Mental health and stigma in the medical profession

Until recently, much of the recent upsurge in interest in physician health has been motivated by concerns about improving patient care and patient safety and reducing medical errors. Increasingly, more attention has turned to examining how the management of mental illness among physicians might be improved within the medical profession and one key direction for change is the reduction of stigma associated with mental illness. I begin this article by presenting a brief overview of the stigma process from the general sociological literature. Next, I provide evidence that illustrates how the stigma of mental illness thrives in the medical profession as a result of the culture of medicine and medical training, perceptions of physicians and their colleagues, and expectations and responses of health care systems and organizations. Lastly, I discuss what needs to change by proposing ways of educating and raising awareness regarding mental illness among physicians, discussing approaches to assessing and identifying mental health concerns for physicians and by examining how safe and confidential support and treatment can be offered to physicians in need. I rely on strategically selected studies to effectively draw attention to and support the central themes of this article.     

How patients' trust relates to their involvement in medical care

OBJECTIVES: To examine the connection between patients' trust and their attitudes toward seeking care, participating in medical decision making, and adhering to treatment recommendations. METHODS: Data were collected from a national telephone survey of English-speaking adults (N=553) in 1999. Eligibility requirements were some type of public or private health care coverage and having seen a physician or other health professional at least twice in the past 2 years. Five questions on preferred role in medical care were asked. Trust in physicians and satisfaction with care were separately measured using validated scales. RESULTS: The most significant predictor of patients' preferred role in medical care is trust in the medical profession. Views also varied by sex, age, health, education, income, number of visits/years with physician, past dispute with a physician, and satisfaction with care, but many of these bivariate associations were no longer significant in multivariate regression models. Views varied slightly by trust in the specific physician. There were no racial differences. CONCLUSIONS: A strong connection exists between patients' preferred involvement in medical care and trust in the medical profession, but only a slight connection with trust in their own physician. Increased trust in physicians generally is associated with greater willingness to seek care, to follow recommendations of physicians, and to grant them decisional authority. Higher trust in a specific physician is strongly associated only with greater reported adherence. Although higher trust in the medical profession appears to entail a more deferential role by patients, higher trust is also consistent with more active patient roles such as seeking care and adhering to treatment regimens.     

The application of Ontario human rights legislation to the practice of occupational medicine

Although human rights legislation has important implications for occupational physicians, these implications may be overlooked in the practice of occupational medicine in other countries where human rights legislation may be different. The potential for significant oversights becomes greater as organizations continue to centralize international business support functions, such as occupational health services, operating from a single site. Human rights legislation has important implications with respect to policy decisions upon which an occupational physician has influence. This includes decisions about whether to conduct drug and alcohol testing; the performance of medical examinations; evaluating issues related to health and safety concerns of pregnant employees; and the need to work accommodate those with handicaps as defined by human rights legislation. This article examines the application of the Ontario human rights legislation in these areas.     

Physicians' capability in home health practice: home health nurses' perceptions.

OBJECTIVES: To examine home health nurses' attitudes towards physician capabilities in home health care, and whether nurses' attitudes are associated with their experience, practice setting, degree of physician interaction, or use of home health guidelines. DESIGN: A multiple regression analysis of a 90 item survey on agency characteristics, degree of interaction with physicians, and ratings of physicians capabilities across multiple dimensions of home health practice. SETTING/PARTICIPANTS: 86 registered visiting nurses from seven Chicago-area home health agencies, who averaged 25 home visits and over one hour of direct contact with physicians weekly. MEASUREMENTS: Nurses' ratings of physician capability in home health practice were scaled from 18 survey items with high internal consistency reliability and correlated with nurses' practice characteristics. RESULTS: While most nurses (72%) felt that physicians responded adequately in emergencies and respected them as colleagues (70%), over 70% of respondents did not agree that physicians were adequately trained in home health. A majority of respondents rated physicians negatively on patient education, cross-coverage and availability, discharge planning, support and medical supply services, and insurance issues. Respondents' years of home health experience correlated negatively (p = .004) and degree of contact with physicians correlated positively (p = .05) with ratings of physician capabilities. CONCLUSION: Nurses' attitudes about physicians' performance can provide important insights for improving the effectiveness of specialized disease and outcomes management programs which rely on care in the home setting.     

Factors associated with self-assessed work ability

BACKGROUND: Symptoms and health problems caused or aggravated by work are common. In order to study perceived work ability and associated factors, including those related to work, a closer analysis was undertaken in an occupational health setting. AIMS: This study aimed to analyse self-assessed work ability and its determinants in employees seeking medical advice, with special emphasis on work-related factors. METHODS: During 723 illness-related visits to occupational physicians, questionnaires covering personal data, main health problems, their work relatedness, duration and effect on work ability were completed by the employee and physician. Factors associated with self-assessed work ability were studied in a multinomial logistic regression model. RESULTS: The majority of employees considered themselves as being able or partially able to work despite the health problem. Independent predictors of impaired work ability were mental or musculoskeletal disorders, self-assessed work relatedness of the disease, older age, blue-collar work and short duration of the symptoms. If the patient was convinced about the benefits of work-related interventions, the risk for disability was significantly reduced. CONCLUSIONS: Special attention should be paid to the recognition and modification of potential work-related causes of disability. In addition, patients with partial work ability should be encouraged to stay at work instead of taking sick leave. For effective disability management, accommodated work and other evidence-based interventions are needed at the workplace.     

The changing role of the occupational physician in the private sector: the Canadian experience

The role of the occupational physician in the private sectoris changing. Fewer large corporations maintain medical departmentsfollowing the ‘downsizing’ trend of the late 1980'sand early 1990's and those that do have extensively redefinedthe duties of the corporate medical director, often extendingthese duties to include responsibility for environmental health.Occupational medical services for employees previously coveredby in-house services are now often provided by outsourcing.The private practice of occupational medicine has become themajor growth area of the speciality in both the US and Canada.These trends have been driven primarily by economic imperativesand new management philosophies; the trend may have gone toofar and a ‘rightsizing’ correction may be in progress.However, it is not clear that corporations in general are derivingthe greatest value they can from their physicians or that thecurrent generation of senior managers is utilizing its healthprofessionals as effectively as they might. This is in partbecause the training, qualifications and capabilities of occupationalphysicians are not well understood. At least as important, however,is persistent confusion over desirable and appropriate rolesthat obscures the potential contribution of the medical professionalwithin a management structure. We suggest that the greatestvalue in occupational medical services may be in the anticipationof risk related to health issues and the flexibility this givesthe organization to manage the problem.     

Quality management of occupational health services: The necessity of a powerful medical profession

Over the past few years there has been a growing interest inquality management in occupational health services. In thisarticle the central role of the medical profession in this areais highlighted from a personal point of view. It is argued thata powerful and active profession is needed as a countervailingpower in the field of tension between employees and the company,and for balancing the interests of these two main clients. Therefore,the medical profession should develop a policy on quality andapply quality management on national and local levels to reacha high professional level. In this way the profession can maintainthe clinical autonomy that is necessary to be a countervailingpower. Elements of such quality management are national guidelines,local peer review and intercolleagual visitation. These activitiesmust be incorporated in the quality management of the occupationalhealth services unit.     

Practising evidence-based occupational health in individual workers: how to deal with a latex allergy problem in a health care setting

BACKGROUND: Natural rubber latex, mainly contained in disposable medical gloves, is an important cause of occupational allergy in health care workers. Management of latex allergy includes education, reduction of cutaneous or mucosal contact with rubber products and minimization of exposure to latex allergens in the work environment. METHODS: This paper reports a case study dealing with the latex allergy health problem of an operating theatre nurse. The examination was required because of a recent onset rhino-conjunctivitis crisis and asthma during usual working activities. The case was investigated and a solution provided according to the evidence-based medicine (EBM) paradigm using the PICO model. RESULTS: The literature search was conducted using Medline and the Cochrane Library. Twenty-one papers were considered to offer appropriate solutions. Two main types of interventions were suggested: (i) changing the work setting, (ii) limiting the work activities. The evidence obtained was discussed with the nurse, who was considered unfit to continue her work in the operating theatre where her colleagues used latex gloves. The resident proposed that she could relocate to a work environment where only non-latex gloves were used and latex medical devices were not present. CONCLUSION: The case study shows that, as for other clinicians, the occupational physician can use the EBM paradigm according to the PICO model as a tool for providing appropriate solutions for the individual worker.     

Facets of Career Satisfaction for Women Physicians in the United States: A Systematic Review

Women make up a growing proportion of the physician workforce, and their career satisfaction may affect their health. The authors hypothesized that many facets adversely affecting career satisfaction in women physicians were extrinsic, therefore, preventable or modifiable. The authors conducted a systematic review of the literature in English published through February 2010 to examine facets of career satisfaction of U.S. women physicians. The authors used the women physician AND job satisfaction OR career satisfaction Medical Subject Headings (MeSH) terms, and reviewed bibliographies of key articles to ensure inclusion of relevant studies. The authors used the “Strengthening the Reporting of Observation Studies in Epidemiology” quality tool. Of an initial 1,000 studies, only 30 met the inclusion criteria. Facets reported most frequently to influence career satisfaction for women physicians were income/prestige, practice characteristics, and personal/family characteristics. Overall, career satisfaction for women and men physicians was 73.4% (range = 56.4% to 90%) and 73.2% (range = 59% to 90%), respectively. When compared with men, women physicians were more concerned with perceived lack of time for relationships with patients, colleagues, and family; less satisfied with mentoring relationships and support from all sources; and less satisfied with career-advancement opportunities, recognition, and salary. Career satisfaction can affect health, as well as health and safety of patients. Many factors adversely affecting career satisfaction for women physicians are extrinsic and, therefore, modifiable.     

Inventory of knowledge and skills relating to disease prevention and health promotion

An inventory of the knowledge and skills appropriate for the instruction of medical students in the disciplines of disease prevention and health promotion was developed by a steering committee of medical practitioners and teachers, with the input of over 70 colleagues. The inventory, which is intended as a guide for curriculum planners, defines the fundamentals of subject areas appropriate for the general education of all physicians, including the skills and knowledge related to delivery of personal disease prevention/health promotion services, quantitative methods, health services organization and delivery, and community dimensions of medical practice, as well as attitudes and philosophy.     

Health promotion referrals in an urban clinic: removing financial barriers influences physician but not patient behavior

PURPOSE: This study describes the prevalence and characteristics of physician health promotion referrals and patient adherence to referrals in a community-based primary care clinic and associated wellness facility. The role of reimbursement for attendance to the wellness facility was specifically examined. DESIGN: Retrospective cohort study. SETTING: The Church Health Center of Memphis, Tennessee: a low-income urban clinic and its affiliated wellness center. SUBJECTS: Patients were primarily African-American, lower-income, urban residents of Shelby County, Tennessee. MEASURES: All study data came from existing medical clinic and wellness facility records of utilization, patient history, and diagnoses. RESULTS: Of 6321 clinic patients, 16.7% (n = 1069) received a provider health promotion referral. Logistic regression analyses identified that physician referral was related to patient factors of access to free wellness-facility membership, employment status, receiving a behavior-related diagnosis, and being African-American and female. Of patients receiving a referral 17.2% (n = 184) adhered to this advice and visited the wellness facility. New patients were more likely to adhere to a referral than established patients. CONCLUSION: Demographic, financial, and patient characteristics influenced whether health behavior change referrals were made by primary care physicians in a community clinic. Removing financial barriers did not influence patient adherence, but new patients were more likely to follow the recommendation than those previously seen at the clinic.     

Biomarkers, screening and ethics

Rapid scientific advances, such as those in biomarker technology,have made a significant impact on the ethics and practice ofoccupational health. Biomarkers are extensively used in occupationalhealth practice. In the pre-employment stage, preventive orpredictive testing can be performed. Preventive testing aimsto avert accidents that may occur if a medically unfit workerundertakes a job that he is unable to perform. For safety sensitivejobs, routine testing of a worker's functional capacity in theactual job would suffice in most cases. However, a recentlyquotes application of a test is the screening for mutationsof the cardiac myosin-heavy chain and troponin genes among asymptomaticpersons with a family history of sudden death from hypertrophicobstructive cardiomyopathy. Predictive testing hopes to forecastthe risk of a worker developing an illness. The aims may vary.One aim may be to exclude a susceptible worker from workingin a hazardous environment. Another aim may be to avoid employmentof a worker who is likely to develop an illness which couldlead to higher employer health care costs. A pertinent questionto consider is whether the test undertaken is to benefit theindividual or to fulfil some administrative or financial need.Among exposed workers, screening may be conducted for biomarkersof exposure or effect. As the aim is to prevent the onset ofclinical illness, the physician must take responsibility forinitiating requests for screening. The appropriate responseto the effect of technical and societal advances on ethics isthe updating of ethical guidelines by the profession. However,in the context of unvalidated biomarkers being used for screening,it may be necessary to require a regulatory body to ensure thatthe tests are accurate and effective, and that they are notused to discriminate against individuals.     

Facets of career satisfaction for women physicians in the United States: a systematic review

Women make up a growing proportion of the physician workforce, and their career satisfaction may affect their health. The authors hypothesized that many facets adversely affecting career satisfaction in women physicians were extrinsic, therefore, preventable or modifiable. The authors conducted a systematic review of the literature in English published through February 2010 to examine facets of career satisfaction of U.S. women physicians. The authors used the women physician AND job satisfaction OR career satisfaction Medical Subject Headings (MeSH) terms, and reviewed bibliographies of key articles to ensure inclusion of relevant studies. The authors used the "Strengthening the Reporting of Observation Studies in Epidemiology" quality tool. Of an initial 1,000 studies, only 30 met the inclusion criteria. Facets reported most frequently to influence career satisfaction for women physicians were income/prestige, practice characteristics, and personal/family characteristics. Overall, career satisfaction for women and men physicians was 73.4% (range = 56.4% to 90%) and 73.2% (range = 59% to 90%), respectively. When compared with men, women physicians were more concerned with perceived lack of time for relationships with patients, colleagues, and family; less satisfied with mentoring relationships and support from all sources; and less satisfied with career-advancement opportunities, recognition, and salary. Career satisfaction can affect health, as well as health and safety of patients. Many factors adversely affecting career satisfaction for women physicians are extrinsic and, therefore, modifiable.     

Wellness:

The American health care system has gone through various stages of development over the past decades. The stages range from a physician dominated medical model to the currently emerging Wellness era in which alternative delivery systems are being designed. These changes in the direction of health care are designed to reduce health care costs and also to promote healthier life styles. Wellness, however, is not a new concept. Occupational therapy has espoused and practiced its principles since its inception as a profession over seventy years ago. This paper looks at the historical development of the health care system and relates the growth of the wellness movement to occupational therapy practice. It suggests that the profession was a forerunner to current wellness activity. Finally, it explores research projects and the creation of occupational therapy positions and curricular alterations to meet the needs of the current wellness movement.     

Concierge,Wellness, and Block Fee Models of Primary Care: Ethical and Regulatory Concerns at the Public–Private Boundary

In bioethics and health policy, we often discuss the appropriate boundaries of public funding; how the interface of public and private purchasers and providers should be organized and regulated receives less attention. In this paper, I discuss ethical and regulatory issues raised at this interface by three medical practice models (concierge care, executive wellness clinics, and block fee charges) in which physicians provide insured services (whether publicly insured, privately insured, or privately insured by public mandate) while requiring or requesting that patients pay for services or for the non-insured services of the physicians themselves or their associates. This choice for such practice models is different from the decision to design an insurance plan to include or exclude user fees, co-payments and deductibles. I analyze the issues raised with regards to familiar health care values of equity and efficiency, while highlighting additional concerns about fair terms of access, provider integrity, and fair competition. I then analyze the common Canadian regulatory response to block fee models, considering their extension to wellness clinics, with regards to fiduciary standards governing the physician–patient relationship and the role of informed consent. I close by highlighting briefly issues that are of common concern across different fundamental normative frameworks for health policy.     

Good medical practice: guidance for occupational physicians

Following a catalogue of serious, highly publicized medical misdemeanours, the General Medical Council (GMC) has introduced plans for a new system of medical licensing in the UK called 'revalidation'. Under this, the onus will fall on individual doctors, including occupational physicians, to demonstrate their continuing fitness to practice. Doctors will need to show that they meet basic minimum standards in terms of the care they provide, their own continuing professional development, and other aspects of professional life like probity and ethical behaviour. As part of the process, the Faculty of Occupational Medicine, Royal College of Physicians, has produced its own guidance on good medical practice for occupational physicians, following an extensive consultation exercise. This paper summarizes the background to the initiative, the development process and the standards that have been recommended to aid professional accountability.     

Payment mechanism and patterns of use of medical services: the example of hypertension

This study explores the relationship between the use of medical services by hypertensive patients and mechanisms for payment within a single primary care practice. Three payment mechanisms were explored: public assistance, a capitated health maintenance organization (HMO), and fee-for-service. Patterns were examined across reimbursement type for the following variables: age, sex, visit reason, number of visits, medications, tests ordered, referrals made, and recommendations for follow-up visits. Illness severity was controlled in two ways: (1) by the study being focused on one diagnosis--mild to moderate hypertension, and (2) by concurrent chronic illnesses being enumerated and included in the analysis. Medical visits to the physician were examined over a 2-year period for 25 to 30 patients randomly sampled from each of the three payment mechanisms. Statistically significant differences were found for patient behaviors (total number of patient visits) and physician behaviors (number of medications and recommendations for revisits). The highest visit frequency was found for those on public assistance, followed closely by those covered by an HMO, and more distantly by those choosing fee-for-service. In a climate of cost consciousness, further study is needed to explore the impact of reimbursement mechanisms on the use of health care services.     

Family physicians' personal experiences of their fathers' health care.

OBJECTIVES: The American health care system is complicated and can be difficult to navigate. The physician who observes the care of a family member has a uniquely informed perspective on this system. We hoped to gain insight into some of the shortcomings of the health care system from the personal experiences of physician family members. STUDY DESIGN: Using a key informant technique, we invited by E-mail any of the chairpersons of US academic departments of family medicine to describe their recent personal experiences with the health care system when their parent was seriously ill. In-depth semi-structured telephone interviews were conducted with each of the study participants. The interviews were transcribed, coded, and labeled for themes. POPULATION: Eight family physicians responded to the E-mail, and each was interviewed. These physicians had been in practice for an average of 19 years, were nationally distributed, and included both men and women. Each discussed their father's experience. RESULTS: All participants spoke of the importance of an advocate for their fathers who would coordinate medical care. These physicians witnessed various obstacles in their fathers's care, such as poor communication and fragmented care. As a result, many of them felt compelled to intervene in their fathers' care. The physicians expressed concern about the care their fathers received, believing that the system does not operate the way it should. CONCLUSIONS: Even patients with a knowledgeable physician family member face challenges in receiving optimal medical care. Patients might receive better care if health care systems reinforced the role of an accountable attending physician, encouraged continuity of care, and emphasized the value of knowing the patient as a person.     

The receptivity to and the feasibility of patient education for patients of private practice, primary care physicians.

This article describes a study of the receptivity to and the feasibility of a patient education service for patients of private practice, primary care physicians. A stratified (by medical specialty), random sample of 400 private practice, primary care physicians in the State of Maryland was selected from the State medical society roster. In addition, a random sample of 800 health care consumers was selected from a listing of residents in a five county area of Maryland. Questionnaires were developed, pilot tested, revised, and eventually mailed to the physician and consumer samples. Completed questionnaires were obtained from 140 physicians and from 314 consumers. Results indicated that both physicians and consumers were receptive to patient education in the private practice medical setting. Based upon the findings, recommendations are offered regarding the manner in which patient education in a private practice medical setting should be organized.