Individual Doctors Research Articles

The impact of patient complaints and compliments on medical performance: a systematic review

Background: Patient complaints and compliments are considered integral to patient safety and quality of care. This review therefore sought to explore the impact of patient complaints and compliments on the medical performance of individual doctors. Method: Database searches were performed in PubMed, PsycInfo, EMBASE, Medline, CINAHL and the Cochrane Library for peer-reviewed publications published in the English language between 2007-2017. Data were thematically analysed and synthesised using a modified narrative approach. Impact was assessed using Barr’s (2000) adaptation of Kirkpatrick’s evaluation model. Results: Of the 355 articles retrieved, 6 were included. One identified a change in measured performance (Kirkpatrick level 3b). Five identified a self-reported change (Kirkpatrick level 3a) in performance or behaviour. No articles identified a change in the health and wellbeing of patients (Kirkpatrick level 4). Improved patient relations, more thorough documentation, enhanced referral, prescription and testing requests were identified as positive impacts, although such changes may also be detrimental. Other detrimental impacts identified included a break down in patient relations, increased defensive practise, early retirement and altered physical or mental wellbeing. Personal, procedural and cultural factors appeared influential. No articles examining the impact of compliments were identified. Conclusion: Patient complaints can have an impact on medical performance. These can be both positive and negative. The intended purpose of complaints may be undermined by personal, procedural and cultural factors. The fear, language and stigmatisation of complaints should be addressed and the recognition of compliments more actively encouraged. Review findings have implications for those involved in designing and supporting complaint and compliment processes within the broader framework of person-centered care approaches in health systems.

Reliability and Validity of a Checklist to Evaluate Student Performance in a Problem-Based Learning Group

Objective. To validate a problem-based learning (PBL) evaluation checklist to assess individual Doctor of Pharmacy (PharmD) students' performance in a group. Methods. In 2013, a performance checklist was developed and standardized. To evaluate the reliability and discriminant validity of the checklist, pharmacy students' evaluation scores from 2015-2016 were assessed along with overall program grade point averages (GPA), and scores on knowledge and problem-solving examinations. Predictive analysis software was used to analyze the data. Results. Seventy facilitators generated 1506 evaluation reports for 191 (90 third-year and 101 second-year) students over eight PBL cases. The mean (SD) total score was 40.6 (2.5) for P3s and 39.1 (2.7) for P2s out of a possible 44.2 points. Students' scores improved each semester. Interrater reliability based on intraclass correlation coefficient for all cases was 0.67. Internal reliability as determined by Cronbach alpha was >0.7 for all binary checklist items across all cases. Discriminant validity assessed using Pearson correlation coefficient showed that the total score from the checklist did not correlate with knowledge or problem-solving examination scores. Conclusion. This unique PBL checklist proved to be a reliable and valid tool to assess student performance in small group sessions in a PharmD curriculum.

Scheduling Emergency Physicians Based on a Multiobjective Programming Approach: A Case Study of West China Hospital of Sichuan University.

In China, emergency room residents (EMRs) generally face high working intensity. It is particularly important to arrange the working shifts of EMRs in a scientific way to balance their work and rest time. However, in existing studies, most of the scheduling models are based on the individual doctor or nurse as a unit, less considering the actuality of operation and management of emergency department (ED) in large public hospitals in China. Besides, the depiction of the hard and soft constraints of EMR scheduling in China is insufficient. So in order to obtain the scientific and reasonable scheduling shifts, this paper considers various management rules in a hospital, physicians' personal preferences, and the time requirements of their personal learning and living and takes the minimum deviation variables from the soft constraints as the objective function to construct a mixed integer programming model with the doctor group as the scheduling unit. The analytic hierarchy process (AHP) is used to determine the weights of deviation variables. Then, IBM ILOG CPLEX 12.8 is used to solve the model. The feasibility and effectiveness of the scheduling method are verified by the actual case from West China Hospital of Sichuan University. The scheduling results can meet the EMRs' flexible work plans and the preferences of the doctor teams for the shifts and rest days. Compared with the current manual scheduling, the proposed method can greatly improve the efficiency and rationality of shift scheduling. In addition, the proposed scheduling method also provides a reference for EMR scheduling in other China's high-grade large public hospitals.

Doctors\u2019 attitudes to, beliefs about, and experiences of the regulation of professional competence: a scoping review protocol

BackgroundHistorically, individual doctors were responsible for maintaining their own professional competence. More recently, changing patient expectations, debate about the appropriateness of professional self-regulation, and high-profile cases of malpractice have led to a move towards formal regulation of professional competence (RPC). Such programmes require doctors to demonstrate that they are fit to practice, through a variety of means. Participation in RPC is now part of many doctors’ professional lives, yet it remains a highly contested area. Cost, limited evidence of impact, and lack of relevance to practice are amongst the criticisms cited. Doctors’ attitudes towards RPC, their beliefs about its objectives and effectiveness, and their experiences of trying to meet its requirements can impact engagement with the process. We aim to conduct a scoping review to map the empirical literature in this area, to summarise the key findings, and to identify gaps for future research.MethodsWe will conduct our review following the six phases outlined by Arksey and O’Malley, and Levac. We will search seven electronic databases: Academic Search Complete, Business Source Complete, CINAHL, PsycINFO, PubMed, Social Sciences Full Text, and SocINDEX for relevant publications, and the websites of medical regulatory and educational organisations for documents. We will undertake backward and forward citation tracking of selected studies and will consult with international experts regarding key publications. Two researchers will independently screen papers for inclusion and extract data using a piloted data extraction tool. Data will be collated to provide a descriptive summary of the literature. A thematic analysis of the key findings will be presented as a narrative summary of the literature.DiscussionWe believe that this review will be of value to those tasked with the design and implementation of RPC programmes, helping them to maximise doctors’ commitment and engagement, and to researchers, pointing to areas that would benefit from further enquiry. This research is timely; internationally existing programmes are evolving, new programmes are being initiated, and many jurisdictions do not yet have programmes in place. There is an opportunity for learning across different programmes and from the experiences of established programmes. Our review will support that learning.Systematic review registrationPROSPERO does not register scoping reviews.

Doctors as moral pioneers: Negotiated boundaries of assisted conception in Colombia.

New biotechnologies such as assisted conception are socially embedded artefacts that raise context‐specific ethical, moral and social anxieties. In contexts where the regulations of these profitable developments are limited or ambiguous, and competition between private facilities is high, individual doctors become morally and socially responsible for determining the parameters of administering such therapies. Ethnographic research at two private fertility centres in Colombia reveals that doctors do not determine boundaries based on monetary gain but rather personal morals, social norms and professional obligations. Medical professionals hold diverse perceptions of assisted conception, and often struggle to make decisions regarding who should access such therapies, who are ideal gamete donors and the fate of extra embryos. The complexity of these perceptions applied in a context of limited regulation and the competition of private medicine impacts the praxis of assisted conception. As doctors determine the boundaries of their practice they not only create variation between clinical practices, but also make moral decisions regarding who should be parents, how families should be formed and the significance of embryos. Thus, in navigating their everyday practices, doctors also shape the social world.

The Tissue Fixation System: How obsolete and potentially dangerous technology continues to be 'sold'.

Gynaecologists have been at the receiving end of much regulatory intervention in recent years, some of it inappropriate and heavy-handed such as the recent ban on midurethral slings in the National Health Service, others appropriate and, if anything, occurring too late. Regulatory agencies have failed, and so have individual doctors and their organisations. An example of individual and systemic failure involves the Tissue Fixation System. It is an Australian story that is not yet widely known, which is why the author has decided to acquaint the readers of ANZJOG with the situation in this country, where the Tissue Fixation System was invented, manufactured and used on thousands of patients over a period of eight years before its manufacture, sale and export from Australia ended in 2014.

Doctors’ characteristics and the use of long consultations at out-of-hours services 2008–2017: a registry-based follow-up study in Norway

Objective: The aim was to analyse whether there was a change in percentage of long consultations over a 10-year period, and whether individual doctors changed their use of time as they got more experience and specialisation during the same period.Design and setting: This is a registry based study encompassing all consultations in primary care out-of-hours service in Norway in 2008 and 2017.Subjects: For both years all doctors were included in cross sectional analyses. In addition, doctors who participated both years were included in a separate follow-up analysis.Main outcome measures: Long consultations (>20 min) were identified by a time fee in the claims’ database.Results: There were 4610 doctors in 2008 and 5620 in 2017, 904 participated both years. In 2008 a time fee was claimed in 38% of consultations, in 2017 in 47%. Older doctors made less use of the time fee, as did doctors who had many consultations, regular general practitioners, and general practice specialists. The general practitioners who participated both years increased their use of the time fee from 33% to 38% of consultations. Those who specialised in general practice during the 10-year period increased their use of the time fee from 34% to 37%.Conclusions: Experienced doctors have fewer long consultations than inexperienced doctors. Over years there is a strong trend towards increasing the use of time fee during out-of-hours consultations. This trend is only partly offset by increasing the experience of the doctors.KEY POINTSAlthough consultation length may be associated with patient satisfaction there is also a cost-efficiency aspect to be taken into account•Percentage long consultations out-of-hours increased from 38% in 2008 to 47% in 2017•Experienced doctors had fewer long consultations•Experience only partly offset the trend towards more long consultations

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

ObjectivesDoctors 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 politics and ethics of hospital infection prevention and control: a qualitative case study of senior clinicians\u2019 perceptions of professional and cultural factors that influence doctors\u2019 attitudes and practices in a large Australian hospital

BackgroundHospital infection prevention and control (IPC) programs are designed to minimise rates of preventable healthcare-associated infection (HAI) and acquisition of multidrug resistant organisms, which are among the commonest adverse effects of hospitalisation. Failures of hospital IPC in recent years have led to nosocomial and community outbreaks of emerging infections, causing preventable deaths and social disruption. Therefore, effective IPC programs are essential, but can be difficult to sustain in busy clinical environments. Healthcare workers’ adherence to routine IPC practices is often suboptimal, but there is evidence that doctors, as a group, are consistently less compliant than nurses. This is significant because doctors’ behaviours disproportionately influence those of other staff and their peripatetic practice provides more opportunities for pathogen transmission. A better understanding of what drives doctors’ IPC practices will contribute to development of new strategies to improve IPC, overall.MethodsThis qualitative case study involved in-depth interviews with senior clinicians and clinician-managers/directors (16 doctors and 10 nurses) from a broad range of specialties, in a large Australian tertiary hospital, to explore their perceptions of professional and cultural factors that influence doctors’ IPC practices, using thematic analysis of data.ResultsProfessional/clinical autonomy; leadership and role modelling; uncertainty about the importance of HAIs and doctors’ responsibilities for preventing them; and lack of clarity about senior consultants’ obligations emerged as major themes. Participants described marked variation in practices between individual doctors, influenced by, inter alia, doctors’ own assessment of patients’ infection risk and their beliefs about the efficacy of IPC policies. Participants believed that most doctors recognise the significance of HAIs and choose to [mostly] observe organisational IPC policies, but a minority show apparent contempt for accepted rules, disrespect for colleagues who adhere to, or are expected to enforce, them and indifference to patients whose care is compromised.ConclusionsFailure of healthcare and professional organisations to address doctors’ poor IPC practices and unprofessional behaviour, more generally, threatens patient safety and staff morale and undermines efforts to minimise the risks of dangerous nosocomial infection.

Digital Cardiology

The increase in life expectancy and Healthy Life Years in Europe is largely attributable to the success of cardiovascular medicine. Technical developments enable ever more detailed insights into disease processes and enable a precise, multimodal diagnosis of even complex diseases using digital imaging, cardiac biomarkers and genomic information. The rapid availability of this data, often in real time, allows optimized planning and performing of tailored interventional, surgical, or pharmacotherapies. But there are also completely new challenges due to the growing flood of data, the integration of which can no longer be achieved by the individual doctor. The active involvement and participation of the patient also requires new digital concepts and should include decision-making, treatment planning, (long-term) history, and feedback on success and adverse drug reactions. By using artificial intelligence, digital communication and decision support systems, economic benefits, quality improvements and acceleration of outpatient and inpatient treatment become possible.The DGK supports these developments in its own activities, both in project planning, communication with specialist groups, and in training and education. In this article you will find excerpts from current developments of digital cardiology.

Job Security, Organizational Support and Employee Performance: Mediating role of Employee Satisfaction in Medical Sector of Pakistan

The study seeks systemic identification of job security, organizational support and employee satisfaction and investigated impact on employee performance in medical sector of Pakistan .The unit of analysis is an individual medical doctor. Cross sectional survey design has been used for data collection and distribution of instrument as distribution of questionnaire. The random sampling technique is used to conduct the study. The analysis was conducted through SPSS software. The job security and organizational support are independent variables, employee satisfaction is the mediator and employee performance is dependent variable. The study found significant positive relation between job security and employee satisfaction. The study also found positive relation of organization support and satisfaction of employees at medical sectors. If organization supports medical doctors for (their job structure), security and payment policies will be influential towards better performance of employees. The mediating relationship was also found to be significant , study found significant positive relation and mediation effect of employee satisfaction between job security , organization support and employee performance.

The emancipation of patients: a theory whose time has come.

A theory can seem unlikely or unwelcome yet make sense of everyday experiences. That patients can be oppressed by doctors and have sought freedom from that oppression — emancipation from it — is such a theory.1 Oppression is the unjust use of its power by a dominant, stronger group over a weaker group.2 Here I argue that patients’ emancipation is taking place and that recognising this would help free doctors and patients from some of the constraints and coercions that hinder medicine from being as humane as doctors’ talents and good motives should ensure. Since the late 1950s, some patients and patient groups have opposed policies and practices that they see as against their interests and those of patients like them. At first they acted intuitively, without an overall goal; however, by the late 1980s, the consistency and coherence of their actions created those actions’ meaning: they were working towards two primary objectives. The first was for patients to be treated as people whose autonomy and moral agency were respected. The second was for patients to have an equal voice with doctors, both in the individual doctor–patient relationship and in wider discourses about policies and standards at various levels of health care. For individual patients, shared decision making can secure equality and voice.3 For patients collectively, the representation of their interests and values through the voices of patient activists (advocates or representatives) can work towards securing equality of voice.4,5 Patient activists’ pursuit of these objectives shows that they are engaged in …

Negotiating Nursing: British Army Sisters and Soldiers in the Second World War by Jane Brooks

Reviewed by: Negotiating Nursing: British Army Sisters and Soldiers in the Second World War by Jane Brooks Corinna Peniston-Bird Jane Brooks. Negotiating Nursing: British Army Sisters and Soldiers in the Second World War. Nursing History and Humanities. Manchester: Manchester University Press, 2018. xii + 236 pp. Ill. $120.00 (978-1-5261-1906-3). The exigencies of war suggest the potential or the need for change in existing gender identities and relationships. In Negotiating Nursing, Jane Brooks traces the impact of the war on the Queen Alexandra's Imperial Military Nursing Service (QA), established by royal warrant in 1902. In the Second World War QA nurses were posted to war zones with their medical colleagues following the recognition that early treatment of the war wounded increased recovery rates. Nurses had multiple challenges to negotiation: their male and female colleagues, the physical spaces, evolving modes of practice and treatment regimes, and their femininity. Nursing exemplified the rhetoric of paradox that characterizes constructions of femininity, and femininity at war in particular: in their interactions with the doctors and the broken combat male, for example, they were to be both subservient and independent, collaborative and reserved, feminine and neuter. [End Page 474] Over the course of five chapters Brooks covers the nature of nursing work in the context of active service overseas, the challenges to nursing care within a mobile war, the contradictions inherent in being female in places of danger, the rapid development of nursing skills and technologies, and demobilization. In the return to peace, and in the postwar context of the welfare state, "the problem for nurses and other women workers was that the normality that was sought was one based on the male hegemony of the mid-twentieth century. Normality meant women being returned to the home, childbirth and child rearing" (p. 183). The main contribution Brooks makes to understandings of the history of British nursing in the Second World War emerges from her commitment to personal testimony for her source materials; these include oral histories, diaries, letters, and memoirs, many unpublished. Such an approach is of particular value in a profession based on "oral rather than written transmission of knowledge" (p. 9). This also makes the most of a genre that seldom fails to challenge the written record. In this case the sources highlight in particular the differences between regulation and practice, the sharing of knowledge gained in the field rather than the textbook, and the tensions between tradition and innovation. Just as members of the auxiliary forces were sometimes taught by male peers or officers to handle weapons, often in contravention of official policy, so might nurses find that individual doctors or situations enabled them to take on roles and responsibilities hitherto reserved for men. "Army nurses shifted the boundaries of their surgical practice as the exigencies of war demanded, and neither they nor their medical colleagues showed any of the professional anxieties of their counterparts on home soil" (p. 149). Herein lay also the reason that much of these innovations remained "for the duration": the lapsing of rigid hierarchies and methods did not translate well into the medical spaces and societal roles of peace. The potential of wartime experiences to instigate enduring change was therefore, in Brooks's word, "squandered." This is not a finding unique to the Second World War: there is ample evidence that nurses in the Boer War, the First World War, and the Vietnam War had similar experiences of complex gendered contradictions and change limited to the short term—and preferably abroad. The contribution made by Negotiating Nursing is to insert the Queen Alexandra's Imperial Military Nursing Service of the Second World War into familiar themes in nursing history and the debate over gendered social change in the Second World War. [End Page 475] Corinna Peniston-Bird Lancaster University Copyright © 2019 Johns Hopkins University Press

人工智能批判的話語悖論

LANGUAGE NOTE | Document text in Chinese; abstract in English only.In the dominant discourse of the "human–machine relationship," people and machines are the subjects, with a mutually shaping influence. However, this framework neglects the crux of the current critical analysis of AI. It reduces the problems with new technology to the relationship between people and machines, ignoring the re-shaping of the relationship between "people and people" in the era of new technology. This simplification may mislead policy and legal regulations for new technologies. Why would a robot killing cause more panic than a murder committed by a human? Why is a robot's misdiagnosis more troubling than a doctor's? Why do patients assume that machines make more accurate diagnoses than doctors? When a medical accident occurs, who is responsible for the mistakes of an intelligent medical system? In the framework of traditional professionalism, the relationship between doctors and patients, whether trusted or not, is based on the premise that doctors have specialized knowledge that patients do not possess. Therefore, the authority of a doctor is the authority of knowledge. In the age of intelligence, do machines provide information or knowledge? Can this strengthen or weaken the authority of doctors? It is likely that in the age of intelligence, the professionalism, authority and trustworthiness of doctors require a new knowledge base. Therefore, the de-skilling of doctors is not an issue of individual doctors, but demands an update of the knowledge of the entire industry. Recognizing this, policy makers must not focus solely on the use of machines, but take a wider perspective, considering how to promote the development of doctors and coordinate the relationship between doctors with different levels of knowledge development. We often ask, "In the era of intelligence, what defines a human?" This philosophical thinking should be directed toward not only the difference between machines and people as individuals, but also how the relationship between human beings, i.e., the social nature of humans, evolves in different technological environments. In short, this commentary stresses that a "good" machine or an "evil" machine—beyond the sci-fi romance of such discourse—reflects the evolution of the relationships between people. In today's smart age, the critical issue is not the relationship between people and machines. It is how people adjust their relationships with other people as machines become necessary tools in life. In the era of intelligence, therefore, our legislation, policy and ethical discussion should resume their focus on evolutionary relationships between people.DOWNLOAD HISTORY | This article has been downloaded 41 times in Digital Commons before migrating into this platform.

Evaluation of Tooth Brushing in Slovak Patients with Sclerosis Multiplex

Objective: To analyse issue of teeth brushing according to age, gender and length in Slovak patients with multiple sclerosis disease (MS). Material and Methods: In this descriptive study, the questionnaires were collected in neurologists from December 2016 until September 2017. The study sample consisted of 103 MS patients (44.7% of men) in a mean age of 38.4 ± 9.95 years. The study sample of MS patients was divided into two sub-groups. The first sub-group consisted of MS patients who were restricted in teeth brushing (n=56) and the second group of MS patients, which had no restrictions in teeth brushing (n=47). Descriptive statistics were used to calculate the absolute and relative frequencies, mean and standard deviation. A two-sample t-test was used to compare of the proportion between sub-groups with restrictions and sub-group no restrictions in teeth brushing. The statistically significant level was determined at p<0.05. Results: The significant higher mean age (40.4 ± 10.8 years) was found in MS patients who had restrictions in teeth brushing (p=0.043). Females described often no restrictions in teeth brushing than males (59.6% vs. 40.4%; p<0.05). Length in MS disease (≤3 years) has significant impact on patients in who were not found restrictions in teeth brushing (31.9%; p=0.037). Conclusion: We recommend individual doctor approach to MS patients in older age and using of electric toothbrushes in MS patients who have hand functioning restrictions.

How Medic–Patient Communication and Relationship Influence Chinese Patients’ Treatment Adherence

The deterioration of medic–patient relation in China raises the question about its impact on patients’ adherence to medical instructions. This study focuses on how the quantity and quality of medic–patient communication influences their relationship, and how the perceived relationship at individual level, institution level, and society level influences patients’ treatment adherence, through a survey conducted in a city of Southern China (N = 597, Response rate = 66%). The results of path analysis show that consulting time is positively associated with patients’ relationship with individual doctors and the whole medical system, as well as their satisfaction with hospital. Unpleasant experience of having disputes with medical workers is negatively associated with the medic–patient relationship at all of the three levels and causes conditional nonadherence. The more positive medic–patient relationship perceived by the patients, the more likely they will display unconditional adherence.

Prioritization not Rationing in Cancer Care.

Conditions of scarcity impact healthcare services for cancer patients. This is the unpleasant reality for nations, local governments, hospitals, and even individual doctors. This means that medical services judged by objective standards as potentially effective by medical professionals are limited because of financial or access scarcity. With this situation of scarcity as premise, one must raise the ethical question of how to deal with scarcity while respecting fundamental principles of human dignity and human rights. This chapter focuses on the German healthcare context where dignity and rights form the basis and framework for medical ethics. Accordingly, in Germany, rationing medical services for life-threatening diseases has been traditionally and appropriately criticized and prohibited. Granting a situation of scarcity, however, some prioritization becomes increasingly necessary. Thus, there is present need for careful ethical analysis of non-emergency regulatory prioritization principles and protocols. Above all, analysis and conclusions must preserve and foster society's deepest moral commitments.

The effect of practice settings on individual Doctor Press Ganey scores: A retrospective cohort review

ObjectiveThe Press Ganey (PG) survey is a patient experience survey mailed to patients upon discharge from the emergency department (ED). It is a nationally recognized survey that is commonly used to measure patient's perception of the healthcare delivered. Emergency medicine physicians at Staten Island University Hospital staff two distinct sites: a tertiary-care setting (SIUH-N) and a community setting (SIUH-S). The goal of our study was to compare the effect of different ED practice settings, within the same hospital and healthcare system, on individual attending physician PG scores. MethodsThis was a retrospective, observational study of EM physicians, conducted at Staten Island University Hospital between January 1, 2015 and December 31, 2016. Physicians with PG survey responses from both sites were included. The number of responses and mean scores for the four doctor specific survey questions and the doctor overall score were extracted from PG surveys. ResultsMean PG scores at SIUH-N were significantly lower than the mean scores at SIUH-S in each of the four doctor-specific questions, as well as the doctor overall score (p < 0.05). 16 out of 18 doctors demonstrated higher doctor overall scores at SIUH-S. ConclusionVariables other than the individual doctor may be influencing the PG survey responses and perceptions of care. The PG survey may underestimate the impact of different practice settings on individual doctor PG scores.

Colonial surgeon Patrick Hill (1794-1852): unacknowledged pioneer of Australian mental healthcare.

Despite making a substantial contribution to the development of mental health services in colonial Australia, until now the story of Dr Patrick Hill's (1794-1852) life has been overlooked by historians. This paper reviews primary sources including clinical notes, patient lists, letters, government documents and newspaper articles which reveal that Dr Hill was a dedicated physician who played a vital role in the development of Australian mental healthcare. He was held in such esteem that by the time of his sudden death in 1852 he had been elevated to the most senior medical office in New South Wales. Dr Hill's career serves to exemplify how the local practice of individual colonial doctors helped build the reputation of medicine in the modern era.

Institutional non-participation in assisted dying: Changing the conversation.

Whether institutions and not just individual doctors have a right to not participate in medical assistance in dying (MAID) is controversial, but there is a tendency to frame the issue of institutional non-participation in a particular way. Conscience is central to this framing. Non-participating health centres are assumed to be religious and full participation is expected unless a centre objects on conscience grounds. In this paper we seek to reframe the issue. Institutional non-participation is plausibly not primarily, let alone exclusively, about conscience. We seek to reframe the issue by making two main points. First, institutional non-participation is primarily a matter of institutional self-governance. We suggest that institutions have a natural right of self-governance which, in the case of health centres such as hospitals or hospices, includes the right to choose whether or not to offer MAID. Second, there are various legitimate reasons unrelated to conscience for which a health centre might not offer MAID. These range from considerations such as institutional capacity and expertise to a potential contradiction with palliative care and a concern to not conflate palliative care and MAID in public consciousness. It is a mistake to frame the conversation simply in terms of conscience-based opposition to MAID or full participation. Our goal is to open up new space in the conversation, for reasons unrelated to conscience as well as for non-religious health centres who might nonetheless have legitimate grounds for not participating in MAID.