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. 

Solving global health problems and healthcare

Do the solutions for global health lie in healthcare? A recent analysis article in the BMJ [BMJ 2014;349:g5457 doi: 10.1136/bmj.g5457] should be sobering reading for all of us. The author Jocalyn Clark reminds us to why putting all our money on healthcare to solve global health problems is doomed to failure. The article does a fine job in arguing why we need to find creative solutions that integrate healthcare into the equation. My own take on the piece is that is has interesting implications for how we train and educate doctors. I will be distributing copies of it to the clinicians that I teach, and exploring their reactions to its implications. 

Safety and quality are not necessarily the same thing!

An excellent article in BMJ Open [Mumford V, et al. BMJ Open 2014;4:e005284. doi:10.1136/bmjopen-2014-005284] reveals how safety and accreditation processes can travel in different directions. The study involved a longitudinal comparative study of hand hygiene compliance and accreditation outcomes in 96 Australian hospitals. The most interesting aspect of the study was that higher accreditation scores as reflected in hand hygiene rates appears to be confounded by an accreditation programme that makes it more difficult for smaller hospitals to achieve high infection control scores. Basically, smaller hospitals (with good hand hygiene scores) failed to score well on the accreditation programme due to organizational size. As the authors conclude themselves; “In this study, a focus on the accreditation results would underestimate the successful implementation of the hand hygiene policy by smaller hospitals. Conversely, just using hand hygiene results would underestimate the research and leadership investment in infection control by larger hospitals.”

Disruptive behaviour among physicians; a few bad apples or the whole barrel?

I am reviewing the literature on disruptive behaviour among physicians, and the Leape et al (2012) article stands out as one worth reading [Acad Med. 2012;87:845–852. doi: 10.1097/ACM.0b013e318258338d]

Some of their conclusions are worth repeating;
"We believe, however, that the fundamental cause of our slow progress is not lack of know-how or resources but a dysfunctional culture that resists change. Central to this culture is a physician ethos that favors individual privilege and autonomy—values that can lead to disrespectful behavior."

"Students and residents suffer from disrespectful treatment. “Education by humiliation” has long been a tradition in medical education and still persists."

While other authors in the field are a bit too focused on repeat offenders (which is a worthy topic), Leape et al provide a cogent series of arguments that should force us to look at the system issues that contribute doc's behaving badly.

The implications for patient safety come screaming out at us......