The Place of Patient-Centred Care in Medical Professional Culture: A Qualitative Study

Despite widespread support, the implementation of patient-centred care (PCC) remains a challenge and it is often assumed that further clinical education and culture change are needed. To inform such efforts, we need to know whether the principles underpinning PCC accord with doctors’ personal and cultural values. In this chapter, we report the results of a qualitative interview study of clinicians, conducted in order to establish whether PCC emerges in the narratives of Australian doctors, and, if so, how. Our findings suggest that doctors both understand and value the principles underpinning PCC. This suggests that patient-centeredness is part of the professional culture of medicine, and that those wanting to ensure that this patient-centeredness remains an integral part of practice for succeeding generations of doctors might need to focus not as much on education and culture change as on ensuring that there are structures and processes in place to support PCC

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Doctors on status and respect : a qualitative study

While doctors generally enjoy considerable status, some believe that this is increasingly threatened by consumerism, managerialism, and competition from other health professions. Research into doctors’ perceptions of the changes occurring in medicine has provided some insights into how they perceive and respond to these changes but has generally failed to distinguish clearly between concerns about “status,” related to the entitlements associated with one’s position in a social hierarchy, and concerns about “respect,” related to being held in high regard for one’s moral qualities. In this article we explore doctors’ perceptions of the degree to which they are respected and their explanations for, and responses to, instances of perceived lack of respect. We conclude that doctors’ concerns about loss of respect need to be clearly distinguished from concerns about loss of status and that medical students need to be prepared for a changing social field in which others’ respect cannot be taken for granted.13 page(s

Meaning and value in medical school curricula

Rationale, aims and objectives: Bioethics and professionalism are standard subjects in medical training programmes, and these curricula reflect particular representations of meaning and practice. It is important that these curricula cohere with the actual concerns of practicing clinicians so that students are prepared for real-world practice. We aimed to identify ethical and professional concerns that do not appear to be adequately addressed in standard curricula by comparing ethics curricula with themes that emerged from a qualitative study of medical practitioners. Method: Curriculum analysis: Thirty-two prominent ethics and professionalism curricula were identified through a database search and were analysed thematically. Qualitative study: In-depth, semi-structured interviews were conducted with 20 medical practitioners. Participants were invited to reflect upon their perceptions of the ways in which values matter in their practices and their educational experiences. The themes emerging from the two studies were compared and contrasted. Results: While representations of meaning and value in ethics and professionalism curricula overlap with the preoccupations of practicing clinicians, there are significant aspects of ‘real-world’ clinical practice that are largely ignored. These fell into two broad domains: (1) ‘sociological’ concerns about enculturation, bureaucracy, intra-professional relationships, and public perceptions of medicine; and (2) epistemic concerns about making good decisions, balancing different kinds of knowledge, and practising within the bounds of professional protocols. Conclusions: Our findings support the view that philosophy and sociology should be included in medical school and specialty training curricula. Curricula should be reframed to introduce students to habits of thought that recognize the need for critical reflection on the social processes in which they are embedded, and on the philosophical assumptions that underpin their practice.9 page(s

Risk, Capacity and Making Decisions about CTOs: A Report From ‘The CTO Study’

This study was commissioned by the Mental Health, Drug and Alcohol Office of NSW Health to address the question of how ‘risk’ and ‘capacity’ can be better conceptualised in the setting of decisions around CTOs in NSW

Community Treatment Orders: The Lived Experience of Consumers and Carers in NSW

Report based on the study commissioned by the Mental Health, Drug and Alcohol Office (MHDAO) of NSW Health to provide a qualitative analysis of the lived experience of consumers subject to CTOs and carers of people subject to CTOs in NSW. This study was linked to another inquiry conducted on behalf of MHDAO by the same research group examining how the concepts of ‘risk’ and ‘capacity’ could be constructed in the context of decisions around the use of CTOs. (The results of the ‘risk and capacity’ arm of the study are reported elsewhere.

Community treatment orders: the lived experience of consumers and carers in NSW

There is limited research examining the lived experiences of consumers and carers subject to community treatment orders (CTOs). Between 2009 and 2012, the Centre for Values Ethics and the Law in Medicine (VELiM) at the University of Sydney conducted a research program examining this area, on behalf of the Mental Health, Drug and Alcohol Office (MHDAO) of NSW Health. (The research was part of a larger project examining CTO decision-making, in which clinicians and Mental Health Review Tribunal members were also interviewed.) Eleven participants - five consumers and six carers - participated in the research project by taking part in in-depth interviews about their experiences. This interview data set was analysed using qualitative methodologies. The lived experience of consumers and carers of CTOs in NSW had five themes: `access', 'isolation', 'loss and trauma', 'resistance and resignation' and `vulnerability and distress'. These spoke to the experiential components of the losses and trauma associated with a severe mental illness, the compromises associated with the assumption of the sick role, and the challenges of managing the relationships and engagements necessitated by these processes. According to the theory that emerges from our analysis of the data, the experience of living under a CTO in NSW is a mixture of distress and of acknowledgement of the value of the process. This generalised across both the consumer and the carer participant groups. In a number of the narratives provided, there were both direct and indirect experiences of sub-optimal care, usually the result of excessive demands on particular health services and the overall deprivation or social injustice faced by many suffering from severe mental illness. The distress, isolation, grief and loss experienced by those affected by CTOs appeared to be a part of the experience of a severe mental illness. Putting aside instances where CTOs were implemented poorly, the kind of illness and level of disability experienced by those who needed such treatment interventions was an intrinsic source of distress. The need for a CTO emerged from that illness and, by extension, that distress. In essence, the experience of distress around a CTO seemed to be indistinguishable from the distress of the severe illness that necessitated it. All of the consumer participants and many of the carer participants described the experience of CTOs as being characterised by problems with communication and understanding. The model of the lived experience of CTOs for consumer and career participants can be distilled as one of profound ambivalence. As a part of the tragic journey taken by consumers and their carers in the course of a severe mental illness, CTOs are associated with distress and a sense of loss, isolation and disempowerment. From these data the study proposed a model of experience of being subject to a CTO in NSW is one of a core distress, emerging from the distress of the illness, communication gaps, difficultly accessing services, and the perceived benefits of CTOs. The findings of this research are in general agreement with other studies in that the loss of autonomy and constraints associated with a CTO are balanced with their clear benefits. These findings build on existing research in the field. From this research, it is evident that the distress arising from being subject to a CTO can be assuaged by those tasked with their implementation by focusing upon clearer communication about the order (including strategies to ensure consumers and their carers are aware of the specifics of the order), strategies to improve access to services for mental and physical services and other social institutions, and acknowledging that the CTO is a part of the overall distress of a severe mental illness.Mental Health, Drug and Alcohol Office (MHDAO), NSW Healt