Changes in harm reduction service providers professional quality of life during dual public health emergencies in Canada.

BACKGROUND: Harm reduction (HR) is a critical response to the pronounced toxicity deaths being experienced in Canada. HR providers report many benefits of their jobs, but also encounter chronic stress from structural inequities and exposure to trauma and death. This research study sought to quantify the emotional toll the toxicity emergency placed on HR providers (Cycle One; 2019). Study objectives were later expanded to determine the impact of the ongoing toxicity as well as the pandemic's impact on well-being (Cycle Two; 2021). METHODS: Standardized measures of job satisfaction, burnout, secondary traumatic stress, and vulnerability to grief were used in an online national survey. Open-ended questions addressed resources and supports. HR partners across Canada validated the findings and contributed to alternative interpretations and implications. RESULTS: 651 respondents in Cycle One and 1,360 in Cycle Two reported moderately high levels of job satisfaction; they reported finding great meaning in their work. Yet, mean levels of burnout and secondary traumatic stress were moderate, with the latter significantly increasing in Cycle Two. Reported vulnerability to grief was moderate but increased significantly during COVID. When available, supports lacked the quality necessary to respond to the complexities of HR workers' experiences, or an insufficient number of sessions were covered through benefits. Respondents shared that their professional quality of life was affected more by policy failures and gaps in the healthcare system than it was by the demands of their jobs. CONCLUSION: Both the benefits and the strain of providing harm reduction services cannot be underestimated. For HR providers, these impacts are compounded by the drug toxicity emergency, making the service gaps experienced by them all the more critical to address. Implications highlight the need for integration of HR into the healthcare system, sustainable and reliable funding, sufficient counselling supports, and equitable staffing models. Support for this essential workforce is critical to ensuring the well-being of themselves, the individuals they serve, and the health of the broader healthcare system.

Rapid Access Addiction Medicine Clinics for People With Problematic Opioid Use.

Importance: New approaches are needed to provide care for individuals with problematic opioid use (POU). Rapid access addiction medicine (RAAM) clinics offer a flexible, low-barrier, rapid access care model for this population. Objective: To assess the associations of RAAM clinics with emergency department (ED) visits, hospitalizations, and mortality for people with POU. Design, Setting, and Participants: A retrospective cohort study involving a matched control group was performed using health administrative data from Ontario, Canada. Anonymized data from 4 Ontario RAAM clinics (cities of Ottawa, Toronto, Oshawa, and Sudbury) were linked with health administrative data. Analyses were performed on a cohort of individuals who received care at participating RAAM clinics and geographically matched controls who did not receive care at a RAAM clinic. All visits occurred between October 2, 2017, and October 30, 2019, and data analyses were completed in spring 2023. A propensity score-matching approach was used to balance confounding factors between groups, with adjustment for covariates that remained imbalanced after matching. Exposures: Individuals who initiated care through the RAAM model (including assessment, pharmacotherapy, brief counseling, harm reduction, triage to appropriate level of care, navigation to community services and primary care, and related care) were compared with individuals who did not receive care through the RAAM model. Main Outcomes and Measures: The primary outcome was a composite measure of ED visits for any reason, hospitalization for any reason, and all-cause mortality (all measured up to 30 days after index date). Outcomes up to 90 days after index date, as well as outcomes looking at opioid-related ED visits and hospitalizations, were also assessed. Results: In analyses of the sample of 876 patients formed using propensity score matching, 440 in the RAAM group (mean [SD] age, 36.5 [12.6] years; 276 [62.7%] male) and 436 in the control group (mean [SD] age, 36.8 [13.8] years; 258 [59.2%] male), the pooled odds ratio (OR) for the primary, 30-day composite outcome of all-cause ED visit, hospitalization, or mortality favored the RAAM model (OR, 0.68; 95% CI, 0.50-0.92). Analysis of the same outcome for opioid-related reasons only also favored the RAAM intervention (OR, 0.47; 95% CI, 0.29-0.76). Findings for the individual events of hospitalization, ED visit, and mortality at both 30-day and 90-day follow-up also favored the RAAM model, with comparisons reaching statistical significance in most cases. Conclusions and Relevance: In this cohort study of individuals with POU, RAAM clinics were associated with reductions in ED visits, hospitalizations, and mortality. These findings provide valuable evidence toward a broadened adoption of the RAAM model in other regions of North America and beyond.

Evaluation of the gap in delivery of opioid agonist therapy among individuals with opioid-related health problems: a population-based retrospective cohort study.

AIMS: Although opioid-related harms have reached new heights across North America, the size of the gap in opioid agonist therapy (OAT) delivery for opioid-related health problems is unknown in most jurisdictions. This study sought to characterize the gap in OAT treatment using a cascade of care framework, and determine factors associated with engagement and retention in treatment. DESIGN: A population-based retrospective cohort study. SETTING: Ontario, Canada. PARTICIPANTS: Individuals who sought medical care for opioid-related health problems or died from an opioid-related cause between 2005 and 2019. MEASUREMENTS: Monthly treatment status for buprenorphine/naloxone or methadone OAT between 2013 and 2019 (i.e. 'off OAT', 'retained on OAT < 6 months', 'retained on OAT ≥ 6 months'). FINDINGS: Of 122 811 individuals in the cohort, 97 516 (79.4%) received OAT at least once during the study period. There was decreasing 6-month treatment retention over time. Model results indicated that males had higher odds of being on OAT each month [odds ratio (OR) = 1.26, 95% confidence interval (CI) = 1.23-1.28] but lower odds of OAT retention (OR = 0.90, 95% CI = 0.88-0.92), while the reverse was observed for older individuals (monthly: OR = 0.76 per 10-year increase, 95% CI = 0.76-0.77; retention: OR = 1.36 per 10-year increase, 95% CI = 1.34-1.38) and individuals with higher neighbourhood income (e.g. highest income quintile, monthly: OR = 0.79, 95% CI = 0.77-0.82; highest income quintile, retention: OR = 1.15, 95% CI = 1.11-1.20). Individuals residing in rural areas and with a history of mental health diagnoses had poorer outcomes overall, including lower odds of being on OAT each month (rural: OR = 0.75, 95% CI = 0.73-0.78; mental health: OR = 0.89, 95% CI = 0.87-0.92) and OAT retention (rural: OR = 0.79, 95% CI = 0.77-0.82; mental health: OR = 0.81, 95% CI = 0.78-0.83), as well as higher risk of starting/stopping OAT [rural, starting OAT: hazard ratio (HR) = 1.07, 95% CI = 1.05-1.10; mental health, starting OAT: HR = 1.20, 95% CI: 1.18-1.23; rural, stopping OAT: HR = 1.24, 95% CI: = 1.22-1.26; mental health, stopping OAT: HR = 1.11, 95% CI = 1.09-1.13]. Individuals with a history of mental health diagnoses also had a higher risk of death, regardless of OAT status (off OAT death: HR = 1.49, 95% CI = 1.33-1.66; on OAT death: HR = 1.20, 95% CI = 1.09-1.31). CONCLUSIONS: Factors influencing engagement and declining retention in treatment with opioid agonist therapy in Ontario's health system include age, sex and neighbourhood income, as well as mental health diagnoses or residing in rural regions.

Supporting community overdose response planning in Ontario, Canada: Findings from a situational assessment.

BACKGROUND: Many communities across North America are coming together to develop comprehensive plans to address and respond to the escalating overdose crisis, largely driven by an increasingly toxic unregulated drug supply. As there is a need to build capacity for successful implementation, the objective of our mixed methods study was to identify the current planning and implementation practices, needs, and priority areas of support for community overdose response plans in Ontario, Canada. METHODS: We used a situational assessment methodology to collect data on current planning and implementation practices, needs, and challenges related to community overdose response plans in Ontario, consisting of three components. Between November 2019 to February 2020, we conducted ten semi-structured key informant interviews, three focus groups with 25 participants, and administered an online survey (N = 66). Purposeful sampling was used to identify professionals involved in coordinating, supporting, or partnering on community overdose response plans in jurisdictions with relevant information for Ontario including other Canadian provinces and American states. Key informants included evaluators, representatives involved in centralised supports, as well as coordinators and partners on community overdose response plans. Focus group participants were coordinators or leads of community overdose response plans in Ontario. RESULTS: Sixty-six professionals participated in the study. The current planning and implementation practices of community overdose response plans varied in Ontario. Our analysis generated four overarching areas for needs and support for the planning and implementation of community overdose response plans: 1) data and information; 2) evidence and practice; 3) implementation/operational factors; and 4) partnership, engagement, and collaboration. Addressing stigma and equity within planning and implementation of community overdose response plans was a cross-cutting theme that included meaningful engagement of people with living and lived expertise and meeting the service needs of different populations and communities. CONCLUSIONS: Through exploring the needs and related supports for community overdose response plans in Ontario, we have identified key priority areas for building local capacity building to address overdose-related harms. Ongoing development and refinement, community partnership, and evaluation of our project will highlight the influence of our supports to advance the capacity, motivation, and opportunities of community overdose response plans.

Evaluating comparative effectiveness of psychosocial interventions adjunctive to opioid agonist therapy for opioid use disorder: A systematic review with network meta-analyses.

BACKGROUND: Guidelines recommend that individuals with opioid use disorder (OUD) receive pharmacological and psychosocial interventions; however, the most appropriate psychosocial intervention is not known. In collaboration with people with lived experience, clinicians, and policy makers, we sought to assess the relative benefits of psychosocial interventions as an adjunct to opioid agonist therapy (OAT) among persons with OUD. METHODS: A review protocol was registered a priori (CRD42018090761), and a comprehensive search for randomized controlled trials (RCT) was conducted from database inception to June 2020 in MEDLINE, Embase, PsycINFO and the Cochrane Central Register of Controlled Trials. Established methods for study selection and data extraction were used. Primary outcomes were treatment retention and opioid use (measured by urinalysis for opioid use and opioid abstinence outcomes). Odds ratios were estimated using network meta-analyses (NMA) as appropriate based on available evidence, and in remaining cases alternative approaches to synthesis were used. RESULTS: Seventy-two RCTs met the inclusion criteria. Risk of bias evaluations commonly identified study limitations and poor reporting with regard to methods used for allocation concealment and selective outcome reporting. Due to inconsistency in reporting of outcome measures, only 48 RCTs (20 unique interventions, 5,404 participants) were included for NMA of treatment retention, where statistically significant differences were found when psychosocial interventions were used as an adjunct to OAT as compared to OAT-only. The addition of rewards-based interventions such as contingency management (alone or with community reinforcement approach) to OAT was superior to OAT-only. Few statistically significant differences between psychosocial interventions were identified among any other pairwise comparisons. Heterogeneity in reporting formats precluded an NMA for opioid use. A structured synthesis was undertaken for the remaining outcomes which included opioid use (n = 18 studies) and opioid abstinence (n = 35 studies), where the majority of studies found no significant difference between OAT plus psychosocial interventions as compared to OAT-only. CONCLUSIONS: This systematic review offers a comprehensive synthesis of the available evidence and the limitations of current trials of psychosocial interventions applied as an adjunct to OAT for OUD. Clinicians and health services may wish to consider integrating contingency management in addition to OAT for OUD in their settings to improve treatment retention. Aside from treatment retention, few differences were consistently found between psychosocial interventions adjunctive to OAT and OAT-only. There is a need for high-quality RCTs to establish more definitive conclusions. TRIAL REGISTRATION: PROSPERO registration CRD42018090761.

Barriers and facilitators to buprenorphine use for opioid agonist treatment: protocol for a scoping review.

INTRODUCTION: In the context of the opioid crisis in North America, the benefits of evidence-based opioid agonist treatments such as buprenorphine/naloxone have not been optimised due to low uptake. Numerous factors contribute to the underuse of buprenorphine, and theory-informed approaches to identify and address implementation barriers and facilitators are needed. This scoping review aims to characterise the barriers and facilitators at the patient, healthcare professional, organisation and system level according to the Theoretical Domains Framework (TDF), and identify gaps to inform practice and policy. METHODS AND ANALYSIS: We will conduct a scoping review using established methods and follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. We will identify English and French-language peer-reviewed literature by searching five electronic bibliographic databases (MEDLINE, Embase, PsychINFO, CINAHL, and SocINDEX), from inception and use Google, websites of key organisations, and two or more custom search engines to identify relevant grey literature. Eligible records will be quantitative or qualitative studies that examine barriers and facilitators to buprenorphine use at the patient, healthcare professional, organisation and system level, and involve participants with diagnosis of opioid use disorder or professionals involved in their care. Two reviewers will be involved in independently screening, reviewing and charting the data and calibration exercises will be conducted at each stage. We will conduct descriptive analysis for the charted data, and deductively code barriers and facilitators using the TDF. ETHICS AND DISSEMINATION: As a scoping review of the literature, this study does not require ethics approval. Our dissemination strategy will focus on developing tailored activities to meet the needs of diverse knowledge user audiences. Barriers and facilitators mapped to the TDF can be linked to evidence-based strategies for change to improve buprenorphine use and access, and enable practice to reduce opioid-related harms.

'Communities are attempting to tackle the crisis': a scoping review on community plans to prevent and reduce opioid-related harms.

OBJECTIVES: We sought to understand the implementation of multifaceted community plans to address opioid-related harms. DESIGN: Our scoping review examined the extent of the literature on community plans to prevent and reduce opioid-related harms, characterise the key components, and identify gaps. DATA SOURCES: We searched MEDLINE, Embase, PsycINFO, CINHAL, SocINDEX and Academic Search Primer, and three search engines for English language peer-reviewed and grey literature from the past 10 years. ELIGIBILITY CRITERIA: Eligible records addressed opioid-related harms or overdose, used two or more intervention approaches (eg, prevention, treatment, harm reduction, enforcement and justice), involved two or more partners and occurred in an Organisation for Economic Co-operation and Development country. DATA EXTRACTION AND SYNTHESIS: Qualitative thematic and quantitative analysis was conducted on the charted data. Stakeholders were engaged through fourteen interviews, three focus groups and one workshop. RESULTS: We identified 108 records that described 100 community plans in Canada and the USA; four had been evaluated. Most plans were provincially or state funded, led by public health and involved an average of seven partners. Commonly, plans used individual training to implement interventions. Actions focused on treatment and harm reduction, largely to increase access to addiction services and naloxone. Among specific groups, people in conflict with the law were addressed most frequently. Community plans typically engaged the public through in-person forums. Stakeholders identified three key implications to our findings: addressing equity and stigma-related barriers towards people with lived experience of substance use; improving data collection to facilitate evaluation; and enhancing community partnerships by involving people with lived experience of substance use. CONCLUSION: Current understanding of the implementation and context of community opioid-related plans demonstrates a need for evaluation to advance the evidence base. Partnership with people who have lived experience of substance use is underdeveloped and may strengthen responsive public health decision making.

Lessons learned from the opioid crisis across the pillars of the Canadian drugs and substances strategy.

BACKGROUND: Canada is facing an urgent challenge to reduce the harms associated with opioids: from January 2016 to December of 2018, more than 11,500 individuals lost their lives due to opioid related harms. This review examines responses to the opioid crisis thus far, the lessons learned from these initiatives and the knowledge gaps that still need to be addressed across the four pillar model adopted by the CDSS. METHODS: A search of peer-reviewed literature was conducted in PubMed and PsycNet, and grey literature was retrieved from reputable substance use and health organizations to determine responses to the opioid crisis and related outcomes between 2013 and 2019. Findings related to actions, outcomes and unintended consequences across the categories of prevention, treatment, harm reduction, enforcement and the evidence base were included and synthesized into a narrative review on lessons learned. RESULTS: The opioid crisis is a result of multiple, complex interrelated factors. Many physicians may not feel competent to appropriately treat pain and/or addiction. Pushes for opioid deprescribing have resulted in some individuals using illicit opioids as treatment. A range of effective and accessible pharmacological and psychological treatments are still required. When regulations are barriers, unsanctioned actions, such as overdose prevention sites, may be enacted by individuals to respond to urgent public health needs. A nimble response with evolving enforcement perspectives can aid individuals experiencing harms from opioid use. CONCLUSIONS: There is no one size fits all response to this crisis, and consideration should be given to the unique needs of different communities and populations, as well as the broader impact of harms on families, communities, and society. A situation so multifaceted requires both immediate and long-term strategies implemented concurrently in order to address the differing and on-going needs of Canadians experiencing opioid harms. The expertise of individuals and families affected by the opioid crisis must be included in consultations and decisions related to different strategies, to ensure responses are not stigmatizing, that they will be effective and acceptable and that unintended consequences are quickly recognized and mitigated.

Evaluating comparative effectiveness of psychosocial interventions for persons receiving opioid agonist therapy for opioid use disorder: protocol for a systematic review.

INTRODUCTION: The opioid crisis has resulted in increasing rates of death caused by problematic opioid use. Current clinical guidelines recommend that individuals with persons with opioid use disorder (OUD) receive pharmacological (eg, opioid agonist therapy) and psychosocial (eg, cognitive behavioural therapy) therapy; however, the best combination of pharmacologic and psychosocial components is not known. Our objective of the planned study is to conduct a comprehensive systematic review to assess the relative benefits of psychosocial interventions as an adjunct to opioid agonist therapy among persons with OUD. METHODS AND ANALYSIS: A comprehensive search for randomised controlled trials published in English or French will be conducted from database inception to March 2018. The search will be conducted in MEDLINE and translated for Embase, PsycINFO and the Cochrane Central Register of Controlled Trials. Two independent reviewers will screen, extract and assess risk of bias of eligible articles. Primary outcomes of interest will be treatment retention and opioid use (based on urinalysis results). Secondary outcomes will include self-reported opioid use, abstinence from illicit drugs, adherence to psychosocial therapy and opioid agonist therapy, risk for sexually transmitted disease, risk for blood borne pathogens, changes in mental health symptoms (eg, depression), measures of craving and changes in patients' quality of life and relevant adverse events. If sufficient data and adequate homogeneity exists, network meta-analyses (NMA) will be performed. ETHICS AND DISSEMINATION: This will be the first systematic review to incorporate NMA to compare psychosocial treatments used as an adjunct to opioid agonist therapy for OUD. Results of this review will inform clinical management of persons with OUD. TRIAL REGISTRATION NUMBER: CRD42018090761.

Intolerance of uncertainty, appraisals, coping, and anxiety: the case of the 2009 H1N1 pandemic.

OBJECTIVES: Although ambiguous and uncertain situations, such as those dealing with the threat of widespread viral illness, may have pronounced psychological ramifications, there have been few studies that examined the factors that contributed to such outcomes. The purpose of the present investigation was to examine emotional reactions to a health threat. DESIGN: A structural equation model examined the interplay between anxiety and intolerance of uncertainty, as sequentially mediated by appraisals and coping strategies. METHODS: Adult participants over the age of 18 (N = 1,027) completed online self-report measures during the H1N1 pandemic in 2009. RESULTS: Greater intolerance of uncertainty was related to lower appraisals of self- and other control, which predicted low levels of problem-focused coping and greater reports of H1N1-related anxiety. Additionally, individuals with a high intolerance of uncertainty were more likely to perceive the pandemic as threatening and also were more apt to use emotion-focused coping strategies, and both of these factors predicted elevated levels of anxiety. CONCLUSIONS: Together, these data indicate that threats, such as those related to a potential pandemic, not only have implications for physical health, but also for psychological distress, and that such outcomes vary with a constellation of appraisal and coping factors. STATEMENT OF CONTRIBUTION: What is already known on this subject? It has been established that the public is often confused by the threat that a potential pandemic virus poses and that they are unsure of what information related to the disease they can trust. Government health agencies often walk the line of minimizing the threat to prevent panic, but simultaneously emphasize the importance of action (vaccination) to prevent a worldwide pandemic. What does this study add? Beyond the physical threat of a pandemic, a significant psychological toll may occur for certain individuals. Anxiety regarding H1N1 is heightened amongst those who cannot tolerate uncertainty. Appraisals of threat, control, and the use of emotion-focused coping mediate the above relationship.

H1N1 was not all that scary: uncertainty and stressor appraisals predict anxiety related to a coming viral threat.

H1N1 reached pandemic proportions in 2009, yet considerable ambivalence was apparent concerning the threat presented and the inclination to be vaccinated. The present investigation assessed several factors, notably appraisals of the threat, intolerance of uncertainty, and familiarity with the virus, that might contribute to reactions to a potential future viral threat. Canadian adults (N = 316) provided with several scenarios regarding viral threats reported moderate feelings of anxiety, irrespective of whether the viral threat was one that was familiar versus one that was entirely unfamiliar to them (H1N1 recurrence, H5N1, a fictitious virus: D3N4). Participants appraised the stressfulness of the threats to be moderate and believed that they would have control in this situation. However, among individuals with high intolerance of uncertainty, the viral threat was accompanied by high levels of anxiety, which was mediated by aspects of appraisals, particularly control and stressfulness. In addition, among those individuals that generally appraised ambiguous life events as being stressful, the viral threat appraisals were accompanied by still greater anxiety. Given the limited response to potential viral threats, these results raise concerns that the public may be hesitant to heed recommendations should another pandemic occur.

The 2009 H1N1 Influenza Pandemic: the role of threat, coping, and media trust on vaccination intentions in Canada.

Swine flu (H1N1) reached pandemic proportions in 2009, yet ambivalence was met concerning intentions to be vaccinated. The present investigation determined predictors of perceived H1N1 contraction risk and vaccination intentions among Canadian adults (N = 1,027) responding to an online questionnaire. The relatively low rate of vaccination intent (30.12%, and 34.99% being unsure of their intent) was related to a sense of invulnerability regarding illness contraction and symptom severity. Most individuals were skeptical that H1N1 would be widespread, believing that less than 10% of the population would contract H1N1. Yet, they also indicated that their attitudes would change once a single person they knew contracted the illness. Also, worry regarding H1N1 was related to self-contraction risk and odds of individuals seeking vaccination. Moreover, vaccination intent was related to the perception that the threat was not particularly great, mistrust of the media to provide accurate information regarding H1N1, and whether individuals endorsed problem-focused versus avoidant coping strategies. Given the role media plays in public perceptions related to a health crisis, trust in this outlet and credibility regarding the threat are necessary for adherence to recommended measures to minimize health risk.

Everyday experiences of women posttreatment after breast cancer: the role of uncertainty, hassles, uplifts, and coping on depressive symptoms.

Considerable research has examined the experiences of women at risk, during diagnosis, and throughout treatment of breast cancer; however, less in known about these women posttreatment. Many women report dealing with extensive long-standing ailments such as lymphedema and fatigue, as well as a fear of illness recurrence. However, women posttreatment also report finding benefit and meaning from their cancer occurrence. These orthogonal outcomes may be related to the uncertainty an individual is able to tolerate. Thus, this online study examined Canadian women who completed treatment for breast cancer (n = 42), and women in a control condition (n = 42), responses to the daily experience of hassles and uplifts, intolerance of uncertainty, coping strategies, and depressive symptoms. Although depressive symptoms and daily hassles did not differ between the two groups of women, women with a previous cancer experience reported a greater amount and frequency of daily uplifts, and hassle intensity predicted fewer depressive symptoms among women posttreatment compared to healthy controls. Furthermore, hassle intensity mediated the relationship between intolerance of uncertainty and depressive symptoms, but only for women in the control condition. Last, for women posttreatment only, the use of emotion-focused coping to deal with a fear of cancer recurrence mediated the relationship between intolerance of uncertainty and depressive symptoms, whereas problem-focused, avoidant, or cognitive-restructuring coping strategies did not. These results point to the need to provide resources to women posttreatment, but also that those women who survive breast cancer can obtain benefits from the experience.

Trust in physician in relation to blame, regret, and depressive symptoms among women with a breast cancer experience.

Following a diagnosis of breast cancer women experience considerable distress and often present with elevated symptoms of depression. A woman's relationship with her oncologist, and particularly trust in the physician, might influence depressive symptoms, as well as emotional and cognitive reactions to medical decisions made concerning treatment. To assess these relationships, women currently undergoing treatment for breast cancer (n = 40) and women who had previously been treated for breast cancer (n = 74) were asked about (1) trust in their physician, (2) who they blamed for negative events during treatment, (3) who made the treatment decisions, (4) regret, and (5) depressive symptoms. As well, community participants (n = 146) without breast cancer were asked about trust in their physician, levels of depression, and questions regarding blame if they hypothetically had breast cancer. Depression was greatest among women in treatment, and trust in physician was greatest among women posttreatment. However, trust in physician was neither related to depressive symptoms, decision making, nor responsibility for presence of metastases/relapse. Paradoxically, greater trust in physician was related to increased blame of the doctor for other negative events that had occurred. Furthermore, depressive scores were higher among women who blamed their doctor for negative events in comparison to women who ascribed blame to no one. As well, individuals who blamed themselves for negative events reported greater regret than individuals who blamed no one. Thus, though a woman may not hold her physician directly responsible for health outcomes, this relationship may be important to consider in other aspects of her psychological well-being.