What is happening during case deliberations in clinical ethics committees? A pilot study.

BACKGROUND: Clinical ethics consultation services have been established in many countries during recent decades. An important task is to discuss concrete clinical cases. However, empirical research observing what is happening during such deliberations is scarce. OBJECTIVES: To explore clinical ethics committees' deliberations and to identify areas for improvement. DESIGN: A pilot study including observations of committees deliberating a paper case, semistructured group interviews, and qualitative analysis of the data. PARTICIPANTS: Nine hospital ethics committees in Norway. RESULTS AND INTERPRETATIONS: Key elements of the deliberations included identifying the ethical problems; exploring moral values and principles; clarifying key concepts and relevant legal regulation; exploring medical facts, the patient's situation, the therapists' perspective, analogous clinical situations, professional uncertainties, the patient's and relatives' perspective, and clinical communication; identifying the involved parties and how to involve them; identifying possible courses of action, and possible conclusion and follow-up. The various elements were closely interwoven. The content and conclusions varied and seemed to be contingent on the committee members' interpretations, experience and knowledge. Important aspects of a clinical ethics deliberation were sometimes neglected. When the committees used a deliberation procedure and a blackboard, the deliberations tended to become more systematic and transparent. Many of the committees were insecure about how to include the involved parties and how to document the deliberations. CONCLUSION: Clinical ethics committees may provide an important arena for multidisciplinary discussions of complex clinical ethics challenges. However, this seems to require adequate composition, adoption of transparent deliberation procedures, and targeted training.

[How is the specialist training in radiology?]. / Hvordan er det å vaere utdanningskandidat i radiologi?

BACKGROUND: On the basis of results from a focus group interview showing that the specialist training in radiology was considered unsatisfactory, we performed a questionnaire survey among residents attending specialist training in Norwegian x-ray departments. MATERIAL AND METHODS: A questionnaire on background and working and study conditions was mailed to 113 radiology residents. RESULTS: The response rate was 73%. More than 50% of the residents reported that the quality of the training they received in magnetic resonance imaging and to some extent in interventional radiology and doppler examinations, was unsatisfactory, independent of type of department. Residents working in larger departments reported more problems in learning the most common interventional procedures, CT examinations and fluoroscopy examinations than did collegues working in smaller departments. Experienced autonomy with regard to organisation of own work was significantly lower among female physicians than among their male collegues. INTERPRETATION: There is shortage of time as well as specific learning possibilities for Norwegian radiology residents. The potential for improvement is large.

[Perception among Norwegian hospital physicians of physician-nurse cooperation]. / Oppfatninger blant norske sykehusleger om samarbeidet mellom lege og sykepleier.

It is generally agreed that a positive and cooperative atmosphere between nurses and doctors is of vital importance to the quality of medical services in hospitals. In this study 1,278 Norwegian hospital doctors were asked how they perceived the working atmosphere between doctors and nurses. 75% replied that the doctors-nurse relationship was characterized by openness and dialogue and half of them felt that there was generally not much competition with regard to medical responsibility. Only 14% found communicating difficult, 20% stated that conflicts between the two groups were seldom discussed openly. Psychiatrists were found to view the relationship in the most positive light, whereas surgeons and non-specialists (mostly residents and interns) perceived the working atmosphere less favourably. Young doctors had a more negative view of the relationship than older ones. Neither gender nor job position were of any significance in predicting the perceptions. A high level of autonomy and a low level of stress were factors which contributed positively to the doctor-nurse relationship.

[Professional learning and collective knowledge. Learning environment in two Norwegian hospital departments]. / Profesjonslaering og kollektiv kunnskap. Laeringsmiljø i to norske sykehusavdelinger.

Conditions for learning in two Norwegian hospital departments are explored in this article. 20 in-depth interviews with physicians working on the surgical and medical departments of a large general hospital were carried out in 1994. We focus on the social aspects of learning and apply access to learning situations as an analytical perspective to explain how possibilities for learning are created in the daily activities of the two departments. Access to learning situations is created in a "zone of possibility" between the formal organisation and the more informal interpersonal networks in the hospital. The division of the department into sections is used as an example of how organisational factors determine with which areas one becomes familiar. The notion of "the good apprentice" and the relationship between initiative and invitation illuminate the significance of interpersonal factors for access to learning situations. Finally, we illustrate how time is an important but scarce resource influencing the development of shared knowledge in the department.

[How to learn medical practice? A qualitative study of physicians' perception of their own learning processes]. / Hvordan laeres medisinsk praksis? En kvalitativ studie av legers oppfatning av egne laeringsprosesser.

In this article we explore how physicians develop professional knowledge in their everyday work. 20 indepth interviews with physicians working in the surgical and internal medicine departments of a Norwegian hospital were conducted in 1994. Explanatory models from situated learning theory were applied to analyse the taped interview material. The expert-novice relation emerges as the core of the traditional medical learning institutions. Here the inexperienced physician learns the necessary practical skills, ways of reasoning and standards of diagnosis and treatment in the hospital. In interaction with a more experienced physician the novice transcends what she can do alone and develops as a professional. The quality of learning depends on the dialogue between the novice and the expert in the actual situation. The physicians' descriptions of their own learning process change with increasing competence and position in the hospital hierarchy.

The communication atmosphere between physician colleagues: competitive perfectionism or supportive dialogue? A Norwegian study.

Open and supportive communication is probably one of the most important promotors of learning, coping and satisfaction at the workplace. The aim of this paper is to describe and predict the communication atmosphere between Norwegian physicians. Twenty statements describing communication, as perceived by the physicians themselves, were presented to a random sample of the members of the Norwegian Medical Association of which more than 90% of the physicians in the country are members (N = 2628). In general, this investigation indicates that the communication atmosphere among Norwegian physicians is characterised by support and mutual respect. More than half of the respondents fully agreed that communication between colleagues in the workplace is marked by solidarity, and that experienced colleagues show respect for the less experienced in both personal and professional matters. Physicians working in hospitals described the communication atmosphere as substantially more selfish and competitive than non-hospital physicians, whilst general practitioners considered the atmosphere between colleagues to be more supportive than non-specialists. In addition, high perceived stress was associated with the perception of a less supportive atmosphere. However, the strongest predictor of the communication atmosphere was clearly the physician's perceived autonomy. The comprehensive retrenchment programmes implemented in Norwegian hospitals during recent years have increased stress and restricted professional autonomy among both physicians and other occupational groups. Our findings indicate that the communication atmosphere necessary to secure continuity of knowledge within the medical profession may have been jeopardised by this process. In the long term, this may prove hazardous to the quality of medical care.

[General practitioners, community physicians and hospital physicians--how different are they?]. / Allmennpraktikere, kommuneleger og sykehusleger--hvor forskjellige er de?

In 1993, 9,226 practising physicians in Norway received extensive questionnaires about their health, working and living conditions. In this article we compare municipality employed community physicians (n = 972), general practitioners in private practice (n = 869), and hospital physicians (n = 3,160) with regard to demographic variables and their experience of stress, professional autonomy and job satisfaction. General practitioners report higher job satisfaction and more autonomy than community and hospital physicians, whereas community physicians seem to have a somewhat higher stress level than the two other categories. The experience of general well being, however, is the same in the three groups. General practitioners also spend more time with patients, and are much more satisfied with their income.

[Physicians and the mass media. Opinion of physicians on the coverage of medicine, health policy and the medical profession by the mass media]. / Leger og massemedier. Legeoppfatninger om massemedienes omtale av medisin, helsepolitikk og legene som yrkesgruppe.

Every fourth physician disapproves of mass media coverage of health policy questions. Four out of ten physicians are dissatisfied with the way scientific medical issues are covered, and seven out of ten are dissatisfied with articles and programmes about the medical profession. The physicians' dissatisfaction was predicted by a low level of perceived job autonomy and a high level of perceived unrealistic expectations from patients, families, superiors and politicians. The doctors' disapproval of press coverage of the medical profession increased with perceived stress. The dissatisfaction was clearly greater among younger than among older physicians. Internists and surgeons tended to be more dissatisfied than physicians in other specialties. Dissatisfaction with mass media was not, however, a question of personal grudge: respondents who felt that they themselves had been unfairly spoken of by the media did not disapprove of the media coverage of health issue, or of the medical profession in general, to any greater degree than did doctors who had no such personal complaints.

[Medical undergraduate education is outdated. From the interns' point of view]. / Medisinsk grunnutdanning i utakt. Grunnutdanninga slik turnuskandidaten opplever ho.

This survey is based on a questionnaire sent to all 517 interns in Norway in December 1990, of whom 93% replied. Ten interns were interviewed personally. The majority felt they received a good theoretical basis during their medical studies, but less than a third stated that the education had adequate vocational orientation. Students from the University of Tromsø, were the exception in this respect. They were more positive towards the vocational aspects of their studies. Most interns had high expectations with regard to learning during internship, and half of them to have to face various traumatic experiences during this period. One out of two stated that, so far, their internship training had been inspiring for their career as medical practitioner. About a third replied that they doubted whether they would choose the same profession if they were to make this decision again. The results of this study emphasize the importance of the current changes in the curriculum at all four medical faculties in Norway. The results also suggest a need for better coordination of university studies and internship, and more structured teaching during the internship.

[Professionalization without management? A study of the scientific content during the internship]. / Profesjonalisering uten styring? En undersøkelse om det faglige innholdet i turnustjenesten.

The basic medical education in Norway ends with one year as house physician or surgeon and six months as assistant to general practitioner. This internship is an important period in the course of education leading to a medical degree. According to a new national standard issued in 1989 all interns should have a personal supervisor and a formal curriculum covering this period. The present survey was carried out in order to evaluate the quality of learning during internship as experienced by the trainees. A questionnaire was sent to all 517 Norwegian interns as of December 1990. 93% replied. Ten of the interns were interviewed personally. 34% of the house officers had an appointed supervisor compared with 54% in primary care. Few of the interns had a formal curriculum. Many of them felt the need for constructive feedback on their professional performance, but few received it. They nevertheless claimed that it was easy both to raise questions and to obtain assistance in solving medical problems. One out of six interns had been severely depressed during the period of internship and related this to experiences at work. Women were generally more sensitive than men in this respect and were more critical of the interpersonal relationships experienced during this period. Despite the new standard, which sets realistic and necessary goals for this part of the medical education, learning during internship is still much a matter of chance. It is a major challenge to the medical profession to take the needs of young medical practitioners seriously.