Is clinician refusal to treat an emerging problem in injury compensation systems?

Objective: The reasons that doctors may refuse or be reluctant to treat have not been widely explored in the medical literature. To understand the ethical implications of reluctance to treat there is a need to recognise the constraints of doctors working in complex systems and to consider how these constraints may influence reluctance. The aim of this paper is to illustrate these constraints using the case of compensable injury in the Australian context. Design: Between September and December 2012, a qualitative investigation involving face-to-face semistructured interviews examined the knowledge, attitudes and practices of general practitioners (GPs) facilitating return to work in people with compensable injuries. Setting: Compensable injury management in general practice in Melbourne, Australia. Participants: 25 GPs who were treating, or had treated a patient with compensable injury. Results: The practice of clinicians refusing treatment was described by all participants. While most GPs reported refusal to treat among their colleagues in primary and specialist care, many participants also described their own reluctance to treat people with compensable injuries. Reasons offered included time and financial burdens, in addition to the clinical complexities involved in compensable injury management. Conclusions: In the case of compensable injury management, reluctance and refusal to treat is likely to have a domino effect by increasing the time and financial burden of clinically complex patients on the remaining clinicians. This may present a significant challenge to an effective, sustainable compensation system. Urgent research is needed to understand the extent and implications of reluctance and refusal to treat and to identify strategies to engage clinicians in treating people with compensable injuries

Approches pour une fertilisation raisonnée des agrumes en pépinière

En pépinière, la fertilisation des agrumes est très souvent conduite de manière empirique. Les équilibres entre les éléments minéraux et les doses apportées ne sont pas toujours raisonnés en fonction des besoins spécifiques de la plante. L'observation de symptômes de déficience et leur identification offrent la possibilité d'une correction de la fertilisation ; mais cette dernière sera faite par approches successives et les proportions entre les éléments apportés ne répondront pas nécessairement aux besoins. Fréquemment des symptômes de déficience en oligo-éléments se révèlent et principalement en Zn et Mn ; leur insuffisance peut perturber fortement la croissance. Leur identification précise permet d'appliquer des traitements de correction ; une réponse rapide est constatée. La mesure des quantités d'éléments minéraux contenus dans des plants de différents âges ayant une croissance et un état végétatif excellents, indique les doses minimales d'engrais nécessaires pour obtenir cet état. Une correction doit être faite en relation avec le taux d'absorption de chacun des éléments pour définir la fertilisation optimale. Au cours des essais, il a été constaté qu'un enrichissement en calcium de la solution de fertigation permet d'obtenir une amélioration du développement des plants. La modification de l'équilibre entre N et K induit également des réponses de croissanc

Experiences of pathways, outcomes and choice after severe traumatic brain injury under no-fault versus fault-based motor accident insurance

Primary objective: To explore experiences of pathways, outcomes and choice after motor vehicle accident (MVA) acquired severe traumatic brain injury (sTBI) under fault-based vs no-fault motor accident insurance (MAI). Methods: In-depth qualitative interviews with 10 adults with sTBI and 17 family members examined experiences of pathways, outcomes and choice and how these were shaped by both compensable status and interactions with service providers and service funders under a no-fault and a fault-based MAI scheme. Participants were sampled to provide variation in compensable status, injury severity, time post-injury and metropolitan vs regional residency. Interviews were recorded, transcribed and thematically analysed to identify dominant themes under each scheme. Results: Dominant themes emerging under the no-fault scheme included: (a) rehabilitation-focused pathways; (b) a sense of security; and (c) bounded choices. Dominant themes under the fault-based scheme included: (a) resource-rationed pathways; (b) pressured lives; and (c) unknown choices. Participants under the no-fault scheme experienced superior access to specialist rehabilitation services, greater surety of support and more choice over how rehabilitation and life-time care needs were met. Conclusions: This study provides valuable insights into individual experiences under fault-based vs no-fault MAI. Implications for an injury insurance scheme design to optimize pathways, outcomes and choice after sTBI are discussed.No Full Tex

General practitioners and sickness certification for injury in Australia

© 2015 Mazza et al. Background: Strong evidence supports an early return to work after injury as a way to improve recovery. In Australia, General Practitioners (GPs) see about 96 % of injured workers, making them the main gatekeepers to workers' entitlements. Most people with compensable injuries in Australia are certified as "unfit to work" by their GP, with a minority of patients certified for modified work duties. The reasons for this apparent dissonance between evidence and practice remain unexplored. Little is known about the factors that influence GP sickness certification behaviour in Australia. The aim of this study is to describe the factors influencing Australian GPs certification practice through qualitative interviews with four key stakeholders. Methods: From September to December 2012, 93 semi-structured interviews were undertaken in Melbourne, Australia. Participants included GPs, injured workers, employers and compensation agents. Data were thematically analysed. Results: Five themes describing factors influencing GP certification were identified: 1. Divergent stakeholder views about the GP's role in facilitating return to work; 2. Communication between the four stakeholder groups; 3. Conflict between the stakeholder groups; 4. Allegations of GPs and injured workers misusing the compensation system and 5. The layout and content of the sickness certificate itself. Conclusion: By exploring GP certification practice from the perspectives of four key stakeholders, this study suggests that certification is an administrative and clinical task underpinned by a host of social and systemic factors. The findings highlight opportunities such as practice guideline development and improvements to the sickness certificate itself that may be targeted to improve GP sickness certification behaviour and return to work outcomes in an Australian context