Everyday ethics in internal medicine resident clinic: an opportunity to teach.

OBJECTIVES: Being a good doctor requires competency in ethics. Accordingly, ethics education during residency training is important. We studied the everyday ethics-related issues (i.e. ordinary ethics issues commonly faced) that internal medical residents encounter in their out-patient clinic and determined whether teaching about these issues occurred during faculty preceptor-resident interactions. METHODS: This study involved a multi-method qualitative research design combining observation of preceptor-resident discussions with preceptor interviews. The study was conducted in two different internal medicine training programme clinics over a 2-week period in June 2007. Fifty-three residents and 19 preceptors were observed, and 10 preceptors were interviewed. Transcripts of observer field notes and faculty interviews were carefully analysed. The analysis identified several themes of everyday ethics issues and determined whether preceptors identified and taught about these issues. RESULTS: Everyday ethics content was considered present in 109 (81%) of the 135 observed case presentations. Three major thematic domains and associated sub-themes related to everyday ethics issues were identified, concerning: (i) the Doctor-Patient Interaction (relationships; communication; shared decision making); (ii) the Resident as Learner (developmental issues; challenges and conflicts associated with training; relationships with colleagues and mentors; interactions with the preceptor), and; (iii) the Doctor-System Interaction (financial issues; doctor-system issues; external influences; doctor frustration related to system issues). Everyday ethics issues were explicitly identified by preceptors (without teaching) in 18 of 109 cases (17%); explicit identification and teaching occurred in only 13 cases (12%). CONCLUSIONS: In this study a variety of everyday ethics issues were frequently encountered as residents cared for patients. Yet, faculty preceptors infrequently explicitly identified or taught these issues during their interactions with residents. Ethics education is important and residents may regard teaching about the ethics-related issues they actually encounter to be highly relevant. A better understanding of the barriers to teaching is needed in order to promote education about everyday ethics in the out-patient setting.

Privacy, privatization, and the politics of patronage: ethnographic challenges to penetrating the secret world of Middle Eastern, hospital-based in vitro fertilization.

In recent years, in vitro fertilization (IVF) has spread around the globe, including to the Middle East. Privacy, privatization, and the politics of patronage are all key issues affecting anthropological research in Middle Eastern hospital-based IVF clinics. IVF-seeking patients generally desire privacy, even total secrecy, when pursuing these treatments, due to cultural issues of stigmatization, particularly regarding male infertility. Thus, ethical issues surrounding the informed consent process are of prime importance. Furthermore, privatization of medical services in the Middle East has left patients--and anthropologists--with few choices other than private IVF clinic settings in which to pursue treatment and research. Both the ethos of patient privacy and medical privatization affect the ability of anthropologists to "penetrate" the secret world of IVF. Permission to conduct ethnography in private hospital IVF clinics may be difficult to obtain without the help of highly motivated physician patrons, who are willing to recruit their private IVF patients for ethnographic interviewing. This article provides a personal account of some of these challenges as faced by a medical anthropologist during a 15-year career of hospital-based IVF research in the Middle East.

Effects of consumer and provider moral hazard at a municipal hospital out-patient department on Ghana's National Health Insurance Scheme.

BACKGROUND: In 2003, Ghana introduced the national health insurance scheme (NHIS) to promote access to healthcare. This study determines consumer and provider factors which most influence the NHIS at a municipal health facility in Ghana. METHOD: This is an analytical cross-sectional study at the Winneba Municipal Hospital (WHM) in Ghana between January-March 2010. A total of 170 insured and 175 uninsured out-patients were interviewed and information extracted from their folders using a questionnaire. Consumers were from both the urban and rural areas of the municipality. RESULTS: The mean number of visits by insured consumers to a health facility in previous six months was 2.48 +/- 1.007 and that for uninsured consumers was 1.18 +/- 0.387(p-value<0.001). Insured consumers visited the health facility at significantly more frequent intervals than uninsured consumers (χ(2) = 55.413, p-value< 0.001). Overall, insured consumers received more different types of medications for similar disease conditions and more laboratory tests per visit than the uninsured. In treating malaria (commonest condition seen), providers added multivitamins, haematinics, vitamin C and intramuscular injections as additional medications more for insured consumers than for uninsured consumers. CONCLUSION: Findings suggest consumer and provider moral hazard may be two critical factors affecting the NHIS in the Effutu Municipality. These have implications for the optimal functioning of the NHIS and may affect long-term sustainability of NHIS in the municipality. Further studies to quantify financial/ economic cost to NHIS arising from moral hazard, will be of immense benefit to the optimal functioning of the NHIS.

Secure web messaging in a pediatric chronic care clinic: a slow takeoff of "kids' airmail".

BACKGROUND: Although e-mail may be an efficient clinician-patient communication tool, standard e-mail is not adequately secure to meet Health Insurance Portability and Accountability Act (HIPAA) guidelines. For this reason, firewall-secured electronic messaging systems have been developed for use in health care. Impact and usability of these secure systems have not been broadly assessed. OBJECTIVE: To evaluate the impact of a secure electronic messaging system implemented for a pediatric subspecialty clinic. METHODS: This study was performed in an outpatient, academic pediatric respiratory clinic in spring 2009 in New Haven, Connecticut. Patients were surveyed prior to implementation regarding internet usage. The Kryptiq messaging system was implemented and messages were monitored continuously and tracked. Open-ended qualitative interviews with 28 users and nonusers were conducted, and we described the process of implementation. RESULTS: All of the 127 patients/families surveyed expressed interest in using the Internet to contact their clinic providers, and they all reported having the ability to access the Internet. In the 8 months after implementation, only 5 messages were initiated by patients in contrast to 2363 phone calls. Themes emerged from the open-ended interviews that indicated promoters, barriers, and potential uses. Prominent barriers included the lack of convenience and personal touch and being technically difficult to use. CONCLUSIONS: Although these patients/families expressed strong interest in e-mailing, secure Web messaging was less convenient than using the phone, too technically cumbersome, lacked a personal touch, and was used only by a handful of patients.