Treating Opioid Use Disorder in Patients Who Are Incarcerated: Quandaries of a Hospitalist.

This Viewpoint discusses the importance of ensuring that life-saving medication for opioid use disorder is available to hospitalized persons who are incarcerated.

A survey of Japanese physician preference for attire: what to wear and why.

Many studies have examined the impression made on patients by physicians' attire. Regardless of practice location, many patients express most confidence in physicians who wear white coats. The number of physicians in Japan who choose not to wear white coats in practice has been increasing, particularly in primary care settings. However, very few studies have examined physician preference for attire. To clarify Japanese general practitioners' preference for attire by practice setting, we conducted a survey of physician preferences and reasons for attire selection. Subjects were 794 general practitioners certified by the Japan Primary Care Association and recruited from a mailing list. We conducted a web-based questionnaire survey. Physicians were asked to choose one of four different dress styles (semi-formal, white coat, scrubs, and casual) for different practice settings and state the reasons for selection. The response rate was 19.3% (n = 153; men 112). Most subjects chose white coats as usual attire for hospital practice (52%), mainly because of custom and professionalism. In contrast, most subjects chose non-white coats for clinics (59%) and home care (hospital-provided, 58%; clinic-provided, 71%). More subjects chose casual dress for clinic and home care practice, mainly to appear empathic. Most subjects chose white coats as the most appropriate hospital attire (54%), mainly because of patient perceptions of this attire being professional. Most subjects considered non-white coat attire more appropriate for clinic and home care practice. The findings indicate that general practitioners choose their clothes depending on practice location.

Frequency of Ethical Issues on a Hospitalist Teaching Service at an Urban, Tertiary Care Center.

Little is known about the daily ethical conflicts encountered by hospitalists that do not prompt a formal clinical ethics consultation. We describe the frequencies of ethical issues identified during daily rounds on hospitalist teaching services at a metropolitan, tertiary-care, teaching hospital. Data were collected from September 2017 through May 2018 by two attending hospitalists from the ethics committee who were embedded on rounds. A total of 270 patients were evaluated and 113 ethical issues were identified in 77 of those patients. These issues most frequently involved discussions about goals of care, treatment refusals, decision-making capacity, discharge planning, cardiopulmonary resuscitation status, and pain management. Only five formal consults were brought to the Hospital Ethics Committee for these 270 patients. Our data are the first prospective description of ethical issues arising on academic hospitalist teaching services and are an important step in the development of a targeted ethics curriculum for hospitalists.

Teaching Clinical Ethics at the Bedside: William Osler and the Essential Role of the Hospitalist.

As the field of hospital medicine celebrates its twenty-first anniversary, we believe it is time to expand its mission to play an even greater role in medical education. Given hospitalists' proximity to students and clinical material, members of this growing cohort of physicians are uniquely positioned to teach normative reasoning, professionalism, communication, and medical ethics in real time to trainees on the wards. But, to do so, we must reimagine the role of the hospitalist in graduate and postgraduate medical education.

The ethics of dysfunctional professional relationships.

Dr N, the chief surgeon at a large private hospital who has been practicing there for decades, has noted recent changes in the administration that are troubling. Multiple advertisements proclaim awards that have not been achieved and various ads employed actors pretending to be patients experiencing miracle cures. Pressures on medical staff to practice more efficiently have become overbearing. Changes in bundling Medicare postoperative care have raised questions about future patient selection. There is a lack of transparency with minimal physician input. The much respected chief-of-staff has moved into the administrative side and no longer advocates for the professionalism of the staff. When Dr N meets with the chief-of-staff and objects to these changes, the chief of staff calls Dr N a complainer and tells him to forget about it. Nothing is done.

Extracorporeal membrane oxygenation in adults: a brief review and ethical considerations for nonspecialist health providers and hospitalists.

Given the pace, distribution, and uptake of technological innovation, patients experiencing respiratory failure, heart failure, or cardiac arrest are, with greater frequency, being treated with extracorporeal membrane oxygenation (ECMO). Although most hospitalists will not be responsible for ordering or managing ECMO, in-hospital healthcare providers continue to be a vital source of patient referral and, accordingly, need to understand the rudiments of these technologies so as to co-manage patients, counsel families, and help ensure that the provision of ECMO is consistent with patient preferences and appropriate goals of care. In an effort to prepare hospitalists for these clinical responsibilities, we review the history and technology behind modern-day ECMO, including venoarterial extracorporeal membrane oxygenation (VA-ECMO) and venovenous extracorporeal membrane oxygenation. Building upon that foundation, we further highlight special ethical considerations that may arise in VA-ECMO, and present an ethically grounded approach to the initiation, continuation, and discontinuation of treatment.

Ethical problems in pediatrics: what does the setting of care and education show us?

BACKGROUND: Pediatrics ethics education should enhance medical students' skills to deal with ethical problems that may arise in the different settings of care. This study aimed to analyze the ethical problems experienced by physicians who have medical education and pediatric care responsibilities, and if those problems are associated to their workplace, medical specialty and area of clinical practice. METHODS: A self-applied semi-structured questionnaire was answered by 88 physicians with teaching and pediatric care responsibilities. Content analysis was performed to analyze the qualitative data. Poisson regression was used to explore the association of the categories of ethical problems reported with workplace and professional specialty and activity. RESULTS: 210 ethical problems were reported, grouped into five areas: physician-patient relationship, end-of-life care, health professional conducts, socioeconomic issues and health policies, and pediatric teaching. Doctors who worked in hospitals as well as general and subspecialist pediatricians reported fewer ethical problems related to socioeconomic issues and health policies than those who worked in Basic Health Units and who were family doctors. CONCLUSIONS: Some ethical problems are specific to certain settings: those related to end-of-life care are more frequent in the hospital settings and those associated with socioeconomic issues and public health policies are more frequent in Basic Health Units. Other problems are present in all the setting of pediatric care and learning and include ethical problems related to physician-patient relationship, health professional conducts and the pediatric education process. These findings should be taken into consideration when planning the teaching of ethics in pediatrics. TRIAL REGISTRATION: This research article didn't reports the results of a controlled health care intervention. The study project was approved by the Institutional Ethical Review Committee (Report CEP-HIJG 032/2008).

Who should be offered sperm banking for fertility preservation? A survey of UK oncologists and haematologists.

BACKGROUND: Fertility after cancer therapy is a significant quality-of-life concern for many patients, their partners and families. Authoritative guidance states that men whose fertility may be affected by impending therapies should be offered sperm banking. Yet some patients are not offered this opportunity and are thereby disadvantaged. We sought to understand oncologists' and haematologists' decision making concerning sperm-banking referrals. DESIGN: We surveyed all oncologists and haematologists on the Royal College of Radiotherapists' Faculty of Oncology and British Society for Haematology circulation lists. RESULTS: From 2357 across all specialties, 499 responses were received: 253 haematologists and 246 oncologists (21% response rate). Twenty-one percent of respondents were unaware of local policies on sperm banking and 42% considered that sperm banking should be offered to more patients. Respondents' decisions reveal either assumptions about patients' needs based on characteristics such as age, sexual orientation and severity of illness or the influence of their own moral conclusions upon their patients. The survey identified paucity of training for clinicians, information for patients and systematic recording of discussions about fertility. CONCLUSIONS: A robust care infrastructure supporting male fertility storage is needed urgently to include targeted information for cancer clinicians and patients, identified individuals responsible for coordination and documentation of discussions with patients.

Physician behavior: not ready for 'Never'land.

Disruptive physician behavior, particularly by surgeons, is a common perception. Increasing awareness and regulatory oversight is being felt in medical practice; however, little data exist regarding the frequency of these behaviors. This study was undertaken to determine the prevalence and type of reported behavioral issues. Blinded data for 2 years of physician behavior reports were reviewed for department, gender, event summary, and peer review conclusions. Chi-square analysis was used with statistical significance at P < 0.05. One hundred ninety-one behavior issues were reported in our 751-bed hospital, which employs 640 active physicians. One hundred fourteen (18%) physicians were reported. Forty-four (7%) physicians had multiple reports, accounting for 121 (63%) reports. Twenty-seven physicians were reported twice, eight 3 times, four 4 times, three 5 times, and one 6 times. Multiple-report physicians compared with single-report physicians showed no difference in distribution of outcomes, but more communication issues and fewer unacceptable behaviors. Specialty groups with a higher incidence of reported behaviors included anesthesia, cardiology, hospitalists, orthopedics, trauma, and obstetrics/gynecology. Female physicians were less likely to be reported. Staff reports were mainly against physicians within their hospital practice area (75 of 94 [80%]), whereas physician reports were mainly against physicians outside their practice area (18 of 25 [72%]). Disruptive physician behavior is variable and culturally defined. Although all reports should be taken seriously, fewer than 1 per cent of reported incidents were found to be definably disruptive and valid. As quality and oversight groups consider making disruptive physician behavior a "never" event, firm definitions and full peer review are mandatory.

The ethics of the hospitalist model.

The hospitalist model was founded on the premise that it could improve the quality and reduce the cost of hospital care. Many randomized studies have all but definitively proven this original assertion. Nevertheless, the hospitalist specialty raises lingering classical ethical issues: protecting the patient-physician relationship in an environment of increasing specialization and discontinuity of care, preserving patient autonomy and choice when structural changes are made in the provision of care, and ensuring that a model founded on efficiency and cost-effectiveness does not erode the public trust in hospitalists to always serve their patients' best interests. This work aims to serve as an update of these initial criticisms, showing how some questions have been answered, while some have not.

[Legal and ethical limitations of competition in healthcare from a hospital owner's perspective]. / Wettbewerb zwischen Krankenhäusern--aus der Sicht eines Krankenhausträgers.

Competition is tough and the cost pressure enormous. Vivantes will actively meet the challenges of the market to gain a strong market position. All measures to improve competitiveness will be taken on the basis of the communal mandate to provide prioritised medical care; quality standards need to be maintained. In times of tight budgets Vivantes uses the limited funds carefully and focuses on using them wherever they will be most beneficial. Vivantes will achieve its ambitious business objectives by concentrating services sensibly, using efficient structures and focussing on interlocking processes.