Negotiated or taken-for-granted trust? Explicit and implicit interpretations of trust in a medical setting

Trust between a patient and a medical doctor is normally both justified and taken for granted, but sometimes it may need to be negotiated. In this paper I will present how trust can be interpreted as both an explicit and implicit phenomenon, drawing on literature from the social sciences and philosophy. The distinction between explicit and implicit interpretations of trust will be used to address problems that may arise in clinical consultations. Negotiating trust in any way very easily brings distrust into a situation, but sometimes this can be helpful for building a more functional patient-doctor relationship.

The need for medical ethics education in family medicine training

Professional and accreditation organizations have endorsed medical ethics as a fundamental component of education for family medicine trainees. Yet various obstacles combine to work against the continuation of formal medical ethics education beyond medical school and into residency training. This article reviews the current consensus on the scope and objectives of medical ethics education in the context of family medicine training. The need for, and outcomes of, medical ethics teaching are analyzed on the basis of the available evidence. Recent trends in medical education that potentially influence graduate medical ethics training are also discussed (specifically ethics training in medical schools and the priority given to training in professionalism). This review shows a strong evidence-based need to provide medical ethics education for family physicians in training, a need that is apparent on many levels. The current reliance on medical school ethics education and emphasis on professionalism does not answer this need. A well-constructed course in medical ethics for family medicine trainees can teach an array of competencies stipulated by professional and accreditation agencies as important in the practice of family medicine. Educators must strive to overcome barriers and provide formal medical ethics programs to better prepare family physicians for modern professional roles.

Primary care physicians' decisions about discharging patients from their practices

OBJECTIVE

There are few data available about factors which influence physicians' decisions to discharge patients from their practices. To study general internists' and family medicine physicians' attitudes and experiences in discharging patients from their practices.

DESIGN

A cross-sectional mailed survey was used.

PARTICIPANTS

One thousand general internists and family medicine physicians participated in this study.

MEASUREMENTS AND MAIN RESULTS

We studied the likelihood physicians would discharge 12 hypothetical patients from their practices, and whether they had actually discharged such patients. The effect of demographic data on the number of scenarios in which patients were likely to be discharged, and the number of patients actually discharged were analyzed via ANOVA and multiple logistic regression analysis. Of 977 surveys received by subjects, 526 (54%) were completed and returned. A majority of respondents were willing to discharge patients in 5 of 12 hypothetical scenarios. Eighty-five percent had actually discharged at least one patient from their practices. Most respondents (71%) had discharged 10 or fewer patients, but 14% had discharged 11 to 200 patients. Respondents who were in private practice (p < 0.000001) were more likely to discharge both hypothetical and actual patients from their practices. Older physicians (> or =48 years old) were more likely to discharge actual patients from their practices (p = 0.005) as were physicians practicing in rural settings (p = 0.003).

CONCLUSIONS

Most physicians in our sample were willing to discharge actual and hypothetical patients from their practices. This tendency may have significant implications for the initiation of pay-for-performance programs. Physicians should be educated about the importance of the patient-physician relationship and their fiduciary obligations to the patient.

Dealing with requests for euthanasia: a qualitative study investigating the experience of general practitioners

BACKGROUND

Caring for terminally ill patients is a meaningful task, however the patient's suffering can be a considerable burden and cause of frustration.

OBJECTIVES

The aim of this study is to describe the experiences of general practitioners (GPs) in The Netherlands in dealing with a request for euthanasia from a terminally ill patient.

METHODS

The data, collected through in-depth interviews, were analysed according to the constant comparative method.

RESULTS

Having to face a request for euthanasia when attempting to relieve a patient's suffering was described as a very demanding experience that GPs generally would like to avoid. Nearly half of the GPs (14/30) strive to avoid euthanasia or physician assisted suicide because it was against their own personal values or because it was emotional burdening to be confronted with this issue. They explained that by being directed on promoting a peaceful dying process, or the quality of end-of-life of a patient by caring and supporting the patient and the relatives it was mainly possible to shorten patient's suffering without "intentionally hastening a patient's death on his request". The other GPs (16/30) explained that as sometimes the suffering of a patient could not be lessened they were open to consider a patient's request for euthanasia or physician assisted suicide. They underlined the importance of a careful decision-making process, based on finding a balance between the necessity to shorten the patient's suffering through euthanasia and their personal values.

CONCLUSION

Dealing with requests for euthanasia is very challenging for GPs, although they feel committed to alleviate a patient's suffering and to promote a peaceful death.

Nullified: women's perceptions of being abused in health care

OBJECTIVE

In a study performed with The NorVold Abuse Questionnaire (NorAQ) among Nordic gynecological patients, the prevalence of lifetime abuse in health care (AHC) was 13 - 28%. In the present study we chose a qualitative approach. Our aim was to develop a more in-depth understanding of AHC; as experienced by female Swedish patients.

STUDY DESIGN

Qualitative interviews with 10 Swedish gynecological patients who had experienced AHC. The interviews were analyzed through Grounded Theory.

RESULTS

Saturation was reached after six interviews. In the analyses four categories emerged which explain what AHC meant to the participating women: felt powerless, felt ignored, experienced carelessness, and experienced non-empathy. To be nullified is the core category that theoretically binds the four categories together. The women's narratives described intensive current suffering even though the abusive event had taken place several years ago.

CONCLUSIONS

The fact that AHC exists is a critical dilemma for an institution that has the society's commission to cure and/or to alleviate pain and suffering. In their narratives, women described the experience of 'being nullified', a core category that embodies AHC.

Responding to medical pluralism in practice: a principled ethical approach

The popularity of complementary and alternative medicine (CAM) raises a range of ethical issues for practicing clinicians. Principles of biomedical ethics define obligations of health care professionals, but applying principles in particular cases at the interface of CAM and biomedicine may be particularly challenging. "Recognition of medical pluralism" can help clinicians' ethical deliberations related to CAM. Here we outline a 3-point practical approach to applying basic principles of biomedical ethics in light of medical pluralism: (1) inquiring about CAM use and the scientific evidence related to CAM, (2) acknowledging the health beliefs and practices of patients, and (3) accommodating diverse healing practices. Construed as such, recognition of medical pluralism encourages pragmatic willingness to examine the personal and cultural meaning associated with CAM use, the biases and assumptions of biomedicine, as well as the risk-benefit ratio of CAM practices. In this way, recognition of medical pluralism can help clinicians enhance patient care in a manner consistent with basic ethical principles.

General practitioners and pharmaceutical sales representatives: quality improvement research

BACKGROUND AND OBJECTIVE

Interaction between pharmaceutical sales representatives (PSRs) and general practitioners (GPs) may have an adverse impact on GP prescribing and therefore may be ethically questionable. This study aimed to evaluate the interactions between PSRs and GPs in an Australian general practice, and develop and evaluate a policy to guide the interaction.

METHODS

Doctors' prescribing, diaries, practice promotional material and samples were audited and a staff survey undertaken. After receiving feedback, the staff voted on practice policy options. The resulting policy was evaluated 3 and 9 months.

RESULTS

Prior to the intervention, GPs spent on average 40 min/doctor/month with PSRs. There were 239 items of promotional material in the practice and 4660 tablets in the sample cupboard. These were reduced by 32% and 59%, respectively, at 3 months after policy adoption and the reduction was sustained at 9 months. Vioxx was the most common drug name in promotional material. Staff adopted a policy of reduced access to PSRs including: reception staff not to make appointments for PSRs or accept promotional material; PSRs cannot access sample cupboards; GPs wishing to see PSRs may do so outside consulting hours. At 3 and 9 months, most staff were satisfied with the changes. Promotional items/room were not significantly reduced at 3 months (-4.0 items/room ; 95% CI -6.61 to -1.39; p = 0.066) or 9 months (-2.63 items/room; 95% CI -5.86 to 0.60; p = 0.24). Generic prescribing significantly increased at 3 months (OR 2.28, 95% CI 1.31 to 3.86; p = 0.0027) and 9 months (OR 2.07, 95% CI 1.13 to 3.82; p = 0.016).

CONCLUSION

There was a marked reduction in interactions with PSRs with majority staff satisfaction and improved prescribing practices. The new policy will form part of the practice's orientation package. Reception staff give PSRs a letter explaining the policy. It is hoped that the extra 40 min/doctor of consulting time translates into more time with patients and time to evaluate more independent sources of drug information.

Insurance reports

Case histories are based on actual medical negligence claims or medicolegal referrals, however certain facts have been omitted or changed by the author to ensure the anonymity of the parties involved. General practitioners find their patients requesting that they complete documentation for a myriad of insurance purposes. Often these forms are time consuming to complete, containing seemingly irrelevant questions. This article examines the responsibilities of GPs in providing reports to insurance companies.

LOCUS: immunizing medical students against the loss of professional values

INTRODUCTION

The Leadership Opportunities with Communities, the Underserved, and Special populations (LOCUS) program at the University of Wisconsin School of Medicine and Public Health is a longitudinal, extracurricular experience for medical students who wish to develop leadership skills and expand their involvement in community health activities during medical school. The program consists of a core curriculum delivered through retreats, workshops, and seminars; a mentor relationship with a physician who is engaged in community health services; and a community service project.

METHODS

On-line surveys and interviews with current and past participants as well as direct observations were used to evaluate the effects of the program on participants.

RESULTS

Participants indicated that the program was worthwhile, relevant, and effective in building a community of like-minded peers and physician role models. Participants also reported that the program sustained their interest in and commitment to community service and allowed them to cultivate new skills during medical school.

CONCLUSIONS

The curriculum and structure of the LOCUS program offers a successful method for helping medical students learn important leadership skills and maintain an altruistic commitment to service.

Considering the case for an antidepressant drug trial involving temporary deception: a qualitative enquiry of potential participants

Background

Systematic reviews of randomised placebo controlled trials of antidepressant medication show small and decreasing differences between pharmacological and placebo arms. In part this finding may relate to methodological problems with conventional trial designs, including their assumption of additivity between drug and placebo trial arms. Balanced placebo designs, which include elements of deception, may address the additivity question, but pose substantial ethical and pragmatic problems. This study aimed to ascertain views of potential study participants of the ethics and pragmatics of various balanced placebo designs, in order to inform the design of future antidepressant drug trials.

Methods

A qualitative approach was employed to explore the perspectives of general practitioners, psychiatrists, and patients with experience of depression. The doctors were chosen via purposive sampling, while patients were recruited through participating general practitioners. Three focus groups and 12 in-depth interviews were conducted. A vignette-based topic guide invited views on three deceptive strategies: post hoc, authorised and minimised deception. The focus groups and interviews were tape-recorded and transcribed. Transcripts were analysed thematically using Framework.

Results

Deception in non-research situations was typically perceived as acceptable within specific parameters. All participants could see the potential utility of introducing deception into trial designs, however views on the acceptability of deception within antidepressant drug trials varied substantially. Authorized deception was the most commonly accepted strategy, though some thought this would reduce the effectiveness of the design because participants would correctly guess the deceptive element. The major issues that affected views about the acceptability of deception studies were the welfare and capacity of patients, practicalities of trial design, and the question of trust.

Conclusion

There is a trade-off between pragmatic and ethical responses to the question of whether, and under what circumstances, elements of deception could be introduced into antidepressant drug trials. Ensuring adequate ethical safeguards within balanced placebo designs is likely to diminish their ability to address the crucial issue of additivity. The balanced placebo designs considered in this study are unlikely to be feasible in future trials of antidepressant medication. However there remains an urgent need to improve the quality of antidepressant drug trials.