'If relevant, yes; if not, no': General practitioner (GP) users and GP perceptions about asking ethnicity questions in Irish general practice: A qualitative analysis using Normalization Process Theory.

CONTEXT: The use of ethnic identifiers in health systems is recommended in several European countries as a means to identify and address heath inequities. There are barriers to implementation that have not been researched. OBJECTIVE: This study examines whether and how ethnicity data can be collected in Irish general practices in a meaningful and acceptable way. METHODS: Qualitative case study data generation was informed by Normalization Process Theory (NPT) constructs about 'sense' making and 'engagement'. It consisted of individual interviews and focus group discussions based on visual participatory techniques. There were 70 informants, including 62 general practitioner (GP) users of diverse ethnic backgrounds recruited through community organisations and eight GPs identified through an inter-agency steering group. Data were analysed according to principles of thematic analysis using NPT. RESULTS: The link between ethnicity and health was often considered relevant because GP users grasped connections with genetic (skin colour, lactose intolerance), geographic (prevalence of disease, early years exposure), behavioural (culture/food) and social determinant (housing) factors. The link was less clear with religion. There was some scepticism and questions about how the collection of data would benefit GP consultations and concerns regarding confidentiality and the actual uses of these data (e.g. risk of discrimination, social control). For GPs, the main theme discussed was relevance: what added value would it bring to their consultations and was it was their role to collect these data? Their biggest concern was about data protection issues in light of the European Union (EU) General Data Protection Regulation (GDPR). The difficulty in explaining a complex concept such as 'ethnicity' in the limited time available in consultations was also worrying. CONCLUSIONS: Implementation of an ethnicity identifier in Irish general practices will require a strong rationale that makes sense to GP users, and specific measures to ensure that its benefits outweigh any potential harm. This is in line with both our participants' views and the EU GDPR.

The role of placebos in family medicine: Implications of evidence and ethics for general practitioners.

BACKGROUND: Placebo use is prevalent in primary care. A wealth of discourse on the ethical use of placebos in clinical contexts invariably assumes that placebos oblige practitioners to peddle in deception. However, the recent surge in empirical findings within the field of 'placebo studies' provides a very different perspective: namely, that placebos may yet prove to be both effective and ethical. OBJECTIVE: The aim of this article is to synthesise state-of-the-art scientific and bioethical research to provide up-to-date recommendations on placebo use for general practitioners. DISCUSSION: After disambiguating placebo concepts, this article outlines experimental studies into placebo effects and explores the ethical and evidence-based arguments for prescribing placebos. Evaluating the latest research into 'open-label placebos', it can be surmised that there are not yet persuasive grounds to incorporate these treatments into routine clinical care. Notwithstanding, the quality of physician interactions may go some way to harnessing remedial placebo effects among patients.

[Diagnostic Test Requests in the Family Medicine Consultation: An Ethical Perspective Concerning Requests for Maxillofacial Computerized Tomography Scan Prior to Dental Implants]. / A Transcrição de Exames na Consulta de Medicina Geral e Familiar: Perspetiva Ética Sobre o Caso do Pedido de Tomografia Computorizada Maxilofacial para Realização de Implantes Dentários.

In the Portuguese National Health Service, little attention has been paid to oral health care. The almost nonexistence of a dentistry network raises concern about accessibility to services, and justifies the need to call on a predominantly private provision of services. The coexistence between the public and private settings is not always easy, especially when services need to interact and actively collaborate in order to find answers to the patient's problems. Dental implant procedures and the need to perform a previous maxillofacial computerized tomography to study the bone bed where osseointegrated dental implants are placed are a common situation. The current governmental regulation, blinded to the clinical context, may limit the accessibility to the tests. Based on this scenario, we discuss the possible options from an ethical point of view, framing the patient's and the physician's perspective and the relation between both. We conclude that the medical decision can't be disregarded from the clinical evaluation, in the intimacy of the medical consultation. This is an ethical duty that overrules the administrative and bureaucratic constraints. A good management of this apparent dichotomy may enhance better health and greater empowerment for the patient.

A saúde oral tem sido pouco cuidada no contexto do Serviço Nacional de Saúde em Portugal. A quase inexistência de uma rede de medicina dentária levanta problemas de acessibilidade que condicionam a necessidade de complementar os serviços públicos com uma oferta predominantemente privada. Mas esta coexistência não é sempre fácil, sobretudo quando há necessidade dos serviços se cruzarem e colaborarem ativamente na resolução dos problemas do doente. Uma situação comum é a colocação de implantes dentários e a necessidade de realizar uma tomografia computorizada maxilofacial prévia para estudo de leito para colocação de implantes dentários osteointegrados, onde a aplicação de regulação governamental desenquadrada do contexto clínico pode condicionar a acessibilidade aos tratamentos. Com base neste cenário, discutem-se as opções do ponto de vista ético, na perspetiva do doente, do médico e da relação entre ambos. Conclui-se que a decisão médica não pode ser desenquadrada de uma avaliação clínica que apenas o ambiente de intimidade da consulta médica pode proporcionar. É um imperativo ético que se sobrepõe aos constrangimentos administrativos e burocráticos e que se bem gerido é potenciador de uma melhor saúde e de maior capacitação da pessoa.

La medicina familiar en Sancti Spíritus, su 35 aniversario / Family medicine in Sancti Spíritus, its 35th anniversary

El Programa del Médico y la Enfermera de la Familia cumple 35 años, ha sido una de las ideas más excelentes y oportunas relacionadas con la salud pública que haya pensado el comandante en jefe Fidel Castro en 1984. Surgió por la necesidad de acercar la atención médica a la comunidad y la familia, asimismo para lograr cambios en el estado de salud de la población; este programa es considerado la piedra angular del sistema nacional de salud pública (SNS), escalón superior de la atención primaria de salud (APS), el cual sustituye la atención sectorizada del policlínico de esa época

Moral Distress with Obstacles to Hepatitis C Treatment: A Council of Academic Family Medicine Educational Research Alliance (CERA) Study of Family Medicine Program Directors.

BACKGROUND AND OBJECTIVE: To determine whether family medicine program directors (PDs) experienced moral distress due to obstacles to Hepatitis C virus (HCV) treatment, and to explore whether they found those obstacles to be unethical. DESIGN: An omnibus survey by the Council of Academic Family Medicine's Educational Research Alliance was administered to 452 and completed by 273 US-based PDs. The survey gauged attitudes and opinions regarding ethical dilemmas in patient access to HCV treatment. RESULTS: Most of the respondents were male. Sixty-four percent of respondents believed that treatment should be an option for all patients regardless of cost. Forty-one percent believed that it was unethical to deny treatment based on past or current substance use, and 38% believed treatment should be offered to patients who were substance abusers. Moral distress was reported by 61% (score >3) of participants when they were unable to offer treatment to patients due to the patient's failure to meet eligibility criteria. In addition, PDs reporting moderate-to-high levels of moral distress were also likely to report the following opinions: 1) treatment should be offered regardless of cost, 2) it is unethical to deny treatment based on past behavior, 3) substance abusers should be offered treatment, 4) it is unethical for medicine to be prohibitively expensive, and 5) Medicaid policy that limits treatment will worsen racial and ethnic disparities. CONCLUSIONS: Currently, important ethical dilemmas exist in the access and delivery of HCV therapy. Although a diversity of opinions is noted, a significant proportion of PDs are concerned about patients' inability to avail equitable care and experience distress. In some cases, this moral distress is in response to, and in conflict with, current guidelines.

"She's on her own": a thematic analysis of clinicians' comments on abortion referral.

OBJECTIVE: The objective was to understand the motivations around and practices of abortion referral among women's health providers. METHODS: We analyzed the written comments from a survey of Nebraska physicians and advanced-practice clinicians in family medicine and obstetrics-gynecology about their referral practices and opinions for a woman seeking an abortion. We analyzed clinician's responses to open-ended questions on abortion referral thematically. RESULTS: Of the 496 completed surveys, 431 had comments available for analysis. We found four approaches to abortion referral: (a) facilitating a transfer of care, (b) providing the abortion clinic name or phone number, (c) no referral and (4) misleading referrals to clinicians or facilities that do not provide abortion care. Clinicians described many motivations for their manner of referral, including a fiduciary obligation to refer, empathy for the patient, respect for patient autonomy and the lack of need for referral. We found that abortion stigma impacts referral as clinicians explained that patients often desire additional privacy and clinicians themselves seek to avoid tension among their staff. Other clinicians would not provide an abortion referral, citing moral or religious objections or stating they did not know where to refer women seeking abortion. Some respondents would refer women to other providers for additional evaluation or counseling before an abortion, while others sought to dissuade the woman from obtaining an abortion. CONCLUSIONS: While practices and motivations varied, few clinicians facilitated referral for abortion beyond verbally naming a clinic if an abortion referral was made at all. IMPLICATIONS: Interprofessional leadership, enhanced clinician training and public policy that addresses conscientious refusal of abortion referral are needed to reduce abortion stigma and ensure that women can access safe care.

[Core values in family medicine revisited]. / Una vuelta a los valores centrales en medicina de familia.

Family medicine has to continually reinvent itself around a core of values that constitutes its navigation system. But accurate data on its impact on the health of people will account for how far the values are actually being implemented. Thus, we can say that family medicine is a specialty based on values and as well as evidence based. The absence of a clarification system of values or its implementation threatens its very existence. Some of the values that are reviewed have shown great recognition and survival over time. Others are presented because they seem sufficiently significant. These are: people, comprehensiveness, trust relationship, patient-centred method, accessibility, continuity, family unity and the community, teamwork, sustainability of the health system, and continuous improvement.

Social Justice as the Moral Core of Family Medicine: A Perspective from the Keystone IV Conference.

A recurring conference theme was the essential place of social justice within family medicine, especially the need to focus on denominator populations, exalt the personal and caring qualities of doctoring, and address social determinants of health. Many expressed solidarity with "community," but it is not always easy to define community in our large and diverse nation. Exhortations for health advocacy were frequently voiced, but putting these into meaningful action agendas is a challenge. There was general agreement that medicine is in flux and that the many expressions of "commodity-centered consumerism" have altered organization and financing. The increasing demands by "consumers", who want low cost, instant availability, and shared decision-making, and yet change doctors when health plans alter coverage also differentially impact high-volume, low-margin specialties such as family medicine. Additional challenges were the electronic health record and calibrating an appropriate work/life balance. Five action steps are recommended: 1) speak out on the important social and moral issues; 2) be the experts on personal care; 3) make common cause with potential allies; 4) help institutions perceive the value of generalism; and 5) help find ways to enrich generalist disciplines to increase the joy of medicine and decrease the threat of burn out.

Health literacy in pregnant women facing prenatal screening may explain their intention to use a patient decision aid: a short report.

BACKGROUND: It has been suggested that health literacy may impact the use of decision aids (DAs) among patients facing difficult decisions. Embedded in the pilot test of a questionnaire, this study aimed to measure the association between health literacy and pregnant women's intention to use a DA to decide about prenatal screening. We recruited a convenience sample of 45 pregnant women in three clinical sites (family practice teaching unit, birthing center and obstetrical ambulatory care clinic). We asked participating women to complete a self-administered questionnaire assessing their intention to use a DA to decide about prenatal screening and assessed their health literacy levels using one subjective and two objective scales. RESULTS: Two of the three scales discriminated between levels of health literacy (three numeracy questions and three health literacy questions). We found a positive correlation between pregnant women's intention to use a DA and subjective health literacy (Spearman coefficient, Rho 0.32, P = 0.04) but not objective health literacy (Spearman coefficient, Rho 0.07, P = 0.65). Hence subjective health literacy may affect the intention to use a DA among pregnant women facing a decision about prenatal screening. CONCLUSION: Special attention should be given to pregnant women with lower health literacy levels to increase their intention to use a DA and ensure that every pregnant women can give informed and value-based consent to prenatal screening.

Moral Distress in Family Health Strategy: experiences expressed by daily life.

OBJECTIVE: Understanding the Moral Suffering experiences expressed in the daily life of the Family Health Strategy. METHOD: This is a case study with a qualitative approach, conducted between August and October 2014 in a municipality of Minas Gerais. The sample was represented by 28 professionals of family health teams. Data were collected through interviews with semi-structured questionnaires, observation, projective technique and submitted to thematic content analysis. RESULTS: The results indicate that routine issues of the health care system lead professionals to experience a challenging practice in dealing with daily situations that contradict their ethical precepts and can compromise the quality of work, becoming triggers of Moral Distress. CONCLUSIONS: Social vulnerabilities such as domestic violence, poor socioeconomic conditions and organizational weaknesses of the health system were the main triggers of Moral Distress. Therefore, it is necessary to amplify this reflection by workers of the Family Health Strategy, aiming to encourage the minimization of suffering experiences, considering their ethical values. OBJETIVO: Compreender as vivências de Sofrimento Moral expressas no cotidiano da Estratégia de Saúde da Família. MÉTODO: Trata-se de um estudo de caso com abordagem qualitativa, realizado entre os meses de agosto a outubro de 2014, cujo cenário foi um município de Minas Gerais. Participaram 28 profissionais das equipes de saúde da família. Os dados foram coletados por meio de entrevistas com roteiro semiestruturado, observação, técnica projetiva e, submetidos à análise de conteúdo temática. RESULTADOS: Os resultados apontaram que as questões rotineiras do serviço de saúde levam os profissionais a vivenciarem uma prática desafiadora ao lidarem diariamente com situações que contradizem seus preceitos éticos capazes de comprometer a qualidade do trabalho tornando-se disparadores de Sofrimento Moral. CONCLUSÃO: As vulnerabilidades sociais, como violência doméstica e condições socioeconômicas precárias, além das fragilidades organizacionais do Sistema de Saúde, foram os principais geradores de Sofrimento Moral. Assim, considera-se necessária a reflexão ampliada sobre a temática por parte dos trabalhadores da Estratégia de Saúde da Família, com intuito de propiciar a minimização de vivências de sofrimento e uma prática profissional em consonância com seus valores éticos.