Ethical issues about shared medical records

Focal points: Patient views on pharmacists' access to medical records was studied using a self-completion questionnaire in medical practice and two community pharmacies There was some support for pharmacist access to records with a third of the sample being unsure There was a majority support when the purpose was clearly pharmacy related A clear majority was confident of confidentiality in the pharmacy

Medical error:a discussion of the medical construction of error and suggestions for reforms of medical education to decrease error

Introduction: There is a growing public perception that serious medical error is commonplace and largely tolerated by the medical profession. The Government and medical establishment's response to this perceived epidemic of error has included tighter controls over practising doctors and individual stick-and-carrot reforms of medical practice. Discussion: This paper critically reviews the literature on medical error, professional socialization and medical student education, and suggests that common themes such as uncertainty, necessary fallibility, exclusivity of professional judgement and extensive use of medical networks find their genesis, in part, in aspects of medical education and socialization into medicine. The nature and comparative failure of recent reforms of medical practice and the tension between the individualistic nature of the reforms and the collegiate nature of the medical profession are discussed. Conclusion: A more theoretically informed and longitudinal approach to decreasing medical error might be to address the genesis of medical thinking about error through reforms to the aspects of medical education and professional socialization that help to create and perpetuate the existence of avoidable error, and reinforce medical collusion concerning error. Further changes in the curriculum to emphasize team working, communication skills, evidence-based practice and strategies for managing uncertainty are therefore potentially key components in helping tomorrow's doctors to discuss, cope with and commit fewer medical errors.

Eye infections caused by fungi (ocular mycoses)

Ocular mycoses are being reported with increasing frequency as a consequence of new medical practice and an increase in the number of immunosuppressed patients in the population, e.g.,, patients who are HIV positive and patients receiving radiation or chemotherapy. This article describes the ocular mycoses likely to be seen in such patients.

Primary care pharmacists: a profile

A survey was carried out in 1998 in 43 English health authorities of primary care pharmacists (employed to provide prescribing advice to GPs at medical practice level). 119 responses were received (66%). Most combined working as a PCP with another occupation, usually community pharmacy (57%), hospital pharmacy (13%) or as an academic (7%). 53% of respondents worked 8 hours or less per week as a PCP. Only 18 respondents were employed full-time as a PCP. The most common activities were drug information (91%), PACT analysis (90%), drug cost containment (90%) and review of individual patient medication (88%). (7 refs.)

The training experience of primary care pharmacists

Objectives — To map the tasks, activities and training provision for primary care pharmacists (PCPs) and to identify perceived future training needs. Methods — Survey undertaken in 1998/1999 using a pre-piloted, postal, self-completion questionnaire to two samples of PCPs. Setting — PCPs in (a) the West Midlands and (b) England (outside West Midlands). Key findings — The response rate was 66 per cent. A majority (68 per cent) had worked in the role for less than two years. Eighty per cent had some form of continuing education or training for the role although only 50 per cent had a formal qualification. Over two-thirds had contributed to the funding of their training, with one-third providing all funding. Seventy-four per cent of PCPs agreed that pharmacists should go through a procedure to ensure competence (accreditation) before being allowed to work for a general medical practice or primary care group. Views on the need for formal education/training prior to work differed: 82 per cent of those with formal qualifications, but only 46 per cent of those without, considered that this should be a requirement. There was general agreement that training/education had met training needs. Views on future training closely reflected previous training experiences, with a focus upon pharmaceutical roles rather than upon generic skill development and the acquisition of management skills. Conclusions — The study provides a snapshot in time of the experience of pioneer PCPs and the training available to them. PCPs will need further training or updating if they are to provide the wider roles required by the developing needs of the National Health Service. Consideration should be given to formal recognition of the training of PCPs in order to assure competence. The expectation that pharmacists should fund their own training is likely to be a barrier to uptake of training and uncertainties over funding will militate against consistency of training.

The Birmingham community pharmacy repeat dispensing project

Report on a pilot project funded by the Dept of Health and involving 350 repeat dispensing patients at 7 community pharmacies and two medical practices. 82% of patients approached were willing to enter a repeat dispensing service and after 6 months 86% liked the system. Concludes that successful repeat dispensing depends on a good infrastructure in both the pharmacy and the medical practice, and requires established inter-professional communication.

Fungal infection of the eye (ocular mycosis)

Although not as important as bacteria or viruses as a cause of eye infection, a large number of fungal species have now been recorded in association with the eye. In addition, several species have been implicated as a cause of eye infection (‘ocular mycosis’) and some may even cause life-threatening conditions. Ocular mycoses are being reported more frequently as a consequence of new medical practice and the increased numbers of immuno-compromised patients in the population, e.g., patients receiving radiation treatment or chemotherapy. This article describes the most common conditions caused by fungi which can affect the different structures of the eye, the importance of fungal contamination of materials as a source of eye infection, and the methods available for treatment.

"Comparing the incomparable":hospital costing and the art of medicine in post-war Britain

This paper examines the relationship between medical and hospital accounting discourses during the two decades after the 1946 National Health Service (NHS) Act for England and Wales. It argues that the departmental costing system introduced into the NHS in 1957 was concerned with the administrative aspects of hospital costliness as contemporary hospital accountants suggested that the perceived incomparability, immeasurability and uncontrollability of medical practice precluded the application of cost accounting to the clinical functions of hospitals. The paper links these suggestions to medical discourses which portrayed the practice of medicine as an intuitive and experience-based art and argues that post-war conceptions of clinical medicine represented this domain in a manner that was neither susceptible to the calculations of cost accountants nor to calculating and normalising intervention more generally. The paper concludes by suggesting that a closer engagement with medical discourses may enhance our understanding of historical as well as present day attempts to make medicine calculable.

The role of suicide risk in the decision for psychiatric hospitalization after a suicide attempt

BACKGROUND: Suicide prevention can be improved by knowing which variables physicians take into account when considering hospitalization or discharge of patients who have attempted suicide. AIMS: To test whether suicide risk is an adequate explanatory variable for predicting admission to a psychiatric unit after a suicide attempt. METHODS: Analyses of 840 clinical records of patients who had attempted suicide (66.3% women) at four public general hospitals in Madrid (Spain). RESULTS: 180 (21.4%) patients were admitted to psychiatric units. Logistic regression analyses showed that explanatory variables predicting admission were: male gender; previous psychiatric hospitalization; psychiatric disorder; not having a substance-related disorder; use of a lethal method; delay until discovery of more than one hour; previous attempts; suicidal ideation; high suicidal planning; and lack of verbalization of adequate criticism of the attempt. CONCLUSIONS: Suicide risk appears to be an adequate explanatory variable for predicting the decision to admit a patient to a psychiatric ward after a suicide attempt, although the introduction of other variables improves the model. These results provide additional information regarding factors involved in everyday medical practice in emergency settings.

Optical in-fiber Bragg grating sensor systems for medical applications

Two in-fiber Bragg grating (FBG) temperature sensor systems for medical applications are demonstrated: (1) an FBG flow-directed thermodilution catheter based on interferometric detection of wavelength shift that is used for cardiac monitoring; and (2) an FBG sensor system with a tunable Fabry-Perot filter for in vivo temperature profiling in nuclear magnetic resonance (NMR) machines. Preliminary results show that the FBG sensor is in good agreement with electrical sensors that are widely used in practice. A field test shows that the FBG sensor system is suitable for in situ temperature profiling in NMR machines for medical applications.

Gender and general practice: the single-handed woman General Practitioner

This research examines women GPs' careers, how they run their practices and how they reconcile professional and domestic lives. It looks at the particular experiences of women GPs who practise alone, and at the pressures in past practice experience which have led them to do so. It is argued that many of the problems of group practice which can be identified are attributable to gender. For example, one reason given for entering general practice is a desire to be able to provide the full range of medical care and not to specialise. Women GPs, however, may find themselves seeing more women patients for "women's problems" and children than they would freely choose. Women have not entered general practice in order to specialise in these areas of medicine. Indeed, if they had wanted to specialise in obstetrics, gynaecology or paediatrics they would have had difficulty advancing very far in these male-dominated areas of hospital hierarchy. Other gender related problems exist for women in general practice and practising single-handedly is one strategy that women GPs have used to counter the problems of working in male-dominated practices and partnerships. However, the twenty-four hour commitment of single-handed practice may bring further pressures in reconciling this with responsibility for home life. Out-of-hours cover, which can be viewed as the link between professional and domestic life, where the one intrudes into the other, is also examined in terms of the gender issues it raises. The interaction of gender and ethnicity is also considered for the 11 Asian women GPs in the study. Interviews were conducted with 29 single-handed women GPs in the Midlands. In addition, some cases were studied in greater depth by being observed in their surgeries and on home visits for a day each. A qualitative/feminist approach to analysis has been employed.

Drug information in general practice pharmacy

The drug information sources currently available to general practice pharmacists have been identified. The use of and attitudes to these sources were assessed as well as the perceived information needs of practising pharmacists. The special requirements of women pharmacists and pharmacists working part-time were studied. The relationship of the medical representative as an information source for pharmacists was evaluated. Participation in continuing education programmes as a vital means of ensuring current information awareness and knowledge for the practising profession has been considered. Investigations were mainly pursued by questionnaire survey, while computer facilities were used for the processing and the analyses of data. The desirability of collated and evaluated information from one or more independent authoritative sources has been discussed. The increasing advisory role of the general practice pharmacist and the needs of the patient and potential customer have been discussed, with projections for the pharmacist's future health care contribution.

The clinical assessment of systemic hypertension in optometric practice

This thesis sets out to examine in detail the condition of systemic hypertension (high Blood Pressure) in relation to optometric practice in the United Kingdom. Systemic hypertension, which is asymptomatic in the early stages, is diagnosed from the Blood Pressure (BP) measurement recorded by a sphygmomanometer and/or from the complications that have developed in target organs. Optometric practice based surveys revealed that diagnosed systemic hypertension was the most prevalent cardiovascular medical condition (20.5%). Measurement of BP of patients in this sample revealed that if an optometrist included sphygmomanometry into the sight examination then at least one patient each day would be referred for suspect systemic hypertension. Optometric opinion felt that the measurement of BP in optometric practice would advance the profession, being appreciated by both patients and General Practitioners (GPs), but was felt to be an unnecessary routine procedure. The present sight examination for the systemic hypertensive is similar to that of the normotensive patient, but may involve an altered fundus examination and a visual field test. The GPs were in favour of optometric BP measurement and a future role in the share care management of the systemic hypertensive. The application of a new pictorial grading scale for the grading of vascular changes associated with pre-malignant systemic hypertension was found to be both accurate and reliable. Clinical trial of the grading scale in optometric practice found positive correlations between BP and increasing severity of the retinal vascular features. The subtle pre-malignant vascular changes require reliable accurate detection and analysis to assist in the management of the systemic hypertensive patient. Vessel width was shown to decrease with increasing age. Image analysis of the A/V ratio, arteriolar tortuosity and focal calibre changes revealed a positive correlation to the patient's BP (p<0.001). The retinal vasculature is relatively stable longitudinally with only minor changes in response to early disease states. Age and elevated BP increased a patient's risk of developing systemic medical conditions over a two-year period. The application of the pictorial grading scale to optometric practice and training the optometrist in the use of sphygmomanometry would improve the management of the systemic hypertensive patient in optometric practice. Future advances in image analysis hold substantial benefits for the detection and monitoring of subtle vascular changes associated with systemic hypertension.

Pre-conception care : current practice and methods of provision

This thesis examines the present provisions for pre-conception care and the views of the providers of services. Pre-conception care is seen by some clinicians and health educators as a means of making any necessary changes in life style, corrections to imbalances in the nutritional status of the prospective mother (and father) and the assessment of any medical problems, thus maximizing the likelihood of the normal development of the baby. Pre-conception care may be described as a service to bridge the gap between the family planning clinic and the first ante-natal booking appointment. There were three separate foci for the empirical research - the Foresight organisation (a charity which has pioneered pre-conception care in Britain); the pre-conception care clinic at the West London Hospital, Hammersmith; and the West Midlands Regional Health Authority. The six main sources of data were: twenty five clinicians operating Foresight pre-conception clinics, couples attending pre-conception clinics, committee members of the Foresight organisation, staff of the West London Hospital pre-conception clinic, Hammersmith, District Health Education Officers working in the West Midlands Regional Health Authority and the members of the Ante-Natal Care Action Group, a sub-group of the Regional Health Advisory Group on Health Promotion and Preventive Medicine. A range of research methods were adopted. These were as follows: questionnaires and report forms used in co-operation with the Foresight clinicians, interviews, participant observation discussions and informal meetings and, finally, literature and official documentation. The research findings illustrated that pre-conception care services provided at the predominantly private Foresight clinics were of a rather `ad hoc' nature. The type of provision varied considerably and clearly reflected the views held by its providers. The protocol which had been developed to assist in the standardization of results was not followed by the clinicians. The pre-conception service provided at the West London Hospital shared some similarities in its approach with the Foresight provision; a major difference was that it did not advocate the use of routine hair trace metal analysis. Interviews with District Health Education Officers and with members of the Ante Natal Care Action Group revealed a tentative and cautious approach to pre-conception care generally and to the Foresight approach in particular. The thesis concludes with a consideration of the future of pre-conception care and the prospects for the establishment of a comprehensive pre-conception care service.

Articulating discursive and materialist conceptions of practice in the logics approach to critical policy analysis

In this article it is argued that while Glynos and Howarth’s logics of critical explanation (LCE) offers an important and promising contribution to critical policy analysis, it, along with other approaches that focus on the meaning of social action, faces a growing challenge in the form of a so-called new materialist turn in social and political theory. The article argues that there is much to be gained for the logics approach in paying closer attention to the materiality of practices in terms not only of lending greater clarity to the conception and role of social practices in the logics approach but also in enabling it fully to deliver on its critical ambition. The article explores an alternative materialist approach to the study of social practices, which hails from the post-actor–networktheory tradition and which has ontological affinities with post-structuralism. The article begins with a brief analysis of the new materialist turn in its various guises. It then critically examines the logics approach, and, in particular its conception of practice. It then explores an alternative materialist and ethnographic reading of practice, focusing on medical and care practices. It concludes with an examination of the implications for a more materialist conception of practices for the LCE’s broad deconstructive, psychoanalytic and onto-political ambitions.