RESUMEN
Growing recognition of the threat of pandemic influenza to global health has led to increased emphasis on pandemic influenza preparedness planning. Previous analysis of national pandemic preparedness plans has revealed that those plans paid scant attention to the needs and interests of the disadvantaged. This paper investigates those findings via critical discourse analysis of the same plans as well as World Health Organization guidance documents. The analysis reveals that the texts operate within and as parts of an ordered universe of discourse. Among the six discourses which emerge from the analysis the scientific, political, and legal dominate the social, cultural, and ethical. This order of discourse delineates a specific regime of truths within which the lives, needs, and interests of the disadvantaged are masked or neglected. Unless the plans recognize their discursive construction, implementation of the policies and practices they prescribe runs the risk of further disadvantaging those very populations most likely to require protection.
Asunto(s)
Planificación en Desastres , Brotes de Enfermedades/prevención & control , Disparidades en Atención de Salud , Gripe Humana/prevención & control , Salud Global , Humanos , Responsabilidad Social , Poblaciones VulnerablesRESUMEN
Because an influenza pandemic would create the most serious hardships for those who already face most serious hardships, countries should take special measures to mitigate the effect of a pandemic on existing social inequalities. Unfortunately, there is little evidence that anybody is thinking about that.
Asunto(s)
Planificación en Desastres , Gripe Humana/epidemiología , Pobreza , Justicia Social , Bibliometría , Brotes de Enfermedades , Humanos , Gripe Humana/prevención & control , Formulación de Políticas , Estados Unidos/epidemiologíaRESUMEN
Deep brain stimulation (DBS) has been approved by the FDA for use in the treatment of Parkinson's disease, essential tremor, and dystonia. Case reports and case series have reported significant psychiatric side effects in some individuals. The goal of this meta-analysis is to characterize the risks and benefits of DBS and to assess its possible use within the psychiatric setting. A search was conducted on PubMed, EBSCO, and PsycInfo in January 2006 that covered the time period 1 Jan 1996-30 Dec 2005. All identified articles were reviewed and those describing adverse events were further examined with a structured instrument. The initial searches yielded 2667 citations; 808 articles met inclusion criteria for the meta-analysis; 98.2% of studies that specifically assessed motor function reported some level of improvement. Most reported side effects were device or procedure related (e.g., infection and lead fracture). The prevalence of depression was 2-4%, mania 0.9-1.7%, emotional changes 0.1-0.2%, and the prevalence of suicidal ideation/suicide attempt was 0.3-0.7%. The completed suicide rate was 0.16-0.32%. In conclusion, DBS is an effective treatment for Parkinson's disease, dystonia, and essential tremor, and case reports suggest that major depression and OCD may also respond to DBS. Reported rates of depression, cognitive impairment, mania, and behavior change are low, but there is a high rate of suicide in patients treated with DBS, particularly with thalamic and GPi stimulation. Because of the high suicide rate, patients should be prescreened for suicide risk prior to DBS surgery. Additionally, patients should be monitored closely for suicidal behavior post-operatively.
Asunto(s)
Estimulación Encefálica Profunda/efectos adversos , Trastornos Mentales/etiología , Trastornos del Movimiento/terapia , Humanos , Trastornos Mentales/epidemiología , PubMed/estadística & datos numéricos , Estudios RetrospectivosRESUMEN
BACKGROUND: Previous studies suggest that patients who are more involved in their medical care have better outcomes. OBJECTIVES: We sought to compare health care processes and outcomes for patients with HIV based on their preferred level of involvement in health decisions. DESIGN: Cross-sectional analysis of audio computer-assisted interviews with patients at an urban HIV clinic. PATIENTS: One thousand and twenty-seven patients awaiting an appointment with their primary care provider. MEASURES: Patients were asked how they preferred to be involved in decisions (doctor makes most or all decisions, doctor and patient share decisions, patient makes all decisions). We also asked patients to rate the quality of communication with their HIV provider, and their self-reported receipt of and adherence to HAART. RESULTS: Overall, 23% patients preferred that their doctor make all or most decisions, 63% preferred to share decisions with their doctor, and 13% preferred to make all final decisions alone. Compared to patients who prefer to share decisions with their HIV provider, patients who prefer that their provider make all/most decisions were significantly less likely to adhere to HAART (OR [odds ratio] 0.57, 95% CI 0.38-0.86) and patients who preferred to make decisions alone were significantly less likely to receive HAART or to have undetectable HIV RNA in unadjusted analyses (OR 0.52, 95% CI 0.31-0.87 for receipt of HAART; OR 0.64, 95% CI 0.44-0.95 for undetectable HIV RNA). After controlling for potentially confounding patient characteristics and differences in patient ratings of communication quality, patients who preferred that their provider make all/most decisions remained significantly less likely to adhere to HAART (OR 0.58, 95% CI 0.38-0.89); however, the associations with receipt of HAART and undetectable HIV RNA were no longer significant (OR 0.60, 95% CI 0.34-1.05 for receipt of HAART; OR 0.80, 95% C.I 0.53-1.20 for undetectable HIV RNA). CONCLUSIONS: Although previous research suggests that more patient involvement in health care decisions is better, this benefit may be reduced when the patient wants to make decisions alone. Future research should explore the extent to which this preference is modifiable so as to improve outcomes.
Asunto(s)
Infecciones por VIH/tratamiento farmacológico , Participación del Paciente , Relaciones Médico-Paciente , Adulto , Terapia Antirretroviral Altamente Activa , Comunicación , Toma de Decisiones , Femenino , VIH-1 , Humanos , Masculino , Persona de Mediana Edad , Cooperación del Paciente , Satisfacción del Paciente , Resultado del TratamientoRESUMEN
Respect is frequently invoked as an integral aspect of ethics and professionalism in medicine, yet it is often unclear what respect means in this setting. While we recognize that there are many reasonable ways to think about and use the term 'respect', in this paper, we develop a conception of respect that imposes a distinct moral duty on physicians. We are concerned mainly with the idea of respect for persons, or more specifically, respect for patients as persons. We develop an account of respect as recognition of the unconditional value of patients as persons. Such respect involves respecting the autonomy of patients, but we challenge the idea that respect for autonomy is a complete or self-sufficient expression of respect for persons. Furthermore, we suggest that the type of respect that physicians owe to patients is independent of a patient's personal characteristics, and therefore, ought to be accorded equally to all. Finally, the respect that we promote has both a cognitive dimension (believing that patients have value) and a behavioral dimension (acting in accordance with this belief).
Asunto(s)
Personal de Salud/ética , Obligaciones Morales , Relaciones Médico-Paciente/ética , Humanos , Derechos del Paciente , Autonomía PersonalRESUMEN
PURPOSE: Patient-centeredness has been advocated to reduce racial/ethnic disparities in health care quality, but no empirical data support such a connection. The authors' purpose was to determine whether students with patient-centered attitudes have better performance and are less likely to demonstrate disparities with African American compared with white standardized patients (SPs). METHOD: Third-year medical students were assessed by SPs at the Clinical Educational Center of the Johns Hopkins University School of Medicine in 2002. One African American and one white actor were trained as SPs for each of four case scenarios; students were randomly assigned to interact with either SP for each case. Before the exam, students were surveyed about their attitudes towards patient-centered medicine. Students with and without patient-centered attitudes were compared with regard to their performance with African American and white SPs. Outcome measures were student exam scores in interpersonal skill, history taking, physical exam, and counseling. RESULTS: All 177 of eligible students participated in all four case scenarios. With white SPs, students with patient-centered attitudes performed similarly to students without patient-centered attitudes in all four areas. However, with African American SPs, students with patient-centered attitudes performed significantly better than students without patient-centered attitudes in interpersonal skills (71.4 versus 69.4, P = .010), history taking (63.8 versus 61.1, P = .003), and counseling (92.1 versus 88.7, P = .002) and not significantly different in physical exam performance (73.6 versus 68.6, P = .311). CONCLUSIONS: Patient-centered attitudes may be more important in improving physician behaviors with African American patients than with white patients and may, therefore, play a role in reducing disparities.
Asunto(s)
Actitud del Personal de Salud , Negro o Afroamericano , Competencia Clínica , Atención Dirigida al Paciente , Estudiantes de Medicina/psicología , Población Blanca , Adulto , Estudios de Casos y Controles , Consejo Dirigido , Femenino , Humanos , Masculino , Anamnesis , Simulación de Paciente , Examen Físico , Relaciones Médico-PacienteRESUMEN
OBJECTIVE: To explore the domain of physician-reported respect for individual patients by investigating the following questions: How variable is physician-reported respect for patients? What patient characteristics are associated with greater physician-reported respect? Do patients accurately perceive levels of physician respect? Are there specific communication behaviors associated with physician-reported respect for patients? METHODS: We audiotaped 215 patient-physician encounters with 30 different physicians in primary care. After each encounter, the physician rated the level of respect that s/he had for that patient using the following item: "Compared to other patients, I have a great deal of respect for this patient" on a five-point scale between strongly agree and strongly disagree. Patients completed a post-visit questionnaire that included a parallel respect item: "This doctor has a great deal of respect for me." Audiotapes of the patient visits were analyzed using the Roter Interaction Analysis System (RIAS) to characterize communication behaviors. Outcome variables included four physician communication behaviors: information-giving, rapport-building, global affect, and verbal dominance. A linear mixed effects modeling approach that accounts for clustering of patients within physicians was used to compare varying levels of physician-reported respect for patients with physician communication behaviors and patient perceptions of being respected. RESULTS: : Physician-reported respect varied across patients. Physicians strongly agreed that they had a great deal of respect for 73 patients (34%), agreed for 96 patients (45%) and were either neutral or disagreed for 46 patients (21%). Physicians reported higher levels of respect for older patients and for patients they knew well. The level of respect that physicians reported for individual patients was not significantly associated with that patient's gender, race, education, or health status; was not associated with the physician's gender, race, or number of years in practice; and was not associated with race concordance between patient and physician. While 45% of patients overestimated physician respect, 38% reported respect precisely as rated by the physician, and 16% underestimated physician respect (r=0.18, p=0.007). Those who were the least respected by their physician were the least likely to perceive themselves as being highly respected; only 36% of the least respected patients compared to 59% and 61% of the highly and moderately respected patients perceived themselves to be highly respected (p=0.012). Compared with the least-respected patients, physicians were more affectively positive with highly respected patients (p=0.034) and provided more information to highly and moderately respected patients (p=0.018). CONCLUSION: Physicians' ratings of respect vary across patients and are primarily associated with familiarity rather than sociodemographic characteristics. Patients are able to perceive when they are respected by their physicians, although when they are not accurate, they tend to overestimate physician respect. Physicians who are more respectful towards particular patients provide more information and express more positive affect in visits with those patients. PRACTICE IMPLICATIONS: Physician respectful attitudes may be important to target in improving communication with patients.
Asunto(s)
Actitud del Personal de Salud , Comunicación , Satisfacción del Paciente , Relaciones Médico-Paciente , Adolescente , Adulto , Afecto , Anciano , Baltimore , Competencia Clínica/normas , Conducta Cooperativa , Estudios Transversales , Interpretación Estadística de Datos , District of Columbia , Femenino , Conocimientos, Actitudes y Práctica en Salud , Humanos , Modelos Lineales , Masculino , Persona de Mediana Edad , Educación del Paciente como Asunto/normas , Atención Primaria de Salud/normas , Encuestas y Cuestionarios , Grabación en CintaRESUMEN
OBJECTIVE: Patient-centeredness is regarded as an important feature of high quality patient care, but little effort has been devoted to grounding patient-centeredness as an explicitly moral concept. We sought to describe the moral commitments that underlie patient-centered care. METHODS: We analyzed the key ideas that are commonly described in the literature on patient-centeredness in the context of three major schools of ethical thought. RESULTS: Consequentialist moral theories focus on the positive outcomes of providing patient-centered care. Deontological theories emphasize how patient-centered care reflects the ethical norms inherent in medicine, such as respect for persons and shared decision-making. Virtue-based theories highlight the importance of developing patient-centered attitudes and traits, which in turn influence physicians' behaviors toward their patients. CONCLUSION: Different ethical theories concentrate on different features of patient-centered care, but all can agree that patient-centeredness is morally valuable. PRACTICE IMPLICATIONS: In order to sustain patient-centeredness as a moral concept, practitioners and students ought to examine these ideas to determine what their own personal reasons are for or against adopting a patient-centered approach.
Asunto(s)
Teoría Ética , Principios Morales , Atención Dirigida al Paciente/ética , Filosofía Médica , Relaciones Médico-Paciente/ética , Actitud del Personal de Salud , Actitud Frente a la Salud , Comunicación , Conducta Cooperativa , Humanismo , Humanos , Individualidad , Participación del Paciente/métodos , Participación del Paciente/psicología , Rol del Médico/psicología , Poder Psicológico , Valores Sociales , VirtudesRESUMEN
PURPOSE: Although involving patients in their own health care is known to be associated with improved outcomes, this study was conducted to determine whether respecting persons more broadly, such as treating them with dignity, has additional positive effects. METHODS: Using data from the Commonwealth Fund 2001 Health Care Quality Survey of 6,722 adults living in the United States, we performed survey-weighted logistic regression analysis to evaluate independent associations between 2 measures of respect (involvement in decisions and treatment with dignity) and patient outcomes (satisfaction, adherence, and receipt of optimal preventive care). Then we calculated adjusted probabilities of these outcomes and performed stratified analyses to examine results across racial/ethnic groups. RESULTS: After adjustment for respondents' demographic characteristics, the probability of reporting a high level of satisfaction was higher for those treated with dignity vs not treated with dignity (0.70 vs 0.38, P < .001) and for those involved in, versus not involved in, decisions (0.70 vs 0.39, P < .001). These associations were consistent across all racial/ethnic groups. Being involved in decisions was significantly associated with adherence for whites, whereas being treated with dignity was significantly associated with adherence for racial/ethnic minorities. The probability of receiving optimal preventive care was marginally greater for those treated with dignity (0.68 vs 0.63, P = .054), but did not differ with respect to involvement in decisions (0.67 vs 0.67, P = .95). CONCLUSIONS: Being treated with dignity and being involved in decisions are independently associated with positive outcomes. Although involving patients in decisions is an important part of respecting patient autonomy, it is also important to respect patients more broadly by treating them with dignity.