The influence of patient and doctor gender on diagnosing coronary heart disease

Using novel methods, this paper explores sources of uncertainty and gender bias in primary care doctors’ diagnostic decision making about coronary heart disease (CHD). Claims about gendered consultation styles and quality of care are re-examined, along with the adequacy of CHD models for women. Randomly selected doctors in the UK and the US (n=112, 56 per country, stratified by gender) were shown standardised videotaped vignettes of actors portraying patients with CHD. ‘Patients’ age, gender, ethnicity and social class were varied systematically. During interviews, doctors gave free-recall accounts of their decision making, which were analysed to determine patient and doctor gender effects. We found differences in male and female doctors’ responses to different types of patient information. Female doctors recall more patient cues overall, particularly about history presentation, and particularly amongst women. Male doctors appear less affected by patient gender but both male and especially female doctors take more account of male patients’ age and consider more age-related disease possibilities for men than women. Findings highlight the need for better integration of knowledge about female presentations within accepted CHD risk models, and do not support the contention that women receive better quality care from female doctors

Flexibility and innovation in response to emerging infectious diseases: Reactions to multi-drug resistant Tuberculosis in India

Emerging infectious diseases regained substantial international attention in recent years and it has been argued that flexibility and innovation in public health systems is needed in order to react to changing challenges. This paper will take these policy claims as a starting point to examine the case of multi-drug resistant Tuberculosis (MDR-TB) in India. Based on fieldwork results it will be examined how the existing control efforts of TB in India respond to the emergence of MDR-TB, what solutions are discussed for diagnosing, treating and preventing MDR-TB and what can be learned from that with regard to innovation and flexibility of a public health system in a country like India. The discussions and reactions to MDR-TB indicate that arguments for flexibility meet constraints of the existing control system and the Indian public health and wider social system. However, the flexibility that is argued for goes beyond what has been envisaged in international policy arenas (mainly focusing on preparation of various capacities in surveillance, detection and research). Rather it involves localized learning and experimenting within existing control structures that are claimed to have become too rigid in trying to keep up quality standards faced with a weakening public health system. Furthermore, the case shows that existing challenges in TB control resurface with the emergence of MDR-TB and reflect a difficult balancing act between biomedical values, socio-cultural values and operational feasibility. However, various actors are striving for change and it is in these instances that one can start to understand what flexibility and innovation could mean for a public health challenge such as TB in India. The paper concludes with an argument for a detailed analysis of these changes from an innovation perspective.Tuberculosis, Multi-drug resistance, India, Innovation, Flexibility

Understanding tensions and identifying clinician agreement on improvements to early-stage chronic kidney disease monitoring in primary care : a qualitative study

Funding This article presents independent research funded by the National Institute for Health Research School for Primary Care Research (NIHR SPCR) (reference:120). JE was also supported by the NIHR Programme Grants for Applied Research programme (Reference: RP-PG-1210-12012). DSL and LL are supported by the NIHR Oxford Biomedical Research CentrePeer reviewedPublisher PD

Constructing Ontology-Based Cancer Treatment Decision Support System with Case-Based Reasoning

Decision support is a probabilistic and quantitative method designed for modeling problems in situations with ambiguity. Computer technology can be employed to provide clinical decision support and treatment recommendations. The problem of natural language applications is that they lack formality and the interpretation is not consistent. Conversely, ontologies can capture the intended meaning and specify modeling primitives. Disease Ontology (DO) that pertains to cancer's clinical stages and their corresponding information components is utilized to improve the reasoning ability of a decision support system (DSS). The proposed DSS uses Case-Based Reasoning (CBR) to consider disease manifestations and provides physicians with treatment solutions from similar previous cases for reference. The proposed DSS supports natural language processing (NLP) queries. The DSS obtained 84.63% accuracy in disease classification with the help of the ontology

Barriers and Facilitators to Use of a Clinical Evidence Technology in the Management of Skin Problems in Primary Care: Insights from Mixed Methods

Objective: Few studies have examined the impact of a single clinical evidence technology (CET) on provider practice or patient outcomes from the provider’s perspective. A previous cluster-randomized controlled trial with patient-reported data tested the effectiveness of a CET (i.e., VisualDx) in improving skin problem outcomes but found no significant effect. The objectives of this follow-up study were to identify barriers and facilitators to the use of the CET from the perspective of primary care providers (PCPs) and to identify reasons why the CET did not affect outcomes in the trial. Methods: Using a convergent mixed methods design, PCPs completed a post-trial survey and participated in interviews about using the CET for the management of patients’ skin problems. Data from both methods were integrated. Results: PCPs found the CET somewhat easy to use but only occasionally useful. Less experienced PCPs used the CET more frequently. Data from interviews revealed barriers and facilitators at four steps of evidence-based practice: clinical question recognition, information acquisition, appraisal of relevance, and application with patients. Facilitators included uncertainty in dermatology, intention for use, convenience of access, diagnosis and treatment support, and patient communication. Barriers included confidence in dermatology, preference for other sources, interface difficulties, presence of irrelevant information, and lack of decision impact. Conclusion: PCPs found the CET useful for diagnosis, treatment support, and patient communication. However, the barriers of interface difficulties, irrelevant search results, and preferred use of other sources limited its positive impact on patient skin problem management