Absence Of Physician Research Articles

Pharmaceutical services for endemic situations in the Brazilian Amazon: organization of services and prescribing practices for Plasmodium vivax and Plasmodium falciparum non-complicated malaria in high-risk municipalities

BackgroundIn spite of the fact that pharmaceutical services are an essential component of all malaria programmes, quality of these services has been little explored in the literature. This study presents the first results of the application of an evaluation model of pharmaceutical services in high-risk municipalities of the Amazon region, focusing on indicators regarding organization of services and prescribing according to national guidelines.MethodsA theoretical framework of pharmaceutical services for non-complicated malaria was built based on the Rapid Evaluation Method (WHO). The framework included organization of services and prescribing, among other activities. The study was carried out in 15 primary health facilities in six high-risk municipalities of the Brazilian Amazon. Malaria individuals ≥ 15 years old were approached and data was collected using specific instruments. Data was checked by independent reviewers and fed to a data bank through double-entry. Descriptive variables were analyzed.ResultsA copy of the official treatment guideline was found in 80% of the facilities; 67% presented an environment for receiving and prescribing patients. Re-supply of stocks followed a different timeline; no facilities adhered to forecasting methods for stock management. No shortages or expired anti-malarials were observed, but overstock was a common finding. On 86.7% of facilities, the average of good storage practices was 48%. Time between diagnosis and treatment was zero days. Of 601 patients interviewed, 453 were diagnosed for Plasmodium vivax; of these, 99.3% received indications for the first-line scheme. Different therapeutic schemes were given to Plasmodium falciparum patients. Twenty-eight (4.6%) out of 601 were prescribed regimens not listed in the national guideline. Only 5.7% individuals received a prescription or a written instruction of any kind.ConclusionsThe results show that while diagnostic procedure is well established and functioning in the Brazilian malaria programme, prescribing is still an activity that is actually not performed. The absence of physicians and poor integration between malaria services and primary health services make for the lack of a prescription or written instruction for malaria patients throughout the Brazilian Amazon. This fact may lead to a great number of problems in rational use and in adherence to medication.

The role of nurses in physician-assisted deaths in Belgium

Belgium's law on euthanasia allows only physicians to perform the act. We investigated the involvement of nurses in the decision-making and in the preparation and administration of life-ending drugs with a patient's explicit request (euthanasia) or without an explicit request. We also examined factors associated with these deaths. In 2007, we surveyed 1678 nurses who, in an earlier survey, had reported caring for one or more patients who received a potential life-ending decision within the year before the survey. Eligible nurses were surveyed about their most recent case. The response rate was 76%. Overall, 128 nurses reported having cared for a patient who received euthanasia and 120 for a patient who received life-ending drugs without his or her explicit request. Respectively, 64% (75/117) and 69% (81/118) of these nurses were involved in the physician's decision-making process. More often this entailed an exchange of information on the patient's condition or the patient's or relatives' wishes (45% [34/117] and 51% [41/118]) than sharing in the decision-making (24% [18/117] and 31% [25/118]). The life-ending drugs were administered by the nurse in 12% of the cases of euthanasia, as compared with 45% of the cases of assisted death without an explicit request. In both types of assisted death, the nurses acted on the physician's orders but mostly in the physician's absence. Factors significantly associated with a nurse administering the life-ending drugs included being a male nurse working in a hospital (odds ratio [OR] 40.07, 95% confidence interval [CI] 7.37-217.79) and the patient being over 80 years old (OR 5.57, 95% CI 1.98-15.70). By administering the life-ending drugs in some of the cases of euthanasia, and in almost half of the cases without an explicit request from the patient, the nurses in our study operated beyond the legal margins of their profession.

An evaluation of prescribing errors in primary care in Bahrain

Prescribing errors are preventable and are considered an important target for improving healthcare. The aim of this study was to identify prescribing errors and their determinants in a primary care setting. Prescriptions with errors were collected on a daily basis by the pharmacy staff during the first two weeks of September 2003 in 18 out of 20 primary care health centers in Bahrain. Prescribing errors were classified as omission (minor and major), commission and integration errors. Out of 77,511 prescriptions dispensed, 5,959 (7.7%) were identified to contain errors. The frequency of prescribed medication items in 5,959 prescriptions was 16,091. Of these medications, 13,630 (84.7%) were with errors and only 13.2% were written using generic names. Minor errors of omission such as absence of physician's stamp (34.4%), date (9.8%), and information about patients' address (3.8%), age (3.5%) and sex (0.5%) were not specified. Major errors of omission accounted for 93.6% and were as follows: strength/dose (31.0%), length of therapy/ quantity (29.5%), dosage form (19.7%), and frequency of dosing (13.4%). In 6.3% errors of commission (incorrect information) the most common was strength/dose (3.3%), followed by frequency of dosing (2.6%), dosage form (0.3%), and length of therapy/quantity (0.1%). Major errors of omission associated with topical preparations were significantly higher than those with systemic preparations. However, prescriptions with systemic preparations had a higher rate of commission errors. Significant differences in errors were found in prescriptions ordered by family physicians and general practitioners. In 9.2% of prescriptions with errors, potential drug-drug interactions were expected. This nationwide survey revealed that in primary care, a considerable proportion of prescriptions contained errors. Strategies to minimize medication errors by improving the prescribing skills, adherence to essential drugs list, and use of National Formulary are needed.

Abortion Care Services Provided by Registered Midwives in South Africa

South Africas Choice on Termination of Pregnancy Act which took effect in 1997 legalized abortion and stipulated that registered midwives can perform abortions for women with pregnancies of no more than 12 weeks gestation. A program was initiated to train registered midwives throughout South Africa to provide abortion services at primary care facilities. From October 1999 through January 2000 an evaluation was conducted at 27 public health care facilities in South Africas nine provinces to assess the quality of care provided by midwives who had been trained and certified to provide abortion services. Data were collected by observing abortion procedures and counseling sessions reviewing facility records and patients charts and interviewing patients and certified midwives. Of 96 abortion procedures performed by 40 midwives 85 involved manual vacuum aspiration. Midwives clinical practice was rated good in 75% of the procedures. No complications occurred during abortion procedures or as a result of the procedures and no abortion clients died. Midwives consistently provided women with contraceptive counseling after the abortion and most clients (89%) received a contraceptive method before leaving the facility. The injectable was the only method that was available at all facilities; of the 90 clients who were interviewed about the contraceptive method they reviewed after their abortion 75% had received this method. Few had received condoms (1%). Midwives can provide high-quality abortion services in the absence of physicians. Training in abortion care should be systematically integrated into midwives basic training. This training should use postabortion counseling as an opportunity to inform women about dual protection from unwanted pregnancy and sexually transmitted infections. (authors)

SHORT TERM LOCUM TENENS FOR RURAL PRACTICE: A TRIAL OF A JAPANESE MEDICAL SCHOOL

This study investigated locum tenens dispatch to rural practices organised by a medical school. Locum tenens has not been studied previously in rural general practice, and little has been reported about locum dispatch from an academic institution. Since 1990, Jichi Medical School (JMS) has sent faculty members as locum tenens to rural practices where its graduates have been working. The details of all locum dispatches between 1990 and 1996 were reviewed and analyzed. Locum dispatches were performed 486 times for a total of 1233 days from April 1990 to March 1996. Locum relief was supplied to 15 group practices and 42 solo practices which are located throughout most of Japan. Most locum reliefs (98.1%) were short and less than one week. There was a wide variety of reasons for requesting a locum, ranging from official to personal. The three main reasons were practice support (30.5%), continuing medical education (13.8%) and physician absence (13.8%). These reasons were different between solo and group practices. Solo practices had a more diverse range of inquiries than group practices. In group practices, practice support amounted to over half of the inquiry reasons. Rural practices face a wide range of circumstances which necessitate locum dispatch. Organised locum dispatch by a medical school can provide practical support of rural practices through locum tenens dispatch.

Physicians and potion makers at the Imperial Court: a colonial legacy

This article aims at analyzing popular practices and representations related to diseases and healing in the city of Rio de Janeiro in the nineteenth century. Based on European travelers' reports, the author emphasizes the fact that both illness and healing used to bear specific implications, which led the low-income population to search for their own means to keep or recover good health regardless the presence or the absence of physicians. After showing evidence of the enormous popularity of homemade medicines and the belief in spiritual healing as opposed to the efforts of academically-formed doctors to keep the "monopoly of competence" in healing, the author attempts to reassess the historical belief that the small number of physicians in Brazil in the 1800's troubled indistinctly all social strata.

The Pharmacist's Role in Patient Care

Richard M. Schultz, associate Professor of pharmacy practice, College of pharmacy, University of South Carolina, Columbia; David B. Brushwood is professor of pharmacy health care administration College of Pharmacy, University of Florida, Gainesville. The role of the pharmacist is frequently omitted from discussions of patient care issues, where the focus is on the physician and other health care providers within the physician's immediate sphere of influence. When attention does turn briefly to pharmacists, confusion often arises about the scope of their responsibilities to the patient and the expectations patients should have of them. Similarly confused views of pharmacy are frequently seen in newspaper articles and judicial opinions.[1] A factor that may contribute to confusion about the role of pharmacists is that observers of health care trends tend to be autonomous decisionmakers, who in their personal lives have little need for the information and counseling that are valued highly by less sophisticated pharmaceutical consumers. Well-educated, high-income policy makers can be their own advocates. They are not likely to leave a doctor's office without a thorough explanation of a drug's beneficial and detrimental effects. Less fortunate and less assertive individuals may have greater need for a pharmacist's assistance with drug-related medical decisions. Class differences between patients and physicians may stifle interaction if physicians withhold information that they consider too technical and detailed for certain levels of understanding or if patients remain silent for fear of appearing ignorant or being a nuisance. Pharmacists frequently live and work in the same community as the people they serve, and are often closer in socioeconomic status to patients than are physicians. Patients, therefore, may view pharmacists as more approachable about health issues. We suggest that the public would be well served if pharmacy practice expanded into new areas, including patient advocacy. Legal scholars, ethicists, and health care analysts must consider whether such expansion should be encouraged. Critical questions shaping this consideration should be: (1) Do physicians currently provide patients with sufficient risk-related information about drugs? (2) Do pharmacists possess sufficient knowledge of drugs and diseases to counsel patients competently in the physician's absence? (3) Is the pharmacist an appropriate person to serve as a patient advocate with respect to drugs? (4) Does pharmacists' providing patients with accurate information about drugs necessarily interfere with the Physician-patient relationship? (5) Is a risk assessment/risk management conceptualization sufficiently rich and flexible to accommodate emerging health care roles? (6) When, if ever, is a pharmacist justified in withholding information from a patient? and (7) Can pharmacists work legally and ethically with a patient to develop an optimal medication practice for that patient if the medication practice might differ from the directions for medication use given by the physician? Stages of Assessment: During the past several decades, there has been a trend in drug therapy toward centralized decisionmaking, with fewer and fewer options being left to the person whose body is to be affected by the drug. New drugs must be approved by the Food and Drug Administration (FDA) before they are marketed, and most effective drugs must be prescribed by a physician. A patient does not have the freedom to decide to use a chemical substance as a medication unless the FDA has first approved it and a physician has prescribed it. The drug distribution system, although rigid in some respects, is sufficiently flexible to accommodate risk evaluation at three stages. The first stage is the negotiation between a new drug's industrial sponsor and the FDA. In deciding whether to approve a new drug, a scientific assessment of risk is made, based on known characteristics of a general population. …

Ethics Teaching in Allied Health Fields

In a physical therapy department of a rehabilitation center a college student injured in an automobile accident has been treated daily for three months. He is a paraplegic and will never regain the use of his legs. However, the physician has written orders not to let the young man know that his disability is permanent. Until now the student has taken for granted that he will walk again. Today he asks the physical therapist directly if he will always be paralyzed. The physical therapist must decide: should I withhold the truth from the patient, or tell the truth, thereby endangering the doctor-patient relationship? Since physicians are regularly faced with awesome ethical decisions, it is appropriate for medical students to be given a basic course in physician ethics. However, the physical therapist's dilemma is only one example of the many cases in which other health-care personnel must make ethical decisions by sharing responsibility with the physician or, in the absence of physicians, assuming full responsibility. Nurses, in particular, have begun to acknowledge unique ethical questions in their work. This, in turn, has given rise to the realization that simply extending to nurses the teaching of physician ethics is inappropriate. The result has been a surge of interest in developing a better understanding of ethical theory, ethics issues, and a hard look at how ethics ought to be addressed in a nursing curriculum.*