Perceptions of Indonesian general practitioners in maintaining standards of medical practice at a time of health reform.

BACKGROUND: There is little research on how GPs experience the demands of maintaining standards of medical practice in developing countries and what strategies might improve their capability to provide high-quality primary health care (PHC). OBJECTIVE: This study aims to explore the underlying factors, which shape GPs' experience within the Indonesian PHC system and impact on their experience of professional practice. METHODS: A grounded theory approach was applied using semi-structured interviews of 25 purposively selected GPs in West Sumatra, Indonesia. The interviews were analysed inductively through an iterative process of the interplay between empirical data, emerging analysis and theory development. RESULTS: Three major health care systems attribute shaped GPs' experiences of professional practice, including (i) a restricted concept of the PHC system, (ii) lack of regulation of private primary care practice conducted by GPs, midwives, nurses and specialists and (iii) low coverage and inappropriate policy of the health insurance system. CONCLUSION: The findings indicate that a major revision of current health care system is required with a focus on promoting the concept of PHC services to the population, redefining the role of the GP to deliver recognised best practice within available resources, changing the way GPs are remunerated by the public health system and the health insurance industry, policing of the regulations related to the scope of practice of other health care professionals, particularly midwives and nurses, and regulation of prescribing. GPs can be the champions of the PHC service that Indonesia needs, but it requires sustained systematic change.

[Internet presence of neurologists, psychiatrists and medical psychotherapists in private practice]. / Internetauftritte niedergelassener Neurologen, Psychiater und ärztlicher Psychotherapeuten.

OBJECTIVE: The world wide web provides new options to physicians in terms practice marketing, information brokerage, and process optimization. This study explores prevalence and content of homepages of neurologists, psychiatrists and medical psychotherapists in private practice. METHODS: Through the legal bodies of physicians in private practice in six northern German states neurologists, psychiatrists and medical psychotherapists were identified. According to a standardized and operationalized criteria catalogue, homepages were rated. RESULTS: 1804 physicians were identified, 352 (19.5 %) had operated a homepage. Higher frequencies of homepages found for male physicians (vs. female physicians), practice centres (vs. single practices) and urban practices (vs. rural practices). In average, practices reached 18.8 (±â€Š5.3) of 42 points; contact data and accessibility information were generally available; information as to qualification and specialization was provided more infrequently. Legal specifications were not considered in more than every second homepage, interactive elements like online appointment of follow-up prescription were only rarely offered. CONCLUSIONS: Only every fifth neurological or psychiatric practice operates an own homepage, higher competition (urban area) and higher professionalization (practice centres) seem to act as promotors. The legal framework has to be focused, and patient needs should be taken into account.

[Naturopathic practitioners and the public health system. Legal principles as well as experience from naturopathic practitioner candidate tests and hygiene inspections of naturopathic practitioner's practices in the Rhine-Main area in 2004-2007]. / Heilpraktiker und öffentliches Gesundheitswesen. Gesetzliche Grundlagen sowie Erfahrungen aus den Uberprüfungen der Heilpraktikeranwärter und der infektionshygienischen Uberwachung von Heilpraktiker-Praxen im Rhein-Main-Gebiet 2004-2007.

In Germany, the naturopathic practitioner, the "Heilpraktiker", is allowed to practice medicine, like medically trained physicians. The German heilpraktiker, a specific German phenomenon embedded in the country's history, practices medicine without being obliged to undertake any medical teaching or training. Anybody 25 years old or older, with a secondary school certificate, and free of disease can participate in a test, conducted by the local health authorities to "exclude danger to the health of the nation." In the case of failure, this test can be repeated ad libitum. Having passed this test, the heilpraktiker is allowed to practice the whole realm of medicine, except for gynecology, dentistry, prescription of medication, and healing infectious diseases. There is no more state control during the heilpraktiker's working life, except in those practices applying invasive methods, such as infusions, injections, oxygen therapy, and acupuncture. These practices are inspected by the public health department based on the Infection Protection Act. Although several cases of fatal errors in treatment are known, the greatest risk in the heilpraktiker's practice is the omission of proper diagnostics and therapies, which is risk by omission. In this paper, the history of the heilpraktiker in Germany as well as the task of the Public Health Departments in testing the candidates are shown. The data of 345 tests from 2004-2007 in the Rhein-Main area are presented, with 53% of the participants failing. Concerning the hygiene control visits, a concept for hygiene was lacking in 79% of 109 practices, while in 49% a concept for cleaning and disinfection was also missing. In 60% of the practices, a dispenser for hand disinfection was lacking. Recommended improvements were quickly performed in most practices. In conclusion, the current legal regulation, i.e., testing the candidates only once before practicing for a lifetime, does not sufficiently protect the population against danger caused by false diagnostics and (invasive) therapy of the heilpraktiker. Considering the population's increasing interest and use of complementary and alternative medicine (CAM) with a heilpraktiker being frequently consulted, there are growing concerns in health services, regarding (1) how to regulate CAM professions and natural health procedures, (2) how to incorporate safe CAM into school medicine, and (3) how best to protect the public from a wide range of possible CAM-conventional medicine interactions.

[Demands of private gastroenterologists for collaborative treatment concepts with clinics. Results of a Germany-wide survey]. / Welche Anforderungen stellen niedergelassene Gastroenterologen an integrierte Versorgungskonzepte mit Kliniken? Ergebnisse einer deutschlandweiten Umfrage.

BACKGROUND: New demands and possibilities of collaboration between hospitals and private practices in Germany have appeared, now that the way has been opened legally. A poll was conducted to analyse the current status of collaboration between outpatient gastroenterologists and hospital surgical departments and to identify possible future collaborations. MATERIALS AND METHODS: One thousand twenty-six private practices specialising in endoscopy were found by contacting the Association of Statutory Health Insurance Physicians and additional internet research. Of these, 50% were randomly selected (513 private practices) and contacted by mail with anonymous questionnaires about cooperation with their clinical partners. Two hundred three (39.6%) practices responded, of which 200 could be analysed. RESULTS: Of all practices reached, 75% considered the cooperation with clinics very valuable or even exceptional. Still, almost half (46%) suggested necessary improvements in these collaborations. Around a third of all contacted colleagues were already involved in projects following integrated care models. In about 80% of all participants, the main interest in integrated models was specified to be common therapy planning. CONCLUSION: The data analysis of this study shows a substantial interest of private-practice gastroenterologists in close collaboration with hospitals. It is now up to the hospitals to open contracts with their medical outpatient partners.

[Radiodermatitis in interventional radiology (hand dose measurement, screening and compensation)]. / Radiodermites en radiologie interventionnelle (doses reçues aux mains, dépistage et réparation).

It is to be feared that the expansion of interventional radiology could lead to the reappearance of chronic radiodermatitis. Only a few studies mention the doses received by the hands, however these radiation doses are always high. Whereas clinical examinations lead to a belated diagnosis, capillary microscopy, a quick and non invasive test, enables to detect vascular injuries at the subclinical stage. Radiological protection is currently based on leaded gloves and on the reduction of exposure duration. Compensation for chronic radiodermatitis depends on the practitioner's status. In spite of a better evaluation of the overall irradiation, hand exposure remains a cause for concern. Capillary microscopy can provide appropriate medical surveillance.

Striking against managed care: the last gasp of la médicine libérale?

The French health care system combines a strong tradition of autonomous private practice with nearly universal health care coverage through the social security system. The French state's responses to rising health care expenditures have included limitation of the number of medical students, control over physician fees, rules to prohibit certain clinical practices, experiments with generalist physicians coordinating care and access to specialists, and collective physician responsibility for expenditures beyond the health care budget. The failure of physicians' protests, including a strike of French residents and fellows in 1997, may signify the end of traditional private practice in the face of France's statist version of managed care.

Regulating the private health care sector: the case of the Indian Consumer Protection Act.

Private medical provision is an important constituent of health care delivery services in India. The quality of care provided by this sector is a critical issue. Professional organizations such as the Medical Council of India and local medical associations have remained ineffective in influencing the behaviour of private providers. The recent decision to bring private medical practice under the Consumer Protection Act (COPRA) 1986 is considered an important step towards regulating the private medical sector. This study surveyed the views of private providers on this legislation. They believe the COPRA will be effective in minimizing malpractice and negligent behaviour, but it does have adverse consequences such as an increase in fees charged by doctors, an increase in the prescription of medicines and diagnostics, an adverse impact on emergency care, etc. The medical associations have also argued that the introduction of COPRA is a step towards expensive, daunting and needless litigation. A number of other concerns have been raised by consumer forums which focus on the lack of standards for private practice, the uncertainty and risks of medicines, the effectiveness of the judiciary system, and the responsibility of proving negligence. How relevant are these concerns? Is the enactment of COPRA really appropriate to the medical sector? The paper argues that while this development is a welcome step, we need to comprehensively look into the various quality concerns. The effective implementation of COPRA presumes certain conditions, the most important being the availability of standards. Besides this, greater involvement of professional organizations is needed to ensure appropriate quality in private practice, since health and medical cases are very different from other goods and services. The paper discusses the results of a mailed survey and interview responses of 130 providers from the city of Ahmedabad, India. The questionnaire study was designed to assess the opinion of providers on various implications of the COPRA. We also analyze the data on cases filed with the Consumer Disputes and Redressal Commission in Gujarat since 1991. Four selected cases filed with the National Commission on Consumers Redressal are discussed in detail to illustrate various issues affecting the implementation of this Act.

PIP: The private sector provides an important proportion of overall health care delivery services in India. As such, efforts must be made to ensure that such services are of acceptable to high quality. With professional organizations such as the Medical Council of India and local medical associations unable to influence the behavior of private providers, the recent decision to bring private medical practice under the Consumer Protection Act (COPRA) 1986 is considered an important step toward regulating the private medical sector. The author surveyed the views of 130 private health care providers from the city of Ahmedabad on the legislation. Data were also analyzed on cases filed with the Consumer Disputes and Redressal Commission in Gujarat since 1991. While respondents believe that COPRA will reduce the levels of malpractice and negligent behavior among private practitioners, they envision an increase in physicians' fees, a greater number of prescriptions made and diagnostic tests conducted, and an adverse effect upon emergency medical care. Medical associations have argued that introducing COPRA will foster expensive and needless litigation. Other concerns have been raised by consumer forums.