Turf wars: The ethics of professional territorialism

Recapturing the Team Approach to Vascular Care

BACKGROUND

The care of the vascular patient remains decentralized rather than coordinated.

METHODS

We reviewed the current state of practice and published competency and care documents created by vascular professional societies.

RESULTS

Vascular professional societies routinely and repeatedly endorse both a team approach and the competency of specialists from disparate training backgrounds. The care of the vascular patient does not always reflect these public endorsements.

CONCLUSIONS

Centering the vascular patient as the mode of organization of care should improve care processes, expertise brought to bear, and outcomes.

Inter-specialty collaboration in the formalization of a new foregut subspecialty

Historical context and converging market conditions present a unique opportunity to study the factors contributing to the formalization of foregut, or upper gastrointestinal, surgery as a new subspecialty in United States healthcare. The aim of this study was to examine the justifications of those pursuing the formalization of a foregut subspecialty and to extract lessons for healthcare leaders on the evolving relationships between competing providers. This was a qualitative, cross-sectional study consisting of interviews, secondary survey data, and observation of society meetings between October 2018 and June 2019. Thirty interviews with healthcare professionals were conducted, transcribed, and analyzed for themes using qualitative coding software. Themes were correlated with observational field notes and archival data and compared against established social theories on professions and medical specialization. Analysis revealed that traditionally competing surgeons and gastroenterologists articulate a professional need to qualify foregut surgical expertise based on superior knowledge and outcomes, to define the allocation of certain tasks and procedures, and to foster collaboration across specialties. Converging market conditions precipitate individual and organizational decisions to pursue formal specialization. Participants in the formalization of this subspecialty should consider the history of professional competition and turf wars to achieve meaningful collaboration. Advocacy for multi-specialty societies and organizational movements could be a model for reduced conflict in other specialties as well.

Safety net, gateway, market, sport, and war: Exploring how emergency physicians conceptualize and ascribe meaning to emergency care

BACKGROUND

Metaphorical expressions and conceptualisations are widely used in medical discourse to convey complex and abstract concepts. Our study uses a novel way to examine the spontaneous use of metaphors by emergency physicians as they articulate their experiences of practicing emergency care. These co-constructions shed light on the values and beliefs that shape their emergency care practice.

METHODS

We invited 25 Taiwanese emergency physicians to participate in one-to-one semi-structured interviews.

RESULTS

Drawing on social constructionism theory, systematic metaphor analysis method and Metaphor Identification Procedure (MIP) we identified metaphorical linguistic expressions in their talk, grouping them into five-overarching conceptual metaphors. We argue that these metaphors underpin emergency physicians' experiences of practicing emergency medical care: Safety Net, Gateway, Market, War, and Sport.

DISCUSSION

The Safety Net, Gateway, and Market conceptualisations highlight physician-patient relationships and the social mission, resource allocation, and consumerism aspects of emergency care practice. The Sport and War conceptualisations highlight the physician-physician relationship and the demanding, team-based nature of emergency care practice.

CONCLUSION

We propose that the choice of metaphorical conceptualisation deployed by emergency physicians has implications on their embodiment of professional identities. This discussion of using metaphors to study professional identities contributes to the literature concerned with finding creative and innovative ways to research identities. Future studies may utilize metaphors to gain a comprehensive understanding of physicians' professional identities in other specialties.

Medical tourism in plastic surgery: ethical guidelines and practice standards for perioperative care

BACKGROUND

The goal of this review was to identify the safety and medical care issues that surround the management of patients who had previously undergone medical care through tourism medicine. Medical tourism in plastic surgery occurs via three main referral patterns: macrotourism, in which a patient receives treatments abroad; microtourism, in which a patient undergoes a procedure by a distant plastic surgeon but requires postoperative and/or long-term management by a local plastic surgeon; and specialty tourism, in which a patient receives plastic surgery from a non-plastic surgeon.

METHODS

The ethical practice guidelines of the American Medical Association, International Society of Aesthetic Plastic Surgery, American Society of Plastic Surgeons, and American Board of Plastic Surgeons were reviewed with respect to patient care and the practice of medical tourism.

CONCLUSIONS

Safe and responsible care should start prior to surgery, with communication and postoperative planning between the treating physician and the accepting physician. Complications can arise at any time; however, it is the duty and ethical responsibility of plastic surgeons to prevent unnecessary complications following tourism medicine by adequately counseling patients, defining perioperative treatment protocols, and reporting complications to regional and specialty-specific governing bodies.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Ethical issues for radiographers: general observations and a pilot qualitative study

This paper is based on general observation arising from many years experience in managing and delivering radiography services in the health service. In addition, it presents the results of a pilot qualitative study based on unstructured interviews. The interviews were undertaken with a view to identifying the reasons for radiography that may not be well justified. The study was undertaken in the public and private sectors and many of the reasons are shared by both. The reasons for poor justification include: inadequate radiation protection education for referrers; avoidance of medical litigation; defensive medicine attitude by referrers and, in the private sector, pursuit of profit. The study provides a starting point for further more quantitative investigations that are clearly required in the area.

Perceptual reasons for resistance to change in the emergency department use of holding chambers for children with asthma

STUDY OBJECTIVE

We explore perceptions surrounding use of portable inhalers and holding chambers (spacers) for delivery of beta-agonist respiratory medications to children in the emergency department (ED) and factors influencing practice change.

METHODS

This was a qualitative study guided by principles of grounded theory. Data were collected through focus groups and individual interviews at 2 sites in eastern Canada: Hospital A, where inhalers and holding chambers are used routinely; and Hospital B, where prevailing practice is the use of nebulization. Participant encounters were transcribed verbatim and analyzed for emerging themes.

RESULTS

At Hospital A, 6 physicians and 7 nurses participated in separate focus groups. Four interviews were conducted with physician, nurse, respiratory therapy, and pharmacy leaders. At Hospital B, 4 physicians and 3 nurses participated in focus groups, and 6 leaders were interviewed. Perceptions negatively influencing the adoption of inhalers and holding chambers included increased workload, increased equipment costs, myths about the superiority of nebulization, and interprofessional conflict. Health professionals reported that their most prominent concern about administering medications with inhalers and holding chambers was the time demand. Nurses especially seemed to think this way, tipping the balance in favor of nebulization despite knowledge of evidence to the contrary and affecting physician decisionmaking as well. Professional territorialism appeared to hinder efforts to ameliorate workload issues through the use of respiratory therapists in the ED.

CONCLUSION

Findings from this study could be used to inform a change program to close the gap between evidence and practice with respect to use of inhalers and holding chambers in the ED.