Mécanisme de référence en orthopédie pour mono-traumatisme dans un centre de traumatologie niveau 1

Les patients atteints de mono-traumatisme à un membre doivent consulter un médecin de première ligne qui assurera la prise en charge initiale et référera au besoin le patient vers un orthopédiste. L‟objectif principal de cette étude est de décrire ce mécanisme de référence envers un Service d‟orthopédie affilié à un Centre de traumatologie Niveau 1. La collecte de données concernant l‟accès aux soins spécialisés et la qualité des soins primaires a été faite lors de la visite en orthopédie. Nous avons étudié 166 patients consécutifs référés en orthopédie sur une période de 4 mois. Avant leur référence en orthopédie, 23 % des patients ont dû consulter 2 médecins de première ligne ou plus pour leur blessure. Le temps entre la consultation en première ligne et la visite en orthopédie (68 heures) dépasse le temps compris entre le traumatisme et l‟accès au généraliste (21 heures). Parmi les cas jugés urgents, 36 % n‟ont pas été vus dans les temps recommandés. La qualité des soins de première ligne fut sous-optimale chez 49 % des patients concernant l‟analgésie, l‟immobilisation et/ou l‟aide à la marche. Les facteurs associés à une diminution d‟accès en orthopédie et/ou une qualité de soins inférieure sont : tabagisme, jeune âge, habiter loin de l‟hôpital, consulter initialement une clinique privée, avoir une blessure au membre inférieur ou des tissus mous et une faible sévérité de la blessure selon le patient. Ces résultats démontrent qu‟il faut mieux cibler l‟enseignement relié aux mono-traumatismes envers les médecins de première ligne afin d‟améliorer le système de référence.

Programa Mais Médicos : uma avaliação dos resultados iniciais referentes ao eixo do provimento emergencial a partir da teoria da avaliação de programas

Dissertação (mestrado)—Universidade de Brasília, Centro de Estudos Avançados Multidisciplinares, Programa de Pós-Graduação em Desenvolvimento Sociedade e Cooperação Internacional, 2016.

Shining the light on the dark side of medical leadership - a qualitative study in Australia

Purpose The paper aims to explore the beliefs of doctors in leadership roles of the concept of "the dark side", using data collected from interviews carried out with 45 doctors in medical leadership roles across Australia. The paper looks at the beliefs from the perspectives of doctors who are already in leadership roles themselves; to identify potential barriers they might have encountered and to arrive at better-informed strategies to engage more doctors in the leadership of the Australian health system. The research question is: "What are the beliefs of medical leaders that form the key themes or dimensions of the negative perception of the 'dark side'?". Design/methodology/approach The paper analysed data from two similar qualitative studies examining medical leadership and engagement in Australia by the same author, in collaboration with other researchers, which used in-depth semi-structured interviews with 45 purposively sampled senior medical leaders in leadership roles across Australia in health services, private and public hospitals, professional associations and health departments. The data were analysed using deductive and inductive approaches through a coding framework based on the interview data and literature review, with all sections of coded data grouped into themes. Findings Medical leaders had four key beliefs about the "dark side" as perceived through the eyes of their own past clinical experience and/or their clinical colleagues. These four beliefs or dimensions of the negative perception colloquially known as "the dark side" are the belief that they lack both managerial and clinical credibility, they have confused identities, they may be in conflict with clinicians, their clinical colleagues lack insight into the complexities of medical leadership and, as a result, doctors are actively discouraged from making the transition from clinical practice to medical leadership roles in the first place. Research limitations/implications This research was conducted within the Western developed-nation setting of Australia and only involved interviews with doctors in medical leadership roles. The findings are therefore limited to the doctors' own perceptions of themselves based on their past experiences and beliefs. Future research involving doctors who have not chosen to transition to leadership roles, or other health practitioners in other settings, may provide a broader perspective. Also, this research was exploratory and descriptive in nature using qualitative methods, and quantitative research can be carried out in the future to extend this research for statistical generalisation. Practical implications The paper includes implications for health organisations, training providers, medical employers and health departments and describes a multi-prong strategy to address this important issue. Originality/value This paper fulfils an identified need to study the concept of "moving to the dark side" as a negative perception of medical leadership and contributes to the evidence in this under-researched area. This paper has used data from two similar studies, combined together for the first time, with new analysis and coding, looking at the concept of the "dark side" to discover new emergent findings.

Prescribing practices of Australian dispensing doctors

Background: In response to health workforce shortages policymakers have considered expanding the roles that a health professional may perform. A more traditional combination of health professional roles is that of a dispensing doctor (DD) who routinely prescribes and dispenses pharmaceuticals. A systematic review conducted on mainly overseas DDs’ practices found that DDs tended to prescribe more items per patients, less often generically, and showed poorer adherence to best practice. Convenience for patients was cited by both patients and DDs as the main reason for dispensing. In Australia, rural doctors are allowed to dispense Pharmaceutical Benefit Scheme (PBS) subsidised pharmaceutical benefits if there is no reasonable pharmacy coverage. Little was known about the practices of these Australian DDs. Objectives: To examine the PBS prescribing patterns of dispensing with matched non-dispensing doctors and identify factors that influence prescribing behaviour. Method: A sequential explanatory (QUAN-->qual) mixed methodology was utilised. Firstly, rurality-matched DDs’ and non-DDs’ PBS data for fiscal years 2005-7 were analysed against criteria distilled from a systematic review and stakeholder consultations. Secondly, structured interviews were conducted with a purposive sample of DDs to examine the quantitative findings. Key findings: DDs prescribed significantly fewer PBS prescriptions per patients but used Regulation 24 significantly more than non-DDs. Regulation 24 biased the prescribing data. DDs prescribed proportionally more penicillin type antibiotics, adrenergic inhalants and non-steroidal anti-inflammatories as compared to non-DDs. Reasons offered by DD-respondents highlighted that prescribing was influenced by an awareness of cost to the patients, peer pressure and confidential prescriber feedback provided on a regular basis. Implications: This innovative census study does not support international data that DDs are less judicious in their prescribing. There is some evidence that DDs might reduce health inequity between rural and urban Australian, and that the DD health model is valuable to patients in isolated communities.

A systematic review of the literature comparing the practices of dispensing and non-dispensing doctors

Objectives: Some doctors perform the dual roles of prescribing and dispensing pharmaceuticals. The dispensing doctors (DDs) role may give rise to prescribing behaviours that vary from those of non-DDs. The aim of this review was to systematically and comparatively appraise the research evidence related to the practices of DDs. Methods: A systematic search of bibliographic databases and reference lists from selected papers were the sources of the data. Inclusion criteria were papers published in English, between 1970 and 2008 that provided quantitative data comparing the practices of DDs and non-DDs. At least two of the authors abstracted data from all eligible papers using a purpose-made data extraction form. Results: Twenty-one papers were included in this review. Evidence indicated that DDs prescribed more pharmaceutical items and less often generically than non-DDs. There was limited evidence to suggest that DDs prescribed less judiciously and were associated with poor dispensing standards. Patient convenience and access to pharmaceuticals were main reasons for doctors to dispense. Conclusion: DDs can fill an important gap in the provision of pharmaceuticals for their patients especially where health workforce shortages exist. There was evidence the dispensing role influenced prescribing. Patient convenience should be balanced against scarce medical resources, being utilised for dispensing.

Australian dispensing doctors' prescribing : quantitative and qualitative analysis

Objective: To evaluate the prescribing practices of Australian dispensing doctors (DDs) and to explore their interpretations of the findings. Design, participants and setting: Sequential explanatory mixed methods. The quantitative phase comprised analysis of Pharmaceutical Benefits Scheme (PBS) claims data of DDs and non-DDs, 1 July 2005 30 June 2007. The qualitative phase involved semi-structured interviews with DDs in rural and remote general practice across Australian states, August 2009 February 2010. Main outcome measures: The number of PBS prescriptions per 1000 patients and use of Regulation 24 of the National Health (Pharmaceutical Benefits) Regulations 1960 (r. 24); DDs' interpretation of the findings. Results: 72 DDs' and 1080 non-DDs' PBS claims data were analysed quantitatively. DDs issued fewer prescriptions per 1000 patients (9452 v 15057; P = 0.003), even with a similar proportion of concessional patients and patients aged >65 years in their populations. DDs issued significantly more r. 24 prescriptions per 1000 prescriptions than non-DDs (314 v 67; P=0.008). Interviews with 22 DDs explained that the fewer prescriptions were due to perceived expectation from their peers regarding prescribing norms and the need to generate less administrative paperwork in small practices. Conclusions: Contrary to overseas findings, we found no evidence that Australian DDs overprescribed because of their additional dispensing role. MJA 2011; 195: 172-175

Honesty about adverse event : more honoured in the breach than in the observance?

Part of the chapter: "Sale of Sperm, Health Records, Minimally Conscious States, and Duties of Candour" Although ethical obligations and good medical practice guidelines clearly contemplate open disclosure, there is a dearth of authority as to the nature and extent of a legal duty on Australian doctors to disclose adverse events to patients.

Honesty about adverse events - more honoured in the breach than in the observance

The medical board of Australia Code of conduct reminds doctors that" "When adverse events occur, you have a responsibility to be open and honest in your communication with your patient, to review what has occurred and to report appropriately." More honoured in the breach rather than the observence may or may not be correct. Faced with the English concerns and the Netherlands research, an evidence based assessment of compliance with the ethical duty to disclose adverse events is warranted.

Swine flu, doctors and pandemics : Is there a duty to treat during a pandemic?

The swine influenza (H1N1) outbreak in 2009 highlighted the ethical and legal pressures facing general practitioners and health workers in emergency departments in determining the nature and limits of their obligations to their patients and the public. Health workers require guidance on the multiple, overlapping, and at times conflicting legal and ethical duties owed to patients and prospective patients, employers and fellow health workers, and their families. Existing sources of advice on these issues in Australia, by way of statements of medical ethics and other sources of advice, are shown to be in need of further amplification if health workers are to be provided with the certainty and guidance required. Given the complexity of the issues, Australia would therefore benefit from more extensive consultation with the variety of stakeholders involved in these questions if pandemic plans are to smoothly deal with future crises in an ethically and legally sound manner.

Assessment of resuscitation skills of Foundation Year 1 hospital doctors

An objective and subjective assessment of performance of CPR by 38 foundation year 1 doctors in a major teaching hospital. The study clearly demonstrated that males are more effective than females, BMI has a significant effect on chest compression depth and that females, especially those with a BMI of <24 are more effective at CPR when using a 15:2 rather than a 30:2 ratio of chest compressions to ventilations.