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Objective To examine how much oncologists tell patients about the survival benefit of palliative chemotherapy during consultations at which decisions about treatment are made. Design Qualitative study in which consultations were observed and digitally recorded. Setting Teaching hospital and district general hospital in south west England. Participants 37 patients with advanced non-small cell lung cancer (n=12), pancreatic cancer (n=13), and colorectal cancer (n=12); and nine oncologists, including four consultants and five registrars. Main outcome measures All recordings were transcribed completely, anonymised, and electronically coded with ATLAS.ti. Constant comparison was used to identify themes and patterns. The framework method of data management, in which data were charted, was used to aid transparency of interpretation. Results During the consultations, information given to patients about survival benefit included numerical data ("about four weeks"), an idea of timescales ("a few months extra"), vague references ("buy you some time"), or no mention at all. In most consultations (26/37) discussion of survival benefit was vague or non-existent. Conclusions Most patients were not given clear information about the survival gain of palliative chemotherapy. To aid decision making and informed consent, we recommend that oncologists sensitively describe the benefits and limitations of this treatment, including survival gain. [ABSTRACT FROM AUTHOR]

Objective To assess the effects on patients, clinicians, and the healthcare system of interventions before consultations to help patients or their representatives gather information in consultations by question asking. Design Systematic review with meta-analysis. Data sources Electronic literature searches of seven databases and hand searching of one journal and bibliographies of relevant articles. Review methods Inclusion criteria included randomised controlled trials. Main outcome measures Primary outcomes were question asking; patients' anxiety, knowledge, and satisfaction; and length of consultation. Results 33 randomised trials of variable quality involving 8244 patients were identified. A few studies showed positive effects. Meta-analyses showed small and statistically significant increases in question asking (standardised mean difference 0.27, 95% confidence interval 0.19 to 0.36) and patients' satisfaction (0.09, 0.03 to 0.16). Non-statistically significant changes occurred in patients' anxiety before consultations (weighted mean difference -1.56, -7.10 to 3.97), patients' anxiety after consultations (standardised mean difference -0.08, -0.22 to 0.06), patients' knowledge (-0.34, -0.94 to 0.25), and length of consultation (0.10, -0.05 to 0.25). Interventions comprisingwritten materials had similar effects on question asking, consultation length, and patients'satisfaction as those comprising the ¦ coaching of patients. Interventions with additional training of clinicians had little further effect than those targeted at patients alone for patients' satisfaction and consultation length. Conclusions Interventions for patients before consultations produce small benefits for patients. This may be because patients and clinicians have established behaviours in consultations that are difficult to change. Alternatively small increases in question asking may not be sufficient to make notable changes to other outcomes. [ABSTRACT FROM AUTHOR]

Objective To examine whether doctors' global assessments of treatment effects agree with patients' global assessments. Design Survey of trials included in systematic reviews of treatments for diverse conditions. Data sources Cochrane database of systematic reviews. Data extracted Data on patients' global assessments and on doctors' global assessment for the same treatment against the same comparator. Main outcome measures Relative odds ratio (ratio of odds ratios of global improvement with the experimental intervention versus control according to doctors compared with patients), and improvement rates according to doctors and patients. Results Doctors' global assessments were compared with patients' global assessments for 63 different treatment comparisons (240 trials) in 18 conditions. The summary relative odds ratio across the comparisons was not significant (0.98, 95% confidence interval 0.88 to 1.08; I2=O%, 95% confidence interval 0% to 30%). In 62 of the 63 comparisons the effects of treatment rated by patients and by doctors did not differ beyond chance, but for single comparisons the confidence intervals were large. Rates of improvement on average did not differ between doctors' assessments and patients' assessments (summary relative odds ratio 0.98,0.88 to 1.06; I2=O%, 0% to 24%). Conclusion Doctors' global assessments of the effects of treatments are on average similar to those of patients. [ABSTRACT FROM AUTHOR]

The article presents an overview of the methods physicians should use to assess and manage medically unexplained symptoms in their patients. A discussion of difficulties physicians often have when attempting to determine whether patients actually have medically unexplained symptoms or some type of somatoform disorder is presented. The psychological aspects of disease and of medically unexplained symptoms are examined. The role diagnostic testing plays in reassuring patients with medically unexplained symptoms is discussed.

The article presents an overview of the management of bloody diarrhea in children, which is uncommon in most children and can indicate the presence of serious disease. A discussion of the prevalence of bloody diarrhea in children, and of the most likely causes of it, is presented. The proper investigation of bloody diarrhea and intestinal infections in children by physicians is discussed. Cases where physicians should suspect inflammatory bowel disease in children who present with bloody diarrhea are examined. INSET: SUMMARY POINTS.

The article presents an overview of the management of depression in adults. A discussion of the difficulties which are associated with diagnosing depression, and of the factors which should be taken in to consideration when deciding on a management plan for a patient's depression, is presented. The appropriate types of treatment settings which should be used with depressed patients and the proper management of patients whose depression has reached the acute phase, is discussed. The differences between minor and major depressive episodes are examined.

The article presents an overview of the Mental Capacity Act of 2005 and on the impact the act will have on physicians in England and Wales since its implementation in 2007. A discussion of the act's purpose, what physicians need to know about it, and the independent mental capacity advocates service, is presented. Subjects related to the act, including the lasting power of attorney, advance decisions and the court of protection, are discussed. The act's directives for treating patients with mental disorders are examined.

ABSTRACT Objective Rapid diagnostic tests for malaria seem cost effective in standard analyses, but these do not take account of clinicians' response to test results. This study tested the impact of clinicians' response to rapid diagnostic test or microscopy results on the costs and benefits of testing at different levels of malaria transmission and in different age groups. Design Cost-benefit analysis using a decision tree model and clinical data on the effectiveness of diagnostic tests for malaria, their costs, and clinicians' response to test results. Setting Tanzania. Methods Data were obtained from a clinical trial of 2425 patients carried out in three settings of varying transmission. Results At moderate and low levels of malaria transmission, rapid diagnostic tests were more cost beneficial than microscopy, and both more so than presumptive treatment, but only where response was consistent with test results. At the levels of prescription of antimalarial drugs to patients with negative tests that have been found in observational studies and trials, neither test method is likely to be cost beneficial, incurring costs 10-250% higher, depending on transmission rate, than would have been the case with fully consistent responses to all test results. Microscopy becomes more cost beneficial than rapid diagnostic tests when its sensitivity under operational conditions approaches that of rapid diagnostic tests. Conclusions Improving diagnostic methods, including rapid diagnostic tests, can reduce costs and enhance the benefits of effective antimalarial drugs, but only if the consistency of response to test results is also improved. Investing in methods to improve rational response to tests is essential. Economic evaluations of diagnostic tests should take into account whether clinicians' response is consistent with test results. [ABSTRACT FROM AUTHOR]

Objective To determine the impact of a simple educational package for general practitioners on adherence to antihypertensive drugs. Design Cluster randomised controlled trial. Setting Six randomly selected communities in Karachi, Pakistan. Participants 200 patients with hypertension taking antihypertensive drugs; 78 general practitioners. Intervention Care by general practitioners specially trained in management of hypertension compared with usual care. Main outcome measure Correct dosing, defined as percentage of prescribed doses taken, measured with electronic medication event monitoring system (MEMS) bottle. Results 200 patients were enrolled, and 178 (89%) successfully completed six weeks of follow-up. Adherence was significantly greater in the special care group than in the usual care group (unadjusted mean percentage days with correct dose 48.1%, 95% confidence interval 35.8% to 60.4%, versus 32.4%, 22.6% to 42.3%; P=0.048). Adherence was also higher among patients who had higher levels of education (P<0.001), were encouraged by family members (P<0.001), believed in the effect of drugs (P<0.001), and had the purpose of the drugs explained to them (P<0.001). Conclusions Special training of general practitioners in management of hypertension, emphasising good communication between doctors and patients, is more effective than usual care provided in the communities in Karachi. Such simple interventions should be adopted by other developing countries that are now facing an increasing burden of hypertension. [ABSTRACT FROM AUTHOR]

ABSTRACT Objective To explore views of patients with type 2 diabetes about self monitoring of blood glucose over time. Design Longitudinal, qualitative study. Setting Primary and secondary care settings across Lothian, Scotland. Participants 18 patients with type 2 diabetes. Main outcome measures Results from repeat in-depth interviews with patients over four years after clinical diagnosis. Results Analysis revealed three main themes--the role of health professionals, interpreting readings and managing high values, and the ongoing role of blood glucose self monitoring. Self monitoring decreased over time, and health professionals' behaviour seemed crucial in this: participants interpreted doctors' focus on levels of haemoglobin Alc, and lack of perceived interest in meter readings, as indicating that self Monitoring was not worth continuing. Some participants saw readings as a proxy measure of good and bad behaviour-with women especially, chastising themselves when readings were high. Some participants continued to find readings difficult to interpret, with uncertainty about how to respond to high readings. Reassurance and habit were key reasons for continuing. There was little indication that participants were using self monitoring to effect and maintain behaviour change. Conclusions Clinical uncertainty about the efficacy and role of blood glucose self monitoring in patients with type 2 diabetes is mirrored in patients' own accounts. Patients tended not to act on their self monitoring results, in part because of a lack of education about the appropriate response to readings. Health professionals should be explicit about whether and when such patients should self monitor and how they should interpret and act upon the results, especially high readings. [ABSTRACT FROM AUTHOR]

Objective To review the evidence of effectiveness of dressings applied to venous leg ulcers. Design Systematic review and meta-analysis. Data sources Hand searches of journals and searches of electronic databases, conference proceedings, and bibliographies up to April 2006; contacts with dressing manufacturers for unpublished studies. Studies reviewed All randomised controlled trials that evaluated dressings applied to venous leg ulcers were eligible for inclusion. Data from eligible studies were extracted and summarised independently by two reviewers using a data extraction sheet. Methodological quality was assessed independently by two reviewers. Results The search strategy identified 254 studies; 42 of these fulfilled the inclusion criteria. Hydrocolloids were no more effective than simple low adherent dressings used beneath compression (eight trials; relative risk for healing with hydrocolloid 1.02, 95% confidence interval 0.83 to 1.28). For other comparisons, insufficient Evidence was available to allow firm conclusions to be drawn. None of the dressing comparisons showed evidence that a particular class of dressing healed more ulcers. Some differences existed between dressings in terms of subjective outcome measures and ulcer healing rates. The results were not affected by the size or quality of trials or the unit of randomisation. Insufficient data were available to allow conclusions to be drawn about the relative cost effectiveness of different dressings. Conclusions The type of dressing applied beneath compression was not shown to affect ulcer healing. The results of the meta-analysis showed that applying hydrocolloid dressings beneath compression produced no benefit in terms of ulcer healing compared with applying simple low adherent dressings. No conclusive recommendations can be made as to which type of dressing is most cost effective. Decisions on which dressing to apply should be based on the local costs of dressings and the preferences of the practiti [ABSTRACT FROM AUTHOR]

The article presents the author's opinions on dignity conserving care in medicine. Arguments are presented which suggest that the more that healthcare providers are able to affirm the patient's value, and see the person that they are or were, rather than just their illness, the more likely the patient's sense of dignity will be upheld, and that those patients who do not retain their dignity may feel that they are only a burden and question the point of their existence. Suggestions for changes which physicians can make to help patients keep their dignity, including examining their own attitudes, changing their own behaviors, using compassion, and engaging in dialogue, are offered.

The article presents information for physicians to help manage acute psychotic episodes seen in patients. An overview of the prevalence of psychosis in society worldwide is presented. A discussion of factors which should be considered when attempting to diagnose psychosis including getting a patient history, getting a mental health history from a patient's family members, performing a mental state examination, and ruling out medical causes for the alleged psychotic behavior is presented. The symptoms treatment and management of acute psychosis disorders including schizophrenia are discussed.

The article discusses the role that non-governmental organizations play in physician assisted suicide in Oregon and Switzerland. Physician assisted suicide is defined as a procedure where a doctor legally gives a lethal dose of drugs to a patient for self-administration. The non-governmental organization Exit operates in Switzerland and facilitates assisted suicides. The organization Compassion and Choices supports, educates, advocates, and litigates for improvements in end of life care and choices.

The article reports on a randomized controlled trial that sought to assess the effect of agenda forms for consultation completed by patients and of doctor's education on identifying the concerns of patients based on the information provided in the forms. The study took place in general practices in Great Britain. The study measured the number of problems identified, the time required to manage them, the duration of consultations, the number of "by the way" questions and patient satisfaction.

The article focuses on the determinants of medical care and the issue of conscientious objection in delivering health care. Examples are given showing how doctors and pharmacists' values have not respected patients' autonomy in the United States. The arguments for and against conscientious objection are mentioned, including the resulting inequity and inefficiency in public medicine. The author suggests that doctors who compromise a patient's care should be disciplined.

Objective To document patients' preferred dress styles of their doctors and modes of address. Design Descriptive survey. Setting Inpatients and outpatients at a tertiary level hospital, New Zealand. Participants 202 inpatients and 249 outpatients, mean age 55.9 (SD 19.3) years. Main outcome measures Ranking of patients' opinions of photographs showing doctors wearing different dress styles. A five point Likert scale was used to measure patient comfort with particular items of appearance. Results Patients preferred doctors to wear semiformal attire, but the addition of a smiling face was even better. The next most preferred styles were semiformal without a smile, followed by white coat, formal suit, jeans, and casual dress. Patients were more comfortable with conservative items of clothing, such as long sleeves, covered shoes, and dress trousers or skirts than with less conservative items such as facial piercing, short tops, and earrings on men. Many less conservative items such as jeans were still acceptable to most patients. Most patients preferred to be called by their first name, to be introduced to a doctor by full name and title, and to see the doctor's name badge worn at the breast pocket. Older patients had more conservative preferences. Conclusions Patients prefer doctors to wear semiformal dress and are most comfortable with conservative items; many less conservative items were, however, acceptable. A smile made a big difference. [ABSTRACT FROM AUTHOR]

The article considers challenges that physicians face when learning in the workplace. It suggests that workplace learning means finding solutions to clinical problems when they arise, or soon after, with minimum effort. The importance of asking clear questions is mentioned. The article refers to sources of information for the physician when faced with a difficulty question. It suggests ways that doctors can maintain their enthusiasm for looking up answers to clinical questions, such as keeping a log book of questions answers and sharing insights. The article concludes that barriers to workplace learning can be overcome but a slight cultural change in the medical profession is needed. It provides a list of possible cultural changes associated with workplace learning.

Examines the psychological impact of chronic diseases on patients and physicians. Impact of chronic diseases on world health systems; Suggestion that a lack of possible cure for chronic diseases causes frustration on the part of physicians; Discussion of treating the chronic diseases of patients in high security psychiatric facilities; Significance of collaborative care management on chronic care; Emphasis on the need for health care providers to address psychological aspects of chronic disease; Recommendations for shaping physician and patient interactions in chronic care; Need for increased training of medical care providers working with chronically ill patients.

Discusses models of payment in the care of patients with chronic diseases. Impact of chronic diseases on world health care systems; Critique of the current fee-for-service payment model; Description of a fee-for-condition payment model, which would allow patients to pay a set fee determined by their established condition; Methods for determining payments in a fee-for-condition model; Significance of outcome data provided by health care personnel to ensuring the effectiveness of care; Impact of a fee-for-condition payment model on health care quality and physician and patient relations.

Objective To evaluate a training intervention aimed at improving healthcare professionals' communication with cancer patients about randomised clinical trials. Design Before and after evaluation of training programme. Setting Members of the National Cancer Research Network, Scottish Trials Network, and the Welsh Cancer Trials Network Participants 101 healthcare professionals (33 clinicians and 68 research nurses). Intervention Four modules delivered by a trained facilitator using videotapes and interactive exercises to cover general issues about discussing randomised clinical trials with patients, problems specific to adjuvant trials, trials with palliation as the goal, and trials where patients had a strong preference for one treatment arm. Main outcome measures Before and after the intervention, participants were videotaped discussing a trial with an actor portraying a patient. These consultations were assessed for presence of information required by good clinical practice guidelines. The actor patients gave an assessment after each interview. Participants reported their self confidence about key aspects of trial discussion. Results Analysis of the videotaped consultations showed that, after intervention, significantly more participants displayed key communication behaviours such as explaining randomisation (69 v 81, odds ratio 2.33, P = 0.033), checking patients' understanding (11 v 31, odds ratio 3.22, P = 0.002), and discussing standard treatment (73 v 88, odds ratio 4.75, P = 0.005) and side effects (69 v 85, odds ratio 3.29, P = 0.006). Participants' self confidence increased significantly (P< 0.001) across all areas. Actor patients' ratings of participants' communication showed significant improvements for 12/15 key items. Conclusion This intensive 8 hour intervention significantly improved participants' confidence and competence when communicating about randomised clinical trials. [ABSTRACT FROM AUTHOR]

Examines fine art work that depicts the patient-doctor relationship. Self portrait of Francisco Goya with his physician which he painted in gratitude for treatment; Piece by Scottish painter John Bellany who charted the course of a liver transplant and healing; The work of Vincent Van Gogh who suffered many recurrent illness; Norwegian artist, Edvard Munch who sketched his mental health care; Mexican artist Frida Kahlo who illustrated her relationships with two doctors; Renditions of Richard Dadd.

Focuses on the controversy over publishing individual surgeon's outcome results, measured by postoperative mortality in Great Britain. Effort of the Society of Cardiothoracic Surgeons of Great Britain and Ireland to address perceived deficiencies during the Bristol Royal Infirmary Inquiry; Reason for choosing in-hospital mortality as a performance measure; The argument of patient choice in publishing individual physician's outcomes for medical and surgical interventions; Comparative cardiac surgery reporting programs in the United States; The national service framework for coronary heart disease and its relation to the Society of Cardiothoracic Surgeons' clinical data; The usefulness of crude mortality in setting confidence limits or standards for cardiac surgery.

Focuses on the pros and cons of electronic mail messages in the delivery of health care. Public and professional attitude concerning email consultations; Research on physician-patient communication; Issues of privacy and secure patient information; Features of software for email consultations in clinical practice.

Objective To obtain feedback from patients receiving palliative care and their relatives from various ethnic backgrounds about their experiences of the disclosure process and their satisfaction with information sharing during the illness. Design A qualitative study with semistructured single interviews. Setting Perth, Western Australia, and Winnipeg, Manitoba, Canada. Participants 72 participants registered with palliative care: 21 patient-family dyads in Perth and 14 dyads and 2 patients in Winnipeg. Results Participants described their experiences in great detail. The analysis indicates that in information sharing the process is as important as the content. The timing, management, and delivery of information and perceived attitude of practitioners were critical to the process. This applied to information interactions at all stages of the illness. Main content areas mentioned related to prognosis and hope. Hope can be conveyed in different ways. Secondary information from various sources is accessed and synthesized with the primary information. All patients, regardless of origin, wanted information about their illness and wanted it fully shared with relatives. Almost all patients requested prognostic information, and all family members respected their wishes. Information was perceived as important for patient-family communication. Information needs of patient and family changed and diverged as illness progressed, and communication between them became less verbally explicit. Conclusions Information delivery for patients needs to be individualized with particular attention to process at all stages of illness. Patients and families use secondary sources of information to complement and verify information given by health carers. [ABSTRACT FROM AUTHOR]

Objectives To identify the ways in which patients with medically unexplained symptoms present their problems and needs to general practitioners and to identify the forms of presentation that might lead general practitioners to feel pressurized to deliver somatic interventions. Design Qualitative analysis of audiorecorded consultations between patients and general practitioners. Setting 7 general practices in Merseyside, England. Participants 36 patients selected consecutively from 21 general practices, in whom doctors considered that patients' symptoms were medically unexplained. Main outcome measures Inductive qualitative analysis of ways in which patients presented their symptoms to general practitioners. Results Although 34 patients received somatic interventions (27 received drug prescriptions, 12 underwent investigations, and four were referred), only 10 requested them. However, patients presented in other ways that had the potential to pressurize general practitioners, including graphic and emotional language; complex patterns of symptoms that resisted explanation; description of emotional and social effects of symptoms; reference to other individuals as authority for the severity of symptoms; and biomedical explanations. Conclusions Most patients with unexplained symptoms received somatic interventions from their general practitioners but had not requested them. Though such patients apparently seek to engage the general practitioner by conveying the reality of their suffering, general practitioners respond symptomatically. [ABSTRACT FROM AUTHOR]

Objective To determine how patients with breast cancer want their doctors to communicate with them. Design Qualitative study. Setting Breast unit and patients' homes. Participants 39 women with breast cancer. Main outcome measure Patients' reports of doctors' characteristics or behaviour that they valued or deprecated. Results Patients were not primarily concerned with doctors' communication skills. Instead they emphasised doctors' enduring characteristics. Specifically, they valued doctors whom they believed were technically expert, had formed individual relationships with them,and respected them.They therefore valued forms of communication that are currently not emphasised in training and research and did not intrinsically value others that are currently thought important, including provision of information and choice. Conclusions Women with breast cancer seek to regard their doctors as attachment figures who will care for them.They seek communication that does not compromise this view and that enhances confidence that they are cared for. Testing and elaborating our analysis will help to focus communication research and teaching on what patients need rather than on what professionals think they need. [ABSTRACT FROM AUTHOR]

Abstract Objective To explore management by general practitioners of victimised female patients, male partners who abuse, and children in the family. Design Triangulated qualitative study comparing doctors' reported management with current recommendations in the literature. Participants 28 general practitioners attending continuing medical education about management of domestic violence. Results Doctors perceived partner abuse in diverse ways. Their gender, perceptions, and attitudes could all affect identification and management of this difficult problem. A few doctors practised in recommended ways, but many showed stress and aversion, difficulties in resolving the tensions involved in managing all family members, and neglect of the risks to children. Some doctors used contraindicated practices, such as breaking confidentiality and undertaking or referring for couple counselling. Doctors who were not familiar with community based agencies were reluctant to use them. A lack of expertise and support could have a negative impact on doctors themselves. Conclusions General practitioners managing partner abuse need to be more familiar with and apply the central principles of confidentiality and safety of women and children. Recommended guidelines for managing the whole family should be developed. Doctors should consider referring one partner elsewhere and avoid couple counselling; always ask about and act on the children's welfare; refer to specialist family violence agencies; and seek training, supervision, and support for the inherent stress. Medical education and administration should ensure comprehensive training and support for doctors undertaking this difficult work.. [ABSTRACT FROM AUTHOR]

Abstract Objective: To assess the impact of leaflets encouraging patients to raise concerns and to discuss symptoms or other health related issues in the consultation. Design: Randomised controlled trial. Setting: Five UK general practices in three settings. Participants: 635 consecutive patients, aged 16-80 years, randomised to receive a general leaflet, a depression leaflet, both, or neither. Main outcomes: Mean item score on the medical interview satisfaction scale, consultation time, prescribing, referral, and investigation. Results: The general leaflet increased patient satisfaction and was more effective with shorter consultations (leaflet 0.64, 95% confidence interval 0.19 to 1.08; time 0.31, 0.0 to 0.06; interaction between both -0.045, -0.08 to --0.009), with similar results for subscales related to the different aspects of communication. Thus for a 10 minute consultation the leaflet increased satisfaction by 7% (seven centile points) and for a five minute consultation by 14%. The leaflet overall caused a small non-significant increase in consultation time (0.36 minutes, -0.54 to 1.26). Although there was no change in prescribing or referral, a general leaflet increased the numbers of investigations (odds ratio 1.43, 1.00 to 2.05), which persisted when controlling for the major potential confounders of perceived medical need and patient preference (1.87, 1.10 to 3.19). Most of excess investigations were not thought strongly needed by the doctor or the patient. The depression leaflet had no significant effect on any outcome. Conclusions: Encouraging patients to raise issues and to discuss symptoms and other health related issues in the consultation improves their satisfaction and perceptions of communication, particularly in short consultations. Doctors do, however, need to elicit expectations to prevent needless investigations. [ABSTRACT FROM AUTHOR]

Abstract Objective: To investigate the experiences of professionals who administered and evaluated treatments for homosexuality in Britain since the 1950s. Design: A nationwide study based on qualitative interviews. Participants: 30 health professionals who developed and practised treatments for homosexuality. Results: A range of treatments were developed to make homosexuals into heterosexuals, the most common of which were behavioural interventions. Treatments were based on little evidence of effectiveness and were open to the criticism that legal or social pressures coerced patients. Treatments did not become mainstream within British mental health services. With hindsight, professionals realised that they had not appreciated the influence of social context on sexual behaviour. Most now regarded same sex attraction as compatible with psychological health, although a small minority considered that the option to try to become heterosexual should still be available to patients who desire it. Conclusions Social and political assumptions sometimes lie at the heart of what we regard as mental pathology and serve as a warning for future practice. [ABSTRACT FROM AUTHOR]

Abstract Objectives: To explore how general practitioners operate the sickness certification system, their views on the system, and suggestions for change. Design: Qualitative focus group study consisting of 11 focus groups with 67 participants. Setting: General practitioners in practices in Glasgow, Tayside, and Highland regions, Scotland. Sample: Purposive sample of general practitioners, with further theoretical sampling of key informant general practitioners to examine emerging themes. Results: General practitioners believed that the sickness certification system failed to address complex, chronic, or doubtful cases. They appeared to develop various operational strategies for its implementation. There seemed to be important deliberate misuse of the system by general practitioners, possibly related to conflicts about roles and incongruities in the system. The doctor-patient relationship was perceived to conflict with the current role of general practitioners in sickness certification. When making decisions about certification, the general practitioners considered a wide variety of factors. They experienced contradictory demands from other system stakeholders and felt blamed for failing to make impossible reconciliations. They clearly identified the difficulties of operating the system when there was no continuity of patient care. Many wished either to relinquish their gatekeeper role or to continue only with major changes. Conclusions: Policy makers need to recognise and accommodate the range and complexity of factors that influence the behaviour of general practitioners operating as gatekeepers to the sickness certification system before making changes. Such changes are otherwise unlikely to result in improvement. Models other than the primary care gatekeeper model should be considered. [ABSTRACT FROM AUTHOR]

Presents observations about what it is important to tell young medical students about medicine as a profession. Advice for students not to conform to the stereotypes that are associated with doctors; Importance of understanding the limitations and complexities of modern medicine; How it is normal for medical students to feel ignorant on various topics; Ways the nurture the relationships between doctors and patients; Value of learning and studying medicine as an intellectual and rewarding exercise.

Abstract Objectives: To identify issues that facilitate the successful integration of evaluation and development of telehealthcare services. Design: Ethnographic study using various qualitative research techniques to obtain data from several sources, including in-depth semistructured interviews, project steering group meetings, and public telehealthcare meetings. Setting: Seven telehealthcare evaluation projects (four randomised controlled trials and three pragmatic service evaluations) in the United Kingdom, studied over two years. Projects spanned a range of specialties--dermatology, psychiatry, respiratory medicine, cardiology, and oncology. Participants: Clinicians, managers, technical experts, and researchers involved in the projects. Results and discussion: Key problems in successfully integrating evaluation and service development in telehealthcare are, firstly, defining existing clinical practices (and anticipating changes) in ways that permit measurement; secondly, managing additional workload and conflicting responsibilities brought about by combining clinical and research responsibilities (including managing risk); and, thirdly, understanding various perspectives on effectiveness and the limitations of evaluation results beyond the context of the research study. Conclusions: Combined implementation and evaluation of telehealthcare systems is complex, and is often underestimated. The distinction between quantitative outcomes and the workability of the system is important for producing evaluative knowledge that is of practical value. More pragmatic approaches to evaluation, that permit both quantitative and qualitative methods, are required to improve the quality of such research and its relevance for service provision in the NHS. [ABSTRACT FROM AUTHOR]

Abstract Objectives: To explore the views of clinicians and lay people about the minimum benefit needed to justify drug treatment to prevent heart attacks, and to explore the rationale behind treatment decisions. Design: Qualitative study using semi-structured interviews. Participants: 4 general practitioners, 4 practice nurses, and 18 lay people. Setting: 8 general practices and 6 community settings across Liverpool. Results: Participants varied widely in the minimum acceptable benefits chosen. Most people found the concepts difficult initially, and few appreciated that increased length of treatment should increase absolute benefits. Lay people usually wanted to make decisions for themselves, and clinicians supported this. Participants wanted to consider adverse effects and costs of treatment. Dislike of drug taking was common, and many people preferred lifestyle change to an imperfect treatment. Quality of life and personal views were more important than an individual's age. Conclusions: Evidence based guidelines make assumptions about people's preferences, and, by using 10 year estimates of risk, inflate the apparent benefits of treatment. It is unlikely that guidelines could incorporate the wide range of people's preferences, and true dialogue is necessary between clinicians and patients before starting long term preventive treatment. [ABSTRACT FROM AUTHOR]

This article discusses effective ways for physicians to explain medical risks to patients. The way doctors communicate risk can affect a patient's perception of risks. Supplement verbal explanations with numerical data and the use of absolute numbers are effective methods. One should not use relative risks or percentage improvements. State the odds from a positive and negative perspective and use a consistent denominator. Use visual aids wherever possible, to maximise understanding. Use of simple visual aids can also improve the doctor-patient relationship. Make sure the patient's informed consent is based on information--not just data.

This article looks at mind tools used for making medical decisions. The inability to understand statistical information is not a mental deficiency of doctors or patients but is largely due to the poor presentation of the information. Poorly presented statistical information may cause erroneous communication of risks, with serious consequences. Single event probabilities, conditional probabilities (such as sensitivity and specificity), and relative risks are confusing because they make it difficult to understand what class of events a probability or percentage refers to. For each confusing representation there is at least one alternative, such as natural frequency statements, which always specify a reference class and therefore avoid confusion, fostering insight. Simple representations of risk can help professionals and patients move from innumeracy to insight and make consultations more time efficient. Instruction in efficient communication of statistical information should be part of medical curriculums and doctors' continuing education.

Epidemiologists have identified a range of risks associated with different patterns of behaviour and the beneficial consequences of changes in behaviour that will reduce preventable disease and premature deaths. The public health response has been to try to reduce risk factors at a population and individual level, especially by communicating information about risks. Hobson-West has examined the nature of the current health promotion and identified three assumptions: Parents make decisions through a comparison of individual risk; Parental concern about vaccination is due to a miscalculation of risk; and A policy of providing more risk statistics is the best response to the controversy. Frewer and Miles have explored the factors that influence the ways in which individuals respond to information about health risks, especially those associated with food. Frewer and Miles argue that trust is particularly important when lack of time or information or the perceived threat of a hazard complicates decision making. Even when official sources of information about the health risks are accepted and individuals may be aware of the risks such as HIV infection, other factors and risks may be seen as more important and may influence continued exposure to the risk of infection or delays in seeking treatment. The mass media play an important part in shaping perceptions of risk. If doctors want to communicate risk effectively to their patients and the public they need to be aware that they are just one source of information and may no longer be the most trusted. Doctors can communicate risk information more effectively if they develop relationships with their patients and if they take into account knowledge and perceptions of health risks in the general public.

Health professionals are increasingly encouraged to involve patients in treatment decisions, recognising patients as experts with a unique knowledge of their own health and their preferences for treatments, health states, and outcomes. We conducted informal interviews with doctors from a range of specialties (general practice, orthopaedics, stroke medicine, accident and emergency, and vascular surgery) and recorded their opinions to provide a focus to this discussion. Medical uncertainty, deficiencies in individual doctors' knowledge, and the highly variable ability of patients to understand and remember clinical information mean that risk communication is often inadequate to support patients in making informed decisions. INSET: Patients' views of being involved in decision making.

Objectives: To describe doctors' emotional reactions to the recent death of an "average" patient and to explore the effects of level of training on doctors' reactions. Design: Cross sectional study using quantitative data. Setting Two academic teaching hospitals in the United States. Participants: 188 doctors (attending physicians (equivalent to UK consultants), residents (equivalent to UK senior house officers), and interns (equivalent to UK junior house officers)) who cared for 68 patients who died in the hospital. Main outcome measures: Doctors' experiences in providing care, their emotional reactions to the patient's death, and their use of coping and social resources to manage their emotions. Results: Most doctors (139/188, 74%) reported satisfying experiences in caring for a dying patient. Doctors reported moderate levels of emotional impact (mean 4.7 (SD 2.4) on a 0-10 scale) from the death. Women and those doctors who had cared for the patient for a longer time experienced stronger emotional reactions. Level of training was not related to emotional reactions, but interns reported needing significantly more emotional support than attending physicians. Although most junior doctors discussed the patient's death with an attending physician, less than a quarter of interns and residents found senior teaching staff (attending physicians) to be the most helpful source of support. Conclusions: Doctors who spend a longer time caring for their patients get to know them better but this also makes them more vulnerable to feelings of loss when these patients die. Medical teams may benefit from debriefing within the department to give junior doctors an opportunity to share emotional responses and reflect on the patient's death. [ABSTRACT FROM AUTHOR]

Discusses how general practitioners have the right to remove patients from their practice list without explaining their decisions. How the process acts as a means for ending professional relationships with problematic patients; Consideration of 393 patients who were removed; Rule that doctors should treat patients as people; Suggestion that practitioners have a clear policy on patient removal that is accessible to patients.

Presents letters to the editor for June 7, 2003. Comment on the statistical method, case selection, and clinical data in a study of mortality associated with foodborne bacterial gastrointestinal infections; Topic of the increased risk of suicides and cancer deaths in a study of mortality in Swedish women with cosmetic breast implants; Opinion that research by Alderson and Chalmers makes inappropriate claims; Concerns about a study on the routine telephone review of asthma and the issue of quality dimension measurement; Consumption of coffee during pregnancy; Doctors as servants of patients.

Describes percutaneous coronary intervention (PCI), and emphasizes the importance of discussing the benefits and risks of the procedure with patients. Likelihood of restenosis after PCI, and the potential for incomplete revascularization compared with bypass surgery; Way that relief of anginal symptoms is the principal clinical indication for percutaneous intervention; Observation that successful PCI depends on adequate visualization of the target stenosis and its adjacent arterial branches; Use of an intra-aortic balloon pump in very high-risk cases; Restenosis within a stent.

Presents letters to the editor on medical topics. View that computer users should design computer interfaces; Opinion that any change in information technology in general practice medicine requires piloting; Comments on an article on ten ways to improve Great Britain's National Health Service; Observation that primary care physicians should become aware of training opportunities; Value of computers in the workplace in medicine; Folate and risk of cardiovascular disease; Opinions on an article about chronic cough; Occurrence of leishmaniasis in Mediterranean countries; Medical experts and the criminal courts; Perception that a statistical monitoring process with high enough sensitivity to detect murder would also give many false-positive signals; View that cleft lip and palate services need to be improved; Argument that insensitivity in physicians should not be encouraged; View that senior medical staff need to be included in severe asthma treatment; Difficulties in giving fully informed consent; Thoughts on the autonomy of children and parenthood.

Objectives: To examine the strengths and weaknesses of the national and local schemes for preregistration house officers to spend four months in general practice, to identify any added value from such placements, and to examine the impact on career choices. Design: Review of all studies that reported on placements of preregistration house officers in general practice. Setting: 19 accounts of preregistration house officers' experience in general practice, ranging from single case reports to a national evaluation study, in a variety of locations in Scotland and England. Participants: Views of 180 preregistration house officers, 45 general practitioner trainers, and 105 consultant trainers. Main outcome measures: Main findings or themes weighted according to number of studies reporting them and weighted for sample size. Results: The studies were unanimous about the educational benefits of the placements. The additional learning included communication skills, social and psychological factors in illness, patient centred consultations, broadening of knowledge base, and dealing with uncertainty about diagnosis and referral. Conclusions: Despite the reported benefits and recommendations of the scheme, it is not expanding. General practitioner trainers reported additional supervision that was unremunerated. The reforms of the senior house officer grade may resolve this problem by offering the placements to senior house officers, who require less supervision. INSETS: Box 1: Experiences gained by preregistration house officers in...;Box 2: Main themes emerging as new areas of learning in...;What is already known on this topic;What this study adds [ABSTRACT FROM AUTHOR]

Discusses the controversy over delivery of clinical care by telephone. Evaluation of evidence that exists to clarify its potential role; How the quality and safety of care can be ensured; Outline of the benefits associated with telephone consultations between patients and physicians.

Objective: To assess the long term effectiveness of the "green prescription" programme, a clinician based initiative in general practice that provides counselling on physical activity. Design: Cluster randomised controlled trial. Practices were randomised before systematic screening and recruitment of patients. Setting: 42 rural and urban general practices in one region of New Zealand. Subjects: All sedentary 40-79 year old patients visiting their general practitioner during the study's recruitment period. Intervention: General practitioners were prompted by the patient to give oral and written advice on physical activity during usual consultations. Exercise specialists continued support by telephone and post. Control patients received usual care. Main outcome measures: Change in physical activity, quality of life (as measured by the "short form 36" (SF-36) questionnaire), cardiovascular risk (Framingham and D'Agostino equations), and blood pressure over a 12 month period. Results: 74% (117/159) of general practitioners and 66% (878/1322) of screened eligible patients participated in the study. The follow up rate was 85% (750/878). Mean total energy expenditure increased by 9.4 kcal/kg/week (P=0.001) and leisure exercise by 2.7 kcal/kg/week (P=0.02) or 34 minutes/week more in the intervention group than in the control group (P=0.04). The proportion of the intervention group undertaking 2.5 hours/week of leisure exercise increased by 9.7% (P=0.003) more than in the control group (number needed to treat= 10). SF-36 measures of serf rated "general health," "role physical," "vitality," and "bodily pain" improved significantly more in the intervention group (P < 0.05). A trend towards decreasing blood pressure became apparent but no significant difference in four year risk of coronary heart disease. Conclusion: Counselling patients in general practice on exercise is effective in increasing physical activity and improving quality of life over 12 months. [ABSTRACT FROM AUTHOR]

Objectives: To examine young people's and parents' accounts of communication about cancer in childhood. Design: Semistructured interviews analysed using the constant comparative method. Setting: Paediatric oncology unit. Participants: 13 families, comprising 19 parents (13 mothers, six fathers) and 13 patients aged 8-17 years. The patients had cancer or brain tumour. Results: Most parents described acting in an executive-like capacity, managing what and how their children were told about their illness, particularly at the time of diagnosis. Their accounts were shaped by concerns to manage their identity as strong and optimistic parents and to protect their child's wellbeing. The patients identified elements of their parents' role that both facilitated and constrained their communication, and while they welcomed their parents' involvement, some expressed unease with the constraining aspects of their parents' role. Some young people described feeling marginalised in consultations and pointed to difficulties they experienced in encounters with some doctors. Conclusions: There are difficulties in managing communication with young people who have a chronic, life threatening illness. Health professionals need to be aware of how the social positioning of young people (relative to adults) and the executive role of parents can contribute to the marginalisation of young people and hamper the development of successful relationships between themselves and young patients. [ABSTRACT FROM AUTHOR]

Reviews empirical research that can guide physicians in decisions of whether to withdraw life support, maximizing patient and family involvement in the decision-making process, and negotiating conflicts that might arise with deaths that occur in intensive care. View that good communication might shorten the dying process; Discussion of withdrawal of life support as a clinical procedure requiring good medical skills, cultural sensitivity, attention to ethical principles, and close collaboration with families.

Abstract Objective To clarify the practice of withholding the artificial administration of fluids and food from elderly patients with dementia in nursing homes. Design Qualitative, ethnographic study in two phases. Setting 10 wards in two nursing homes in the Netherlands. Participants 35 patients with dementia, eight doctors, 43 nurses, and 32 families. Results The clinical course of dementia was considered normal and was rarely reason to begin the artificial administration of fluids and food in advanced disease. Fluids and food seemed to be given mainly when there was an acute illness or a condition that needed medical treatment and which required hydration to be effective. The medical condition of the patient, the wishes of the family, and the interpretations of the patients' quality of life by their care providers were considered more important than living wills and policy agreements. Conclusions Doctors' decisions about withholding the artificial administration of fluids and food from elderly patients with dementia are influenced more by the clinical course of the illness, the presumed quality of life of the patient, and the patient's medical condition than they are by advanced planning of care. In an attempt to understand the wishes of the patient doctors try to create the broadest possible basis for the decision making process and its outcome, mainly by involving the family. [ABSTRACT FROM AUTHOR]

Objectives: To identify evidence from comparative studies on the effects of involving users in the delivery and evaluation of mental health services. Data sources: English language articles published between January 1966 and October 2001 found by searching electronic databases. Study selection: Systematic review of randomised controlled trials and other comparative studies of involving users in the delivery or evaluation of mental health services. Data extraction: Patterns of delivery of services by employees who were current or former users of services and professional employees and the effects on trainees, research, or clients of mental health services. Results: Five randomised controlled trials and seven other comparative studies were identified. Half of the studies considered involving users in managing cases. Involving users as employees of mental health services led to clients having greater satisfaction with personal circumstances and less hospitalisation. Providers of services who had been trained by users had more positive attitudes toward users. Clients reported being less satisfied with services when interviewed by users. Conclusions: Users can be involved as employees, trainers, or researchers without detrimental effect. Involving users with severe mental disorders in the delivery and evaluation of services is feasible. [ABSTRACT FROM AUTHOR]