Discernimento e realidade são necessários / Discerniment and reality are required

Temos vivido uma situação extremamente delicada e alarmante diante do cenário da pandemia da doença pelo coronavírus 2019 (Covid-19). Como se não bas-tassem as perdas de milhares de vidas, incluindo as de colegas médicos, presenciamos algumas ações errôneas que, infelizmente, têm o intuito mercadológico. Evi-dentemente, esse tipo de postura denota uma falta de formação e cultura médica, abstendo-se do compro-misso real com a população. Vale ressaltar que a Sociedade Brasileira de Clínica Médica (SBCM) prima pela honestidade, pela valo-rização do médico e pela proteção da comunidade. Condenamos veementemente o uso das mídias como veículos contra a vacina. Diante dessa postura, man-temo-nos firmes e fortes, para salientar a importância da boa formação do médico clínico, da conduta e ética médica e, sobretudo, do atendimento humanístico ao paciente. Faz-se necessário sempre lembrar que "o im-portante não é tratar a doença que o homem tem, mas o homem que possui a doença". Desde a sua fundação, em 1989, a SBCM, que com-pletou 33 anos no último dia 16 de março, vê-se diante de muitas transformações no cenário da saúde. No entanto, ela manteve-se firme em relação às questões que envolvem a qualidade e a valorização do médico clínico em sua essência profissional e humanística. Um bom médico é norteado por bases científicas e dados epidemiológicos de fontes fidedignas, com reco-nhecimento notório de entidades que validam os reais cenários globais. Também, fazemos zelo ao médico que procura sempre melhorar sua bagagem teórica e práti-ca para se inspirar em resultados conquistados por seus colegas, vistos nos congressos, nos cursos de reciclagem, em webnários e, principalmente, no dia a dia, tendo como exemplo a beira do leito e a atenção ao enfermo. Para valorizar e enaltecer essa conduta, o médico clínico é um dos especialistas mais capacitados para acompanhar e deliberar quadros clínicos com êxito, sem a necessidade de explorar campos supérfluos para a cura. Portanto, nossa luta em valorizar o médico clínico será contínua e firme pelos nossos princípios e valores.Parabéns aos colegas clínicos pelo seu empenho diário e por se manterem firmes em sua especialidade, mesmo diante de tantos desafios! A SBCM faz parte da sua história e sempre estará ao seu lado.

A survey of Japanese physician preference for attire: what to wear and why.

Many studies have examined the impression made on patients by physicians' attire. Regardless of practice location, many patients express most confidence in physicians who wear white coats. The number of physicians in Japan who choose not to wear white coats in practice has been increasing, particularly in primary care settings. However, very few studies have examined physician preference for attire. To clarify Japanese general practitioners' preference for attire by practice setting, we conducted a survey of physician preferences and reasons for attire selection. Subjects were 794 general practitioners certified by the Japan Primary Care Association and recruited from a mailing list. We conducted a web-based questionnaire survey. Physicians were asked to choose one of four different dress styles (semi-formal, white coat, scrubs, and casual) for different practice settings and state the reasons for selection. The response rate was 19.3% (n = 153; men 112). Most subjects chose white coats as usual attire for hospital practice (52%), mainly because of custom and professionalism. In contrast, most subjects chose non-white coats for clinics (59%) and home care (hospital-provided, 58%; clinic-provided, 71%). More subjects chose casual dress for clinic and home care practice, mainly to appear empathic. Most subjects chose white coats as the most appropriate hospital attire (54%), mainly because of patient perceptions of this attire being professional. Most subjects considered non-white coat attire more appropriate for clinic and home care practice. The findings indicate that general practitioners choose their clothes depending on practice location.

Practitioners' perspectives on ethical issues within the treatment of eating disorders: Results from a concept mapping study.

OBJECTIVE: Treating patients with eating disorders (EDs) is associated with an array of ethical concerns, including balancing patients' health and autonomy, access to care, and use of harm-reduction versus recovery-oriented treatment models. The primary aim of the current study is to gain a better understanding of ethical issues faced by ED practitioners by using a concept mapping, or Q-sort, approach. METHOD: A total of 12 practitioners completed the brainstorming phase and generated statements regarding ethical issues they faced while treating patients with EDs. A subsequent 38 practitioners completed a sorting task, where they created and labeled piles, into which they grouped each statement. Of those 38 participants, 30 rated both the frequency with which they encountered each ethical issue and its impact on patient care. RESULTS: A total of six clusters emerged: Insufficient Level of Care, Lack of Evidence-Based Practice, Insurance Barriers, Family Involvement, Patient Autonomy, and Limited Access to Expertise. Lack of Evidence-Based Practice, Insurance Barriers, and Insufficient Level of Care was the most frequent problem faced by ED practitioners, whereas Insurance Barriers and Patient Autonomy had the greatest impact. DISCUSSION: Findings outline frequent and impactful areas of ethical concern that arise when treating patients diagnosed with EDs. Practitioners most commonly reported that patient- and insurance-driven factors limited patient access to appropriate care. Regulations supporting the provision of evidence-based care should be emphasized in public health policy and advocacy efforts, given their impact in limiting the delivery of adequate patient care.

Predicting GP visits: A multinomial logistic regression investigating GP visits amongst a cohort of UK patients living with Myalgic encephalomyelitis.

BACKGROUND: Myalgic Encephalomyelitis (ME) is a chronic condition whose status within medicine is the subject of on-going debate. Some medical professionals regard it as a contentious illness. Others report a lack of confidence with diagnosis and management of the condition. The genesis of this paper was a complaint, made by an ME patient, about their treatment by a general practitioner. In response to the complaint, Healthwatch Trafford ran a patient experience-gathering project. METHOD: Data was collected from 476 participants (411 women and 65 men), living with ME from across the UK. Multinomial logistic regression investigated the predictive utility of length of time with ME; geographic location (i.e. Manchester vs. rest of UK); trust in GP; whether the patient had received a formal diagnosis; time taken to diagnosis; and gender. The outcome variable was number of GP visits per year. RESULTS: All variables, with the exception of whether the patient had received a formal diagnosis, were significant predictors. CONCLUSIONS: Relationships between ME patients and their GPs are discussed and argued to be key to the effective delivery of care to this patient cohort. Identifying potential barriers to doctor patient interactions in the context of ME is crucial.

Hypnotic prescription by GPs is associated with their personal drug consumption but not by their insomnia status.

French general practitioners (GPs) are known to widely prescribe medications to treat insomnia despite their negative effects. GPs' easy access to self-medication may affect their mental representation of sleep and hypnotics, and subsequently their professional behaviour. Our aim was to examine the association between GPs' personal hypnotic drug consumption habits and their management of patients with sleep disturbances. A randomized sample of Alsatian GPs participated in a survey based on questionnaires including the Pittsburgh Sleep Quality Index, the Dysfunctional Beliefs About Sleep in 10 questions to characterize sleep, and an evaluation of their management strategies regarding sleep for both patients and themselves. Two-hundred and forty-nine GPs were included (response rate of 51%). Demographics of the GPs' samples were representative of those of the Alsatian GP population. Fifteen percent of the survey respondents met insomnia criteria. For the management of their own sleep disturbances, 14.3% of GPs were taking hypnotic drugs and 8.7% were taking anxiolytics, with greater drug consumption in the insomnia group. In a multivariate analysis, GPs who personally consumed these medications prescribed significantly more of them to patients, whereas their insomnia status had less impact. Other factors such as gender and type of practice were not associated with a higher prescription rate. Our results indicate that GPs' personal drug consumption can have a significant impact on the management of their patients, therefore suggesting that actions towards GPs' health improvement may also benefit their patients and the public.

Medical cannabis: knowledge and expectations in a cohort of North Island New Zealand general practitioners.

AIM: To investigate GP knowledge of the use of cannabis as a medicine and its regulation in New Zealand. METHOD: A convenience sample of GPs completed a questionnaire during continuing medical education sessions. Key domains investigated were: patient interactions around use of cannabis as a medicine; prescription facilitation and impediments; knowledge of evidence for and against the use of cannabis as a medicine; knowledge of the New Zealand regulatory processes and knowledge of pharmaceutical grade products. Questionnaires were administered between June and October 2018. RESULTS: There were 42/76 (55%) GPs who stated at least one patient had asked for a cannabis prescription for medical use in the last 12 months and 43/76 (57%) were aware of pharmaceutical grade preparations, the majority Sativex. There were 59/75 (79%) who expressed concerns about future prescribing; however, 63/75 (84%) indicated they would be 'somewhat' or 'very' likely to prescribe a PHARMAC-funded product with good evidence in specific conditions. CONCLUSION: Some GPs have concerns about prescribing medicinal cannabis. Due to regulatory restrictions, including no currently funded products, and uncertain scientific evidence of efficacy and safety, education programmes will be required to inform the medico-legal, evidential and practical elements of prescribing cannabis as a medicine.

How general practitioners decide on maxims of action in response to demands from conflicting sets of norms: a grounded theory study.

BACKGROUND: The work of general practitioners (GPs) is infused by norms from several movements, of which evidence based medicine, patient-centredness, and virtue ethics are some of the most influential. Their precepts are not clearly reconcilable, and structural factors may limit their application. In this paper, we develop a conceptual framework that explains how GPs respond, across different fields of interaction in their daily work, to the pressure exerted by divergent norms. METHODS: Data was generated from unstructured interviews with and observations of sixteen Swedish GPs (who have by definition more than five years of experience after license to practice) and family medicine residents (with less than five years of experience) between 2015 and 2017. Straussian Grounded Theory was used for analysis. RESULTS: We found that GPs' maxims of action can be characterised in terms of dichotomous responses to demands from four distinct sets of norms, or "voices": the situation, the self, the system, and the profession. From the interactions between these voices emerge sixteen clusters of maxims of action. Based on the common features of the maxims in each cluster, we have developed a conceptual framework that appears to be rich enough to capture the meaning of the ethical decisions that GPs make in their daily work, yet has a high enough level of abstraction to be helpful when discussing the factors that influence those decisions. CONCLUSIONS: Our four-dimensional model of GPs' responses to norms is a first step toward a middle-range theory of quality from GPs' perspective. It brings out the complexity of their practice, reveals tensions that easily remain invisible in more concrete accounts of their actions, and aids the transferability of substantive theories on GPs' ethical decision making. By explaining the nature of the ethical conflicts that they experience, we provide some clues as to why efforts to improve quality by imposing additional norms on GPs may meet with varying degrees of success.

Advance directives in France: do junior general practitioners want to improve their implementation and usage? A nationwide survey.

BACKGROUND: The doctor-patient relationship has evolved to respect "the autonomy and patients' rights". One of the cornerstones in such autonomy is the opportunity for patients to draw living wills, also known as advance directives (AD). However, information about AD available to patients remains scarce largely due to the lack of involvement of General practitioners for several reasons. The aim of our study was to evaluate current general practitioner residents' (GPR) behavior concerning their role in informing their patients about AD. METHOD: We built a French nationwide survey from GPR class of 2012 to 2014. RESULTS: Two thousand three hundred ten residents completed our survey (21.1% of the total population of GPR during the period). 89.8% declared their willingness to offer patients the opportunity of writing AD. When asked about the usefulness of AD, 73.6% of residents responded that these are a suitable help for patients, but 19.7% considered that AD are essentially geared towards frail patients. Among residents who want to inform patients about AD (n = 2075), 14.7% wanted to involve all patients. Only 20.5% thought that elderly people should be systematically informed about AD. When the question involves other frail people in various disease areas, information seems relevant for 60.1% of GPR considering patient with cancer or malignant hematologic disease and for 56.2% about patients affected by neurodegenerative disease. When considering the routine use of AD, 20.5% of GPR would take them into account only if they are in agreement with the patient's decision. CONCLUSIONS: The results of the survey indicate that GPR would rather choose to decide who should be informed about AD, and when to take AD into account for ethical concerns.

In search of good care: the methodology of phenomenological, theory-oriented 'N=N case studies' in empirically grounded ethics of care.

This paper proposes a new perspective on the methodology of qualitative inquiry in (care) ethics, especially the interaction between empirical work and theory development, and introduces standards to evaluate the quality of this inquiry and its findings. The kind of qualitative inquiry the authors are proposing brings to light what participants in practices of care and welfare do and refrain from doing, and what they undergo, in order to offer 'stepping stones', political-ethical insights that originate in the practice studied and enable practitioners to deal with newly emerging moral issues. As the authors' aim is to study real-life complexity of inevitably morally imprinted care processes, their empirical material typically consists of extensive and comprehensive descriptions of exemplary cases. For their research aim the number of cases is not decisive, as long as the rigorous analysis of the cases studied provides innovative theoretical insights into the practice studied. Another quality criterion of what they propose that should be called 'N=N case studies' is the approval the findings receive from the participants in the practice studied.

[The Frequency of Ethical Conflicts in Primary Care and the Need for Ethical Consultations - The Perspective of General Practitioners]. / Häufigkeit ethischer Konflikte in der ambulanten Versorgung und Bedarf an Ethikberatung ­ aus Sicht von Hausärzten.

BACKGROUND: Our knowledge about ethical conflicts in primary care is limited. The aim of this study was to ascertain the frequency of ethical conflicts and the need of professional consultation services - seen from the perspective of general practitioners (GPs). METHODS: A random sample of GPs from Lower Saxony, a federal state of Germany, received a standardized questionnaire about their experiences with ethical conflicts and their need for an ethical consultation. RESULTS: A total of 456 GPs took part in the survey (response rate = 45.6 %). Eighty percent experienced the conflict of a "withdrawal of medicines due to questionable benefit for the patient" once in 3 months, at least (95 % confidence interval: 76.0 to 83.6 %). Further frequent conflicts were "the continuation of a therapy of questionable benefit" (68 %; 63.3 to 72.0 %) and the "usefulness of diagnostic procedures for early detection of diseases and risk factors in seriously ill patients" (62 %; 57.7 to 66.8 %). About one-third (138/451) of the participants requested an ethical consultation. GPs frequently wished an ethical consultation by phone. CONCLUSIONS: Although GPs experienced several of the ethical conflicts frequently, only one-third requested an ethical consultation. Low threshold offers may be a way to make ethical consultations more attractive for GPs.

The dilemma of repeat weak opioid prescriptions - experiences from swedish GPs.

OBJECTIVE: To explore general practitioners' (GP) experiences of dealing with requests for the renewal of weak opioid prescriptions for chronic non-cancer pain conditions. DESIGN: Qualitative focus group interviews. Systematic text condensation analysis. SETTING AND SUBJECTS: 15 GPs, 4 GP residents and 2 interns at two rural and two urban health centres in central Sweden. MAIN OUTCOME MEASURES: Strategies for handling the dilemma of prescribing weak opioids without seeing the patient. RESULTS: After analysing four focus group interviews we found that requests for prescription renewals for weak opioids provoked adverse feelings in the GP regarding the patient, colleagues or the GP's inner self and were experienced as a dilemma. To deal with this, the GP could use passive as well as active strategies. Active strategies, like discussing the dilemma with colleagues and creating common routines regarding the renewal of weak opioids, may improve prescription habits and support physicians who want to do what is medically correct. CONCLUSION: Many GPs feel umcomfortable when prescribing weak opioids without seeing the patient. This qualitative study has identified strategic approaches to deal with that issue. Key points  Opioid prescription for chronic non-cancer pain is known to cause discomfort, feelings of guilt and conflicts for the prescribing doctor. From focus group interviews with GPs we found that to deal with this: • Doctors can use active strategies, such as confronting the patient or creating common routines together with their colleagues, or… • They can use passive coping strategies such as accepting the situation, handing over the responsibility to the patient or choosing not to see that there is a problem. • Opportunities for doctors to discuss prescription routines may be the best way to influence prescription habits.

Decision making process and factors contributing to research participation among general practitioners: A grounded theory study.

INTRODUCTION: The participation of general practitioners (GPs) in primary care research is variable and often poor. We aimed to develop a substantive and empirical theoretical framework to explain GPs' decision-making process to participate in research. METHODS: We used the grounded theory approach to construct a substantive theory to explain the decision-making process of GPs to participate in research activities. Five in-depth interviews and four focus group discussions were conducted among 21 GPs. Purposeful sampling followed by theoretical sampling were used to attempt saturation of the core category. Data were collected using semi-structured open-ended questions. Interviews were recorded, transcribed verbatim and checked prior to analysis. Open line-by-line coding followed by focus coding were used to arrive at a substantive theory. Memoing was used to help bring concepts to higher abstract levels. RESULTS: The GPs' decision to participate in research was attributed to their inner drive and appreciation for primary care research and their confidence in managing their social and research environments. The drive and appreciation for research motivated the GPs to undergo research training to enhance their research knowledge, skills and confidence. However, the critical step in the GPs' decision to participate in research was their ability to align their research agenda with priorities in their social environment, which included personal life goals, clinical practice and organisational culture. Perceived support for research, such as funding and technical expertise, facilitated the GPs' participation in research. In addition, prior experiences participating in research also influenced the GPs' confidence in taking part in future research. CONCLUSIONS: The key to GPs deciding to participate in research is whether the research agenda aligns with the priorities in their social environment. Therefore, research training is important, but should be included in further measures and should comply with GPs' social environments and research support.