Legal Issues in Critical Care Medicine

This article introduces some of the legal problems facing physicians practicing critical care medicine. Although there is considerable scholarship dealing with the legal and ethical consequences of withdrawing life-sustaining care from terminally ill or irreversibly comatose patients, little has been written about the legal problems that are the inevitable consequence of the pressure to reduce expenditures for intensive care. Because this is a new area of inquiry, this article draws lessons from analogous situations such as anesthesia care. It is important to stress that legal standard setting may be influenced by concerted action by critical care practitioners; however, if the profession is silent on standards, the law will impose standards that it arrives at in an ad hoc fashion.

Patient Satisfaction in Gastroenterology Clinics

Satisfaction surveys of patients who had a gastrointestinal procedure at an ambulatory surgery center in 2002 were drawn from a national database and analyzed. The resulting data were used to report the status of patient satisfaction with their care and to illustrate several ways in which patient satisfaction data can be used to guide quality improvement efforts. It was found that patient satisfaction is generally quite high, with ratings of nurses and physicians topping the list. On the other hand, convenience factors such as parking and waiting times were rated lower. Uses of data to guide quality improvement efforts were illustrated in terms of response category percentages (i.e., percentage of time an item was rated "good," "poor," etc.) and a measure of item priority.

Evaluations of care by ambulatory surgery patients

As medical care increasingly moves from inpatient to outpatient delivery settings, attention must be paid to patient assessments of the care received in these ambulatory medical centers. This study of patients in ambulatory surgery centers (N = 275) across the United States reports on the ratings given to the varied attributes of the ambulatory surgery experience. The respondents (N = 36,078) gave highest ratings to those items which evaluated the nurses and physicians and lower marks to items related to registration and access. The article concludes with an illustration of a quadrant analysis technique that managers can use to identify the specific care issues that should be addressed to increase positive word-of-mouth referrals.

Health system reforms--toward a framework for international comparisons

Health care reform efforts internationally are focused more on efficiency than on effectiveness or equity. We lack a coherent theoretical framework for understanding those reforms or for engaging in comparative research. This paper presents some theoretical ideas that could contribute to such a framework. A model constructed from expert opinion suggests that hegemonic systems, national systems and medical care systems all contribute, with specific elements identified in each. Three sociological ideas are suggested: a model of trends leading to a fiscal crisis and a crisis of alienation; communities, professions and markets as ideal typical organizational alternatives; global post-Fordist and world systems theories; and hegemonic projects. Together these could explain the timing, speed and direction of health care reform efforts throughout the world.

Teaching risk management to physicians

In summary, the risk manager should take an active role in educating the medical staff. The seven areas discussed can serve as a checklist for the risk manager and, of course, can be expanded. The risk management strategies described should be encouraged to become a part of physicians' daily practice patterns. Physicians then will be better prepared to help their patients deal with adverse outcomes as well as feel more comfortable about the medical-legal environment in which they practice.

Malpractice: a case-control study of claimants

Efforts by hospitals to minimize the frequency of malpractice claims require knowledge of which patients file claims and why. Utilizing a case-control method to investigate the characteristics of patients, of providers, and of the course of care at a university hospital, the authors found several factors to be associated with notification of an intent to file a claim. White collar workers, patients dissatisfied with their care, those who experienced more complications, and those admitted to a particular medical floor were more likely to make a claim. There was no significant association between notice of a claim and complexity of care as indicated by number of diagnoses, invasive procedures, blood tests, and x-rays. Furthermore, the number of different primary care physicians and different consultants did not influence the patient's decision to pursue legal action. Attention to these findings may help avert malpractice claims; however, further study with a larger sample is needed to validate these results.

Levels of explanation and cautions for a critical clinical anthropology

The appearance of a critical approach to clinical anthropology raises a question of relevance. Critical medical anthropology itself has developed with a primary concern for the impact of capitalism on Third World health, the inequality of medical resource distribution both in the U.S. and abroad, and the hegemony of Western biomedicine over local medical systems. Such an orientation may be of but modest relevance for an understanding of clinical phenomena in the heartland of capitalism itself. In the U.S., both patients and clinicians tend to share multiple values, including commitment to capitalism and the biomedical paradigm. Moreover, various negative behavioral characteristics visible in the clinical setting (such as racism) are common outside medicine, and may not be profitably understood through usual critical orientations. A heuristic model that gives excessive weight to a single element (capitalism) of a single (macro) level of explanation may not be as useful as one that utilizes a multi-level, multi-element approach. The argument is made that such a broader, more holistic approach may offer greater understanding of so-called micro level processes--specifically the patient/clinician interaction in specific clinical settings. An example is provided from a midwest hospital. It is suggested that if change in the biomedical system is a goal of a critical clinical anthropology, the impact will be greater where objective and broad causal connections can be demonstrated with minimal use of rote or polemic arguments.

Sensitivity to patients' psychosocial concerns: relationships among ratings by primary care and traditional internal medicine house officers and patient self-assessments

This study examined house officers' sensitivity to patients' psychosocial concerns. Primary care house officers, traditionally trained internal medicine house officers, a social worker, and 104 ambulatory care patients independently completed an assessment instrument to indicate the extent to which a set of 20 defined psychosocial issues concerned the patients. We examined the magnitude of difference and extent of correlation in the independent reports of the patient, house officer, and social worker. These analyses were conducted on both the individual psychosocial issues and on sets of concerns derived from an oblique rotation factor analysis of the patients' responses. Primary care trainees' assessments of their patients' concerns correlated more frequently with the independent assessments of the patients and a social worker than did the judgments of the traditionally trained house officers. The factor analysis identified six factors that accounted for 64.4% of the variance in patients' responses. The correlations between the primary care trainees' and patients' assessments were statistically significant on five of these six factors; the correlations between the traditionally trained residents' and patients' assessments were statistically significant on two of the factors. These results provide evidence of the primary care house officer training program's achievement of the goal of enhanced physician awareness of patients' psychosocial concerns. The results also support training efforts aimed at increasing physicians' ability to assess their patients' psychosocial concerns.