Patients' and medical practitioners' approaches to the use of prescribed steroids in asthma: the potential for informed choice

Recent changes in legislation and access to information, through sources such as the media, may have influenced peoples' expectations for information about their prescribed medication. As a result, health care professionals may perceive an increased pressure to provide information. A case study approach was employed to examine the sources and scope of information patients draw upon when they are prescribed oral steroids for asthma. The aim was to examine the extent to which patients can be said to exercise an `informed choice' when they take prescribed medication. The role and importance of GPs (general practitioners) in informing the choices patients make was also examined. Both qualitative and quantitative methods were employed. Interviews conducted with both patients and GPs indicated `gaps' in understanding. Although the GP was the preferred source of information, patients reported that the choices they made were based on information from a range of sources. General practitioners justified not providing information to patients so as to `protect' patients from knowledge of side effects. However, there was some awareness of the range of sources of information used by patients. A vignette technique was employed to further investigate GPs' recognition and understanding of the range of sources of information patients' use to inform the choices they make. Approximately half of the GPs who responded to the vignette recognised the influences presented. General practitioners who had been practising for a shorter period of time were significantly more likely to recognise these influences. The conclusions draw on the literature of the sociology of the professions. In spite of the way in which the Government has sought to encourage patients to act as consumers, the state has also continued to endorse GPs right to make decisions concerning the level of information to provide. If GPs do not believe it is in the interests of patients to be provided with information to make choices about their medications then the information available to patients may be limited. This will have an impact on the ease with which patients may make `medically' informed choices about their prescribed medication. Only when the communication between patients and GPs improves, will it be possible for a relationship to develop where patients may be assured of gaining information from their GP at the level they feel is appropriate to enable them to make informed choices about their medication

Generating change from below: what role for leadership from above?

In recent years the benefits of distributed leadership have often assumed the status of an unchallengeable orthodoxy. There is a general acceptance that leadership is best when it is dispersed. In reality this is often little more than a form of ‘licensed leadership’ in which those working in subordinate roles can only exercise their leadership in tightly prescribed contexts. This article investigates the contribution of teacher professional development to promoting a more optimistic vision of teacher leadership and, ultimately, organisational change. It explores the role of leadership ‘from above’ in supporting classroom teachers to engage with and sustain change. The study, which was situated in the Republic of Ireland, employed a case study approach with 20 participants in five urban disadvantaged schools. The article seeks to demonstrate how a professional development initiative was used to promote significant and sustained change in four of the five case study schools. It argues that in order to understand sustained change in schools it is necessary to better understand the complex ways in which leadership from above can generate change agency from below. This article offers a critical perspective in relation to mainstream distributed leadership theory and practice

Communicating decisions about care with patients and companions in emergency department consultations

INTRODUCTION: This paper explores doctor-patient and companion communication about care decisions in a UK emergency department (ED). Doctors interface between patients and healthcare systems and facilitate access to care across a range of encounters, drawing on information and authority to make and communicate clinical care decisions. MATERIALS AND METHODS: We explored characteristics of communication through ethnographic observation of 16 video-recorded case studies of ED consultations (average length: 1 h) collected over 6 months. Companions were present in 10 cases. We conducted a framework analysis to understand the roles of doctors, consultants, patients and companions in relaying ED care decisions. FINDINGS: We present two cases to reflect companion roles and their effect on the consultation. The urgency for care and scarcity of resources means clinicians justify decisions and strategize to move patients along ED pathways. DISCUSSION: Everyday care interactions between patients and doctors are goal-oriented and companions participate by providing case information, querying decisions and advocating for care. Our findings reflect how doctors justify decisions made in communicating the next steps in ways that characterize the clinical encounter. CONCLUSION: By exploring everyday interactions our study contributes to a growing understanding of patient-clinician and companion communication in the ED. PATIENT OR PUBLIC CONTRIBUTION: Patients and caregivers voluntarily participated in data collection and consented to video recordings being conducted of ED consultations between them and junior doctors. There was extensive consultation with all grades of staff about the acceptability of the work and the best way to conduct it to minimize the impact on patients and staff. Through this manuscript, we have demonstrated the presence and important role of companions. On reflection it would have been valuable to have included patients and companions in discussions about the work; however, this project was conducted with very limited funding and no resources were committed to patient and public involvement. Given the setting and scope of the study, it was not feasible to involve patients or members of the public in other stages of the research or preparation of the manuscript. We recognize this as a potential limitation of the work

The relationship between medicine and the public: the challenge of concordance

Concordance is based on the idea that patients and practitioners should work together towards an agreement on treatment choice. This requires a redefinition of the relations and encounters between doctors and their patients. This redefinition emphasizes the need for patient involvement and participation. In this article we examine concordance against the background of wider social change, structural as well as interpersonal. We focus in particular on challenges to trust, noting that the almost instinctive trust that people formerly had for professional experts has for many reasons diminished. One consequence of this, we suggest, is that concordance is being espoused at a time when its accomplishment may be particularly threatened. In fact there are strong grounds for claiming that support for the notion of concordance could possibly result in a growth of ‘hidden’ communication pathologies by means of what the social theorist Habermas (1984) has termed ‘systematically distorted communication’

Investigating Whether Bereavement by Suicide and Other Unnatural Causes Has a Deterrent Effect on Alcohol or Drug Use in Young Adults

Bereavement by suicide and other unnatural causes is associated with suicide but evidence regarding risk of substance misuse is inconsistent. This may be due to heterogeneity in patterns of alcohol or drug use after traumatic bereavement; some increasing use to cope with the loss and others reducing use. To highlight the problems of focussing on diagnostic thresholds when investigating substance use after traumatic loss, we aimed to test whether people bereaved by suicide or other unnatural causes are more likely to reduce or stop their substance use than people bereaved by sudden natural causes. Using multivariable logistic regression and data from an online survey of 1854 UK-based bereaved adults, we tested the association between bereavement by suicide and other unnatural causes and post-bereavement reduction/cessation in (i) alcohol and (ii) drug use. There were no group differences in the proportions who reduced/stopped alcohol use, but a significantly greater proportion of people bereaved by sudden unnatural causes reduced/stopped drug use post-bereavement than people bereaved by sudden natural causes (AOR = 2.61; 95% CI = 1.44–4.71; p = 0.001; 4.1% versus 1.7%). In sub-group analyses this applied separately to people bereaved by suicide and non-suicide unnatural causes. Research into post-bereavement substance use should accommodate apparent divergent sub-diagnostic patterns

Analysis and clinical findings of cases positive for the novel synthetic cannabinoid receptor agonist MDMB-CHMICA

Context: MDMB-CHMICA is a synthetic cannabinoid receptor agonist which has caused concern due to its presence in cases of adverse reaction and death. Method: 43 cases of suspected synthetic cannabinoid ingestion were identified from patients presenting at an Emergency Department and from post-mortem casework. These were subjected to liquid-liquid extraction using tertiary-butyl methyl ether and quantitatively analysed by Electospray Ionisation Liquid Chromatography – tandem Mass Spectrometry. For positive samples, case and clinical details were sought and interrogated. Results: 11 samples were found positive for MDMB-CHMICA. Concentrations found ranged from <1 – 22 ng/mL (mean: 6 ng/mL, median: 3 ng/mL). The age range was 15 – 44 years (mean: 26 years, median: 21 years), with the majority (82%) of positive results found in males. Clinical presentations included hypothermia, hypoglycaemia, syncope, recurrent vomiting, altered mental state and serotonin toxicity, with corresponding concentrations of MDMB-CHMICA as low as <1 ng/mL. Duration of hospitalisation ranged from 3 – 24 hours (mean: 12 hours, median: 8 hours). Discussion: The concentration range presented in this case series is indicative of MDMB-CHMICA having a high potency, as is known to be the case for other synthetic cannabinoid receptor agonists. The age range and gender representation were consistent with that reported for users of other drugs of this type. The clinical presentations observed were typical of synthetic cannabinoid receptor agonists and show the difficulties in identifying reactions potentially associated with drugs of this type. Conclusion: The range of MDMB-CHMICA concentrations in Emergency Department presentations (n=9) and post-mortem cases (n=2) was reported. No correlation between the concentration of this drug and clinical presentation or cause of death was reported in this sample. However, the potential for harm associated with low concentrations of MDMB-CHMICA and the symptoms of toxicity being non-specific was highlighted

Negotiating the 'grey area between normal social drinking and being a smelly tramp':a qualitative study of people searching for help online to reduce their drinking

INTRODUCTION AND AIMS: Delivering brief interventions for hazardous and harmful drinking on the Internet may broaden the availability of services and overcome some barriers to accessing help in person. The Down Your Drink (DYD) website, an extended brief intervention, attracted a large number of people looking to reduce their drinking. The aim was to explore the experiences of this e-help seeking population.  METHOD: Semi-structured interviews were conducted with participants in the DYD trial - an online trial of the effectiveness of DYD compared with an information-only website. Interviewees were asked how they came across the DYD website. Interviews were recorded and transcribed verbatim. Data were analysed by a multidisciplinary team using detailed thematic analysis.  RESULTS: Eighteen participants were interviewed. Most interviewees perceived their drinking to be a problem, which led them to search the Internet and register for the DYD trial in order to gain access to an intervention to help them reduce their drinking. The type of help required varied from information on the harms of drinking to help with a recognized problem. The privacy of the Internet was perceived as important when searching for help with drinking, as this avoids the stigma and embarrassment associated with help seeking in person. Almost all interviewees perceived a lack of services both online and offline for people wanting to moderate their drinking.  CONCLUSION: There is a perceived gap in services for hazardous and harmful drinkers wanting to reduce their drinking which could be addressed using online interventions

Examining the language demands of informed consent documents in patient recruitment to cancer trials using tools from corpus and computational linguistics

Obtaining informed consent (IC) is an ethical imperative, signifying participants’ understanding of the conditions and implications of research participation. One setting where the stakes for understanding are high is randomized controlled trials (RCTs), which test the effectiveness and safety of medical interventions. However, the use of legalese and medicalese in ethical forms coupled with the need to explain RCT-related concepts (e.g. randomization) can increase patients’ cognitive load when reading text. There is a need to systematically examine the language demands of IC documents, including whether the processes intended to safeguard patients by providing clear information might do the opposite through complex, inaccessible language. Therefore, the goal of this study is to build an open-access corpus of patient information sheets (PIS) and consent forms (CF) and analyze each genre using an interdisciplinary approach to capture multidimensional measures of language quality beyond traditional readability measures. A search of publicly-available online IC documents for UK-based cancer RCTs (2000-17) yielded corpora of 27 PIS and 23 CF. Textual analysis using the computational tool, Coh-Metrix, revealed different linguistic dimensions relating to the complexity of IC documents, particularly low word concreteness for PIS and low referential and deep cohesion for CF, although both had high narrativity. Key part-of-speech analyses using Wmatrix corpus software revealed a contrast between the overrepresentation of the pronoun ‘you’ plus modal verbs in PIS and ‘I’ in CF, exposing the contradiction inherent in conveying uncertainty to patients using tentative language in PIS while making them affirm certainty in their understanding in CF

Engagement with emotional concerns in general practice: thematic analysis of GP consultations

BACKGROUND: Emotional concerns (defined as any expression of low mood, anxiety or psychosocial stress) are an important part of the biopsychosocial care model used in modern medical practice. Previous work has demonstrated variable engagement with emotional concerns and that improved communication has been associated with reductions in emotional distress. AIM: To examine how emotional concerns are engaged with during routine GP consultations. DESIGN AND SETTING: Secondary study using the HARI database. The available dataset contains 231 recordings from 10 GPs across 8 urban and suburban practices recorded in 2017 and 2018. METHOD: The dataset was reviewed to identify any consultations containing emotional concerns (as defined as any expression of low mood, anxiety or psychosocial stress) before being imported into NVivo 12 to facilitate thematic analysis and coding. Reflexive inductive thematic analysis resulted in two major themes. RESULTS: Engagement with emotional concerns is dynamic throughout consultations (Theme 1). This dynamism relates to competing areas of focus, immediate versus delayed engagement and re-iteration of concerns throughout consultations. Emotional concerns can be engaged with in a similar way to physical concerns (Theme 2) using a diagnostic and treatment-based approach, however in addition to this therapeutic listening and conversation is utilised. CONCLUSION: Awareness of the dynamic nature of emotional concerns within consultations and encouraging engagement with concerns in a flexible and patient-oriented manner may help improve doctor-patient communication. In addition, investigating how GPs and patients build shared understanding around emotional concerns may identify methods to reduce patients' emotional distress