treatment (54%) and non-treatment (46%) populations. RESULTS: Sixty-five per cent of the sample were men and 35% women. Subjects were predominantly heterosexual, were in their late twenties, had not completed secondary school, and were on sickness, unemployment or pension benefits. The majority were poly-drug users, but heroin and amphetamines were the only drugs that had been injected by more than 20% of the sample more than once a month. Respondents reported injecting an average of 43.6 (SD 83.6) times a month and using 33.7 (SD 55.4) new needles a month. The majority (70%) had injected within weeks of the interview. Sixty-seven per cent had shared needles within months. Respondents claimed to pass on used needles more frequently than to accept them, and were most likely to share with close friends or lovers when clean needles were unavailable and/or when they were withdrawing. While most respondents cleaned used needles, few used bleach all or most of the time. Most (78%) respondents had been tested for HIV seropositivity at least once. Most had multiple sexual partners and 92.3% had engaged in at least one unsafe sexual practice during the previous six months. Sixty-four per cent had changed some aspect of drug using, and 38% some aspect of sexual behaviour since hearing about the acquired immunodeficiency syndrome (AIDS). HIV seroprevalence for the 179 respondents who were tested was 2.2%, but this figure should not be taken as an estimate of seroprevalence for the Perth IDU population. CONCLUSION: Respondents' behaviour placed them at a high level of risk for HIV infection. Based on reported behaviour, it is recommended that education for IDUs in Perth should emphasise, among other things: not passing on used needles; cleaning used needles and syringes with bleach; planning ahead so that sterile equipment is available; and further risk reduction, particularly the adoption of safer sexual practices.     

护理创新性实验项目的创建与实践

目的:创建并实践护理创新性实验教学项目,激发护生创新思维,提高护生创新能力。方法:对2008级护理专业五年制本科632名学生进行创新性实验项目教学,并采用问卷的方式进行调查。结果:99.6%的护生认可创新性实验教学方式,82.4%的护生认为改变了思维习惯,培养了创新能力。76.8%的护生认为激发了学习兴趣,提高了自主学习能力。75.0%的护生认为增强团队合作精神,发挥了团队或个人创造力。结论:护理实验学教学中开展创新性实验不仅有利于护生创新精神及能力的培养,而且可以提高护生综合能力。     

"GP Psych Opinion": evaluation of a psychiatric consultation service

OBJECTIVE: To evaluate a hospital-based psychiatric consultation service for patients referred by general practitioners (GPs), and the effect on its use of a focused marketing strategy aimed at GPs. DESIGN AND SETTING: Postal survey of GPs in the catchment area (inner north Brisbane, Queensland), September to November 2003; and assessment of referrals, March to August 2003. MAIN OUTCOME MEASURES: Patient referrals, satisfaction among GPs who had referred, and awareness and opinions of the service among GPs who had not referred, compared with results of a similar survey conducted before marketing. RESULTS: In the 6 months after marketing, 43 patients were referred by 23 GPs, an average of 7.2 patients per month, compared with 2.5 per month in the first 12 months of the service. Survey responses were received from 13 of 36 GPs who had referred patients and 97 of 282 GPs who had not (response rate, 35%). Satisfaction among GPs who had referred remained high, and 12/13 felt the service should continue. Among GPs who had not referred, 76% were aware of the service, up from 26% in the previous survey, and 99% liked the concept of the service. CONCLUSION: Given the ongoing low utilisation of this service, we question whether this model is accepted by most GPs in our district. Possibly, they prefer more traditional models, where treatment is taken over by psychiatrists in the public or private system. We believe there is a need to increase the capacity and scope of publicly funded services to treat mental health problems.     

Correlates of certification in family medicine in the billing patterns of Ontario general practitioners.

There is conflicting evidence as to whether physicians who are certified in family medicine practise differently from their noncertified colleagues and what those differences are. We examined the extent to which certification in family medicine is associated with differences in the practice patterns of primary care physicians as reflected in their billing patterns. Billing data for 1986 were obtained from the Ontario Health Insurance Plan for 269 certified physicians and 375 noncertified physicians who had graduated from Ontario medical schools between 1972 and 1983 and who practised as general practitioners or family physicians in Ontario. As a group, certificants provided fewer services per patient and billed less per patient seen per month. They were more likely than noncertificants to include counselling, psychotherapy, prenatal and obstetric care, nonemergency hospital visits, surgical services and visits to chronic care facilities in their service mix and to bill in more service categories. Certificants billed more for prenatal and obstetric care, intermediate assessments, chronic care and nonemergency hospital visits and less for psychotherapy and after-hours services than noncertificants. Many of the differences detected suggest a practice style consistent with the objectives for training and certification in family medicine. However, whether the differences observed in our study and in previous studies are related more to self-selection of physicians for certification or to the types of educational experiences cannot be directly assessed.     

Workforce trends in specialist and GP obstetric practice in Victoria

OBJECTIVE: To provide a contemporary picture of the general practitioner and specialist obstetric workforce in Victoria. DESIGN, PARTICIPANTS AND SETTING: Postal census by questionnaire of all 317 Fellows and 961 Diplomates on the Victorian database of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists in September 2003. MAIN OUTCOME MEASURES: Sex, age and geographical distributions and patterns of retirement from and recruitment to the GP and specialist obstetric workforce in Victoria. RESULTS: 244 Fellows (77.0%) and 652 Diplomates (67.8%) participated. The average age of Diplomates was 42 years; only 20% were involved in procedural obstetrics. Of GPs practising procedural obstetrics, 56% intended to cease within 7 years. Two-thirds of specialist obstetricians continued to practise obstetrics. Among those ceasing obstetrics, almost half had done so since 2000. Among Fellows ceasing obstetric practice, there is a peak in the 50-60-years age group, but cessation of obstetric practice occurred across all age groups. CONCLUSION: The proportion of GPs involved in procedural obstetrics has fallen markedly over the past decade, with half of those ceasing practice in the 40-50-years age group. New GPs entering the workforce with the Diploma and overseas doctors are unlikely to meet the procedural workforce shortfall. Attracting the large cohort of doctors aged 40-50 years back to obstetric practice must be a priority. Given the pattern of retirements from obstetrics, there will be insufficient numbers of specialists to maintain current levels of service. The reasons include non-participation in obstetrics by new graduates and international medical graduates, the inadequate number of new graduates, and the predominance of women among specialists aged under 40 years, whose work output tends to be affected by family commitments.     

Survey of attitudes of mental health professionals in Singapore towards at-risk mental states

INTRODUCTION: Schizophrenia is a severe, chronic mental illness with a worldwide prevalence of about one percent. It is possible to define at-risk mental states (ARMS) that predict conversion to schizophrenia in up to 40 percent of help-seeking individuals within a year of screening. Treatment of ARMS is controversial due to difficulties with diagnosis and uncertainties of treatment effectiveness. There is currently no consensus among psychiatrists in Singapore or internationally, regarding the diagnosis of ARMS, or its treatment. This survey was conducted to assess current attitudes of Singaporean psychiatrists towards ARMS. METHODS: An anonymous survey containing a clinical vignette and questions related to the diagnosis and management of ARMS was sent out to all registered psychiatrists and psychiatric trainees in Singapore. RESULTS: There was a response rate of 62.1 percent (87/140). 60.9 percent of respondents were fully-trained psychiatrists. 44.8 percent versus 43.7 percent of respondents diagnosed ARMS versus psychosis, respectively. 74.4 percent (29/39) of respondents who diagnosed ARMS would treat the patient with active management rather than watchful waiting. 64.4 percent felt that there was no consensus regarding the management of ARMS. There was no significant relationship between responses and age, gender, training or place of practice. CONCLUSION: There is currently clinical equipoise with regard to both diagnosis and management of ARMS in Singapore. Most psychiatrists would manage ARMS actively rather than with watchful waiting.     

Rural background and clinical rural rotations during medical training: effect on practice location

BACKGROUND: Providing health care services in rural communities in Canada remains a challenge. What affects a family medicine resident's decision concerning practice location? Does the resident's background or exposure to rural practice during clinical rotations affect that decision? METHODS: Cross-sectional mail survey of 159 physicians who graduated from the Family Medicine Program at Queen's University, Kingston, Ont., between 1977 and 1991. The outcome variables of interest were the size of community in which the graduate chose to practise on completion of training (rural [population less than 10,000] v. nonrural [population 10,000 or more]) and the size of community of practice when the survey was conducted (1993). The predictor or independent variables were age, sex, number of years in practice, exposure to rural practice during undergraduate and residency training, and size of hometown. RESULTS: Physicians who were raised in rural communities were 2.3 times more likely than those from nonrural communities to choose to practise in a rural community immediately after graduation (95% confidence interval 1.43-3.69, p = 0.001). They were also 2.5 times more likely to still be in rural practice at the time of the survey (95% confidence interval 1.53-4.01, p = 0.001). There was no association between exposure to rural practice during undergraduate or residency training and choosing to practise in a rural community. INTERPRETATION: Physicians who have roots in rural Canada are more likely to practise in rural Canada than those without such a background.     

论卫气失常是肥胖的核心病机

依据《灵枢·卫气失常》的有关论述,结合先前所述的卫气具有气态、液态、固态三种形态的观点,提出卫气失常是肥胖发病之病机核心的论点,并进行了理论探讨。卫气生于水谷,是人体脏腑气化、肌肉运动的基础;多余的卫气可以转化为膏、脂存储于体内。若膏脂堆积过多,就会产生膏人、脂人、肉人,按照当代的认识,均属于肥胖范畴。因此,基于卫气失常阐述以肥胖为形态学特征的慢病病机,为采取少食多动的方法调整失常之卫气提供理论依据,对防治肥胖有指导意义。     

Practical experience and confidence in managing emergencies among preregistration house officers

Objectives: To assess the experience gained by pre-registration house officers (PRHOs) at the end of their first post. To assess confidence in managing common emergencies and experience gained in practical procedures. To compare traditional six month posts with four month posts and to compare the experiences of PRHOs posted in teaching hospitals (THs) with those based in district general hospitals (DGHs). Design: Interview questionnaire. Participants: 152 graduates from Edinburgh University Medical School in 2000 who had completed their first PRHO post by February 2001. Results: There were few significant differences in confidence in managing emergencies and in numbers of practical procedures attempted between respondents from four and six month posts or between those holding TH and DGH posts. PRHOs had gained little experience in practical procedures: fewer than 15% had performed five or more of a number of procedures including lumbar puncture, pleural aspiration, chest drainage, and insertion of nasogastric tube. A high proportion of PRHOs indicated that they felt confident initiating management of conditions in specialties of which they had little or no experience. Conclusions: Rotations of three four month posts do not seem to reduce overall experience in the PRHO year. There is little difference in experience gained between TH and DGH posts. PRHOs perform few practical procedures and some may be overconfident in their own abilities.     

Practice of breast self-examination amongst women attending a Malaysian Well Person's Clinic

The practice of breast self-examination (BSE) amongst 1,303 women registered with the Well Person's Clinic, Outpatient Department, Hospital Ipoh between April 1995 and March 1997 were assessed through a questionnaire. Majority (98.2%) were never taught and did not practise BSE, 17(1.3%) practised BSE while 6 (0.5%) were taught BSE but failed to put it into practice. Only 5.8% of 52 women with past/family history of breast cancer/lump and 2.9% of 207 women with past/family history of other cancers were practising BSE regularly. Three out of 64 women with breast lumps found on clinical breast examination discovered the lumps themselves. Five of the 64 women were subsequently confirmed to have breast carcinoma.