Should a patient's socioeconomic status count in decisions about treatment in medical care? A longitudinal study of Norwegian doctors

AIMS

The major causes of social inequalities in health are found outside of healthcare. However, healthcare can also play a role in maintaining, reducing, or reinforcing inequality. We present and discuss results from a panel study of doctors' views on whether and how socioeconomic factors should play a role in clinical decision making.

METHODS

The panel comprised a representative sample of Norwegian doctors, established in 1994. For the current study, the doctors received postal questionnaires in 2008, 2012 and 2016. Data were analysed using descriptive statistics, correlation analysis, factor analysis and mixed models for repeated measurements.

RESULTS

The sample sizes were 1072 (65%), 1279 (71%) and 1605 (73%), respectively. The doctors were increasingly positive towards considering socioeconomic factors, and reported giving more time and advice and asking for less pay to compensate for unfavorable socioeconomic factors. General practitioners were more likely to consider socioeconomic factors and changed their practice accordingly compared to other clinicians. The percentage of doctors who agreed that different amounts of resources should be used to obtain similar health effects was high and increased over time.

CONCLUSIONS

Increasingly more doctors are willing to consider patients' socioeconomic factors in clinical care. This could be contrary to professional ethics, in which only medical need should count. However, it depends on how 'need' is interpreted. As treatment outcomes partly depend on non-medical factors, socioeconomic factors should be considered because they influence patients' ability to benefit from medical care. Equality requires mitigating factors with negative impacts on health outcomes.

Duty to treat and perceived risk of contagion during the COVID-19 pandemic: Norwegian physicians' perspectives and experiences-a questionnaire survey

BACKGROUND

The COVID-19 pandemic actualised the dilemma of how to balance physicians´ obligation to treat patients and their own perceived risk of being infected. To discuss this in a constructive way we need empirical studies of physicians´ views of this obligation.

METHODS

A postal questionnaire survey was sent to a representative sample of Norwegian physicians in December 2020. We measured their perceived obligation to expose themselves to infection, when necessary, in order to provide care, concerns about being infected themselves, for spreading the virus to patients or to their families. We used descriptive statistics, chi-square tests and logistic regression analyses.

RESULTS

The response rate was 1639/2316 (70.9%), 54% women. Of doctors < 70, 60,2% (95% CI 57.7-62.7) acknowledged to some or a large degree an obligation to expose themselves to risk of infection, and 42.0% (39.5-44.5) held this view despite a scarcity of personal protective equipment (PPE). Concern about being infected oneself to some or to a large extent was reported by 42.8% (40.3-45.3), 47.8% (45.3-50.3) reported concern about spreading the virus to patients, and 63.9% (61.5-66.3) indicated worry about spreading it to their families. Being older increased the odds of feeling obligated (ExpB = 1.02 p < 0.001), while experiencing scarcity of PPE decreased the odds (ExpB = 0.74, p = 0.01). The odds of concern about spreading virus to one´s family decreased with higher age (Exp B = 0.97, p < 0.001), increased with being female (Exp B = 1.44, p = 0.004), and perceived lack of PPE (Exp B = 2.25, p < 0.001). Although more physicians working in COVID-exposed specialties experienced scarcity of PPE and reported perceived increased risks for health personnel, the odds of concern about being infected themselves or spreading the virus to their families were not higher than for other doctors.

CONCLUSION

These empirical findings lead to the question if fewer physicians in the future will consider the duty to treat their top priority. This underscores the need to revisit and revitalise existing ethical codes to handle the dilemma between physicians´ duty to treat versus the duty to protect physicians and their families. This is important for the ability to provide good care for the patient and the provider in a future pandemic situation.

An empirical bioethical examination of Norwegian and British doctors' views of responsibility and (de)prioritization in healthcare

In a world with limited resources, allocation of resources to certain individuals and conditions inevitably means fewer resources allocated to other individuals and conditions. Should a patient's personal responsibility be relevant to decisions regarding allocation? In this project we combine the normative and the descriptive, conducting an empirical bioethical examination of how both Norwegian and British doctors think about principles of responsibility in allocating scarce healthcare resources. A large proportion of doctors in both countries supported including responsibility for illness in prioritization decisions. This finding was more prominent in zero-sum scenarios where allocation to one patient means that another patient is denied treatment. There was most support for incorporating prospective responsibility (through patient contracts), and low support for integrating responsibility into co-payments (i.e. through requiring responsible patients to pay part of the costs of treatment). Finally, some behaviours were considered more appropriate grounds for deprioritization (smoking, alcohol, drug use)-potentially because of the certainty of impact and direct link to ill health. In zero-sum situations, prognosis also influenced prioritization (but did not outweigh responsibility). Ethical implications are discussed. We argue that the role that responsibility constructs appear to play in doctors' decisions indicates a needs for more nuanced-and clear-policy. Such policy should account for the distinctions we draw between responsibility-sensitive and prognostic justifications for deprioritization.

Do you recommend cancer screening to your patients? A cross-sectional study of Norwegian doctors

OBJECTIVE

Guidelines for cancer screening have been debated and are followed to varying degrees. We wanted to study whether and why doctors recommend disease-specific cancer screening to their patients.

DESIGN

Our cross-sectional survey used a postal questionnaire. The data were examined with descriptive methods and binary logistic regression.

SETTING

We surveyed doctors working in all health services.

PARTICIPANTS

Our participants comprised a representative sample of Norwegian doctors in 2014/2015.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome is whether doctors reported recommending their patients get screening for cancers of the breast, colorectum, lung, prostate, cervix and ovaries. We examined doctors' characteristics predicting adherence to the guidelines, including gender, age, and work in specialist or general practice. The secondary outcomes are reasons given for recommending or not recommending screening for breast and prostate cancer.

RESULTS

Our response rate was 75% (1158 of 1545). 94% recommended screening for cervical cancer, 89% for breast cancer (both established as national programmes), 42% for colorectal cancer (upcoming national programme), 41% for prostate cancer, 21% for ovarian cancer and 17% for lung cancer (not recommended by health authorities). General practitioners (GPs) adhered to guidelines more than other doctors. Early detection was the most frequent reason for recommending screening; false positives and needless intervention were the most frequent reasons for not recommending it.

CONCLUSIONS

A large majority of doctors claimed that they recommended cancer screening in accordance with national guidelines. Among doctors recommending screening contrary to the guidelines, GPs did so to a lesser degree than other specialties. Different expectations of doctors' roles could be a possible explanation for the variations in practice and justifications. The effectiveness of governing instruments, such as guidelines, incentives or reporting measures, can depend on which professional role(s) a doctor is loyal to, and policymakers should be aware of these different roles in clinical governance.

How do doctors experience the interactions among professional fulfilment, organisational factors and quality of patient care? A qualitative study in a Norwegian hospital

OBJECTIVES

Doctors increasingly experience high levels of burnout and loss of engagement. To address this, there is a need to better understand doctors' work situation. This study explores how doctors experience the interactions among professional fulfilment, organisational factors and quality of patient care.

DESIGN

An exploratory qualitative study design with semistructured individual interviews was chosen. Interviews were transcribed verbatim and analysed by a transdisciplinary research group.

SETTING

The study focused on a surgical department of a mid-sized hospital in Norway.

PARTICIPANTS

Seven doctors were interviewed. A purposeful sampling was used with gender and seniority as selection criteria. Three senior doctors (two female, one male) and four in training (three male, one female) were interviewed.

RESULTS

We found that in order to provide quality care to the patients, individual doctors described 'stretching themselves', that is, handling the tensions between quantity and quality, to overcome organisational shortcomings. Experiencing a workplace emphasis on production numbers and budget concerns led to feelings of estrangement among the doctors. Participants reported a shift from serving as trustworthy, autonomous professionals to becoming production workers, where professional identity was threatened. They felt less aligned with workplace values, in addition to experiencing limited management recognition for quality of patient care. Management initiatives to include doctors in development of organisational policies, processes and systems were sparse.

CONCLUSION

The interviewed doctors described their struggle to balance the inherent tension among professional fulfilment, organisational factors and quality of patient care in their everyday work. They communicated how 'stretching themselves', to overcome organisational shortcomings, is no longer a feasible strategy without compromising both professional fulfilment and quality of patient care. Managers need to ensure that doctors are involved when developing organisational policies, processes and systems. This is likely to be beneficial for both professional fulfilment and quality of patient care.

Doctors' attitudes to assisted dying

BAKGRUNN

Aktiv dødshjelp er ulovlig i Norge, men et flertall av befolkningen støtter legalisering. Legers holdninger til aktiv dødshjelp ble sist undersøkt i 1993. Har legers holdninger endret seg?

MATERIALE OG METODE

To spørreundersøkelser sendt til Legeforskningsinstituttets legepanel i henholdsvis 2014 og 2016 inneholdt spørsmål om aktiv dødshjelp. Svarene ble analysert med deskriptiv statistikk og logistisk regresjonsanalyse.

RESULTATER

Svarprosenten var henholdsvis 75,0 (2014) og 73,1 (2016). Majoriteten var motstandere av legalisering av aktiv dødshjelp. I 2016-undersøkelsen sa 9,1 % av respondentene seg «svært enig» og 21,5 % «litt enig» i at legeassistert selvmord bør tillates for personer som har «en dødelig sykdom med kort forventet levetid». Yngre og ikke-religiøse var oftere positive til legalisering. I 2014-undersøkelsen svarte 8,6 % at de ville ha vært villige til å utføre legeassistert selvmord hvis dette ble tillatt.

FORTOLKNING

Som i 1993 var et flertall av norske leger imot aktiv dødshjelp, men det synes å være flere enn før som støttet legalisering i visse tilfeller. De færreste var selv villige til å utføre aktiv dødshjelp hvis det ble tillatt.

Between professional values, social regulations and patient preferences: medical doctors' perceptions of ethical dilemmas

BACKGROUND

We present and discuss the results of a Norwegian survey of medical doctors' views on potential ethical dilemmas in professional practice.

METHODS

The study was conducted in 2015 as a postal questionnaire to a representative sample of 1612 doctors, among which 1261 responded (78%). We provided a list of 41 potential ethical dilemmas and asked whether each was considered a dilemma, and whether the doctor would perform the task, if in a position to do so. Conceptually, dilemmas arise because of tensions between two or more of four doctor roles: the patient's advocate, a steward of societal interests, a member of a profession and a private individual.

RESULTS

27 of the potential dilemmas were considered dilemmas by at least 50% of the respondents. For more than half of the dilemmas, the anticipated course of action varied substantially within the professional group, with at least 20% choosing a different course than their colleagues, indicating low consensus in the profession.

CONCLUSIONS

Doctors experience a large range of ethical dilemmas, of which many have been given little attention by academic medical ethics. The less-discussed dilemmas are characterised by a low degree of consensus in the profession about how to handle them. There is a need for medical ethicists, medical education, postgraduate courses and clinical ethics support to address common dilemmas in clinical practice. Viewing dilemmas as role conflicts can be a fruitful approach to these discussions.

Commentary to ‘Social Health Disparities in Clinical Care: A New Approach to Medical Fairness’ by Puschel, Furlan and Dekkers

The commentary brings up two topics. The first concerns whether and how a patient’s socioeconomic status (SES) should count in clinical care. We provide a brief summary of Puschel and colleagues’ view and discuss it in relation to other accounts. We share their conclusion; considering SES in clinical care can be justified from a fairness perspective. Yet, we question the claim that this is a new perspective, and argue that the reason for the claim of novelty is an insufficient use of references. This leads to the second topic, which is a discussion of citation practices in philosophical/ethics papers. We describe common deviations from academic standards, and suggest how unfortunate practices can be reduced.

Commercialism, holism, and individual responsibility comment on "buying health: the costs of commercialism and an alternative philosophy"

Churchill and Churchill's editorial discusses negative (health) effects of commercialism in the provision of health care and nutrition. Three parts of their argument are commented: the claim that the fundamental problem of markets is the decomposition of the whole into parts ("reductionism"); the call for individual responsibility; and the notion of holism. On the three aspects the commentary concludes thus: Because provision of health and food must be controlled and managed in some form, an alternative to some kind of decomposition is hard to see. The call for individual responsibility is controversial due to its lack of attention to socioeconomic inequalities. The concept of "holism" is problematic due to its epistemological and normative status.

Norwegian physicians' knowledge of the prices of pharmaceuticals: a survey

The objectives of this study are to measure physicians’ knowledge of the prices of pharmaceuticals, and investigate whether there are differences in knowledge of prices between groups of physicians. This article reports on a survey study of physicians’ knowledge of the prices of pharmaceuticals conducted on a representative sample of Norwegian physicians in the autumn of 2010. The importance of physicians’ knowledge of costs derives from their influence on total spending and allocation of limited health-care resources. Physicians are important drivers in the effort to contain costs in health care, but only if they have the knowledge needed to choose the most cost-effective treatment options. A survey was sent to 1 543 Norwegian physicians, asking them for price estimates and their opinions on the importance of considering the cost of treatment to society as a decision factor when treating their patients. This article deals with a subsection in which the physicians were asked to estimate the price of five pharmaceuticals: simvastatin, alendronate (Fosamax), infliximab (Remicade), natalizumab (Tysabri) and escitalopram (Cipralex). The response rate was 65%. For all the five pharmaceuticals, more than 50% and as many as 83% gave responses that differed more than 50% from the actual drug price. The price of more expensive pharmaceuticals was underestimated, while the opposite was the case for less expensive medicines. The data show that physicians in general have poor knowledge of the prices of the pharmaceuticals they offer their patients. However, the physicians who frequently deal with a drug have better knowledge of its price than those who do not handle a medication as often. The data also suggest that those physicians who agree that cost of care to society is an important decision factor have better knowledge of drug prices.

Social and diagnostic inequality in health

Aims: Empirical studies of social inequalities in health commonly take the diagnosing of disease for granted. Social inequalities in health are seen as the result of social processes, yet the diagnosis itself is rarely considered to contribute to such inequality. We argue that the influence of sociocultural and cognitive bias in the diagnosing process follows a social pattern, such that certain diagnoses are disproportionally over- or underrepresented in different socioeconomic groups due to interpretive bias of underlying symptoms. Methods: Norwegian data on sick leave for diffuse musculoskeletal and diffuse psychiatric disease in 2006 were analysed to study the distribution of the two diagnoses in different status groups. Socioeconomic status was measured by years of education. Diagnoses and occupational codes were based on national registers; diagnoses in accordance with the International Classification of Primary Care second edition. We compared occupations in technical sectors to occupations in the health sector and the relative number of cases of sick leave controlled for years of education, gender, occupational sector, and diagnosis. Data were analysed by cross-tabulation, ratio of diffuse psychiatric/musculoskeletal diseases, and logistic regression. Results: The ratio of diffuse psychiatric/musculoskeletal diseases increases with education and decreases if the employee works in a technical job. Conclusion: The results challenge the traditional explanation that job features alone can explain the distribution of disease and suggest that a part of the persistent social inequality in health can be caused by the diagnosing process. In order to reach a better understanding of the processes behind the social inequalities in health, the diagnosing process itself should also be studied.

Just health: On the conditions for acceptable and unacceptable priority settings with respect to patients' socioeconomic status

It is well documented that the higher the socioeconomic status (SES) of patients, the better their health and life expectancy. SES also influences the use of health services-the higher the patients' SES, the more time and specialised health services provided. This leads to the following question: should clinicians give priority to individual patients with low SES in order to enhance health equity? Some argue that equity is best preserved by physicians who remain loyal to 'ordinary medical fairness' in non-ideal circumstances when health disparities persist; ie, doctors should allocate care according to needs only and treat everyone with equal regard by being neutral with respect to patients' SES. This paper furthers a discussion of this view by questioning how equitable needs relate to SES. To clarify, it distinguishes between four versions of 'healthcare need' and approaches an acceptable conceptualisation of the notion supported by Norman Daniels' theory on health equity. It concludes that doctors should remain neutral to patients' SES in cases in which several patients require the same health care. However, equitable health care requires considerations of the impact of socioeconomic factors (SEF) on patients' capacity to benefit from the care. Remaining neutral towards patients' SES in this respect does not promote equal regard. It follows that priority setting on the basis of SEF is required in fair clinical distribution of care, eg, through allocating more time to patients with low SES. In order to advance equity accurately, the concept of ordinary medical fairness should be amplified according to this clarification.

On the relevance of personal responsibility in priority setting: a cross-sectional survey among Norwegian medical doctors

The debate on responsibility for health takes place within political philosophy and in policy setting. It is increasingly relevant in the context of rationing scarce resources as a substantial, and growing, proportion of diseases in high-income countries is attributable to lifestyle. Until now, empirical studies of medical professionals' attitudes towards personal responsibility for health as a component of prioritisation have been lacking. This paper explores to what extent Norwegian physicians find personal responsibility for health relevant in prioritisation and what type of risk behaviour they consider relevant in such decisions. The proportion who agree that it should count varies from 17.1% ('Healthcare priority should depend on the patient's responsibility for the disease') to 26.9% ('Access to scarce organ transplants should depend on the patient's responsibility for the disease'). Higher age and being male is positively correlated with acceptance. The doctors are more willing to consider substance use in priority setting decisions than choices on food and exercise. The findings reveal that a sizeable proportion have beliefs that conflict with the norms stated in the Norwegian Patient Act. It may be possible that the implementation of legal regulations can be hindered by the opposing attitudes among doctors. A further debate on the role personal responsibility should play in priority setting seems warranted. However, given the deep controversies about the concept of health responsibility and its application, it would be wise to proceed with caution.

DESIGN

Nationally representative cross-sectional study.

SETTING

Panel-data.

PARTICIPANTS

1072 respondents, response rate 65%.

Attitudes to clinical guidelines--do GPs differ from other medical doctors?

BACKGROUND

Clinical guidelines are important for ensuring quality of treatment and care. For this reason, it is essential that clinicians adhere to guidelines. Review studies conclude that barriers to using guidelines are context specific. Nevertheless, there is a lack of studies that compare the attitudes of different groups of doctors to guidelines.

OBJECTIVES

To survey the attitudes of Norwegian medical practitioners to clinical guidelines and the reasons for any scepticism, and to compare general practitioners (GPs) with other medical doctors in Norway in this respect.

METHOD

Postal questionnaire to a panel of 1649 Norwegian medical doctors.

RESULTS

1072 doctors responded (65%). 97% claimed to be familiar with and following guidelines. A majority expressed confidence in guidelines issued by the health authorities and the medical association. GPs are significantly more uncertain about the legal status of, accessibility of and evidence in guidelines than other doctors. The most important barriers to guideline adherence are concerns about the uniqueness of individual cases and reliance on one's own professional discretion. Both groups rank attitudinal constraints higher than practical constraints, but GPs more often report practical issues as reasons for non-adherence.

CONCLUSION

It is suggested that creating trust in guidelines could be more important than more efforts to improve guideline format and accessibility. It may also be worth considering whether guidelines should be implemented using different processes in generalist and specialist care.

[Age limit for authorization and licensing of doctors]

BACKGROUND

As outlined in the Norwegian Act relating to medical practitioners (of 1980), doctors practising in Norway loose their authorization automatically at age 75, but have the possibility of applying for a continued license. Such a regulation is rather unique from an international point of view. We have investigated doctors' attitude towards this regulation.

MATERIAL AND METHOD

The article is based on two postal questionnaire surveys; one sent to 1400 practising doctors in 2006 and one sent to 900 retired doctors in 2007.

RESULTS

69% (969/1400) of the practising and 92 % (829/900) of the retired doctors responded. 80 % (772/969) of the practising and 34 % (284/829) of the retired doctors agreed with the requirement to apply for an extended licence at age 75. 25 % (97/389) of the respondents over 74 years had retained their license at the time of the investigation.

INTERPRETATION

Most doctors under age 70 accept automatic discontinuation of authorization at age 75, but support of the regulation decreases with increasing age.

[Should medical doctors contribute to reducing social inequality in health?]

BACKGROUND

Which role the health care system has and should have in reducing social inequality in health is unclear. The study objective is to gain knowledge about what Norwegian medical doctors believe their role should be.

MATERIAL AND METHOD

A questionnaire on how doctors take socioeconomic factors into account when treating patients was sent to a representative sample of 1,650 Norwegian doctors in 2008.

RESULTS

1,153 (70 %) doctors responded. 55 % believed doctors should contribute to reducing social inequality by offering patients with a low socioeconomic status extra help. However, the majority reported that they seldom/never take the patients' socioeconomic situation (such as bad private economy [81 %], little education [80 %], or unemployment [85 %]) into account in their clinical work. Some would consider lack of a social network (33 %), or heavy caring responsibilities (43 %) to be relevant. When responding to the question about how medical doctors take socioeconomic factors into account, 71 % said they give advice, 69 % spend more time, and 58 % offer an extra consultation. More regular GPs than other doctors reported they would take bad private economy (31 % vs. 15 %), unemployment (25 % vs. 12 %), or heavy caring responsibilities (54 % vs 39 %) into account.

INTERPRETATION

To treat all patients equally is a fundamental value among doctors. Practical implications of equal treatment to all are not clear. Apparently inconsistent answers reveal a need for a professional and political clarification of which principles of equality that should guide doctors' practice.

[What do doctors think an MR examination costs?]

BACKGROUND

By law, Norwegian physicians are required to evaluate costs and benefits of various medical interventions before patients are subjected to them. A prerequisite for filling this "gate-keeping" role adequately is to be informed about medical benefits and costs. This article examines physicians' knowledge of costs related to an MR (magnetic resonance) examination of a knee.

MATERIAL AND METHODS

In 2006, the Research Institute of the Norwegian Medical Association sent a questionnaire to a representative sample of 1 400 Norwegian physicians. The following question was included: "What do you think is the total cost for a standard MR-examination of a knee (the sum of that paid by patients and the standard reclaimable fee [from health authorities] for this type of examination)". An unpaired t-test was used to compare answers from subgroups of doctors, and Pearson's correlation coefficient was used to establish relationships between cost estimates and other variables.

RESULTS

Physicians' estimates for the costs of an MR examination showed great variation. 57 % of respondents over or underestimated the costs by 50 % or more than the actual price of 1250 NOK. The most common mistake was overestimation; 47 % estimated the cost to be above NOK 1875, while 10 % thought it was below NOK 625.

INTERPRETATION

The results indicate that doctors should know more about costs, they cannot fulfil their role as gate-keepers without such knowledge.

[Doctors' use and assessment of a fee-for-service life-style advice scheme]

BACKGROUND

Fee-for-service life-style advice, a "green prescription" was introduced in Norway in 2003 as an alternative to the prescription of drugs to patients with moderate hypertension or risk of type 2 diabetes. The prescription includes an assessment of diet and/or physical activity, and an individual plan for change with systematic follow up from the GP. Material was provided by the Directorate of Health and Social Affairs, and a special fee of NOK 200 was established. The Research Institute of the Norwegian Medical Association has evaluated GPs' attitudes to and use of this scheme.

MATERIAL AND METHODS

A representative sample of 1134 Norwegian GPs, of whom 59% responded. Ten of the respondents were also interviewed comprehensively over the telephone.

RESULTS AND INTERPRETATION

Green prescriptions has low legitimacy among Norwegian GPs. Advise on lifestyle to patients with moderate hypertension or risk of type 2 diabetes is already an integral and natural component of GP work and calls for no extra fee or bureaucratic procedures. There is a risk of medicalisation in that non-patients become patients. On the other hand, patients who already are on drugs, but who may be able to reduce or eliminate these if they change their lifestyle, are not included in the scheme. Further development of the concept should to a larger degree include collaboration with the GPs.

[Childbirth preparation classes--parenteral education on the right track? An evaluation study based on questionnaires sent to women in Sogn and Fjordane]

Three hundred and fifteen women were sent a questionnaire within 8 months after delivery. They were interviewed about various aspects of pregnancy, delivery and the postpartum period. The response rate was 82%. This paper deals with the women's experience of childbirth preparation classes. Eighty per cent reported that such classes were available. Of this eighty per sent, 50% had attended such classes. Women having their first baby were more likely to attend. Forty-three per cent of the attending women found the classes very beneficial whereas 50% reported little and 7% no benefit from the childbirth education. The results indicate that in the women's view the classes are not especially important in ante-natal care. Furthermore, the quality of the classes seems to be inadequate.