Identifying barriers to psychosocial spiritual care at the end of life: a physician group study

OBJECTIVE: The recent literature addresses the need to improve care for dying patients. The purpose of this study was to identify barriers to the psychosocial spiritual care of these patients by their physicians. Psychosocial spiritual care is defined as aspects of care concerning patient emotional state, social support and relationships, and spiritual well-being. The study was an exploratory means for generating hypotheses and identifying directions for interventions, research, and training in care for the dying. DESIGN AND PARTICIPANTS: The study used a qualitative group discussion format. Seventeen physicians at a university-based health sciences center representing 10 areas of medical specialty--including internal medicine, oncology, pediatrics, and geriatrics met in two groups for 20 75-minute discussion sessions over the course of one year. Discussions were recorded, analyzed, and categorized. RESULTS: Barriers to psychosocial spiritual care were grouped into three domains and seven themes. The cultural domain included the themes of training, selection, medical practice environment, and debt/delay. Participants believed that medical selection and training combine to marginalize psychosocial spiritual approaches to patient care, while the practice environment and debt/delay augment emotional isolation and dampen idealism. The organizational domain included the themes of dissatisfaction and time/business. Physicians indicated that the current reimbursement climate and time pressures contribute to dissatisfaction and the tendency to avoid patient psychosocial spiritual issues. The clinical domain included the theme of communication. Physicians were concerned about their ability to communicate nonmedical issues effectively and manage the patient s reactions and needs in the psychosocial spiritual arena. CONCLUSIONS: This study suggests that research and educational approaches to improving the psychosocial spiritual care of the dying by physicians should address barriers at the cultural, organizational, and clinical levels. Suggestions for interventions at various levels are offered.     

The end of autonomy? Reflections on the postprofessional physician.

Of the many characteristics that classify the practice of medicine as a profession, autonomy plays the most important role. There are currently assaults on the profession's ability to select, train, and license its own practitioners and on the medical knowledge base itself, as well as the standards for applying it. This article examines factors contributing to this reduction in autonomy and reviews potential impacts on the profession, patients, payors, health care organizations, and managers.     

Intestinal obstruction from cecal bezoar; a complication of fiber-containing tube feedings

Dietary fiber increases stool bulk, regulates bowel transit time, and decreases intraluminal pressure. Because these actions constitute a natural way to stop diarrhea, a frequent problem with tube feedings, enteral tube feeding manufacturers have marketed several fiber-containing formulae. While bulk-forming agents such as fiber may not be appropriate for every tube-fed patient, we were unable to find any published contraindications to the use of fiber-containing enteral products. We present the case of a seriously ill man who received a fiber-containing tube feeding while also getting intestinal motility-suppressing medications. A large fiber bezoar developed, with resultant mesenteric hemorrhage. We conclude that fiber-containing tube feedings are contraindicated in certain types of patients.     

The family physician looks at occupational health information

Although much is known about occupational and environmental health risks, this information is rarely used by physicians practicing primary-care medicine. As a specialty with roots in the epidemiologic tradition, family medicine should be able to use these data to help care for the individual in the context of the family and community. In this discussion, the historical links between family medicine and epidemiology are reviewed, barriers to the use of epidemiologically derived occupational health information are analyzed, and solutions to the problem of integration are proposed. The relationship between primary care and occupational medicine is a subset of the relationship of clinical practice to epidemiology in general.     

Implementing a physician leader compensation program at a major community hospital

The roles of physician leaders in Canadian hospitals and health regions are becoming more complex and time consuming. Physician leaders are increasingly being seen by hospital boards and executives as key to achieving strategic and operational outcomes. Given the growing importance of these roles and the increasing performance expectations being placed on physician leaders, it is critical that organizations are able to recruit and retain individuals who demonstrate the skills required to fulfill these critical roles or commit themselves to acquiring them.