'If relevant, yes; if not, no': General practitioner (GP) users and GP perceptions about asking ethnicity questions in Irish general practice: A qualitative analysis using Normalization Process Theory

Context

The use of ethnic identifiers in health systems is recommended in several European countries as a means to identify and address heath inequities. There are barriers to implementation that have not been researched.

Objective

This study examines whether and how ethnicity data can be collected in Irish general practices in a meaningful and acceptable way.

Methods

Qualitative case study data generation was informed by Normalization Process Theory (NPT) constructs about ‘sense’ making and ‘engagement’. It consisted of individual interviews and focus group discussions based on visual participatory techniques. There were 70 informants, including 62 general practitioner (GP) users of diverse ethnic backgrounds recruited through community organisations and eight GPs identified through an inter-agency steering group. Data were analysed according to principles of thematic analysis using NPT.

Results

The link between ethnicity and health was often considered relevant because GP users grasped connections with genetic (skin colour, lactose intolerance), geographic (prevalence of disease, early years exposure), behavioural (culture/food) and social determinant (housing) factors. The link was less clear with religion. There was some scepticism and questions about how the collection of data would benefit GP consultations and concerns regarding confidentiality and the actual uses of these data (e.g. risk of discrimination, social control). For GPs, the main theme discussed was relevance: what added value would it bring to their consultations and was it was their role to collect these data? Their biggest concern was about data protection issues in light of the European Union (EU) General Data Protection Regulation (GDPR). The difficulty in explaining a complex concept such as ‘ethnicity’ in the limited time available in consultations was also worrying.

Conclusions

Implementation of an ethnicity identifier in Irish general practices will require a strong rationale that makes sense to GP users, and specific measures to ensure that its benefits outweigh any potential harm. This is in line with both our participants’ views and the EU GDPR.

[Diagnostic Test Requests in the Family Medicine Consultation: An Ethical Perspective Concerning Requests for Maxillofacial Computerized Tomography Scan Prior to Dental Implants]

In the Portuguese National Health Service, little attention has been paid to oral health care. The almost nonexistence of a dentistry network raises concern about accessibility to services, and justifies the need to call on a predominantly private provision of services. The coexistence between the public and private settings is not always easy, especially when services need to interact and actively collaborate in order to find answers to the patient's problems. Dental implant procedures and the need to perform a previous maxillofacial computerized tomography to study the bone bed where osseointegrated dental implants are placed are a common situation. The current governmental regulation, blinded to the clinical context, may limit the accessibility to the tests. Based on this scenario, we discuss the possible options from an ethical point of view, framing the patient's and the physician's perspective and the relation between both. We conclude that the medical decision can't be disregarded from the clinical evaluation, in the intimacy of the medical consultation. This is an ethical duty that overrules the administrative and bureaucratic constraints. A good management of this apparent dichotomy may enhance better health and greater empowerment for the patient.

Residency Curricula on Physician-Pharmaceutical Industry Interaction: A CERA Study

BACKGROUND AND OBJECTIVES

Physician interaction with pharmaceutical representatives results in less evidence-based prescribing and increased costs. Many organizations have called for strong conflict of interest policies in academic institutions. Implementing policy without educational interventions may not adequately address the influence of industry on physician prescribing patterns. The objective of this study is to assess the implementation and content of family medicine residency curricula on the physician-pharmaceutical industry relationship.

METHODS

We surveyed US family medicine program directors using the Council of Academic Family Medicine Educational Research Alliance (CERA) platform. The presence of a formal curriculum on the physician-industry interaction and specific curricular elements (ethics of interaction, understanding detailing sessions and advertisements, use of unbiased pharmaceutical information) were the outcome measures of interest.

RESULTS

Fifty-two percent (212 of 406) of program directors responded. Forty percent (95% confidence interval [CI]: 33%--46%) reported having a formal curriculum on physician-pharmaceutical industry interactions. The presence of a formal curriculum was more likely in residencies permitting interaction with industry (52% [48/92] versus 30% [36/120]) or with a university affiliation (43% [75/173] versus 19% [7/36]). The use of unbiased sources of information relating to pharmaceutical products and the ethics of the physician-pharmaceutical industry relationship were the most common curricular elements (59% and 55%, respectively).

CONCLUSIONS

This study shows that less than half of US family medicine programs have a curriculum addressing physician-industry interactions. Further research on the efficacy of and barriers to curriculum creation and implementation is warranted.

Advance directives: survey of primary care patients

OBJECTIVE

To establish the prevalence of patients with advance directives in a family practice, and to describe patients' perspectives on a family doctor's role in initiating discussions about advance directives.

DESIGN

A self-administered patient questionnaire.

SETTING

A busy urban family medicine teaching clinic in Hamilton, Ont.

PARTICIPANTS

A convenience sample of adult patients attending the clinic over the course of a typical business week.

MAIN OUTCOME MEASURES

The prevalence of advance directives in the patient population was determined, and the patients' expectations regarding the role of their family doctors were elucidated.

RESULTS

The survey population consisted of 800 participants (a response rate of 72.5%) well distributed across age groups; 19.7% had written advance directives and 43.8% had previously discussed the topic of advance directives, but only 4.3% of these discussions had occurred with family doctors. In 5.7% of cases, a family physician had raised the issue; 72.3% of respondents believed patients should initiate the discussion. Patients who considered advance directives extremely important were significantly more likely to want their family doctors to start the conversation (odds ratio 3.98; P < .05).

CONCLUSION

Advance directives were not routinely addressed in the family practice. Most patients preferred to initiate the discussion of advance directives. However, patients who considered the subject extremely important wanted their family doctors to initiate the discussion.

[Palliative Care in Nursing Homes: Characteristics and Specificities]

Elderly patients in palliative situations residing in a nursing home present characteristics and specificities that clearly distinguish them from patients with advanced cancer. Besides the difficulty to define a precise prognosis, their many comorbidities, their communication difficulties because of cognitive disorders, their high sensitivity to primary and secondary effects of drugs render their management a real challenge for physician and caregivers. Accompanying these patients at the end of their life also raises many ethical problems, especially when they are no longer able to express their wishes and have not previously expressed advance directives.

Contributors to primary care guidelines: What are their professions and how many of them have conflicts of interest?

OBJECTIVE

To determine the professions of those who contribute to guidelines, guideline variables associated with differing contributor participation, and whether conflict of interest statements are provided in primary care guidelines.

DESIGN

Retrospective analysis of the primary care guidelines from the Canadian Medical Association website. Two independent data extractors reviewed the guidelines and extracted relevant data.

SETTING

Canada.

MAIN OUTCOME MEASURES

Sponsors of guidelines, jurisdiction (national or provincial) of guidelines, the professions of those who contribute to guidelines, and the reported conflict of interest statements within guidelines.

RESULTS

Of the 296 guidelines in the family medicine section of the CMA Infobase, 65 were duplicates and 35 had limited relevance to family medicine. Twenty did not provide contributor information, leaving 176 guidelines for analysis. In total, there were 2495 contributors (authors and committee members): 1343 (53.8%) non-family physician specialists, 423 (17.0%) family physicians, 141 (5.7%) nurses, 75 (3.0%) pharmacists, 269 (10.8%) other clinicians, 203 (8.1%) nonclinician scientists, and 41 (1.6%) unknown professions. The proportion of contributors from the various professions differed significantly between provincial and national guidelines, as well as between industry-funded and non-industry-funded guidelines (both P < .001). For provincial guidelines, 30.8% of contributors were family physicians and 37.3% were other specialists compared with 13.9% and 57.4%, respectively, for national guidelines. Of industry-funded guidelines, 7.8% of contributors were family physicians and 68.6% were other specialists compared with 19.4% and 49.9%, respectively, for non-industry-funded guidelines. Conflicts of interest were not reported in 68.9% of guidelines. When reported, conflict of interest statements were present for 48.6% of non-family physician specialists, 30.0% of pharmacists, 27.7% of family physicians, and 10.0% or less of the remaining groups; differences were statistically significant (P < .001).

CONCLUSION

Non-family physician specialists outnumber all other health care providers combined and are more than 3 times more likely to contribute to primary care guidelines than family physicians are. Conflict of interest statements were provided in the minority of guidelines, and for guidelines in which conflict of interest statements were included, non-family physician specialists were most likely to report them. Guidelines targeted to primary care should have much more primary care and family medicine representation and include fewer contributors who have conflicts of interest.

General practice ethics: Continuing medical education and the pharmaceutical industry

This is the fifth in a six-part series on general practice ethics. Cases from practice are used to trigger reflection on common ethical issues where the best course of action may not be immediately apparent. The case presented in the article is an illustrative compilation and not based on specific individuals.

[Medicine and Law: abdication of therapy by practitioners at the end of life]

The question, how and when an individual decision for and end of medical treatment or abdication of therapy should be made remains difficult. Ethical considerations have to be taken into account with respect to a humane and dignified decease. The goal of our manuscript there for is to achieve more certainty with respect to juridical and legal preconditions and frameworks. The conditions in Switzerland support general practitioners and family doctors to fulfill patients' requests, wishes and wills in an outpatient setting. An awareness and sensitization for a dignified and humane care at the end of life - despite social changes and an increased importance of health economics - as well increasing support of outpatient palliative care become more and more important. Existing legal certainty and security of practitioners, therefore, will be outlined in the following.

Primary care provider reflections on common themes from special issue on ethical quandaries when delivering integrated primary care

Comments on the articles by Hudgins, Rose, Fifield, & Arnault, (see record 2013-11498-002), Reiter & Runyan, (see record 2013-11498-003), Hodgson, Mendenhall, & Lamson (see record 2013-11498-004), and Kanzler, Goodie, Hunter, Glotfelter, & Bodart (see record 2013-11498-005), regarding the topic of common themes for the special issue on ethical quandaries when delivering integrated primary care. The current author provides brief reflections on each article.

Doctor-patient dialogue--basic aspect of medical consultation

Family medicine is the specialty that provides ongoing primary medical care and improves the health status of the individual, of the family and of the community through preventive, educational, therapeutic and rehabilitation measures. The family doctor often makes the interdisciplinary synthesis, in a flexible manner, either alone or in most cases with interdisciplinary consultation. In the latter case, the family doctor initiates the team work and makes the final evaluation by using the longitudinal follow-up of the disease. The doctor-patient encounter represents the "confrontation" with the greatest moral weight, due to the complexity of the values involved, the status of the doctor in a society, and patient's involvement in decision making. The patient is a person who should be treated with respect, honesty, professionalism and loyalty, whatever the clinical status, severity of illness, mental competence or incompetence. A focus, on an international scale, is represented by the characteristics of a good doctor, family physician included, as the latter is the first link in the network of health services. Each model of consultation varies in a more or less subtle way in priorities assignment, and suggests slight differences regarding the role played by doctor and patient in their collaboration. The qualities of a good family physician include not only the strictly professional competences, that also apply to other medical specialties, but also duties, such as, clearly explaining to patients issues concerning their health, informing them about all the possible preventive measures of diseases, making a diagnosis, initiating and supervising a therapy. Medical responsibility lies at the crossroads between medical science and the conscience of the doctor.

Ethical and legal issues in the clinical practice of primary health care

Since it was conceived, the notion of primary care has been a crucial concept in health services. Most health care is provided at this level and primary care clinicians have an essential role, both in terms of disease prevention and disease management. During the last decades, primary health care has evolved from a traditional paternalistic model, in which patients played the role of passive recipient of care, towards a situation in which patients are partners involved in the decision making-process. This new context opened a considerable number of new ethical and legal aspects, which need to be comprehensively analyzed and discussed in order to preserve the quality of primary health care all around the world. This work reviews the most important ethical and legal issues in primary health care. Legislation issues are explained in the context of the Spanish Health Services.

Teaching and evaluation of ethics and professionalism: in Canadian family medicine residency programs

OBJECTIVE

To document the scope of the teaching and evaluation of ethics and professionalism in Canadian family medicine postgraduate training programs, and to identify barriers to the teaching and evaluation of ethics and professionalism.

DESIGN

A survey was developed in collaboration with the Committee on Ethics of the College of Family Physicians of Canada. The data are reported descriptively and in aggregate.

SETTING

Canadian postgraduate family medicine training programs.

PARTICIPANTS

Between June and December of 2008, all 17 Canadian postgraduate family medicine training programs were invited to participate.

MAIN OUTCOME MEASURES

The first part of the survey explored the structure, resources, methods, scheduled hours, and barriers to teaching ethics and professionalism. The second section focused on end-of-rotation evaluations, other evaluation strategies, and barriers related to the evaluation of ethics and professionalism.

RESULTS

Eighty-eight percent of programs completed the survey. Most respondents (87%) had learning objectives specifically for ethics and professionalism, and 87% had family doctors with training or interest in the area leading their efforts. Two-thirds of responding programs had less than 10 hours of scheduled instruction per year, and the most common barriers to effective teaching were the need for faculty development, competing learning needs, and lack of resident interest. Ninety-three percent of respondents assessed ethics and professionalism on their end-of-rotation evaluations, with 86% assessing specific domains. The most common barriers to evaluation were a lack of suitable tools and a lack of faculty comfort and interest.

CONCLUSION

By far most Canadian family medicine postgraduate training programs had learning objectives and designated faculty leads in ethics and professionalism, yet there was little curricular time dedicated to these areas and a perceived lack of resident interest and faculty expertise. Most programs evaluated ethics and professionalism as part of their end-of-rotation evaluations, but only a small number used novel means of evaluation, and most cited a lack of suitable assessment tools as an important barrier.

Controlling pain and reducing misuse of opioids: ethical considerations

OBJECTIVE

To help family physicians achieve an ethical balance in their opioid prescribing practices.

QUALITY OF EVIDENCE

MEDLINE was searched for English-language articles published between 1985 and 2011. Most available evidence was level III.

MAIN MESSAGE

It is essential to follow practice guidelines when prescribing opioids, except when another course of action is demonstrably justified. In addition, when considering the appropriateness of an opioid prescription, with its many ethical implications, the decision can be usefully guided by the application of the ethical principles of beneficence, nonmaleficence, respect for autonomy, and justice. As well, it is essential to keep current about legal and regulatory changes and provincial electronic registries of opioid prescriptions.

CONCLUSION

Physicians need to ensure that their patients' pain is properly assessed and managed. Reaching optimal pain control might necessitate prescribing opioids. But the obligation to provide pain relief needs to be balanced with an equally important responsibility not to expose patients to risk of addiction and not to create opportunities for drug diversion, trafficking, and the addiction of others. Basic ethical principles can provide a framework to help physicians make ethically appropriate decisions about opioid prescribing.

Findings from a Delphi exercise regarding conflicts of interests, general practitioners and safeguarding children: 'Listen carefully, judge slowly'

General practitioners (GPs) have to negotiate a range of challenges when they suspect child abuse or neglect. This article details findings from a Delphi exercise that was part of a larger study exploring the conflicts of interest that arise for UK GPs in safeguarding children. The specific objectives of the Delphi exercise were to understand how these conflicts of interest are seen from the perspectives of an expert panel, and to identify best practice for GPs. The Delphi exercise involved four iterative rounds with questionnaires completed by an expert panel. Results from each round were distilled and findings sent to panel members until consensus was reached. Panel members shared insights regarding their understanding of conflicts of interest in relation to GPs and safeguarding children and responses when conflicts of interests arise. Findings suggested a broader understanding of conflicts of interest (intrapersonal, interpersonal, interprofessional and interagency), the importance of professional judgement in uncertain situations when both action and inaction have potentially negative consequences and the importance of trust. The Delphi exercise was an effective means to bring together a wide range of professional and disciplinary perspectives on a complex topic. Findings caution against the oversimplification of the conceptual and practical issues, emphasise the importance of professional judgement, and support the development of open and trusting relationships with families and among professionals in health and social care agencies.

Ethics and privacy issues of a practice-based surveillance system: need for a national-level institutional research ethics board and consent standards

OBJECTIVE

To describe the challenges the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) experienced with institutional research ethics boards (IREBs) when seeking approvals across jurisdictions and to provide recommendations for overcoming challenges of ethical review for multisite and multijurisdictional surveillance and research.

BACKGROUND

The CPCSSN project collects and validates longitudinal primary care health information (relating to hypertension, diabetes, depression, chronic obstructive lung disease, and osteoarthritis) from electronic medical records across Canada. Privacy and data storage security policies and processes have been developed to protect participants' privacy and confidentiality, and IREB approval is obtained in each participating jurisdiction. Inconsistent interpretation and application of privacy and ethical issues by IREBs delays and impedes research programs that could better inform us about chronic disease.

RESULTS

The CPCSSN project's experience with gaining approval from IREBs highlights the difficulty of conducting pan-Canadian health surveillance and multicentre research. Inconsistent IREB approvals to waive explicit individual informed consent produced particular challenges for researchers.

CONCLUSION

The CPCSSN experience highlights the need to develop a better process for researchers to obtain timely and consistent IREB approvals for multicentre surveillance and research. We suggest developing a specialized, national, centralized IREB responsible for approving multisite studies related to population health research.