We still don't know what patients value

Great systematic review in PLoS One [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4498685/] regarding self-management outcomes. Basically, long term chronic illnesses mean that self-management is crucial, but we don't seem to do enough research about what patients actually value. Great article. My selected highlights are as follows;
"Patients in our review identified that receiving support for self-management which is meaningful and relevant to the context of their lives is an important outcome. However, services often focus upon process driven outcomes, such as length of stay, or change in blood glucose, without necessarily considering the meaningfulness of this for the patient."
"few studies explicitly identified families’ perspectives".

We are left we the interesting problem, of how we can train physicians to better elicit the values of the their patients. Indeed, it begs interesting questions about what values health professionals bring to their work and practice. 

Violence against health care workers - exploring why patients do it

The American Medical Association (AMA) is to support more research to find interventions to help deal with violence against health care workers. The statistics are quite revealing. According to the Bureau of Labour Statistics in the US health care workers experience the most nonfatal workplace violence compared to other professions, with attacks at hospital and social service settings accounting for almost 70 percent of nonfatal workplace assaults.

Research suggests that health-care workers are hit, kicked, scratched, bitten, spat on, threatened and harassed by patients with surprising regularity (especially nurses). The current health care environment often requires that health care workers maintain optimal performance even in the immediate chaotic aftermath of workplace violence. Workplace violence prevention has not been given the priority it rates.

The rates of violence in both developing and developed countries strongly suggest that the problem is a system issue, and not a small minority.

Violence may represent an opportunity to revaluate the degree to which we involve patients and the public in healthcare delivery, healthcare policy and healthcare research. Health care workers must be appalled that individuals are ‘fighting’ against the people trying to help them, but answering such questions may help to provide a more ‘patient’ view of the healthcare journey. We can’t seem to really involve patients and the public (for a myriad of reasons), and the violence issue is part of this.  

How Physicians react to complaints

Using a large data set of 7926 doctors, a paper in BMJ Open* sheds some interesting light on how complaints affect doctors. The response rate was low (8.3%), so conclusions have to be interpreted with caution. That said, some of the highlights of study were:
- Of doctors who had a recent complaint (of any kind) 77%  were more likely to suffer from moderate to severe depression than those who have never had a complaint. They also have double the risk of having thoughts of self-harm and double the risk of anxiety.
-  80% of doctors answering the survey reported changing the way they practiced as a result of either complaints against themselves, or after observing a colleague go through a complaints process.

It's a cross sectional paper, so its difficult to establish any casual link. For example, it is possible that doc's suffering from mental health problems may be more likely to have complaints made against them.
Anyway, interesting paper, limitations aside.

* Bourne T, Wynants L, Peters M, et al. The impact of complaints procedures on the welfare, health and clinical practise of 7926 doctors in the UK: a cross-sectional survey. BMJ Open 2015;4:e006687. doi:10.1136/bmjopen-2014- 006687

Should physicians wear white coats?

Does physician attire influence patient trust and satisfaction? A 2015 systematic review in BMJ Open [BMJ Open 2015;5:e006578. doi:10.1136/bmjopen-2014-006578] suggests wide variability in preferences, and difficulty in reaching robust conclusions. However, a fine grained reading of the paper highlights some interesting findings:

1.    Patients who received clinical care were less likely to voice preference for any type attire than patients that did not

2.    Studies that included physician encounters were less likely to find specific preferences (3/12 studies) compared to studies conducted outside of a physician–patient meeting (18/18 studies).

3.    Studies originating from the UK, Asia, Ireland and Europe most often expected formal attire with or without white coats (especially among older people.

So, conclusions 1 and 2 seem to suggest that issues concerning physician attire become less important as the patient experience becomes more real.

Is technology the enemy of patient history taking?

No one doubts the potential for technology to aid medical decision making and the organization of health systems. However, there is a thought provoking viewpoint in JAMA [http://jama.jamanetwork.com/article.aspx?articleid=2020379] on the potential downside to Electronic Health Records (EHR). The authors use the idea of the 'flipped' patient to argue that EHRs may degrade history taking. To quote the authors; "For a generation for whom texting can be more intimate than face-to-face conversation, there might be an assumption that the EHR is the dialogue with the patient, not a representation of one." Food for thought for any teaching medical students.

HPs perceptions of clinical governance

Great paper in the latest issue of BMJ Open [Gauld R, et al. BMJ Open 2015;5:e006157. doi:10.1136/bmjopen-2014-006157] on HP perceptions of clinical governance in New Zealand. The response rate was 25%, but the results are instructive.  Five key themes illustrating barriers to clinical governance implementation were found, representing problems with: developing management–clinical relations; clinicians stepping up into clinical governance and leadership activities; interprofessional relations; training needs for governance and leadership; and having insufficient time to get involved.

Interestingly, only 47% respondents said they were ‘familiar’ or ‘very familiar’ with the concept of clinical governance. 

Healthcare organizations are populated by educated and motivated people, so the results of the paper seem to suggest that there is a problem with a common/shared vision?

Medical students’ view about deceiving patients with dementia

Dementia is set to become one of the major challenges of the next 50 years, in both the developed and developing world. In a 2014 paper in Aging and Mental health [Aging & Mental Health, 2014 http://dx.doi.org/10.1080/13607863.2014.967173] students expressed uncertainty as to their ability to make judgments about honest communication with patients with dementia and their families. In this very interesting qualitative study, the researchers found that whilst students recognised the importance of the autonomy of each individual with dementia, they expressed difficulties with determining an individual’s‘best interests’ in isolation. Students commented on the apparent mismatch between rule based ethical ideals, as promoted in formal documents about professionalism, and the complexities that they had seen in practice. They expressed anxiety about their own ability to interpret professional guidelines and act in the best interests of individual patients at all times. This is a great paper for both researchers and as a teaching tool.