Competing and coexisting logics in the changing field of English general medical practice

Recent reforms, which change incentive and accountability structures in the English National Health Service, can be conceptualised as trying to shift the dominant institutional logic in the field of primary medical care (general medical practice) away from medical professionalism towards a logic of "population based medicine". This paper draws on interviews with primary care doctors, conducted during 2007–2009 and 2011–2012. It contrasts the approach of active management of populations, in line with recent reforms with responses to patients with medically unexplained symptoms. Our data suggest that rather than one logic becoming dominant, different dimensions of organisational activity reflect different logics. Although some aspects of organisational life are relatively untouched by the reforms, this is not due to ‘resistance’ on the part of staff within these organisations to attempts to ‘control’ them. We suggest that a more helpful way of understanding the data is to see these different aspects of work as governed by different institutional logics.     

Developments in euthanasia practice in the Netherlands: Balancing professional responsibility and the patient’s autonomy

In 2015, euthanasia accounted for 4.5% of deaths in the Netherlands, of which 93% were performed by a GP. Historically, a conflict of physician’s duties—to alleviate unbearable suffering and at the same time preserve the patient’s life—is central to the justification of euthanasia practice in the Netherlands. However, there seems to be a shift towards a greater emphasis on the patient’s autonomous wish as the primary basis for euthanasia. This shift has consequences for the role and interpretation of the physician’s duties in end-of-life care. This paper aims to describe these developments in euthanasia practice and end-of-life decision-making. We describe important relevant developments and look into the role and the meaning of two dimensions of the concept of ‘patient autonomy’ regarding end-of-life decisions, in particular, the euthanasia request. We claim that the concept of autonomy ‘as a right,’ which can be distinguished from autonomy ‘as an ideal,’ narrows the physician’s window of opportunity to offer end-of-life care other than euthanasia.     

Contract care in dentistry: sense‐making of the concept and in practice when multiple institutional logics are at play

In 2009 contract dental care was introduced into Sweden's Public Dental Service under a programme called Dental Care for Health (DCH). Previous research has revealed a possible dilemma whereby dental care professionals had the role of insurance agent foisted upon them, as they were assigned the task of ‘selling contracts’. Using qualitative interviews, this study explores how these professionals make sense of contract dental care today. Drawing on the concepts of occupational and organisational professionalism, in combination with the institutional logics perspective, we discern that dental care professionals are entangled in multiple rationalities when reasoning about and dealing with DCH. A professional logic comes into play over health issues and preventive care, while market and corporate logics are present in relation to selling contracts and taking responsibility for the financial aspects of DCH, all of which creates tensions in these professionals. Overall, dental care professionals in the welfare sector respond both to an organisational and an occupational professionalism.     

Introducing incident reporting in primary care: a translation from safety science into medical practice

In this article, we examine how incident reporting procedures become part of the way primary health care professionals deal with safety problems. Between 2006 and 2010, we studied documents, observed incident reporting committee meetings and conducted formal and informal interviews in five Dutch primary health care centres and one general practitioner's out-of-hours service to describe the introduction of incident reporting procedures. In this article, we distinguish two approaches towards patient safety, the logic of risk management and the logic of medical practice. In the logic of risk management, safety is seen in terms of the prevention of recurrence of specific well-defined incidents. In the logic of medical practice, safety involves recognising uncertainties and strengthening implicit initiatives that underpin patient safety. Care providers alternated between the two logics and aligned them. Most reported incidents in primary care concern non-clinical incidents with no or limited impact on the patient. We observed that both physicians and medical assistants changed the significance of a particular incident by frequent reporting. By reporting apparently insignificant risks, those providing care were able to deal with these risks more explicitly and actively. The alignment of the two logics was different for clinical, more harmful incidents. Care providers rarely reported serious clinical incidents and we could find little evidence that they actively engaged with recommendations following the investigation of serious incidents. Both logics mutually shaped and informed each other. Incident reporting procedures made implicit initiatives explicit and the two logics ensure that safety involved multiple and different actions.     

Understanding patient needs without understanding the patient: the need for complementary use of professional interpreters in end-of-life care

High-quality doctor-patient communication in end-of-life care results in better quality of life for patients. In linguistically and culturally diverse societies, language discordant consultations become daily practice, leading to difficulties in eliciting patient preferences toward end-of-life care. Although family members invariably act as informal interpreters, this may cause some ethical dilemmas. We present a case of a palliative patient whose son acted as an interpreter. This case generated a triple- layered ethical dilemma: (i) how to safeguard patient autonomy against paternalistic interventions by family members, (ii) how to respect the relational context in which patient autonomy can be realized, and (iii) how to respect the ethno-cultural values of the patient and his family. These issues are being discussed and reflected upon within the framework shared decision making involving informal- and professional interpreters. The complementary use of professional interpreters next to family members acting as informal interpreters is recommended.     

Public health and palliative care: principles into practice?

Public health approaches to palliative care have a valuable contribution to make in understanding and developing community capacity related to death, dying, loss and care, acknowledging that carers of the dying and bereaved are an important group who have their own significant needs in end-of-life care. Drawing upon a sociological framework, this article suggests that an even greater contribution is possible by an emphasis upon understanding lay and community logic within a social context. In particular, the article examines an emerging but significant shift to public health approaches in the ‘developing world’ and the ‘developed world’. It is argued that such approaches can contribute to a much broader agenda and potential for palliative care. Some obstacles to achieving this considerable potential are also noted. These relate to imbalances of power between a number of groups including medicine, palliative care, socio-cultural scientists and, not least, communities themselves. It is concluded that Weber's ideas about understanding may have much to offer in broadening out the principles of a palliative care that works with, and for, communities.     

Diagnostic ambivalence: psychiatric workarounds and the Diagnostic and Statistical Manual of Mental Disorders

In 1980 the American Psychiatric Association (APA), faced with increased professional competition, revised the Diagnostic and Statistical Manual of Mental Disorders (DSM). Psychiatric expertise was redefined along a biomedical model via a standardised nosology. While they were an integral part of capturing professional authority, the revisions demystified psychiatric expertise, leaving psychiatrists vulnerable to infringements upon their autonomy by institutions adopting the DSM literally. This research explores the tensions surrounding standardisation in psychiatry. Drawing on in‐depth interviews with psychiatrists, I explore the ‘sociological ambivalence’ psychiatrists feel towards the DSM, which arises from the tension between the desire for autonomy in practice and the professional goal of legitimacy within the system of mental health professions. To carve a space for autonomy for their practice, psychiatrists develop ‘workarounds’ that undermine the DSM in practice. These workarounds include employing alternative diagnostic typologies, fudging the numbers (or codes) on official paperwork and negotiating diagnoses with patients. In creating opportunities for patient input and resistance to fixed diagnoses, the varied use of the DSM raises fundamental questions for psychiatrists about the role of the biomedical model of mental illness, especially its particular manifestation in the DSM.     

Commentary on a participatory inquiry paradigm used to assess EOL simulation participant outcomes and design

Care at the end-of-life has attracted global attention, as health care workers struggle with balancing cure based care with end-of-life care, and knowing when to transition from the former to the latter. Simulation is gaining in popularity as an education strategy to facilitate health care provider decision-making by improving communication skills with patients and family members. This commentary focuses on the authors’ simulation evaluation process. When data were assessed using a participatory inquiry paradigm, the evaluation revealed far more than a formative or summative evaluation of participant knowledge and skills in this area of care. Consequently, this assessment strategy has ramifications for best practices for simulation design and evaluation.     

Accountability,organisational learning and risks to patient safety in England: Conflict or compromise?

This article examines the current risk regulation regime, within the English National Health Service (NHS), by investigating the two, sometimes conflicting, approaches to risk embodied within the field of policies towards patient safety. The first approach focuses on promoting accountability and is built on legal principles surrounding negligence and competence. The second approach focuses on promoting learning from previous mistakes and near-misses, and is built on the development of a ‘safety culture’. Previous work has drawn attention to problems associated with risk-based regulation when faced with the dual imperatives of accountability and organisational learning. The article develops this by considering whether the NHS patient safety regime demonstrates the coexistence of two different risk regulation regimes, or merely one regime with contradictory elements. It uses the heuristic device of ‘institutional logics’ to examine the coexistence of and interrelationship between ‘organisational learning’ and ‘accountability’ logics driving risk regulation in health care.     

‘Constrained collaboration’: Patient empowerment discourse as resource for countervailing power

Countervailing powers constrain the authority and autonomy of the medical profession. One countervailing power is patient consumerism, a movement with roots in health social movements. Patient empowerment discourses that emerge from health social movements suggest that active patienthood is a normative good, and that patients should inform themselves, claim their expertise, and participate in their care. Yet, little is known about how patient empowerment is understood by physicians. Drawing on ethnographic fieldwork in an American medical school, this article examines how physicians teach medical students to carry out patient encounters while adhering to American cultural expectations of a collaborative physician–patient relationship. Overt medical paternalism is characterised by professors as ‘here's the orders’ paternalism, and shown to be counterproductive to ‘closing the deal’ – achieving patient agreement to a course of treatment. To explain how physicians accomplish their therapeutic goals without violating cultural mandates of patient empowerment I develop the concept of ‘constrained collaboration’. This analysis of constrained collaboration contrasts with structural‐level narratives of diminishing professional authority and contributes to a theory of the micro‐level reproduction of medical authority as a set of interactional practices.     

A Legal and Ethical Analysis of the Effects of Triggering Conditions on Surrogate Decision-Making in End-of-Life Care in the US

The central claim of this paper is that American states’ use of so-called “triggering conditions” to regulate surrogate decision-making authority in end-of-life care leaves unresolved a number of important ethical and legal considerations regarding the scope of that authority. The paper frames the issue with a case set in a jurisdiction in which surrogate authority to withdraw life-sustaining treatment is triggered by two specific clinical conditions. The case presents a quandary insofar as the clinical facts do not satisfy the triggering conditions, and yet both the appropriate surrogates and the care team agree that withdrawal of life-sustaining treatment is in the best interest of the patient. The paper surveys applicable law across the 50 states and weighs the arguments for and against the inclusion of such triggering conditions in relevant legal regimes. The paper concludes by assessing the various legal and policy options states have for regulating surrogate decision-making authority in light of the moral considerations (including epistemic difficulties), and notes the possibility for conflict within ethics teams arising from the potential tension between prudence, risk-aversion, and moral obligation.     

Negotiating the ‘buffet’ of choice: advances in technology and end-of-life decision-making in the intensive care unit setting

In recent years, increases in medical technologies in the critical care setting have advanced the practice of medicine, enabling patients to live longer while also creating dilemmas for end-of-life decision-making. Clinicians have increasingly been called on to involve patients and family members in decision-making through a process of shared decision-making (SDM), yet less is known about how SDM plays out in the critical care setting and the ways in which clinicians engage in SDM. Using observational data from 14 months of ethnographic fieldwork in two intensive care units and interviews with 33 family members of 25 critically ill patients and 51 clinicians, I explore how clinicians refer to the choices available in medical decision-making paradoxically as a ‘buffet’ of choice while they simultaneously recognise that such rhetoric is misaligned with complex and emotional decision-making, often involving pain and suffering. Lastly, this paper considers the role of SDM and the ways in which clinicians push back on the ‘buffet’ rhetoric and engage in practices to guide families in end-of-life decision-making by granting permission for families to make decisions and validating their decisions to decline treatment when there is an opportunity for more treatment.     

Complex care and contradictions of choice in the safety net

This article explores the complicated and often‐contradictory notions of choice at play in complex care management (CCM) programmes in the US healthcare safety net. Drawing from longitudinal data collected over two years of ethnographic fieldwork at urban safety‐net clinics, our study examines the CCM goal of transforming frequent emergency department (ED) utilisers into ‘active’ patients who will reduce their service utilisation and thereby contribute to a more rational, cost‐effective healthcare system. By considering our data alongside philosopher Annemarie Mol's (2008) conceptualisation of the competing logics of choice and care, we argue that these premises often undermine CCM teams' efforts to support patients and provide the care they need – not only to prevent medical crises, but to overcome socio‐economic barriers as well. We assert that while safety‐net CCM programmes are held accountable for the degree to which their patients successfully transform into self‐managing, cost‐effective actors, much of the care CCM staff provide in fact involves attempts to intervene on structural obstacles that impinge on patient choice. CCM programmes thus struggle between an economic imperative to get patients to make better health choices and a moral imperative to provide care in the face of systemic societal neglect. (A virtual abstract of this paper can be viewed at: https://www.youtube.com/channel/UC_979cmCmR9rLrKuD7z0ycA ).     

Efficacy of Advance Care Planning: A Systematic Review and Meta-Analysis

ObjectiveTo systematically review the efficacy of advance care planning (ACP) interventions in different adult patient populations.DesignSystematic review and meta-analyses.Data SourcesMedline/PubMed, Cochrane Central Register of Controlled Trials (1966 to September 2013), and reference lists.Study SelectionRandomized controlled trials that describe original data on the efficacy of ACP interventions in adult populations and were written in English.Data Extraction and SynthesisFifty-five studies were identified. Study details were recorded using a predefined data abstraction form. Methodological quality was assessed using the PEDro scale by 2 independent reviewers. Meta-analytic techniques were conducted using a random effects model. Analyses were stratified for type of intervention: ‘advance directives’ and ‘communication.’Main Outcomes and MeasuresPrimary outcome measures were completion of advance directives and occurrence of end-of-life discussions. Secondary outcomes were concordance between preferences for care and delivered care, knowledge of ACP, end-of-life care preferences, quality of communication, satisfaction with healthcare, decisional conflict, use of healthcare services, and symptoms.ResultsInterventions focusing on advance directives as well as interventions that also included communication about end-of-life care increased the completion of advance directives and the occurrence of end-of-life care discussions between patients and healthcare professionals. In addition, interventions that also included communication about ACP, improved concordance between preferences for care and delivered care and may improve other outcomes, such as quality of communication.ConclusionsACP interventions increase the completion of advance directives, occurrence of discussions about ACP, concordance between preferences for care and delivered care, and are likely to improve other outcomes for patients and their loved ones in different adult populations. Future studies are necessary to reveal the effective elements of ACP and should focus on the best way to implement structured ACP in standard care.     

Evolving the multiple roles of 'patients' in health-care research: reflections after involvement in a trial of shared decision-making

Objective This paper offers ‘consumer‐led’ reflections by steering group members of a patient‐centred research study involving consumer advocates, patients’ associations and patients, throughout the whole study, from pre‐ to post‐study phases. Original Study Design The study: ‘Shared decision making and risk communication in general practice’ incorporated systematic reviews, psychometric evaluation of outcome measures, and quantitative, qualitative and health economic analyses of a cluster randomized trial of professional skill development, all informed by consumer and patient engagement. Setting and participants The work was produced by a wide collaboration led by researchers from the Department of General Practice, University of Wales College of Medicine, Cardiff, including a consumers’ advisory group and a patients’ association. The study participants were 20 general practitioners from Gwent, their practice staff, and almost 800 patients at these practices. Discussion Consumers and patients contributed to several stages of the research from inception and design, securing of funding, implementation of the protocol, and interpretation and dissemination of the findings. ‘Patient involvement’ research initiatives that include an equally wide variety of ‘user’ participants as ‘health‐professional’ participants, accountable to a ‘Health in Partnership’ funded project, require a user‐led viewpoint to be presented and disseminated. This paper presents reflections on the processes of the research, the interpretations of study findings by the involved parties, and notes how this model is fundamental to effective research in the field of patient‐centred health care if future practice, policy and research are to change.     

Anaesthetists, the discourse on patient fitness and the organisation of surgery

The organization of daily procedures within the operating theatre is considered in terms of rival perspectives on their patient held by surgeon and anaesthetist. The privileging of the surgeon's authority is challenged in anaesthetists' efforts to fabricate a distinctive position on the patient. While surgeons focus on patient as the carrier of disease, for the anaesthetist, the focus is upon the patient's complement of fitness. A postmodern analysis of the organization of surgery reflects the continual struggle between the two specialisms to privilege its particular definition of the surgical patient. In some circumstances, the struggle can have damaging consequences for patient care.     

Free Choice and Patient Best Interests

In medical practice, the doctrine of informed consent is generally understood to have priority over the medical practitioner’s duty of care to her patient. A common consequentialist argument for the prioritisation of informed consent above the duty of care involves the claim that respect for a patient’s free choice is the best way of protecting that patient’s best interests; since the patient has a special expertise over her values and preferences regarding non-medical goods she is ideally placed to make a decision that will protect her interests. In this paper I argue against two consequentialist justifications for a blanket prioritisation of informed consent over the duty of care by considering cases in which patients have imperfect access to their overall best interests. Furthermore, I argue that there are cases where the mere presentation of choice under the doctrine of informed consent is detrimental to patient best interests. I end the paper by considering more nuanced approaches to resolving the conflict between informed consent and the duty of care and consider the option of permitting patients to waive informed consent.     

Initiating decision‐making in neurology consultations: ‘recommending’ versus ‘option‐listing’ and the implications for medical authority

This article compares two practices for initiating treatment decision‐making, evident in audio‐recorded consultations between a neurologist and 13 patients in two hospital clinics in the UK. We call these ‘recommending’ and ‘option‐listing’. The former entails making a proposal to do something; the latter entails the construction of a list of options. Using conversation analysis (CA), we illustrate each, showing that the distinction between these two practices matters to participants. Our analysis centres on two distinctions between the practices: epistemic differences and differences in the slots each creates for the patient’s response. Considering the implications of our findings for understanding medical authority, we argue that option‐listing – relative to recommending – is a practice whereby clinicians work to relinquish a little of their authority. This article contributes, then, to a growing body of CA work that offers a more nuanced, tempered account of medical authority than is typically portrayed in the sociological literature. We argue that future CA studies should map out the range of ways – in addition to recommending – in which treatment decision‐making is initiated by clinicians. This will allow for further evidence‐based contributions to debates on the related concepts of patient participation, choice, shared decision‐making and medical authority.     

Defining effective clinician roles in end-of-life care

OBJECTIVE: Our goal was to determine primary care clinician perceptions of what is important to the provision of quality end-of-life care. STUDY DESIGN: We used ethnography, a qualitative research method involving the use of open-ended semistructured interviews. POPULATION: We included 38 family practice residency faculty from 9 community residency programs of the Affiliated Family Practice Residency Network, Department of Family Medicine, University of Washington School of Medicine. OUTCOMES MEASURED: The roles described by interviewees when discussing their best practices while delivering end-of-life care were compiled. RESULTS: Primary care clinicians organize their delivery of quality end-of-life care predominantly through their relationships with patients and families. They play 3 roles when providing end-of-life care. As consultants, clinicians provide expert medical advice and treatment. As collaborators, they seek to understand the patient and family experience. Seasoned clinicians act as guides, using their personal intuitive knowledge of patient and family to facilitate everyone's growth when providing end-of-life care. CONCLUSIONS: Shifting clinician focus from skills and knowledge toward relationship, meaning, and roles provides new opportunities to improve end-of-life care for patients, families, and clinicians.