Views Of Physicians Research Articles

Can a multicomponent multidisciplinary implementation package change physicians\u2019 and nurses\u2019 perceptions and practices regarding thrombolysis for acute ischemic stroke? An exploratory analysis of a cluster-randomized trial

BackgroundThe Thrombolysis ImPlementation in Stroke (TIPS) trial tested the effect of a multicomponent, multidisciplinary, collaborative intervention designed to increase the rates of intravenous thrombolysis via a cluster randomized controlled trial at 20 Australian hospitals (ten intervention, ten control). This sub-study investigated changes in self-reported perceptions and practices of physicians and nurses working in acute stroke care at the participating hospitals.MethodsA survey with 74 statements was administered during the pre- and post-intervention periods to staff at 19 of the 20 hospitals. An exploratory factor analysis identified the structure of the survey items and linear mixed modeling was applied to the final survey domain scores to explore the differences between groups over time.ResultThe response rate was 45% for both the pre- (503 out of 1127 eligible staff from 19 hospitals) and post-intervention (414 out of 919 eligible staff from 18 hospitals) period. Four survey domains were identified: (1) hospital performance indicators, feedback, and training; (2) personal perceptions about thrombolysis evidence and implementation; (3) personal stroke skills and hospital stroke care policies; and (4) emergency and ambulance procedures. There was a significant pre- to post-intervention mean increase (0.21 95% CI 0.09; 0.34; p < 0.01) in scores relating to hospital performance indicators, feedback, and training; for the intervention hospitals compared to control hospitals. There was a corresponding increase in mean scores regarding perceptions about the thrombolysis evidence and implementation (0.21, 95% CI 0.06; 0.36; p < 0.05). Sub-group analysis indicated that the improvements were restricted to nurses’ responses.ConclusionTIPS resulted in changes in some aspects of nurses’ perceptions relating to the evidence for intravenous thrombolysis and its implementation and hospital performance indicators, feedback, and training. However, there is a need to explore further strategies for influencing the views of physicians given limited statistical power in the physician sample.Trial registrationACTRN12613000939796, UTN: U1111–1145-6762.

Necessity for preparation of the patient for upcoming clinical laboratory analysis

The analytical and diagnostic reliability of the results of clinical laboratory tests depend mostly on the preparation of the patient and duly to the type of study. The patient has to be fully aware if before taking the test material he has to be hungry and if it is necessary to maintain a diet regime for a few days. He must be aware of the drugs that he can and cannot take in relation to the upcoming study. There are currently approved by the WHO criteria for diagnosing, which includes the preparation of the patient. The article presents an analysis on the views of patients, laboratory physicians, laboratory technicians and general practitioners about the level of preparation of patients and the need for training in upcoming laboratory studies.

From context to contexting: professional identity un/doing in a medical leadership development programme.

Physicians are known for safeguarding their professional identities against organisational influences. However, this study shows how a medical leadership programme enables the reconstruction of professional identities that work with rather than against organisational and institutional contexts to improve quality and efficiency of care. Based on an ethnographic study, the results illustrate how physicians initially construct conflicting leadership narratives – heroic (pioneer), clinical (patient's guardian) and collaborative (linking pin) leader – in reaction to changing organisational and clinical demands. Each narrative contains a particular relational‐agentic view of physicians regarding the contexts of hospitals: respectively as individually shapeable; disconnected or collectively adjustable. Interactions between teachers, participants, group discussions and in‐hospital experiences led to the gradual deconstruction of the heroic –and clinical leader narrative. Collaborative leadership emerged as the desirable new professional identity. We contribute to the professional identity literature by illustrating how physicians make a gradual transition from viewing organisational and institutional contexts as pre‐given to contexting, that is, continuously adjusting the context with others. When engaged in contexting, physicians increasingly consider managers and directors as necessary partners and colleague‐physicians who do not wish to change as the new ‘anti‐identity’.

Challenges to achieving appropriate and equitable access to Caesarean section: ethnographic insights from rural Pakistan.

Access to Caesarean section (C-section) remains inadequate for some groups of women while others have worryingly high rates. Understanding differential receipt demands exploration of the socio-cultural, and political economic, characteristics of the health systems that produce them. This extensive institutional ethnography investigated under- and over-receipt of C-section in two rural districts in Pakistan - Jhelum and Layyah. Data were collected between November and July 2013 using semi-structured interviews from a randomly selected sample of 11 physicians, 38 community midwives, 18 Lady Health Visitors and nurses and 15 Traditional Birth Attendants. In addition, 78 mothers, 35 husbands and 23 older women were interviewed. The understandings of birth by C-section held by women and their family members were heavily shaped by gendered constructions of womanhood, patient-provider power differentials and financial constraints. They considered C-section an expensive and risky procedure, which often lacked medical justification, and was instead driven by profit motive. Physicians saw C-section as symbolizing obstetric skill and status and a source of legitimate income. Physician views and practices were also shaped by the wider health care system characterized by private practice, competition between providers and a lack of regulation and supervision. These multi-layered factors have resulted in both unnecessary intervention, and missed opportunities for appropriate C-sections. The data indicate a need for synergistic action at patient, provider and system levels. Recommendations include: improving physician communication with patients and family so that the need for C-section is better understood as a life-saving procedure, challenging negative attitudes and promoting informed decision-making by mothers and their families, holding physicians accountable for their practice and introducing price caps and regulations to limit financial incentives associated with C-sections. The current push for privatization of health care in low-income countries also needs scrutiny given its potential to encourage unnecessary intervention.

Vaccination status of patients using anti-TNF therapy and the physicians' behavior shaping the phenomenon: Mixed-methods approach.

ObjectiveAnti-tumor necrosis factor (Anti-TNF) therapy improves the prognosis and reduces the morbidity and mortality associated with many chronic inflammatory autoimmune diseases. However, as it is linked to an increased infection risk, appropriate vaccination is required. The study aimed at investigating the vaccination status of patients receiving Anti-TNF therapy and physicians’ perceptions of and views about vaccinating these patients.MethodsA sequential explanatory mixed-methods approach was used. The study comprised a quantitative, retrospective drug utilization review for determining institutional consumption of Anti-TNF therapy and an assessment of vaccination status in patients prescribed Anti-TNF therapy to audit physicians’ adherence to Anti-TNF therapy-related vaccination recommendations. Patient data from electronic medical records (EMRs) obtained from tertiary care hospitals between September 2015 and September 2017 were used. Further, a qualitative study using a phenomenographic approach with semi-structured interviews of 12 physicians was carried out to explore the physicians’ perceptions, views, and recommendations of vaccinating patients who are undergoing Anti-TNF therapy and identifying factors that may cause poor adherence to vaccination recommendations.ResultsForty-three of 310 patients receiving Anti-TNF therapy were vaccinated. Infliximab was the most frequently prescribed agent, accounting for 96.7% of total orders. Eight of the 12 physicians stated that they were aware of vaccination guidelines and seven viewed pre–Anti-TNF therapy vaccination as essential because of the high infection risk and claimed to incorporate it in their daily practice. Barriers to adherence included ignorance of recommendations, workload, vaccine unavailability, and advanced disease state.ConclusionAlthough the recommendations published by professional medical societies emphasized the importance of vaccination before initiating Anti-TNF therapy, few patients were vaccinated. Medical administration in hospitals should develop policies, procedures, and guidelines for vaccination; implement education programs for physicians and patients and procure vaccines in a timely way to improve their use.

Patient engagement or information overload: patient and physician views on sharing the medical record in the acute setting

Background: Patient and professional views about the impact of providing full real-time access to the medical record in the in-hospital setting are unknown.Methods: Likert-scale and free-text validated questionnaire survey of physicians and patients from acute medical units in two hospitals. The questionnaire explored recent experiences; views on the formation of trust, and views on sharing either the entire medical record or a summary.Results: Two-hundred and forty-eight patient questionnaires (62% response rate) and 32 physician questionnaires (21% response rate) were returned. Twenty-seven per cent of patients did not recall being told their diagnosis. Doctors and patients differed on what practices that they believed built trust.Eighty-one per cent of patients supported the idea of having access to the full medical record (for empowerment; the right to information about oneself; as an aide-memoire for discussion). Doctors feared it might provoke anxiety and change the nature of what was written. A written lay summary record was preferred by doctors and patients.Conclusions: The current system of providing information verbally to patients is inadequate. Patients want more information and are less concerned than physicians about potential negative effects of real-time access to their records. Patient access to medical records (in both full and summary forms) should be evaluated.

Evaluation of a shared decision-making communication skills training for physicians treating patients with asthma: a mixed methods study using simulated patients

BackgroundShared decision-making (SDM) is a key principle in asthma management, but continues to be poorly implemented in routine care. This study aimed to evaluate the impact of a SDM communication skills training for physicians treating patients with asthma on the SDM behaviors of physicians, and to analyze physician views on the training.MethodsA mixed methods study with a partially mixed sequential equal status design was conducted to evaluate a 12 h SDM communication skills training for physicians treating patients with asthma. It included a short introductory talk, videotaped consultations with simulated asthma patients, video analysis in small group sessions, individual feedback, short presentations, group discussions, and practical exercises. The quantitative evaluation phase consisted of a before (t0) after (t1) comparison of SDM performance using the observer-rated OPTION5, the physician questionnaire SDM-Q-Doc, and the patient questionnaire SDM-Q-9, using dependent t-tests. The qualitative evaluation phase (t2) consisted of a content analysis of audiotaped and transcribed interviews.ResultsInitially, 29 physicians participated in the study, 27 physicians provided quantitative data, and 22 physicians provided qualitative data for analysis. Quantitative results showed significantly improved performance in SDM following the training (t1) when compared with performance in SDM before the training (t0) (OPTION5: t (26) = − 5.16; p < 0.001) (SDM-Q-Doc: t (26) = − 4.39; p < 0.001) (SDM-Q-9: t (26) = − 5.86; p < 0.001). The qualitative evaluation showed that most physicians experienced a change in attitude and behavior after the training, and positively appraised the training program. Physicians considered simulated patient consultations, including feedback and video analysis, beneficial and suggested the future use of real patient consultations.ConclusionThe SDM communication skills training for physicians treating patients with asthma has potential to improve SDM performance, but would benefit from using real patient consultations.

Debates over NICE Guideline Update: What Are the Roles of Nuclear Cardiology in the Initial Evaluation of Stable Chest Pain?

Recent clinical trials have demonstrated the values of cardiac computed tomography (CT) in the initial evaluation of stable chest pain which led to drastic changes in the National Institute for Health and Care Excellence (NICE) guidelines in 2016. According to the updated NICE guidelines, cardiac CT should be performed as the initial cardiac testing in stable chest pain regardless of pre-test probability (PTP) of coronary artery disease (CAD). As a result, cardiac CT is now considered as a validated gatekeeper for assessing stable chest pain, which precedes all the functional studies including nuclear myocardial perfusion imaging (MPI). Nuclear MPI, in contrast, has been assigned as one of the second-line studies, which is inevitably dependent on the results of cardiac CT. However, nuclear MPI has genuine values in the diagnosis, treatment decision, and prognostic stratification of stable chest pain, which cannot be replaced by cardiac CT. In this review, the updated NICE guidelines and related cardiac CT trials will be critically reviewed from the view of nuclear physicians and the exceptional values of nuclear MPI will be described along with the future perspectives.

Applied Uses of Extracorporeal Membrane Oxygenation Therapy.

Extracorporeal membrane oxygenation (ECMO) therapy has been around since the 1970s and has completely changed how critical care physicians view supportive therapy for certain patients. ECMO therapy is a supportive therapy provided by a mechanical extracorporeal circuit that is able to directly oxygenate and remove carbon dioxide from the blood. By performing this, ECMO can provide cardiac, respiratory, or combined cardiopulmonary supportive therapy in cases of failure. ECMO therapy also places less emphasis on invasive mechanical ventilation, which prevents barotrauma and gives rest to the lungs. Therefore, they are used for several different conditions. This review article focuses on the definition, principles, types, and practical applications of ECMO therapy.

Physician View and Experience of the Diagnosis of Autism Spectrum Disorder in Young Children.

Introduction: Clinicians working with children with autism spectrum disorder (ASD) occupy an important position between parents and the wide-ranging research findings. However, it is not widely known how clinicians view and experience ASD in children, even though their perspective has been shown to significantly influence their work. Material and methods: Sixteen physicians working with preschool children without a diagnosis of (intellectual or other) disability with a (presumed) diagnosis of ASD participated in a semistructured interview. They described their professional views on ASD, and how they experienced its use in their clinical practice. The data were analyzed by applying the qualitative research method of interpretative phenomenological analysis of the data through Nvivo 11. Results: The main topic of the interviewed physicians’ views and experiences of ASD in a young child comprised three inductively established themes: 1) physicians’ views on ASD are multifaceted but fit within their personal clinical styles; 2) the ASD diagnosis is a “descriptive” part of a clinical trajectory; and 3) ASD treatment is a mix of “standard” approaches and a personalized search. These physicians’ perspectives on ASD are composed of multiple and sometimes ambiguous facets. However, their views are embedded in their personal clinical styles in general (i.e., beyond ASD) and are experienced as clinically “workable.” With the aim of finding an adequate approach to the problems parents bring to their office, many interviewed physicians say that—complementary to or rather than a classificatory diagnosis—they prefer using a personalized “profile” of a child in a therapeutic “process.” Conclusions: The interviewed physicians consider doubts and concerns to be an inherent part of their clinical work with ASD in young children, but do not experience this ambiguity as an obstacle to clinical care. These physicians deal with the multiplicity of their views on ASD by basing their eclectic views on their generally adopted clinical styles, and by selecting what works for them, and for the parents and child, from what they regard as the ‘textbook knowledge’ on ASD. We discuss the implications of these findings for translating research results to the clinic.

Fluid management and deresuscitation practices: A survey of critical care physicians.

Accumulation of a positive fluid balance is common in critically ill patients, and is associated with adverse outcomes, including mortality. However, there are few randomised clinical trials to guide clinicians as to the most appropriate fluid strategy following initial resuscitation and on the use of deresuscitation (removal of accumulated fluid using diuretics and/or renal replacement therapy). To inform the design of randomised trials, we surveyed critical care physicians with regard to perceptions of fluid overload in critical care, self-reported practice, acceptability of a variety of approaches to deresuscitation, appropriate safety parameters, and overall acceptability of a randomised trial of deresuscitation. Of 524 critical care specialists completing the survey, the majority practiced in mixed medical/surgical intensive care units in the United Kingdom. Most (309 of 363 respondents, 85%) believed fluid overload to be a modifiable source of morbidity; there was strong support (395 of 457, 86%) for a randomised trial of deresuscitation in critical illness. Marked practice variability was evident among respondents. In a given clinical scenario, self-reported practice ranged from the administration of fluid (N = 59, 14%) to the administration of a diuretic (N = 285, 67%). The majority (95%) considered it appropriate to administer diuretics for fluid overload in the setting of noradrenaline infusion and to continue to administer diuretics despite mild dysnatraemias, hypotension, metabolic alkalosis, and hypokalaemia. The majority of critical care physicians view fluid overload as a common and modifiable source of morbidity; deresuscitation is widely practiced, and there is widespread support for randomised trials of deresuscitation in critical illness.

Physician Knowledge, Attitudes, and Practices Regarding Breast Density.

Background: Many states have enacted breast density laws, requiring that women be informed of their breast density status; however there is currently no consensus for screening guidelines or recommendations for women with dense breasts. The objective of this study is to access physician views about breast density and their practices for breast cancer screening of women with dense breasts in light of breast density laws. Materials and Methods: Setting: Academic medical centers, community and private practices mostly in New York City. Participants: Primary care providers (PCPs), radiologists and gynecologists. Procedure: We conducted the study through anonymous, self-administered surveys about physician knowledge, attitudes, and practices regarding screening of women with dense breasts. Bivariate and multivariate analyses were performed to assess differences between PCPs and specialists. Results: We received 155 responses of which 75% were female, 77% were attending-level physicians, 42% were PCPs, 28% were radiologists, 17% were gynecologists, and 9% other. Almost half of the respondents (48%) were unaware of breast density laws, and two-thirds (67%) felt they needed more education about breast density and supplemental screening. More than half of the respondents (62%) were unaware of the increased risk of breast cancer related to dense breasts. Compared to specialists, PCPs were less aware of their state's breast density laws (odds ratio [OR] 0.21; 95% confidence interval [CI] 0.09-0.50) and of the increased breast cancer risk for women with dense breasts (OR 0.23; 95% CI 0.09-0.60). Conclusion: Breast density laws have not translated into greater knowledge of breast density and recommendations for supplemental screening among PCPs.

Multidisciplinary Evaluation in Patients with Lung Disease Associated with Connective Tissue Disease.

Multidisciplinary diagnosis is now viewed as the diagnostic reference standard in interstitial lung disease (ILD). This process consists of the integration of the evidence base with clinical reasoning in the formulation of a diagnosis and requires input from clinicians, radiologists, and, in selected cases, histopathologists. In ILD associated with connective tissue disease (CTD-ILD), multidisciplinary evaluation is especially helpful when CTD is suspected but cannot be diagnosed using strict criteria. In this context, the integration of systemic clinical data, serologic information, and computed tomography and biopsy findings may allow CTD-ILD to be diagnosed. However, the value of multidisciplinary evaluation in CTD-ILD is not confined to diagnosis. The frequent coexistence of pulmonary processes other than ILD, including pulmonary vascular disease, extrapulmonic restriction, and airways disease, often has a major impact on symptoms and pulmonary function tests (PFTs). In this review, we highlight the value of multidisciplinary discussion (MDD) in reconciling clinical data, PFT, and imaging data in the accurate staging of disease severity, baseline prognostic evaluation, and the identification of progression of ILD. MDD also provides a means to combine the views of respiratory physicians and rheumatologists in formulating a treatment strategy. It is often possible to reach a robust view as to whether management should be driven by systemic disease, pulmonary disease, or both. When treatment needs to be introduced or modified for both systemic and pulmonary reasons, face-to-face discussion facilities the selection of therapeutic agents that are likely to be efficacious for both systemic and pulmonary diseases.

The practice of glycaemic control in intensive care units: A multicentre survey of nursing and medical professionals.

To determine the views of nurses and physicians working in intensive care units (ICU) about the aims of glycaemic control and use of their protocols. Evidence about the optimal aims and methods for glycaemic control in ICU is controversial, and current local protocols guiding practice differ between ICUs, both nationally and internationally. The views of professionals on glycaemic control can influence their practice. Cross-sectional, multicentre, survey-based study. An online short survey was sent to all physicians and nurses of seven ICUs, including questions on effective glycaemic control, treatment of hypoglycaemia and deviations from protocols' instructions. STROBE reporting guidelines were followed. Over half of the 40 respondents opined that a patient spending <75% admission time within the target glycaemic levels constituted poor glycaemic control. Professionals with more than 5years of experience were more likely to rate a patient spending 50%-74% admission time within target glycaemic levels as poor than less experienced colleagues. Physicians were more likely to rate a patient spending <50% admission time within target as poor than nurses. There was general agreement on how professionals would rate most deviations from their protocols. Nurses were more likely to rate insulin infusions restarted late and incorrect dosage of rescue glucose as major deviations than physicians. Most professionals agreed on when they would treat hypoglycaemia. When surveyed on various aspects of glycaemic control, ICU nurses and physicians often agreed, although there were certain areas of disagreement, in which their profession and level of experience seemed to play a role. Differing views on glycaemic control amongst professionals may affect their practice and, thus, could lead to health inequalities. Clinical leads and the multidisciplinary ICU team should assess and, if necessary, address these differing opinions.

The Effect of Online Effort and Reputation of Physicians on Patients' Choice: 3-Wave Data Analysis of China's Good Doctor Website.

BackgroundNowadays, patients are seeking physician information more frequently via the internet. Physician-rating websites (PRWs) have been recognized as the most convenient way to gain insight and detailed information about specific physicians before receiving consultation. However, little is known about how the information provided on PRWs may affect patients’ decisions to seek medical advice.ObjectiveThis study aimed to examine whether the physicians’ online efforts and their reputation have a relationship with patients’ choice of physician on PRWs.MethodsA model, based on social exchange theory, was developed to analyze the factors associated with the number of online patients. A 3-wave data collection exercise, covering 4037 physicians on China’s Good Doctor website, was conducted during the months of February, April, and June 2017. Increases in consultation in a 60-day period were used as the dependent variable, whereas 2 series of data were analyzed using linear regression modeling. The fixed-effect model was used to analyze the 3-wave data.ResultsThe adjusted R2 value in the linear regression models were 0.28 and 0.27, whereas in the fixed-effect model, it was .30. Both the linear regression and fixed-effect models yielded a good fit. A positive effect of physicians’ effort on the aggregated number of online patients was identified in all models (R2=0.30 and R2=0.37 in 2 regression models; R2=0.23 in fixed effect model; P<.001). The proxies of physicians’ reputations indicated different results, with total number of page views of physicians’ homepages (R2=0.43 and R2=0.46; R2=0.16; P<.001) and number of votes received (R2=0.33 and R2=0.27; R2=0.43; P<.001) being seen as positive. Virtual gifts were not significant in all models, whereas thank-you messages were only significant in the fixed-effect model (R2=0.11; P=.02). The effort made by physicians online is positively associated with their aggregated number of patients consulted, whereas the effect of a physician’s reputation remains uncertain. The control effect of a physician’s title and hospital’s level was not significant in all linear regressions.ConclusionsBoth the effort and reputation of physicians online contribute to the increased number of online patients’ consultation; however, the influence of a physician’s reputation varies. This may imply that physicians’ online effort and reputation are critical in attracting patients and that strategic manipulation of physician profiles is worthy of study. Practical insights are also discussed.

Health care professionals' attitudes towards deprescribing in older patients with limited life expectancy: A systematic review.

The aim of this systematic review was to explore health care professionals' attitudes towards deprescribing in older people with limited life expectancy. A systematic literature search was conducted from inception to December 2017 using MEDLINE, EMBASE and CINAHL. Studies were included if they specifically concerned older people (≥65years) with limited life expectancy, including those residing in any type of aged care facility, or were based on representative patient profiles. Results were analyzed inspired by the Joanna Briggs Institute's method for synthesis of qualitative data. Studies were characterized using a checklist for reporting of qualitative research. Eight studies were included. Six studies explored health care professionals' views on deprescribing in general, and two studies focused specifically on psychotropic agents. All eight studies explored the views of physicians, mostly general practitioners, while three studies also considered other health care professionals. Four themes related to health care professionals' attitudes towards deprescribing were identified: (i) patient and relative involvement; (ii) the importance of teamwork; (iii) health care professionals' self-assurance and skills; and (iv) the impact of organizational factors. Within each of these themes, 3-4 subthemes were identified and analysed. Our results suggest that health care professionals' decisions to engage in deprescribing activities with older people with limited life expectancy depend on multiple factors which are highly interdependent. Consequently, there is an urgent need for more research on how to approach deprescribing in clinical practice within this population.

Use of biosimilars in inflammatory bowel disease: a position update of the Italian Group for the Study of Inflammatory Bowel Disease (IG-IBD)

The first infliximab biosimilar for the treatment of inflammatory bowel disease (IBD) was introduced in 2013, and today eight anti-TNF alpha biosimilars (three for infliximab and five for adalimumab) have been approved and licensed by the European Medicines Agency. Biosimilars present great potential in terms of cost saving and possible consequential reinvestment in the health care system. The increasing knowledge about the process of biosimilar development and use in IBD and the publication of many prospective clinical studies and real-life clinical experiences have progressively changed the point of view of IBD physicians. In the present position paper, the Italian Group for the Study of Inflammatory Bowel Disease present and discuss their updated statements and positions on this topic, with emphasis on the concepts of biosimilarity and extrapolation across indications, safety and immunogenicity, interchangeability and switching, automatic substitution, and, finally, patient education about biosimilars.

Long-term use of benzodiazepines and Z drugs: a qualitative study of patients' and healthcare professionals' perceptions and possible levers for change.

BackgroundAlthough long-term use of benzodiazepines (BZDs) and Z drugs is associated with various side effects, they remain popular among the older population. Possible reasons for this phenomenon could be ineffective ways of transmitting information on the health risks associated with long-term use, and communication gaps between patients and healthcare professionals.AimThe aim was to investigate the views of patients, physicians, nurses, and pharmacists regarding long-term BZD and Z drug use.Design & settingThe qualitative study design used focus group interviews with physicians, pharmacists, and nurses in Hamburg. Patient interviews were conducted in Lippstadt, Germany.MethodThe interviews were audiotaped with each participant’s permission, transcribed, and thematically analysed using a software program for qualitative research (MAXQDA).ResultsThe data from the four focus groups consisting of 28 participants were analysed. Patients indicated lack of knowledge about risks and side effects, difficult access to alternatives, and fears of ceasing drug use without professional support. Although the physicians were reported to be cautious about prescribing BZDs and Z drugs, the psychosocial problems of older patients are often considered to be complex and treatment knowledge, experience, and resources are frequently unsatisfactory. Nurses described that when BZDs were prescribed, they did not feel it was their responsibility to evaluate their effects. Pharmacists were reported to be strongly ambivalent in informing patients about the risks, which may contradict the prescription advice provided by the physician.ConclusionPatients, physicians, nurses, and pharmacists reported differences in the perception of long-term BZD and Z drug use. Nevertheless, all of the participants described lack of information and expressed the need for greater communication exchange.

Financial risk protection at the bedside: How Ethiopian physicians try to minimize out-of-pocket health expenditures.

BackgroundOut-of-pocket health expenditures can pose major financial risks, create access-barriers and drive patients and families into poverty. Little is known about physicians’ role in financial protection of patients and families at the bedside in low-income settings and how they perceive their roles and duties when treating patients in a health care system requiring high out-of-pocket costs.ObjectiveAssess physicians’ concerns regarding financial welfare of patients and their families and analyze physicians’ experiences in reducing catastrophic health expenditures for patients in Ethiopia.MethodA national survey was conducted among physicians at 49 public hospitals in six regions in Ethiopia. Descriptive statistics were used.ResultsTotally 587 physicians responded (response rate 91%) and 565 filled the inclusion criteria. Health care costs driving people into financial crisis and poverty were witnessed by 82% of respondants, and 88% reported that costs for the patient are important when deciding to use or not use an intervention. Several strategies to save costs for patients were used: 37–79% of physicians were doing this daily or weekly through limiting prescription of drugs, limiting radiologic studies, ultrasound and lab tests, providing second best treatments, and avoiding admission or initiating early discharge. Overall, 75% of the physicians reported that ongoing and future costs to patients influenced their decisions to a greater extent than concerns for preserving hospital resources.ConclusionIn Ethiopia, a low-income country aiming to move towards universal health coverage, physicians view themselves as both stewards of public resources, patient advocates and financial protectors of patients and their families. Their high concern for family welfare should be acknowledged and the economic and ethical implications of this practice must be further explored.

Sensemaking through a storytelling lens

PurposeDrawing from the extant literature on sensemaking theory, the purpose of this paper is to understand how physicians view health information exchange (HIE) implementation and how their stories frame the situation.Design/methodology/approachThis paper utilizes content analysis with sensemaking theory as a theoretical lens to analyze physicians’ interviews.FindingsThe stories within this study draw attention to how sensemaking might impact the HIE implementation process. The findings demonstrated four well-defined manifest themes specific to sensemaking: bracketing, enactment, social and identity construction. There were sub-themes that cut across major themes: financial implications, practice changes and impact on professional reputation. The data demonstrated that each participant singled out items or events specific to the HIE change process in order to make sense of the change as an entirety.Originality/valueNo other study has applied sensemaking in an effort to gain insight into the ways physicians view the HIE process. Therefore, this study offers a unique perspective which might provide a framework through which to understand the possible barriers to successful implementation of HIE from a physician.