I am a good patient, believe it or not

From Individuals to Systems and Contributions to Creations: Novel Framework for Mapping the Efforts of Individuals by Convening The Center of Health and Health Care

Background

People with lived health care experiences (often referred to as “patients”) are increasingly contributing to health care and are most effective when they are involved as partners who can contribute complementary knowledge alongside other stakeholders in health care.

Objective

Convening The Center aimed to bring together “people known as patients”—the center of health care—to address priorities as they defined them.

Methods

According to the original project design, an in-person gathering was to be conducted; however, as a result of the COVID-19 pandemic, the in-person gathering was transformed into a series of digital gatherings, including an in-depth interview phase, small-group gatherings, and a collective convening of 25 participants (22 women and 3 men from the United States, India, Costa Rica, Sweden, and Pakistan). Each participant was interviewed on Zoom (Zoom Video Communications Inc), and the interview data were thematically analyzed to design a subsequent small group and then full cohort Zoom sessions. Visual note-taking was used to reinforce a shared understanding of each individual- and group-level conversation.

Results

The interviews and gatherings for Convening The Center offered unique perspectives on patient activities in research, health innovation, and problem-solving. This project further developed a novel, two-spectrum framework for assessing different experiences that patients may have or seek to gain, based on what patients actually do, and different levels of patients’ involvement, ranging from individual to community to systemic involvement.

Conclusions

The descriptors of patients in academic literature typically focus on what health care providers think patients “are” rather than on what patients “do.” The primary result of this project is a framework for mapping what patients “do” and “where” they do their work along two spectra: from creating their own projects to contributing to work initiated by others and from working at levels ranging from individual to community to systems. A better understanding of these spectra may enable researchers to more effectively engage and leverage patient expertise in health care research and innovation.

Survey of Opioid Risk Tool Among Cancer Patients Receiving Opioid Analgesics

BACKGROUND

The risk of opioid-related aberrant behavior (OAB) in Korean cancer patients has not been previously evaluated. The purpose of this study is to investigate the Opioid Risk Tool (ORT) in Korean cancer patients receiving opioid treatment.

METHODS

Data were obtained from a multicenter, cross-sectional, nationwide observational study regarding breakthrough cancer pain. The study was conducted in 33 South Korean institutions from March 2016 to December 2017. Patients were eligible if they had cancer-related pain within the past 7 days, which was treated with strong opioids in the previous 7 days.

RESULTS

We analyzed ORT results of 946 patients. Only one patient in each sex (0.2%) was classified as high risk for OAB. Moderate risk was observed in 18 males (3.3%) and in three females (0.7%). Scores above 0 were primarily derived from positive responses for personal or familial history of alcohol abuse (in men), or depression (in women). In patients with an ORT score of 1 or higher (n = 132, 14%), the score primarily represented positive responses for personal history of depression (in females), personal or family history of alcohol abuse (in males), or 16-45 years age range. These patients had more severe worst and average pain intensity (proportion of numeric rating scale ≥ 4: 20.5% vs. 11.4%, P < 0.001) and used rescue analgesics more frequently than patients with ORT scores of 0. The proportion of moderate- or high-risk patients according to ORT was lower in patients receiving low doses of long-acting opioids than in those receiving high doses (2.0% vs. 6.6%, P = 0.031). Moderate or high risk was more frequent when ORT was completed in an isolated room than in an open, busy place (2.7% vs. 0.6%, P = 0.089).

CONCLUSIONS

The score of ORT was very low in cancer patients receiving strong opioids for analgesia. Higher pain intensity may associate with positive response to one or more ORT item.

"What do I need to know about you?": the Patient Dignity Question, age, and proximity to death among patients with cancer

PURPOSE

The Patient Dignity Question (PDQ), "What do I need to know about you as a person to give you the best care possible?" is a validated instrument designed to assess patient priorities and stressors. Administration of the PDQ has been demonstrated to improve patient-provider relationships. The PDQ has been evaluated in multiple settings, but never as a standard component of palliative care consultation. The primary objectives of this study were to determine the feasibility of PDQ screening in palliative care consultation and to characterize responses. The secondary objective was to determine patient and disease factors associated with PDQ response among patients diagnosed with cancer.

METHODS

PDQ responses were collected from 2015 to 2017, and patient survival data collected through 2018. A codebook was developed to categorize responses using literature review and template analysis; coding was performed until thematic saturation was achieved. We descriptively analyzed thematic distribution among responders and performed multivariable multinomial regression to determine the association between patient characteristics and PDQ response.

RESULTS

Response to the PDQ was documented in 2053/5002 consultations (41.1%); 1877 patient responses were included in final analysis. A total of 544 (29.5%) patients referenced illness-related concerns, 879 (46.8%) shared personal insights, and 283 (15.1%) cited interpersonal relationships. Younger patients frequently reported illness-related concerns; older respondents (age > 65) often responded with insights into their identity. Patients' responses evaluated less than 1 year before death were more likely to focus upon identity and interpersonal relationships than illness-related concerns.

CONCLUSION

The PDQ can be used as a means of eliciting values among patients with cancer. Variations in response pattern suggest that approaches to distress may be tailored to age and proximity to death.

Cognitive Processing of Miscommunication in Interactive Listening: An Evaluation of Listener Indecision and Cognitive Effort

Purpose The purpose of the current study was to evaluate the social and cognitive underpinnings of miscommunication during an interactive listening task. Method An eye and computer mouse-tracking visual-world paradigm was used to investigate how a listener's cognitive effort (local and global) and decision-making processes were affected by a speaker's use of ambiguity that led to a miscommunication. Results Experiments 1 and 2 found that an environmental cue that made a miscommunication more or less salient impacted listener language processing effort (eye-tracking). Experiment 2 also indicated that listeners may develop different processing heuristics dependent upon the speaker's use of ambiguity that led to a miscommunication, exerting a significant impact on cognition and decision making. We also found that perspective-taking effort and decision-making complexity metrics (computer mouse tracking) predict language processing effort, indicating that instances of miscommunication produced cognitive consequences of indecision, thinking, and cognitive pull. Conclusion Together, these results indicate that listeners behave both reciprocally and adaptively when miscommunications occur, but the way they respond is largely dependent upon the type of ambiguity and how often it is produced by the speaker.

DooR to DooR's Acoustics of Care: Interrupting and Transforming the Biomedical Landscapes of Western Hospitals

The present study was conducted at the University of North Carolina Hospitals. Data were collected from DooR to DooR (D2D), a healing arts program that brings professional artists into the hospital. Drawing from ethnographic data, we forefront music in health communication literature by exploring its performance by D2D artists in hospital settings that range from in-patient oncology wards, waiting rooms, and even burn units. From a narrative theoretical approach, we situate art programming in the historical development of the contemporary hospital system in the U.S. and our analysis amidst growing bodies of literature on the narrative and aesthetic potentials of healthcare. We offer an in-depth analysis of how D2D's music disrupts the soundscape of UNC hospitals, distracts patients from troubling exigencies, and fosters self-expression and storytelling among participants.

From a Digital Bottle: A Message to Ourselves in 2039

We are fully aware that we could have wasted our time writing this message, as nobody might read it. Even those who read it might ignore it, and those who read and care about it might be unable to do anything. It may simply be too late. Nevertheless, this message describes the hopes we had back in 1999, imagining how the incredible digital tools whose birth we were witnessing, could change the world for the better. In 2019, when we wrote these words, we were saddened to realize that most of what we had imagined and proposed in the past 20 years could have been written the day before, without losing an iota of relevance. Whoever or whatever you might be, dear reader-a human, a sentient machine, or a hybrid-we would like you to understand that, rather than an attempt to predict the future, which probably continues to be an impossible endeavor, this message was meant to act as an invitation, regardless of when or where it is found, to engage in a conversation that has already transcended time and space, even if the issues it contains have become irrelevant.

A patient focused relationship for specialists in laboratory medicine

Technological change is driving individualized healthcare delivery including laboratory medicine. Ensuring patients gain from their empowerment it is essential that they access data that enables them to utilize reliable information. The potential difficulties of comprehension, information retention and imperfect modes of communication can significantly impair utilization of information by patients. Support for understanding and decision-making needs to be clinically competent and integrated within the healthcare team. Specialists in laboratory medicine are well placed to undertake such a role, the issues around this are explored and proposals for better direct engagement with patients made.

How patients' use of social media impacts their interactions with healthcare professionals

INTRODUCTION

Patients are increasingly accessing online health information and have become more participatory in their engagement with the advent of social media (SM). This study explored how patients' use of SM impacted their interactions with healthcare professionals (HCPs).

METHODS

Focus groups (n=5) were conducted with 36 patients with chronic conditions and on medication who used SM for health-related purposes. The discussions lasted 60-90min, were audio-recorded, transcribed verbatim, and thematically analysed.

RESULTS

Participants did not interact with HCPs on SM and were not expecting to do so as they used SM exclusively for peer interactions. Most reported improvement in the patient-HCP relationship due to increased knowledge, better communication, and empowerment. Participants supplemented HCP-provided information with peer interactions on SM, and prepared themselves for consultations. They shared online health information with HCPs, during consultations, to validate it and to actively participate in the decision-making. Although some participants reported HCP support for their online activities, most perceived overt or tacit opposition.

CONCLUSION

Participants perceived that their SM use positively impacted relationships with HCPs. They felt empowered and were more assertive in participating in decision-making.

PRACTICE IMPLICATIONS

HCPs should be aware of patients' activities and expectations, and support them in their online activities.

Moral Economy and Moral Capital in the Community of Clinical Practice

This New Zealand study used focused ethnography to explore the activities of communities of clinical practice (CoCP) in a community-based long-term conditions management program within a large primary health care clinic. CoCP are the informal vehicles by which patient care was delivered within the program. Here, we describe the CoCP as a micro-level moral economy within which values such as trust, respect, authenticity, reciprocity, and obligation circulate as a kind of moral capital. As taxpayers, citizens who become patients are credited with moral capital because the public health system is funded by taxes. This moral capital can be paid forward, accrued, banked, redeemed, exchanged, and forfeited by patients and their health care professionals during the course of a patient's journey. The concept of moral capital offers another route into the "black box" of clinical work by providing an alternative theoretic for explaining the relational aspects of patient care.

Digital health is a cultural transformation of traditional healthcare

Under the term "digital health", advanced medical technologies, disruptive innovations and digital communication have gradually become inseparable from providing best practice healthcare. While the cost of treating chronic conditions is increasing and doctor shortages are imminent worldwide, the needed transformation in the structure of healthcare and medicine fails to catch up with the rapid progress of the medical technology industry. This transition is slowed down by strict regulations; the reluctance of stakeholders in healthcare to change; and ignoring the importance of cultural changes and the human factor in an increasingly technological world. With access and adoption of technology getting higher, the risk of patients primarily turning to an accessible, but unregulated technological solution for their health problem is likely to increase. In this paper, we discuss how the old paradigm of the paternalistic model of medicine is transforming into an equal level partnership between patients and professionals and how it is aided and augmented by disruptive technologies. We attempt to define what digital health means and how it affects the status quo of care and also the study design in implementing technological innovations into the practice of medicine.

Factors Influencing Likelihood of Voice Therapy Attendance

Objective To identify factors associated with the likelihood of attending voice therapy among patients referred for it in the CHEER (Creating Healthcare Excellence through Education and Research) practice-based research network infrastructure. Study Design Prospectively enrolled cross-sectional study. Setting CHEER network of community and academic sites. Methods Data were collected on patient-reported demographics, voice-related diagnoses, voice-related handicap (Voice Handicap Index-10), likelihood of attending voice therapy (VT), and opinions on factors influencing likelihood of attending VT. The relationships between patient characteristics/opinions and likelihood of attending VT were investigated. Results A total of 170 patients with various voice-related diagnoses reported receiving a recommendation for VT. Of those, 85% indicated that they were likely to attend it, regardless of voice-related handicap severity. The most common factors influencing likelihood of VT attendance were insurance/copay, relief that it was not cancer, and travel. Those who were not likely to attend VT identified, as important factors, unclear potential improvement, not understanding the purpose of therapy, and concern that it would be too hard. In multivariate analysis, factors associated with greater likelihood of attending VT included shorter travel distance, age (40-59 years), and being seen in an academic practice. Conclusions Most patients reported plans to attend VT as recommended. Patients who intended to attend VT reported different considerations in their decision making from those who did not plan to attend. These findings may inform patient counseling and efforts to increase access to voice care.

Readability, relevance and quality of the information in Spanish on the Web for patients with rheumatoid arthritis

BACKGROUND

Education is a major health determinant and one of the main independent outcome predictors in rheumatoid arthritis (RA). The use of the Internet by patients has grown exponentially in the last decade.

OBJECTIVE

To assess the characteristics, legibility and quality of the information available in Spanish in the Internet regarding to rheumatoid arthritis.

MATERIAL AND METHODS

The search was performed in Google using the phrase rheumatoid arthritis. Information from the first 30 pages was evaluated according to a pre-established format (relevance, scope, authorship, type of publication and financial objective). The quality and legibility of the pages were assessed using two validated tools, DISCERN and INFLESZ respectively. Data extraction was performed by senior medical students and evaluation was achieved by consensus.

RESULTS

The Google search returned 323 hits but only 63% were considered relevant; 80% of them were information sites (71% discussed exclusively RA, 44% conventional treatment and 12% alternative therapies) and 12.5% had a primary financial interest. 60% of the sites were created by nonprofit organizations and 15% by medical associations. Web sites posted by medical institutions from the United States of America were better positioned in Spanish (Arthritis Foundation 4th position and American College of Rheumatology 10th position) than web sites posted by Spanish speaking countries.

CONCLUSIONS

There is a risk of disinformation for patients with RA that use the Internet. We identified a window of opportunity for rheumatology medical institutions from Spanish-speaking countries to have a more prominent societal involvement in the education of their patients with RA.

What motivates Australian health service users with chronic illness to engage in self-management behaviour?

CONTEXT

Health policy in Australia emphasizes the role of health service users (HSU) in managing their own care but does not include mechanisms to assist HSUs to do so.

OBJECTIVE

To describe motivation towards or away from self-management in a diverse group of older Australians with diabetes, chronic heart failure (CHF) or chronic obstructive pulmonary disease (COPD) and suggest policy interventions to increase patient motivation to manage effectively.

DESIGN

Content and thematic analyses of in-depth semi-structured interviews. Participants were asked to describe their experience of having chronic illness, including experiences with health professionals and health services. Secondary analysis was undertaken to expose descriptions of self-management behaviours and their corresponding motivational factors.

PARTICIPANTS

Health service users with diabetes, COPD and/or CHF (N=52).

RESULTS

Participant descriptions exposed internal and external sources of motivation. Internal motivation was most often framed positively in terms of the desire to optimize health, independence and wellness and negatively in terms of avoiding the loss of those attributes. External motivation commonly arose from interactions with family, carers and health professionals. Different motivators appeared to work simultaneously and interactively in individuals, and some motivators seemed to be both positive and negative drivers.

CONCLUSION

Successful management of chronic illness requires recognition that the driving forces behind motivation are interconnected. In particular, the significance of family as an external source of motivation suggests a need for increased investment in the knowledge and skill building of family members who contribute to care.

Probing, impelling, but not offending doctors: the role of the internet as an information source for patients' interactions with doctors

The Internet has become a major health information source for many patients, and they might discuss the information they get from the Internet with their doctors. I explored how the Internet as an information source influences cancer patients' communication with their doctors in Taiwan, where the doctor-patient relationship is traditionally doctor dominated. Forty-six cancer patients or families participated in seven focus group discussions. I conducted inductive analysis to examine themes emerging from discussions. Participants searched for information on the Internet to probe and verify their doctors' competence. Participants took responsibility for understanding the doctors' jargon, and the Internet helped them to do that. The Internet also helped participants spur doctors to think further about their condition, but these patients did so cautiously, with an effort not to offend doctors. The Internet as an information source did help participants talk to doctors, but the effect on changing the doctor-dominant nature of the relationship was limited.

'I didn't want her to panic': unvoiced patient agendas in primary care consultations when consulting about antidepressants

BACKGROUND

Patient participation in primary care treatment decisions has been much debated. There has been little attention to patients' contributions to primary care consultations over a period of time, when consulting about depression and its treatment with antidepressants.

AIM

To explore: (1) what issues remain unsaid during a primary care consultation for depression but are later raised by the patient as important during a research interview; (2) patients' reasons for non-disclosure; (3) whether unvoiced agendas are later voiced; and (4) the nature of the GP-patient relationship in which unvoiced agendas occur.

DESIGN OF STUDY

Qualitative interview study.

SETTING

Primary health care.

METHOD

Patients were recruited through six general practices in the south west of England. Qualitative interviews were carried out with 10 'pairs' of GPs and patients who presented with a new or first episode of moderate to severe depression and were prescribed antidepressants. Follow-up patient interviews were conducted at 3 and 6 months. Throughout the 6-month period, patients were invited to record subsequent consultations (with GPs' consent), using a patient-held tape recorder.

RESULTS

Twenty-three unvoiced agendas were revealed, often within decision-making relationships that were viewed in positive terms by patients. Unvoiced agendas included: a preference for immediate treatment, a preference to increase dosage, and the return or worsening of suicidal thoughts. In some cases, patients were concerned that they were 'letting the GP down' by not being able to report feeling better.

CONCLUSION

Unvoiced agendas are not necessarily an indication that 'shared decision making' is absent but may in some cases represent patients' attempts to 'protect' their GPs.

Sharing qualitative research findings with participants: study experiences of methodological and ethical dilemmas

OBJECTIVE

Sharing qualitative research findings with participants, namely member-check, is perceived as a procedure designed to enhance study credibility and participant involvement. It is rarely used, however, and its methodological usefulness and ethical problems have been questioned. This article explores benefits and risks in applying member-check when studying healthcare topics, questioning the way it should be performed.

METHODS

We discuss researchers' experiences in applying member-check, using four examples from three different studies: healthcare-providers' experiences of working with sexual-abuse survivors; adolescents' exposure to domestic-violence, and delivering and receiving bad news.

RESULTS

Methodological and ethical difficulties can arise when performing member-check, challenging the day-to-day researcher-participant experience, and potentially, the physician-patient relationship.

CONCLUSION

Applying member-check in healthcare settings is complex. Although this strategy has good intentions, it is not necessarily the best method for achieving credibility. Harm can be caused to participants, researchers and the doctor-patient relationship, risking researchers' commitment to ethical principles.

PRACTICE IMPLICATIONS

Because participants' experience regarding member-check is difficult to predict, such a procedure should be undertaken cautiously. Prior to initiating member-check, researchers should ask themselves whether such a procedure is potentially risky for participants; and if anonymity cannot be guaranteed, use alternative procedures when needed.

Effective communication is crucial to self-management: the experiences of immigrants to Australia living with diabetes

OBJECTIVES

Ageing immigrant populations now pose problems for the management of chronic illness in Australia. This article asks questions about the experiences of immigrants in Australia with type II diabetes mellitus (DM). What impact, if any, have health policies had on the lives of immigrants? How do their experiences of living with DM compare with those of people with DM who were born in Australia?

METHODS

Semi-structured interviews were conducted with 32 participants who had DM (n = 25) or cared for someone with DM (n = 7). Fifteen participants had migrated to Australia and English was not their first language. Participants were asked to describe their experience of managing diabetes.

RESULTS

Immigrants to Australia confront linguistic and cultural barriers that create an extra layer of problems not experienced by Australian-born people. Older people who were born overseas face obstacles to effective engagement with the health system that weaken their ability to take an active part in the management of their conditions.

CONCLUSIONS

Chronic disease policy is failing immigrants to Australia. Health professionals and services must recognize the central role that cultural diversity plays in self-management and the impact that this can have on health outcomes for immigrants with chronic illness.

["Good practices" and patient satisfaction]

OBJECTIVE

The Patient Autonomy Act should contribute to a "patient-centred" health care. The study objectives were to determine to what extent patients believe that their basic rights under the LAP (best practices) are being met. Secondly, to study the relationship between this performance and reported patient satisfaction levels.

MATERIALS & METHODS

A total of 13,773 patients were interviewed (31.7% >60 years and 53.6% women) receiving health care at 21 Spanish public hospitals. The number of "good practices" (GP) was analysed using descriptive statistics; relationship between GP and satisfaction was measured using logistic regression.

RESULTS

The medical discharge information was one of the most established practices. The compliance level ranged from 97.4% of parents of children over 6 years in paediatric service and 76.2% of patients attending obstetric services. The welcome process (Odds Ratio 3.53, IC-95% CI; 1.95-6.41, P<0.001), informed consent (Odds Ratio 2.77, 95% CI; 1.40-5.47), to recognize which type of professional was providing care at all the times (Odds Ratio 3.36, 95% CI; 1.96-5.78), were the aspects that increased probability that the patient felt satisfied.

CONCLUSIONS

Compliance to patient rights was increased in all services analysed. When these rights are respected patient satisfaction increases.

What patients with cancer want to know about pain: a qualitative study

Research indicates that patients feel more satisfied and obtain better health outcomes when they are able to discuss their questions with their health professionals. A better understanding of cancer patients' questions may help guide interventions to address their information needs and improve pain management. This study sought to explore and describe the questions that women with breast cancer have about pain related to cancer. Semistructured interviews were conducted with women with pain related to breast cancer or its treatment, recruited from a large teaching hospital in Toronto, Canada. Interviews were audio recorded and fully transcribed. Data saturation was reached after 18 participants were interviewed. Analysis involved the identification of themes and the development of a taxonomy of questions about pain. In total, over 200 questions concerning seven main themes were identified: (1) understanding cancer pain, (2) knowing what to expect, (3) options for pain control, (4) coping with cancer pain, (5) talking with others with cancer pain, (6) finding help managing cancer pain, and (7) describing pain. The information collected suggests that formulating and articulating questions about pain is a context-dependent, time-intensive process that requires reflection, knowledge, and a good use of language. Patients have numerous and diverse questions about pain and its treatment, which may be difficult to address within the context of a typical consultation. To manage pain adequately, innovative efforts are needed to enable patients and health professionals to recognize, articulate, and answer such questions. Internet-based tools could provide some of these solutions.

Expectations held by type 1 and 2 diabetes mellitus patients and their relatives: the importance of facilitating the health-care process

AIM

To understand the expectations held by type 1 and 2 diabetes mellitus (DM 1 & 2) patients and their relatives regarding the health-care provided to them.

DESIGN

qualitative. Focus groups.

SETTING AND PARTICIPANTS

Andalusia. A theoretical sample that includes the most characteristic profiles. Thirty-one subjects with DM. segmentation characteristics receiving health-care for DM in Primary or Specialized care, living in urban and rural areas, men and women, age, varying diagnosis times, DM course and consequences. Subjects were recruited by health-care professionals at reference care centres.

RESULTS

Patients expect their health-care professionals to be understanding, to treat them with kindness and respect, to have good communication skills, to provide information in a non-authoritarian manner while fully acknowledging patients' know-how. Regarding the health-care system, their expectations focus on the system's ability to respond when required to do so, through a relevant professional, along with readily available equipment for treatment. The expectations of people affected by DM1 focus on leading a normal life and not having their educational, labour, social and family opportunities limited by the disease. Expectations in people with DM2 tend towards avoiding what they know has happened to other patients.

CONCLUSIONS

'Facilitating', is a key word. Both the health-care system and its professionals must pay keener attention to the emotional aspects of the disease and its process, adopting a comprehensive approach to care. It is vital that health-care professionals take an active interest in the course of their patient's disease, promoting accessibility and an atmosphere of trust and flexibility.

A Study of Information Seeking by Cancer Patients and their Carers

AIMS

To examine cancer patients' and carers' use of, and attitudes to, the Internet as an information source compared with other media.

MATERIALS AND METHODS

The study was carried out in two phases: in phase I, interviews were used to construct a suitable instrument. In phase II, interviews were completed with 800 recently diagnosed patients and 200 carers.

RESULTS

Relatively few patients (4.8%), but a high proportion of carers (48%), accessed the Internet directly for cancer information. However, around half of the patients used Internet information provided by someone else, generally a family member. The use of Internet information was uniformly low among ethnic minorities. Those who accessed Internet information reported high levels of satisfaction and generally rated it higher than booklets or leaflets. When asked who they would like to provide Internet information, overwhelmingly patients wanted the hospital doctor to do so. When this was done, there was very high compliance. Carers were much more proactive information seekers than patients.

CONCLUSIONS

The Internet is an effective means of information provision in those who use it. Facilitated Internet access and directed use by health professionals would be effective ways of broadening access to this medium.

Is patient involvement possible when decisions involve scarce resources? A qualitative study of decision-making in primary care

Greater patient involvement has become a key goal of health care provision. This study explored the way in which general practitioners (GPs) in the UK manage the dual responsibilities of treating individual patients and making the most equitable use of National Health Service (NHS) resources in the context of the policy of greater patient involvement in decision-making. We undertook a qualitative study incorporating a series of interviews and focus groups with a sample of 24 GPs. We analysed GP accounts of decision-making by relating these to substantive ethical principles and the key procedural principle of explicitness in decision-making. GPs saw patient involvement in positive terms but for some GPs involvement served an instrumental purpose, for instance improving patient 'compliance'. GPs identified strongly with the role of patient advocate but experienced role tensions particularly with respect to wider responsibilities for budgets, populations, and society in general. GPs had an implicit understanding of the key ethical principle of explicitness and of other substantive ethical principles but there was incongruence between these and their interpretation in practice. Limited availability of GP time played an important role in this theory/practice gap. GPs engaged in implicit categorisation of patients, legitimating this process by reference to the diversity and complexity of general practice. If patient involvement in health care decision-making is to be increased, then questions of scarcity of resources, including time, will need to be taken into account. If strategies for greater patient involvement are to be pursued then this will have significant implications for funding primary care, particularly in terms of addressing the demands made on consultation time. Good ethics and good professional practice cost money and must be budgeted for. More explicit decision-making in primary care will need to be accompanied by greater explicitness at the national level about roles and responsibilities. Increased patient involvement has consequences for GP training and ways of addressing rationing dilemmas will need to be an important part of this training. Further research is needed to understand micro-decision-making, in particular the spaces in which processes of implicit categorisation lead to distorted communication between doctor and patient.

How the internet affects patients' experience of cancer: a qualitative study

OBJECTIVE

To explore how men and women with cancer talk about using the internet.

DESIGN

Qualitative study using semistructured interviews collected by maximum variation sampling.

SETTING

Respondents recruited throughout the United Kingdom during 2001-2.

PARTICIPANTS

175 men and women aged 19-83 years, with one of five cancers (prostate, testicular, breast, cervical, or bowel) diagnosed since 1992 and selected to include different stages of treatment and follow up.

RESULTS

Internet use, either directly or via friend or family, was widespread and reported by patients at all stages of cancer care, from early investigations to follow up after treatment. Patients used the internet to find second opinions, seek support and experiential information from other patients, interpret symptoms, seek information about tests and treatments, help interpret consultations, identify questions for doctors, make anonymous private inquiries, and raise awareness of the cancer. Patients also used it to check their doctors' advice covertly and to develop an expertise in their cancer. This expertise, reflecting familiarity with computer technology and medical terms, enabled patients to present a new type of "social fitness."

CONCLUSION

Cancer patients used the internet for a wide range of information and support needs, many of which are unlikely to be met through conventional health care. Serious illness often undermines people's self image as a competent member of society. Cancer patients may use the internet to acquire expertise to display competence in the face of serious illness.

Preoperative assessment

Although anaesthetic and surgical procedures should be individualised for every patient, in practice many preoperative protocols and routines are used generally. In this article, we aim to emphasise: why preoperative assessment is important; how it should be done, and by whom; what can be expected; and the importance of test selection based on patients' needs and on scientific evidence of effectiveness. We outline the roles of preoperative medical assessment in otherwise healthy patients. Clinical history, preoperative questionnaires, physical examination, routine tests, individual risk-assessment, and fasting policies are investigated by review of published work. Cost of routine preoperative assessment, the anaesthetist's legal responsibility, and patients'views in the preoperative process are also considered. A thorough clinical preoperative assessment of the patient is more important than routine preoperative tests, which should be requested only when justified by clinical indications. Moreover, this practice eliminates unnecessary cost without compromising the safety and quality of care. Education and training of medical doctors should be more scientifically guided, emphasising the relevance of effectiveness, and cost-effectiveness in clinical decision-making and complemented by audit.