Evidence-based medicine in primary care: qualitative study of family physicians.
(33/750)
BACKGROUND: The objectives of this study were: a) to examine physician attitudes to and experience of the practice of evidence-based medicine (EBM) in primary care; b) to investigate the influence of patient preferences on clinical decision-making; and c) to explore the role of intuition in family practice. METHOD: Qualitative analysis of semi-structured interviews of 15 family physicians purposively selected from respondents to a national survey on EBM mailed to a random sample of Canadian family physicians. RESULTS: Participants mainly welcomed the promotion of EBM in the primary care setting. A significant number of barriers and limitations to the implementation of EBM were identified. EBM is perceived by some physicians as a devaluation of the 'art of medicine' and a threat to their professional/clinical autonomy. Issues regarding the trustworthiness and credibility of evidence were of great concern, especially with respect to the influence of the pharmaceutical industry. Attempts to become more evidence-based often result in the experience of conflicts. Patient factors exert a powerful influence on clinical decision-making and can serve as trumps to research evidence. A widespread belief that intuition plays a vital role in primary care reinforced views that research evidence must be considered alongside other factors such as patient preferences and the clinical judgement and experience of the physician. DISCUSSION: Primary care physicians are increasingly keen to consider research evidence in clinical decision-making, but there are significant concerns about the current model of EBM. Our findings support the proposed revisions to EBM wherein greater emphasis is placed on clinical expertise and patient preferences, both of which remain powerful influences on physician behaviour. (+info)
Attaching a new understanding to the patient-physician relationship in family practice.
(34/750)
BACKGROUND: As a result of continuity of care with patients and their families, family physicians are uniquely poised to form enduring clinical relationships with their patients. The degree of collaboration in and satisfaction with the patient-provider alliance has been shown to have important implications for treatment outcomes across a range of medical problems. Providing optimal care can require family physicians to appreciate the sequelae of having clinically relevant aspects of past relationships emerge in the health care relationship, both in their patients and in themselves. A conceptual model is essential to assist in recognizing these key aspects. METHODS: A literature search was conducted using MEDLINE. Key words entered were "illness" and "attachment theory." Thirty-five English-only articles appeared from which further relevant references were gathered. RESULTS: Attachment theory serves as a useful model for highlighting important features of physician-patient relationships, which can affect treatment outcome in the family practice setting. It posits that everyone has an innate need to form strong attachment bonds to their earliest caregivers. To ensure survival, the child adapts its bonding to the caregiver's attachment style. With time, the maturing person develops a style of relating in subsequent caregiving relationships based on these early, and to some extent later, close relationships. Insecure attachment styles that can develop--dismissing, preoccupied, and fearful--have been shown to affect the clinical relationship and medical treatment outcomes often in important and predictable ways. CONCLUSION: Family physicians can more easily adopt an understanding, compassionate, and flexible treatment stance by recognizing patients' unique attachment relationship patterns, thereby improving medical treatment outcome. (+info)
Patient choice. A randomized controlled trial of provider selection.
(35/750)
OBJECTIVE: To evaluate the impact of an intervention designed to help patients choose a new primary care provider (PCP) compared with the usual method of assigning patients to a new PCP. DESIGN: Randomized controlled trial conducted between November 1998 and June 2000. INTERVENTION: Provision of telephone or web-based provider-specific information to aid in the selection of a provider. SETTING: Medical center within a large HMO. PATIENTS: One thousand and ninety patients who were >/=30 years old, whose previous PCP had retired and who responded to a mailed questionnaire 1 year after linkage with a new PCP. MEASUREMENTS AND MAIN RESULTS: The questionnaire assessed perceptions of choice, satisfaction, trust, and retention of the PCP. During the intervention period, 85% of subjects obtained a new PCP. Intervention subjects were more likely to perceive that they chose their PCP (78% vs 22%; P <.001), to retain their PCP at 1 year (93% vs 69%; P <.001), and to report greater overall satisfaction with the PCP (67% vs 57%; P <.01), compared to control subjects who were assigned to a PCP. The intervention subjects also reported greater trust in their PCP on most measures, but these differences did not remain statistically significant after adjustments for patient age, gender, ethnicity, education, and health status. CONCLUSIONS: Encouraging patients to choose their PCP can result in mutually beneficial outcomes for both patients and providers, such as greater overall satisfaction and duration of the relationship. Further research is needed to identify the types of information most useful in making this choice and to understand the relevant underlying patient expectations. (+info)
Non-heart beating organ donation: old procurement strategy--new ethical problems.
(36/750)
The imbalance between supply of organs for transplantation and demand for them is widening. Although the current international drive to re-establish procurement via non-heart beating organ donation/donor (NHBOD) is founded therefore on necessity, the process may constitute a desirable outcome for patient and family when progression to brain stem death (BSD) does not occur and conventional organ retrieval from the beating heart donor is thereby prevented. The literature accounts of this practice, however, raise concerns that risk jeopardising professional and public confidence in the broader transplant programme. This article focuses on these clinical, ethical, and legal issues in the context of other approaches aimed at increasing donor numbers. The feasibility of introducing such an initiative will hinge on the ability to reassure patients, families, attendant staff, professional bodies, the wider public, law enforcement agencies, and the media that practitioners are working within explicit guidelines which are both ethically and legally defensible. (+info)
The altruistic act of asking.
(37/750)
There are a number of obstacles to increasing the supply of cadaveric organs for transplantation. These include reluctance on the part of relatives to agree to the so called harvesting of organs from their deceased relative, and the unwillingness of some doctors to approach grieving families and ask consent for this harvesting to take place. In this paper I will focus on the altruistic act of asking that the latter entails, and will argue that failure to acknowledge the personal cost of this act to physicians is having an adverse impact on the supply of organs. I will draw analogies with the almost equally neglected altruistic act of undertaking anatomy dissection and all of the related breaking of societal taboos. I will examine the language used in discussions about increasing organ supply and conclude that the terms cadaveric and harvest are unhelpful in gaining public confidence. A process and vocabulary that openly acknowledges and validates the altruistic acts demanded of all the human beings involved--donors, recipients, their respective relatives, and the health professionals who mediate between them--is needed if the supply of organs is to be increased. (+info)
Race and trust in the health care system.
(38/750)
OBJECTIVE: A legacy of racial discrimination in medical research and the health care system has been linked to a low level of trust in medical research and medical care among African Americans. While racial differences in trust in physicians have been demonstrated, little is known about racial variation in trust of health insurance plans and hospitals. For the present study, the authors analyzed responses to a cross-sectional telephone survey to assess the independent relationship of self-reported race (non-Hispanic black or non-Hispanic white) with trust in physicians, hospitals, and health insurance plans. METHODS: Respondents ages 18-75 years were asked to rate their level of trust in physicians, health insurance plans, and hospitals. Items from the Medical Mistrust Index were used to assess fear and suspicion of hospitals. RESULTS: Responses were analyzed for 49 (42%) non-Hispanic black and 69 (58%) non-Hispanic white respondents (N=118; 94% of total survey population). A majority of respondents trusted physicians (71%) and hospitals (70%), but fewer trusted their health insurance plans (28%). After adjustment for potential confounders, non-Hispanic black respondents were less likely to trust their physicians than non-Hispanic white respondents (adjusted absolute difference 37%; p=0.01) and more likely to trust their health insurance plans (adjusted absolute difference 28%; p=0.04). The difference in trust of hospitals (adjusted absolute difference 13%) was not statistically significant. Non-Hispanic black respondents were more likely than non-Hispanic white respondents to be concerned about personal privacy and the potential for harmful experimentation in hospitals. CONCLUSIONS: Patterns of trust in components of our health care system differ by race. Differences in trust may reflect divergent cultural experiences of blacks and whites as well as differences in expectations for care. Improved understanding of these factors is needed if efforts to enhance patient access to and satisfaction with care are to be effective. (+info)
Trust, benefit, satisfaction, and burden: a randomized controlled trial to reduce cancer risk through African-American churches.
(39/750)
BACKGROUND: Community-based participatory research (CBPR) approaches that actively engage communities in a study are assumed to lead to relevant findings, trusting relationships, and greater satisfaction with the research process. OBJECTIVE: To examine community members' perceptions of trust, benefit, satisfaction, and burden associated with their participation. DESIGN, SETTING, AND PARTICIPANTS: A randomized controlled trial tested a cancer prevention intervention in members of African-American churches. Data were collected at baseline and 1-year follow-up. MEASUREMENTS: Subscales measured perception of trust in the research project and the project team, benefit from involvement with the project, satisfaction with the project and the team, and perception of burden associated with participation. MAIN RESULTS: Overall, we found high levels of trust, perceived benefit, and satisfaction, and low perceived burden among community members in Partnership to Reach African Americans to Increase Smart Eating. In bivariate analyses, participants in the intervention group reported more perceived benefit and trust (P <.05). Participants in smaller churches reported more benefit, satisfaction and trust, while participants from churches without recent health activities perceived greater benefit, greater satisfaction, and lower burden with the project and the team (P <.05). Participants whose pastors had less educational attainment noted higher benefit and satisfaction; those whose pastors were making personal lifestyle changes noted higher benefit and satisfaction, but also reported higher burden (P <.05). CONCLUSIONS: A randomized clinical trial designed with a CBPR approach was associated with high levels of trust and a perceived benefit of satisfaction with the research process. Understanding variations in responses to a research partnership will be helpful in guiding the design and implementation of future CBPR efforts. (+info)
Community action against asthma: examining the partnership process of a community-based participatory research project.
(40/750)
BACKGROUND: Community Action Against Asthma (CAAA) is a community-based participatory research (CBPR) project that assesses the effects of outdoor and indoor air quality on exacerbation of asthma in children, and tests household- and neighborhood-level interventions to reduce exposure to environmental asthma triggers. Representatives of community-based organizations, academia, an integrated health system, and the local health department work in partnership on CAAA's Steering Committee (SC) to design and implement the project. OBJECTIVE: To conduct a process evaluation of the CAAA community-academic partnership. DESIGN: In-depth interviews containing open-ended questions were conducted with SC members. Analysis included established methods for qualitative data, including focused coding and constant comparison methods. SETTING: Community setting in Detroit, Michigan. PARTICIPANTS: Twenty-three members of the CAAA SC. MEASUREMENTS: Common themes identified by SC members relating to the partnership's ability to achieve project goals and the successes and challenges facing the partnership itself. MAIN RESULTS: Identified partnership accomplishments included: successful implementation of a complex project, identification of children with previously undiagnosed asthma, and diverse participation and community influence in SC decisions. Challenges included ensuring all partners' influence in decision-making, the need to adjust to "a different way of doing things" in CBPR, constraints and costs of doing CBPR felt by all partners, ongoing need for communication and maintaining trust, and balancing the needs of science and the community through intervention. CONCLUSIONS: CBPR can enhance and facilitate basic research, but care must be given to trust issues, governance issues, organizational culture, and costs of participation for all organizations involved. (+info)