Exploring defensive medicine: examples, underlying and contextual factors, and potential strategies - a qualitative study.

BACKGROUND: Medical errors, unsatisfactory outcomes, or treatment complications often prompt patient complaints about healthcare providers. In response, physicians may adopt defensive practices to mitigate objections, avoid complaints, and navigate lengthy trial processes or other potential threats. However, such defensive medicine (DM) practices can carry risks, including potential harm to patients and the imposition of unnecessary costs on both patients and the healthcare system. Moreover, these practices may run counter to accepted ethical standards in medicine. METHODS: This qualitative study involved conducting semi-structured interviews with 43 physicians, among whom 38 were faculty members at medical universities, 42 had administrative experience at various levels of the health system, and 23 had previously served as health system policymakers. On average, the participants had approximately 23.5 years of clinical experience. The selection of participants was based on purposive sampling. Data collection through interviews continued until data saturation was achieved. RESULTS: Based on the findings, DM manifests in both positive and negative forms, illustrated by instances like ordering unnecessary lab tests, imaging, or consultations, reluctance to admit high-risk patients, and avoiding high-risk procedures. The study participants identified a range of underlying and contextual factors contributing to DM, encompassing organizational-managerial, social, personal, and factors inherent to the nature of defensive medical practices. The results also highlight proposed strategies to address and prevent DM, which can be grouped into organizational-managerial, social, and those focused on modifying the medical complaints management system. CONCLUSION: DM is a multifaceted and significant phenomenon that necessitates a comprehensive understanding of its various aspects, including interconnected and complex structures and underlying and contextual factors. While the results of this study offer a solid foundation for informing policy decisions within the healthcare system and include some explanatory policy suggestions, we encourage policymakers to complement the findings of this study with other available evidence to address any potential limitations and to gain a more comprehensive understanding of the policymaking process related to DM.

Developing a comprehensive tool to assess professional attitude among physicians and medical students.

It appears that up until now, no comprehensive tool has been developed to assess medical students' attitudes toward the different dimensions of professionalism. The present study aimed to develop a comprehensive quantitative tool to evaluate medical students' attitudes toward professionalism. This study consisted of two phases: The first phase was item generation and questionnaire design based on literature review and a qualitative survey. The qualitative data were extracted from 49 semi-structured individual interviews and one focus group discussion. In the second phase, the questionnaire was developed and its face, content, and structure validity and reliability were evaluated. To measure the construct validity of the questionnaire, a cross-sectional study was conducted on 354 medical students at different academic levels at Isfahan University of Medical Sciences. The final questionnaire was loaded on five factors. The factors accounted for 43.5% of the total variance. Moreover, Cronbach's alpha was 0.84 for the total scale, and the interclass correlation coefficient was 0.77 for the test-retest reliability. The 17-item questionnaire measuring medical students' professional attitude had acceptable validity and reliability and can be adopted in other studies on physicians' and medical students' professional attitudes.

Obstacles of professional behavior among medical trainees: A qualitative study from Iran (2018).

INTRODUCTION: Despite all efforts that have been made to promote professional behavior among medical trainees, unfortunately, reports from medical schools around the world confirm the prevalence of nonprofessional behaviors by medical students. Experts in the field of medical ethics and medical education in different countries have suggested several reasons for failing to minimize unprofessional performance among medical students. MATERIALS AND METHODS: This qualitative study aimed to promote our understanding from the challenges faced by Iranian medical students in providing professional behavior. The study was first conducted in the form of a semi-structured face-to-face interview with medical students and then completed with a focus group discussion (FGD) session. Forty-nine medical students participated in the interviews and 11 students participated in the FGD session. Qualitative conventional content analysis was used for examining the data. RESULTS: The participants classified the obstacles of professional behavior into the following three main categories: problems related to educational system, problems related to the society, and problems related to students themselves. CONCLUSION: Regarding the impact of various personal, social, and educational factors on the creation and expansion of unprofessional behaviors among medical students, it is essential to have a comprehensive approach for solving the problem.

Flexible hybrid structure piezoelectric nanogenerator based on ZnO nanorod/PVDF nanofibers with improved output.

This study aimed to develop a novel hybrid piezoelectric structure based on poly(vinylidene difluoride) nanofibers (PVDF NFs) and zinc oxide nanorods (ZnO NRs) which eliminate the need for post poling treatment in such hybrid structures. Mechanism of electrical performance enhancement of the hybrid structure is also discussed in this paper. To study the effect of hybridization on piezoelectric performance, pristine ZnO NRs and pristine PVDF NF nanogenerators were also fabricated. The piezoelectric performance of these three nanogenerators was evaluated under periodic deformation at low frequency. The output power of the hybrid structure was found to be enhanced compared to pristine ZnO NRs and PVDF NFs nanogenerators. Such simple hybrid devices that do not need to complicated post poling treatment are more efficient than previous hybrid PVDF/ZnO nanogenerators for practical application. This improved piezoelectric nanogenerator is expected to enable various applications in the field of self-powered devices and wearable energy harvesting to harvest mechanical energy from the human activities.

Does medical education erode medical trainees' ethical attitude and behavior?

In the last few years, medical education policy makers have expressed concern about changes in the ethical attitude and behavior of medical trainees during the course of their education. They claim that newly graduated physicians (MDs) are entering residency years with inappropriate habits and attitudes earned during their education. This allegation has been supported by numerous research on the changes in the attitude and morality of medical trainees. The aim of this paper was to investigate ethical erosion among medical trainees as a serious universal problem, and to urge the authorities to take urgent preventive and corrective action. A comparison with the course of moral development in ordinary people from Kohlberg's and Gilligan's points of view reveals that the growth of ethical attitudes and behaviors in medical students is stunted or even degraded in many medical schools. In the end, the article examines the feasibility of teaching ethics in medical schools and the best approach for this purpose. It concludes that there is considerable controversy among ethicists on whether teaching ethical virtues is plausible at all. Virtue-based ethics, principle-based ethics and ethics of care are approaches that have been considered as most applicable in this regard.

Overexpression and Purification of C-terminal Fragment of the Passenger Domain of Hap Protein from Nontypeable Haemophilus influenzae in a Highly Optimized Escherichia coli Expression System.

BACKGROUND: Nontypeable Haemophilus influenzae (NTHi) is a common cause of respiratory tract disease and initiates infection by colonization in nasopharynx. The Haemophilus influenzae (H. influenzae) Hap adhesin is an auto transporter protein that promotes initial interaction with human epithelial cells. Hap protein contains a 110 kDa internal passenger domain called "HapS" and a 45 kDa C-terminal translocator domain called "Hapß". Hap adhesive activity has been recently reported to be connected to its Cell Binding Domain (CBD) which resides within the 311 C-terminal residues of the internal passenger domain of the protein. Furthermore, immunization with this CBD protein has been shown to prevent bacterial nasopharynx colonization in animal models. METHODS: To provide enough amounts of pure HapS protein for vaccine studies, we sought to develop a highly optimized system to overexpress and purify the protein in large quantities. To this end, pET24a-cbd plasmid harboring cbd sequence from NTHi ATCC49766 was constructed and its expression was optimized by testing various expression parameters such as growth media, induction temperature, IPTG inducer concentration, induction stage and duration. SDS-PAGE and Western-blotting were used for protein analysis and confirmation and eventually the expressed protein was easily purified via immobilized metal affinity chromatography (IMAC) using Ni-NTA columns. RESULTS: The highest expression level of target protein was achieved when CBD expressing E. coli BL21 (DE3) cells were grown at 37°C in 2xTY medium with 1.0 mM IPTG at mid-log phase (OD600 nm equal to 0.6) for 5 hrs. Amino acid sequence alignment of expressed CBD protein with 3 previously published CBD amino acid sequences were more than %97 identical and antigenicity plot analysis further revealed 9 antigenic domains which appeared to be well conserved among different analyzed CBD sequences. CONCLUSION: Due to the presence of high similarity among CBD from NTHi ATCC49766 and other NTHi strains, CBD protein expressed here sounds to be theoretically ideal as a universal candidate for being used in vaccine studies against NTHi strains of various geographical areas. Further investigations to corroborate the potency of this protein as a vaccine candidate are under process.

C-X-C motif receptor 2, endostatin and proteinase-activated receptor 1 polymorphisms as prognostic factors in NSCLC.

The progress of non-small cell lung cancer (NSCLC) is dependent on sufficient angiogenesis. Thrombin induced activation of proteinase-activated receptor 1 (PAR-1) on platelets leads to platelet secretion and aggregation. This influences cell survival, apoptosis and angiogenesis by the release of VEGF and Endostatin (ES), a potent angiogenesis inhibitor. Interleukin-8 (IL-8) induces tumor angiogenesis independent of the VEGF pathway through the chemokine C-X-C motif receptor 2 (CXCR-2). Our purpose was to evaluate germline polymorphisms of these potential therapy targets as prognostic markers for disease free survival (DFS) and overall survival (OS) in surgically treated NSCLC patients. In total 209 Caucasian patients, treated between 1996 and 2011, were included in this study. Genomic DNA was extracted from peripheral blood leucocytes. Genotyping of CXCR-2 +1208 C > T and +785 C > T, PAR-1 -506 Ins/del and -14 Ivs A > T and ES +4349 G > A was performed by TaqMan(®) genotyping assays or by polymerase chain reaction (PCR) followed by capillary electrophoresis. Chi-square test, Kaplan-Meier estimator and cox regression hazard model were used to assess the prognostic value of selected polymorphisms. The PAR-1 -14 Ivs A/A genotype was associated with advanced tumor stages (p = 0.024) and, in univariate analysis, with shorter median OS in squamous cell lung carcinoma (SqCC, p = 0.035). The CXCR-2 + 1208T/T genotype was associated with aggressive tumor biology (p = 0.038), and shorter DFS and OS (p = 0.018, p = 0.021) in NSCLC and especially in SqCC a negative predictor for DFS and OS (p = 0.045, p = 0.041). Genotyping of the CXCR-2 +1208 C >T polymorphism could be a useful tool to identify high-risk SqCC subgroups.