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PubMed2006

A secure web-based approach for accessing transitional health information for people with traumatic brain injury.

A web-based transitional health record was created to provide regional healthcare professionals with ubiquitous access to information on people with brain injuries as they move through the healthcare system. Participants included public, private, and community healthcare organizations/providers in Eastern Ontario (Canada). One hundred and nineteen service providers and 39 brain injury survivors registered over 6 months. Fifty-eight percent received English and 42% received bilingual services (English-French). Public health providers contacted the regional service coordinator more than private providers (52% urban centres, 26% rural service providers, and 22% both areas). Thirty-five percent of contacts were for technical difficulties, 32% registration inquiries, 21% forms and processes, 6% resources, and 6% education. Seventeen technical enquiries required action by technical support personnel: 41% digital certificates, 29% web forms, and 12% log-in. This web-based approach to clinical information sharing provided access to relevant data as clients moved through or re-entered the health system. Improvements include automated digital certificate management, institutional health records system integration, and more referral tracking tools. More sensitive test data could be accessed on-line with increasing consumer/clinician confidence. In addition to a strong technical infrastructure, human resource issues are a major information security component and require continuing attention to ensure a viable on-line information environment.

Brain Injuries↗

PubMed2005

The routine and the traumatic in prenatal genetic diagnosis: does clinical information inform patient decision-making?

With the increasing technical sophistication of medicine, clinicians' task of assuring patient informed consent is increasingly elusive. Taking the example of prenatal genetic testing, we examine efforts to communicate the complexities of genetic knowledge and risk calculation to patients. In this qualitative, descriptive study, we interviewed 50 clinicians and 40 patients, and observed 101 genetic counseling sessions. We found the clinicians and patients have different goals, purposes, and values regarding testing, which affect their clinical interactions. The information the clinicians provide patients reflects their clinical interest in identifying and controlling pathophysiology, while patients, in contrast, are most concerned with protecting and nurturing their pregnancy. We argue informed patient decision-making about prenatal testing options requires information that is responsive to patient interests. We recommend developing a shared decision-making approach, to facilitate the full participation of both clinicians and patients in the decision-making process.

Adult↗

PubMed2005

Optimal matches of patient preferences for information, decision-making and interpersonal behavior: evidence, models and interventions.

OBJECTIVE: A comprehensive review was conducted of the theoretical and empirical work that addresses the preference-match strategy in physician-patient communication. METHODS: Searches were conducted on Medline, PsychINFO, InFoTrac One File Plus, Sociological Abstracts, and Dissertation Abstracts through 2004. The following keywords were used: patient preferred and received information; patient preferred and actualized treatment decision-making; patient-physician beliefs in shared decision-making; patient-physician match, fit, or concordance; reciprocal relationship or mutuality; doctor-patient affiliation, control, relationship; match/fit between patient and physician in affiliation, control, or relationship. RESULTS: Findings revealed varying degrees of support for the positive effects of matching patients' preferred levels of information, decisional control, and consultative interpersonal behavior. CONCLUSIONS: Findings justify not only continued but expanded research efforts in this area that would incorporate recommended changes in research design and implementation. PRACTICE AND RESEARCH IMPLICATIONS: Assessment strategies and match interventions are discussed that, if evidence continues to be supportive, might routinely optimize patient-physician encounters toward more positive outcomes. Methodological guidelines are suggested that can improve future preference-match studies of the patient-physician interaction. Practitioners need to consider adoption of patient-match assessment and intervention strategies in addition to recent exclusive concentrations on patient-centered and shared decision-making approaches.

Communication↗

PubMed1986

Organization of an organ donation network.

The National Organ Donation Network involves numerous organizations and institutions, with the organ procurement agencies playing a key role. Figure 2 depicts the complex structure of the procurement process. There is little consistency in structure among community procurement networks, but there is a strong unified approach to the national sharing of organs and tissues. More regionalization has led to better coordination of all procurement and educational efforts, and the role of the procurement coordinator has evolved into a new health profession.

Canada↗

PubMed1996

A genetic study of maternal and paternal ratings of problem behaviors in 3-year-old twins.

Genetic and environmental influences on problem behaviors were studied in 3-year-old twins. Fathers' and mothers' ratings of problem behaviors in twins-236 monozygotic (MZ) girls, 210 MZ boys, 238 dizygotic (DZ) girls, 265 DZ boys, and 409 DZ opposite sex pairs- were obtained with the Child Behavior Checklist for Ages 2-3 (T.M. Achenbach, 1992). Twin correlations and results from a model fitting approach showed that genetic, shared environmental, and nonshared environmental influences accounted on average for about 64%, 9%, and 27% of the variance. Although shared environmental influences were small for most scales, they were important for Total Problems and somewhat larger for Externalizing than for Internalizing behaviors. Significant sex differences in genetic and environmental influences and evidence for sibling contrast effects were found for the Overactive scale.

Child Behavior Disorders↗

PubMed1999

Synergy: working together with volunteers in community well woman clinics.

Despite promotion of the participation of volunteers in community and primary care services, there are few British studies which have explored the benefits and challenges of collaborative working between volunteer and paid workers, and in particular, women's experiences of volunteering within the National Health Service (NHS). The study presented here seeks to add to the limited, existing knowledge in this area. The experiences of volunteer and paid workers working together in two community well woman clinics are discussed, focusing on the benefits of working together for volunteers, paid workers and clients. Discussion is based on data collected over an 18-month period of participant observation in two community well woman clinics, interviews with 26 volunteer and paid workers and a review of the clinics' operational policy documents. Drawing on the concept of synergy, relationships between volunteer and paid workers are illuminated. In this paper it is argued that working together renders the opportunity for volunteer and paid workers to share insights, perspectives and approaches which enhance clients' health assessments. It provides an added value dimension to client care and yields benefits for the service provider. The implications of the study for practice and policy are considered.

Female↗

PubMed1993

"Telling one's story" in an incest survivors group.

This article discusses the technical considerations that contribute to making "telling one's story" in an incest survivors group a ritual of active mastery leading to psychological growth. Survivors approach the task of sharing memories with a variety of wishes and fears that can emerge as powerful group transference paradigms. These paradigms, while they vividly illuminate the survivor's past and present interpersonal expectations, can threaten to derail the telling experience. Actively interpreted, however, the group transference aspects of the telling experience can yield valuable insights that become the focus for the remainder of the survivor's group treatment. This article details the process of preparing the individual survivor and the group for the process of telling (and listening) and the subsequent task of working through the insights derived from the telling experience. Two case examples demonstrate these techniques.

Adaptation, Psychological↗

PubMed1998

Talking with women about personal health resources in general practice. Key questions about salutogenesis.

We want to share experiences from an approach for clinical communication and research, intended to identify and mobilize personal health resources in female patients, and promote strategies for resource oriented talk in general practice. We used an action research design with qualitative evaluation to summarize the process where we developed a key question about self-assessed health resources in women, based on The Health Resource/Risk Balance Model, including salutogenesis, patient-centredness and gender perspectives. From consultations with 49 female patients in our own practices, we have drawn a narrative description of the development process, a summary of issues that facilitated resource talk, and our final version of the key question. We suggest that resource talk is based on 1) an explicit shift of language from disease to health, but nevertheless recognizing the fact that illness occurs, 2) options for answers given by the female patient and not by the doctor, 3) signification of the woman's assessment of her own situation (in contrast to the doctor's assessment), and 4) taking for granted that women's personal health resources exist as numerous strategies which are utilized, and may be identified. We have learnt that communicative action can provide tools for shifting the attention of doctor and patients from risks and diseases to resources and strengths. This is an example of one way to change your practice through systematic reflection in dialogue with a colleague.

Attitude to Health↗

PubMed2006

Avoiding iatrogenic harm to patient and family while discussing goals of care near the end of life.

BACKGROUND: Treatment of suffering is a core mission of medicine. Communication about treatment planning with the patient and family, called the goals of care discussion, offers the opportunity to provide effective relief. Such communication is particularly important near the end of life, because many medical decisions are determined then by emotional considerations and personal values. OBJECTIVE: To define common unintended clinician behaviors, which impair discussion about goals of care near the end of life. To discuss the relationship between: (1) the medical decision-making responsibilities of patient and family, (2) clinician communication, (3) iatrogenic suffering, (4) the impact on medical decision-making, and (5) patient and family outcomes. DESIGN: Thematic literature review. RESULTS: The authors discuss how omission of the integral emotional and social elements of the goals of care discussion are reflected in five unintended clinician behaviors, each of which may impair medical decision-making and unknowingly induce patient and family suffering. We posit that such impaired decision-making and suffering may contribute to demands for ineffective, life-sustaining interventions made by the patient and family or, conversely, to requests for hastened death. CONCLUSIONS: Understanding the challenges in the discussion about goals of care near the end of life will facilitate the development of more effective approaches to communication and shared decision-making. The authors hypothesize how decreased suffering through improved communication should diminish the occurrence of depression, anxiety disorders, and complicated grief in the patient and survivors, potentially improving medical outcomes. Proposed experiments to test this hypothesis will address important public health goals.

Communication↗

PubMed2001

Living with failing lungs: the doctor-patient relationship.

OBJECTIVE: The aim of the present study was to explore the perceptions and needs of chronic obstructive pulmonary disease (COPD) patients by a qualitative study using semi-structured interviews. METHODS: Sixteen patients with a diagnosis of COPD (age range 59-75 years) were recruited from two sample frames. One group were under the care of GPs and the second had received in-patient care previously at a district general hospital. Participants had either moderate or severe impairment of respiratory function identified by spirometric testing [forced expiratory volume in 1 second (FEV(1)) <50% of predicted value]. RESULTS: Primary and secondary care samples were chosen in the hope of identifying various aspects of care. However, the patients in this study primarily chose to discuss their relationship with their GP when considering aspects of their lives as a COPD patient. The most significant findings related to the respondents' chronic patient status, their ability to control symptoms and expectations of health care support. All these factors were connected to their perceived relationship with their GP. CONCLUSIONS: Doctors, as gatekeepers of health care resources, were seen to have immense power over the patients' lives. The need to be perceived in a good light by their doctor was intensified by their low self-esteem, poor control of symptoms and their chronic disease status. The majority of patients expressed a need to take a more active part in the decision-making processes involved in the management of their disease. A more balanced doctor-patient relationship could develop if frank and open discussions are based upon a shared decision-making approach.

Adaptation, Psychological↗

PubMed1984

Vulnerability to depressive and schizophrenic disorders--conference report.

A conference was held to foster improved research on vulnerability to psychiatric disorder. By bringing together groups studying vulnerability to depression and those studying vulnerability to schizophrenia, commonalities and differences across these two fields were clarified, and research approaches and problems were shared. Five major areas of particular importance were covered: (1) diagnosis and the assessment of function and intermediate clinical states, (2) statistical analysis and project design, (3) personality and family variables, (4) biochemical and physiological markers, and (5) comparison of vulnerability to schizophrenia and depression: models of causation and possibilities for collaborative research. Potential directions for increasing progress in the important area of vulnerability research were outlined.

Depressive Disorder↗

PubMedDate not supplied

The emergence of Ideal Micro Practices for patient-centered, collaborative care.

Ideal Micro Practices are capable of delivering patient-centered collaborative care. With respect to comparable adult patients in "usual" care settings, twice as many patients who use Ideal Micro Practices report they receive care that is "exactly what they want and need exactly when and how they want and need it" (68% vs 35%). Compared to usual care, these very small, low-overhead practices are more likely to have patients report very high levels of continuity (98% vs 88%), efficiency (95% vs 73%), and access (72% vs 53%). Patient ratings of very good information (83% vs 67%) and clinician awareness of pain or emotional problem are also higher (87% vs 69%). However, only a slim majority of patients using Ideal Micro Practices report that they are confident in their ability to manage and control their health problems or concerns. Ideal Micro Practices are sharing new tools and approaches to better understand their patients' needs and increase patients' confidence in their ability to manage conditions. In addition, these practices are working collaboratively to standardize their approaches and make the essential elements of Ideal Micro Practice replicable.

Adult↗

PubMed2005

Long-term outcomes of surgical and nonsurgical management of lumbar spinal stenosis: 8 to 10 year results from the maine lumbar spine study.

STUDY DESIGN: A prospective observational cohort study. OBJECTIVE: To assess long-term outcomes of patients with lumbar spinal stenosis treated surgically or nonsurgically. SUMMARY OF BACKGROUND DATA: The relative benefit of various treatments for lumbar spinal stenosis is uncertain. Surgical treatment has been associated with short-term improvement, but recurrence of symptoms has been documented. Few studies have compared long-term outcomes of surgical and nonsurgical treatments. METHODS: Patients recruited from the practices of orthopaedic surgeons, neurosurgeons, and occupational medicine physicians throughout Maine had baseline interviews with follow-up questionnaires mailed at regular intervals over 10 years. Clinical data were obtained at baseline from a physician questionnaire. Most patients initially undergoing surgery had a laminectomy without fusion performed. Outcomes including patient-reported symptoms of leg and back pain, functional status, and satisfaction were assessed at 8- to 10-year follow-up. Primary analyses were based on initial treatment received with secondary analyses examining actual treatment received by 10 years. RESULTS: Of 148 eligible consenting patients initially enrolled, 105 were alive after 10 years (67.7% survival rate). Among surviving patients, long-term follow-up between 8 and 10 years was available for 97 of 123 (79%) patients (including 11 patients who died before the 10-year follow-up but completed a 8 or 9 year survey); 56 of 63 (89%) initially treated surgically and 41 of 60 (68%) initially treated nonsurgically. Patients undergoing surgery had worse baseline symptoms and functional status than those initially treated nonsurgically. Outcomes at 1 and 4 years favored initial surgical treatment. After 8 to 10 years, a similar percentage of surgical and nonsurgical patients reported that their low back pain was improved(53% vs. 50%, P = 0.8), their predominant symptom (either back or leg pain) was improved (54% vs. 42%, P = 0.3), and they were satisfied with their current status (55% vs. 49%, P = 0.5). These treatment group findings persisted after adjustment for other determinants of outcome in multivariate models. However, patients initially treated surgically reported less severe leg pain symptoms and greater improvement in back-specific functional status after 8 to 10 years than nonsurgically treated patients. By 10 years, 23% of surgical patients had undergone at least one additional lumbar spine operation, and 39% of nonsurgical patients had at least one lumbar spine operation. Patients undergoing subsequent surgical procedures had worse outcomes than those continuing with their initial treatment. Outcomes according to actual treatment received at 10 years did not differ because individuals undergoing additional surgical procedures had worse outcomes than those continuing with their initial treatment. CONCLUSIONS: Among patients with lumbar spinal stenosis completing 8- to 10-year follow-up, low back pain relief, predominant symptom improvement, and satisfaction with the current state were similar in patients initially treated surgically or nonsurgically. However, leg pain relief and greater back-related functional status continued to favor those initially receiving surgical treatment. These results support a shared decision-making approach among physicians and patients when considering treatment options for lumbar spinal stenosis.

Aged↗

PubMed2006

Undergraduate public health education in UK medical schools - struggling to deliver.

INTRODUCTION: Recent policy initiatives in the United Kingdom (UK) have underlined the importance of public health education for health care professionals. We aimed to describe teaching inputs to medical undergraduate curricula, to identify perceived challenges in the delivery of public health teaching and strategies that may overcome them. METHODS: We undertook a cross-sectional survey; questionnaires were sent electronically to 28 teaching leads in academic departments of public health in UK medical schools. These were followed-up by telephone interviews. RESULTS: We obtained a 75% response rate. We found a great deal of variability between schools in teaching methods, curricular content and resources used. In 76% of medical schools, public health and clinical teaching were integrated to some extent. The proportion of teaching delivered as lectures is decreasing and that of self-directed learning is increasing. A range of methods is used to assess students and in 33% of schools these assessments contributed to final Medical School marks. More than half the medical schools had difficulty finding teachers and staffing levels had deteriorated in 55% of schools. Many interviewees felt that their contributions were undervalued. Few were aware of the level of funding received to support teaching. DISCUSSION: There is a need to increase the supply of well-trained and motivated teachers and combine the best traditional teaching methods with more innovative, problem-based approaches. Faculties need to share 'learning about what works' and teaching resources across medical schools as well as addressing a culture of neglect of teaching in some departments. Suggestions are made as to how undergraduate public health teaching can be strengthened.

Cross-Sectional Studies↗

PubMed1992

Epilepsy care in The Netherlands.

In this article models of epilepsy care in the Netherlands are outlined. Mostly this care is aimed at people with uncontrolled epilepsy who may have suffered from the adverse effects of ignorance, prejudice and even discrimination. Many of these adverse factors should be avoidable in future as the educational programmes for people with epilepsy, professionals and the general public take full effect. Meanwhile there is a great deal that can be done to rehabilitate people whose seizures are a problem and whose social abilities fall short of the standards that are required for independent and self-fulfilling living in any society. The models of care described are very sophisticated and they have been developed over many years. They require well-trained and motivated staff and sometimes elaborate and expensive medical diagnostic equipment. But this should not put anybody off as the principles behind any model of care should be the same: Accurate diagnosis. Optimal drug and other treatment (this should be optimal treatment available in that country). Education of the patient and family about all aspects of epilepsy. Opportunity to share experiences. A multidisciplinary approach to identified problems (a multidisciplinary approach can be taken by one person, although a team of people from different disciplines is ideal.) Objectives agreed by all participants.

Ambulatory Care↗

PubMed2005

The coming paradigm shift in forensic identification science.

Converging legal and scientific forces are pushing the traditional forensic identification sciences toward fundamental change. The assumption of discernible uniqueness that resides at the core of these fields is weakened by evidence of errors in proficiency testing and in actual cases. Changes in the law pertaining to the admissibility of expert evidence in court, together with the emergence of DNA typing as a model for a scientifically defensible approach to questions of shared identity, are driving the older forensic sciences toward a new scientific paradigm.

DNA↗

PubMed2005

The public health infrastructure and our nation's health.

Threats to Americans' health-including chronic disease, emerging infectious disease, and bioterrorism-are present and growing, and the public health system is responsible for addressing these challenges. Public health systems in the United States are built on an infrastructure of workforce, information systems, and organizational capacity; in each of these areas, however, serious deficits have been well documented. Here we draw on two 2003 Institute of Medicine reports and present evidence for current threats and the weakness of our public health infrastructure. We describe major initiatives to systematically assess, invest in, rebuild, and evaluate workforce competency, information systems, and organizational capacity through public policy making, practical initiatives, and practice-oriented research. These initiatives are based on applied science and a shared federal-state approach to public accountability. We conclude that a newly strengthened public health infrastructure must be sustained in the future through a balancing of the values inherent in the federal system.

Accreditation↗

PubMed1995

Narrative and psychotherapy--the phenomenology of healing.

In part I, I presented some results of empirical research on mind/body relationship: writing about traumatic experiences brings about improved psychological and physiological health. One important factor of healing in psychotherapy is thereby isolated empirically. In part II, it was shown that the cognitive science explanation of these findings, however, is based on categories deriving from common sense and is insufficient. Phenomenological method can serve as a form of criticism of the assumptions shared by most contemporary approaches to the human mind and brain in psychology, psychiatry, and medicine (e. g. cognitive, psychodynamic, behavioral, and biological). In part III, I presented research and concepts developed in the phenomenological tradition that have bearing on the problem of the healing factor in narrative acts (in writing and speech), including the "talking cure" of psychoanalysis and psychotherapy. I described the problem of the unconscious in narrative acts from the phenomenological point of view and provide an alternative explanation for their healing effects. In short, the way we overcome painful and traumatic experiences is not seen in terms of the cognitive theory in which a painful feeling is "translated" into a cognitive or linguistic representation that organizes it. Such a theory objectifies the human subject. Healing through narration and "opening up," involves an existential act of self-transcendence of an embodied person who organizes his/her experience in time.

Defense Mechanisms↗