Public health physicians' knowledge of core skills and current policy: clinical audit by questionnaire.
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BACKGROUND: The aim of this study was to facilitate the assessment of the knowledge of general public health physicians on a range of topics relating to everyday areas of work and core skills, and to encourage learning in the process, by means of an educational clinical audit exercise. METHODS: A group of experts in different aspects of public health were asked to contribute multiple-choice questions. These were developed into a questionnaire that could be marked by computer. The questionnaire was circulated to all members of the Faculty registered for Continuing Professional Development (CPD) and to specialist registrar members, but participation was voluntary. The experts marked answers according to a marking scheme against model answers agreed. RESULTS: A total of 499 public health doctors returned answer sheets. There was no 'pass mark' as this was a learning exercise, not an examination. However, although the negative marking system meant that the possible range of scores was -100 per cent to 100 per cent, no one had a negative score. The median uncorrected result was 44 out of 80. Questions on communicable disease and critical appraisal had the highest scores, and one on Primary Care Trusts the lowest. Participants thought the most interesting questions were those on epidemiology and evidence-based medicine, whereas the most unpopular was on Personal Medical Services pilots. Most comments were favourable to the approach but several commented that the whole exercise was too general and questions outside their current area of specialization were irrelevant. CONCLUSION: The general public health physicians who took part in this audit appeared to be mainly competent in their knowledge of core skills and up to date with current health policy issues. However, the audit raises a debate about what 'core' knowledge is required in the post-training period. The place of UK-wide CPD initiatives over national or regional, or local approaches needs consideration, as do potential regional or national variations in CPD. This will receive further impetus because of revalidation and the need to demonstrate valid CPD activities in public health medicine. (+info)
Continuing care of the terminally ill.
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Terminal care has specific goals for the attending medical team. In truth, most dying patients do not expect miracles. What they ask for is assurance that they will not be abandoned or discarded because they have an incurable condition. Truth can be gentle and merciful, and not necessarily without hope. Grieving is normal for patients, families, nurses and doctors. Weeping with sad friends is not evidence of weakness, rather it displays great empathy, and can be therapeutic for patients and doctors together. (+info)
Patients who want to die: a survey.
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Representative samples of Ontario physicians and nurses, plus first and fourth year medical and nursing students in Kingston, were surveyed concerning experiences with and attitudes toward patients who want to die.Many respondents had been asked by some hopelessly ill patients for help in hastening death. Over 25 percent had known at least one such patient commit suicide. Abstention from food and drink was a common method in such suicides, and was frequently thwarted by forced feeding.A majority of respondents were definitely in favor of legal and social changes to permit compliance with requests from hopelessly ill patients for no forced feeding when the patient stopped eating, and for withdrawal of life-supporting procedures, but a solid majority opposed changes to permit compliance with requests for lethal drugs. Student respondents were neither consistently more nor consistently less favorable toward these changes than practitioners. (+info)
Facilitating end-of-life decision-making: strategies for communicating and assessing.
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End-of-life decision-making is often a difficult process and one that many elderly patients and their families will undergo. The grounded theory study of nurses, physicians, and family members (n = 20) reported in this article examined provider behaviors that facilitated the process of decision-making near the end of patients' lives. According to participants, providers who are experienced and comfortable are more likely to engage in communication and assessment strategies that facilitate end-of-life decision-making. Communication strategies included: being clear, avoiding euphemisms, spelling out the goals and expectations of treatment, using words such as "death" and "dying," and being specific when using such words as "hope" and "better." Assessment strategies included: assessing patients' physical conditions and end-of-life wishes, patients' and family members' understandings of the disease and prognosis, and their expectations and goals. An important first step for improved care is making explicit the provider's communicating and assessing strategies that facilitate end-of-life decision-making. (+info)
To gown or not to gown: the effect on acquisition of vancomycin-resistant enterococci.
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Infection-control recommendations include the use of gowns and gloves to prevent horizontal transmission of vancomycin-resistant enterococci (VRE). This study sought to determine whether the use of a gown and gloves gives greater protection than glove use alone against VRE transmission in a medical intensive care unit (MICU). From 1 July 1997 through 30 June 1998 and from 1 July 1999 through 31 December 1999, health care personnel and visitors were required to don gloves and gowns upon entry into rooms where there were patients infected with nosocomial pathogens. From 1 July 1998 through 30 June 1999, only gloves were required under these same circumstances. During the gown period, 59 patients acquired VRE (9.1 cases per 1000 MICU-days), and 73 patients acquired VRE during the no-gown period (19.6 cases per 1000 MICU-days; P<.01). The adjusted risk estimate indicated that gowns were protective in reducing VRE acquisition in an MICU with high VRE colonization pressure. (+info)
Sexual health clinics for women led by specialist nurses or senior house officers in a central London GUM service: a randomised controlled trial.
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OBJECTIVES: To assess the care process and clinical outcomes for two different models of GUM clinic for women: one led by specialist nurses and the other by senior house officers (SHOs). METHOD: An open randomised controlled trial was carried out in a central London genitourinary medicine (GUM) women's clinic. Of 1172 women telephoning for an appointment, 880 were randomised to provide 169 eligible patients in the specialist nurse arm and 178 in the SHO arm. Of the eligible patients a total of 224 attended their appointment. The clinical records of the randomised women were audited for adequacy of care according to local guidelines. 30 key variables were objectively assessed and recorded on a standard audit form. An overall unitary index score (%) was calculated for each patient. The main variables associated with the outcome of specialist nurse and SHO decision making (diagnostic test request, preliminary diagnosis, and treatment provided) were then analysed independently. RESULTS: The median documentation audit scores for specialist nurses (n=103) and SHOs (n=121) were 92% and 85% respectively (p<0.0001). The specialist nurses' documentation was significantly (p<0.05) more complete than the SHOs' for five variables: details of menstrual cycle, physical examination, medication instructions given to patients, health promotion discussion, and provision of condoms. Specialist nurses performed equally to the SHOs with regard to requesting the correct diagnostic tests, providing the correct preliminary diagnosis, and providing the correct treatment. CONCLUSIONS: A model of care using trained GUM nurses working within agreed protocols can provide comprehensive patient care for female patients that is equal to care provided by SHOs. Our results raise important issues regarding advanced GUM nursing education and training, protocol development, and accountability. (+info)
Patient-physician communication as organizational innovation in the managed care setting.
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Despite changes in the healthcare system, the relationship between patients and physicians remains fundamental to high-quality care. Managed care rules and restrictions, such as constraints on choice of providers, review processes, and decreasing length of visits, are creating potential conflicts between patients and their physicians. To strengthen the patient-physician relationship, some managed care organizations are implementing communication skills training for physicians. This article provides case studies describing how 2 large managed care organizations successfully incorporated communication skills training into their environments. An organizational perspective is used to delineate the 3 stages--adoption, implementation, and institutionalization--that managed care organizations generally traverse in incorporating communication skills programs and making them an integral part of their organizational culture. Specific suggestions are provided for physician leaders and administrators who are considering similar programs in their settings. (+info)
Optimizing antibiotics in residents of nursing homes: protocol of a randomized trial.
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BACKGROUND: Antibiotics are frequently prescribed for older adults who reside in long-term care facilities. A substantial proportion of antibiotic use in this setting is inappropriate. Antibiotics are often prescribed for asymptomatic bacteriuria, a condition for which randomized trials of antibiotic therapy indicate no benefit and in fact harm. This proposal describes a randomized trial of diagnostic and therapeutic algorithms to reduce the use of antibiotics in residents of long-term care facilities. METHODS: In this on-going study, 22 nursing homes have been randomized to either use of algorithms (11 nursing homes) or to usual practise (11 nursing homes). The algorithms describe signs and symptoms for which it would be appropriate to send urine cultures or to prescribe antibiotics. The algorithms are introduced by inservicing nursing staff and by conducting one-on-one sessions for physicians using case-scenarios. The primary outcome of the study is courses of antibiotics per 1000 resident days. Secondary outcomes include urine cultures sent and antibiotic courses for urinary indications. Focus groups and semi-structured interviews with key informants will be used to assess the process of implementation and to identify key factors for sustainability. (+info)