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1.
PLoS One ; 15(8): e0238141, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32866171

RESUMO

Academic dishonesty is a common problem at universities around the world, leading to undesirable consequences for both students and the education system. To effectively address this problem, it is necessary to identify specific predispositions that promote cheating. In Polish undergraduate students (N = 390), we examined the role of psychopathy, achievement goals, and self-efficacy as predictors of academic dishonesty. We found that the disinhibition aspect of psychopathy and mastery-goal orientation predicted the frequency of students' academic dishonesty and mastery-goal orientation mediated the relationship between the disinhibition and meanness aspects of psychopathy and dishonesty. Furthermore, general self-efficacy moderated the indirect effect of disinhibition on academic dishonesty through mastery-goal orientation. The practical implications of the study include the identification of risk factors and potential mechanisms leading to students' dishonest behavior that can be used to plan personalized interventions to prevent or deal with academic dishonesty.


Assuntos
Motivação/fisiologia , Má Conduta Profissional/psicologia , Má Conduta Profissional/estatística & dados numéricos , Estudantes/psicologia , Estudantes/estatística & dados numéricos , Universidades/estatística & dados numéricos , Adulto , Transtorno da Personalidade Antissocial/psicologia , Decepção , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Motivação/ética , Polônia , Má Conduta Profissional/ética , Autoeficácia , Inquéritos e Questionários , Universidades/ética , Adulto Jovem
2.
Vet Rec ; 187(4): 140-141, 2020 08 22.
Artigo em Inglês | MEDLINE | ID: mdl-32826370

RESUMO

In this article exploring some of the key recommendations from the RCVS Legislation Working Party (LWP), RCVS registrar and director of legal services Eleanor Ferguson discusses disciplinary reform.


Assuntos
Técnicos em Manejo de Animais/legislação & jurisprudência , Legislação Veterinária/organização & administração , Má Conduta Profissional/legislação & jurisprudência , Sociedades Veterinárias , Médicos Veterinários/legislação & jurisprudência , Humanos , Reino Unido
4.
PLoS One ; 15(8): e0237713, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32813685

RESUMO

Germinal studies have described the prevalence of sex-based harassment in high schools and its associations with adverse outcomes in adolescents. Studies have focused on students, with little attention given to the actions of high schools themselves. Though journalists responded to the #MeToo movement by reporting on schools' betrayal of students who report misconduct, this topic remains understudied by researchers. Gender harassment is characterized by sexist remarks, sexually crude or offensive behavior, gender policing, work-family policing, and infantilization. Institutional betrayal is characterized by the failure of an institution, such as a school, to protect individuals dependent on the institution. We investigated high school gender harassment and institutional betrayal reported retrospectively by 535 current undergraduates. Our primary aim was to investigate whether institutional betrayal moderates the relationship between high school gender harassment and current trauma symptoms. In our pre-registered hypotheses (https://osf.io/3ds8k), we predicted that (1) high school gender harassment would be associated with more current trauma symptoms and (2) institutional betrayal would moderate this relationship such that high levels of institutional betrayal would be associated with a stronger association between high school gender harassment and current trauma symptoms. Consistent with our first hypothesis, high school gender harassment significantly predicted college trauma-related symptoms. An equation that included participant gender, race, age, high school gender harassment, institutional betrayal, and the interaction of gender harassment and institutional betrayal also significantly predicted trauma-related symptoms. Contrary to our second hypothesis, the interaction term was non-significant. However, institutional betrayal predicted unique variance in current trauma symptoms above and beyond the other variables. These findings indicate that both high school gender harassment and high school institutional betrayal are independently associated with trauma symptoms, suggesting that intervention should target both phenomena.


Assuntos
Ética Institucional , Má Conduta Profissional/estatística & dados numéricos , Trauma Psicológico/epidemiologia , Instituições Acadêmicas/ética , Assédio Sexual/estatística & dados numéricos , Estudantes/psicologia , Adolescente , Feminino , Humanos , Masculino , Prevalência , Trauma Psicológico/psicologia , Psicologia do Adolescente , Estudos Retrospectivos , Instituições Acadêmicas/organização & administração , Sexismo/psicologia , Sexismo/estatística & dados numéricos , Assédio Sexual/prevenção & controle , Assédio Sexual/psicologia , Denúncia de Irregularidades/psicologia
7.
Rev. esp. med. legal ; 46(2): 56-65, abr.-jun. 2020. tab, graf
Artigo em Espanhol | IBECS | ID: ibc-193991

RESUMO

En los últimos años ha habido un incremento de reclamaciones contra médicos por presunta mala praxis. Nuestro objetivo ha sido analizar retrospectivamente las denuncias por responsabilidad médica en los juzgados de Barcelona durante los años 2004-2009, evaluadas en el Instituto de Medicina Legal y Ciencias Forenses de Cataluña. MATERIAL Y MÉTODO: Se realizó a partir de 3 bases de datos: la primera, las 283 periciales elaboradas por los médicos forenses durante estos años; la segunda, el programa informático judicial TEMIS-2; y la tercera, revisión de sentencias judiciales. RESULTADOS: En 257 casos (90,81%) la reclamación fue penal, 18 (6,36%) procedimientos contencioso-administrativos, 5 civiles (1,77%) y 3 de Fiscalía (1,06%). La edad media fue de 48,38 años (DE±19,39), en el 62,77% la perjudicada fue una mujer, siendo estas las que sufrieron más secuelas. En el 88,34% la reclamación era contra un médico, siendo la más habitual el mal resultado terapéutico (32,86%). Las especialidades más denunciadas fueron la traumatología, obstetricia y ginecología y cirugía general. Hubo más reclamaciones en la sanidad privada. En el 72,41% de los casos que llegaron a juicio la sentencia fue absolutoria y de los 8 que fueron condenados, solo en uno hubo prisión. La mediana del tiempo hasta la sentencia fue de 1.602 días. CONCLUSIONES: La vía penal es la más frecuente. Las mujeres reclaman más y sufren más secuelas. Las especialidades quirúrgicas son las más denunciadas. En el 27,59% de los casos que llegaron a juicio hubo sentencias condenatorias y solo en uno privación de libertad


In recent years there has been an increase in claims against doctors for alleged malpractice. Our objective was to retrospectively analyze complaints of medical liability in the courts of Barcelona between 2004-2009, evaluated at the Institute of Legal Medicine and Forensic Sciences of Catalonia. MATERIAL AND METHOD: We used 3 databases: the first, the 283 forensic reports prepared by forensic doctors during those years; the second, the judicial computer programme TEMIS-2; and the third, a review of judicial sentences. RESULTS: In 257 cases (90.81%) the claim was criminal, 18 (6.36%) contentious-administrative proceedings, 5 civil (1.77%) and 3 Prosecutor's Office claims (1.06%). The average age was 48.38 years (SD±19.39), in 62.77% the injured party was a woman, and they suffered more sequelae. In 88.34% the claim was against a doctor, a poor therapeutic outcome being the most common (32.86%). The most reported specialties were traumatology, obstetrics and gynaecology, and general surgery. There were more complaints in private healthcare. In 72.41% of the cases that came to trial the sentence was acquittal, and of the 8 convictions, only one was imprisoned. The median time to sentencing was 1,602 days. CONCLUSIONS: The criminal route is the most frequent. Women claim more and suffer more consequences. Surgical specialties are the most reported. In 27.59% of the cases that came to trial there were convictions, and only one resulted in deprivation of liberty


Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Imperícia/legislação & jurisprudência , Seguro de Responsabilidade Civil/legislação & jurisprudência , Má Conduta Profissional/legislação & jurisprudência , Segurança do Paciente/legislação & jurisprudência , Imperícia/estatística & dados numéricos , Responsabilidade Legal , Gestão da Segurança/organização & administração
8.
Pain Physician ; 23(3): E297-E304, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32517406

RESUMO

BACKGROUND: Prescribing opioids has become a challenge. The US Drug Enforcement Agency (DEA) and Centers for Disease Control and Prevention (CDC) have become more involved, culminating in the March 2016 release of the CDC's "Guidelines for Prescribing Opioids for Chronic Pain." OBJECTIVES: Given the new guidelines, we wanted to see if there have been any changes in the numbers, demographics, physician risk factors, charges, and sanctions involving the DEA against physicians who prescribe opioids, when compared to a previous DEA database review from 1998 to 2006. STUDY DESIGN: This study involved an analysis of the DEA database from 2004 to 2017. SETTING: The review was conducted at the Henry Ford Health System Division of Pain Medicine. METHOD: After institutional review board approval at Henry Ford Health System, an analysis of the DEA database of criminal prosecutions of physician registrants from 2004-2017 was performed. The database was reviewed for demographic information such as age, gender, type of degree (doctor of medicine [MD] or doctor of osteopathic medicine [DO]), years of practice, state, charges, and outcome of prosecution (probation, sentencing, and length of sentencing). An internet-based search was performed on each registrant to obtain demographic data on specialty, years of practice, type of medical school (US vs foreign), board certification, and type of employment (private vs employed). RESULTS: Between 2004 and 2017, Pain Medicine (PM) had the highest percentage of in-specialty action at 0.11% (n = 5). There was an average of 18 prosecutions per year vs 14 in the previous review. Demographic risk factors for prosecution demonstrated the significance of the type of degree (MD vs. DO), gender, type of employment (private vs. employed), and board certification status for rates of prosecution. Having a DO degree and being male were associated with significantly higher risk as well as being in private practice and not having board certification (P < .001). In terms of type of criminal charges as a percent of cases, possession with intent to distribute (n = 90) was most prevalent, representing 52.3% of charges, with new charges being prescribing without medical purpose outside the usual course of practice (n = 71) representing 41.3% of charges. Comparison of US graduates (MD/DO) vs. foreign graduates showed higher rates of DEA action for foreign graduates but this was of borderline significance (P = .072). LIMITATIONS: State-by-state comparisons could not be made. Specialty type was sometimes self-reported, and information on all opioid prosecutions could not be obtained. The previous study by Goldenbaum et al included data beyond DEA prosecution, so direct comparisons may be limited. CONCLUSION: The overall risk of DEA action as a percentage of total physicians is small but not insignificant. The overall rates of DEA prosecution have increased. New risk factors include type of degree (DO vs. MD) and being in private practice with a subtle trend toward foreign graduates at higher risk. With the trend toward less prescribing by previously high-risk specialties such as Family Medicine, there has been an increase in the relative risk of DEA action for specialties treating patients with pain such as PM, Physical Medicine and Rehabilitation, neurology, and neurosurgery bearing the brunt of prosecutions. New, more subtle charges have been added involving interpretation of the medical purpose of opioids and standard of care for their use. KEY WORDS: Certification, CDC, criminal, DEA, opioid, prescribing, prosecution, sanctions.


Assuntos
Analgésicos Opioides/uso terapêutico , Médicos/legislação & jurisprudência , Padrões de Prática Médica/legislação & jurisprudência , Má Conduta Profissional/legislação & jurisprudência , Adulto , Prescrições de Medicamentos , Disciplina no Trabalho/estatística & dados numéricos , Feminino , Órgãos Governamentais/legislação & jurisprudência , Regulamentação Governamental , Fidelidade a Diretrizes , Humanos , Masculino , Pessoa de Meia-Idade , Estados Unidos
10.
Med Leg J ; 88(1_suppl): 35-37, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32519568

RESUMO

The Covid-19 pandemic caused a marked increase in admissions to intensive care units. The critically ill patients' condition from the infection resulted in their deaths. The healthcare facilities have got into trouble because of the pandemic. In fact, they had to create additional beds in a very short time and to protect health workers with personal protective equipment. Healthcare professionals fear that there will be an increase in complaints and medico-legal malpractice claims and hence they have urged politicians to discuss this. The Italian Parliament recently debated the topic of medical liability and passed the Decree-Law no. 18 of 17 March 2020 (DL - so called Cura Italia) by which they want to extend the concept of "gross negligence" to healthcare facilities. Several Extended Care Units have suffered from outbreaks of Covid-19, so the Prosecutor's Office of several cities initiated investigations against them. This situation has reached Sicily, where the Prosecutor's Office of Palermo has opened an inquiry against an Extended Care Unit. Simultaneously, the Covid-19 pandemic may change patients' attitudes towards healthcare professionals, who are risking their lives daily. So the Italian medico-legal community is debating these questions, with one last pending question remaining: is the number of medico-legal claims likely to increase or trend down?


Assuntos
Betacoronavirus , Pessoal de Saúde/legislação & jurisprudência , Imperícia/legislação & jurisprudência , Pandemias/legislação & jurisprudência , Administração da Prática Médica/legislação & jurisprudência , Infecções por Coronavirus/terapia , Erros de Diagnóstico/legislação & jurisprudência , Humanos , Legislação Hospitalar/estatística & dados numéricos , Responsabilidade Legal , Imperícia/estatística & dados numéricos , Pneumonia Viral/terapia , Má Conduta Profissional/legislação & jurisprudência , Sicília
12.
J Med Internet Res ; 22(5): e16708, 2020 05 14.
Artigo em Inglês | MEDLINE | ID: mdl-32406851

RESUMO

BACKGROUND: Physician rating websites are commonly used by the public, yet the relationship between web-based physician ratings and health care quality is not well understood. OBJECTIVE: The objective of our study was to use physician disciplinary convictions as an extreme marker for poor physician quality and to investigate whether disciplined physicians have lower ratings than nondisciplined matched controls. METHODS: This was a retrospective national observational study of all disciplined physicians in Canada (751 physicians, 2000 to 2013). We searched ratings (2005-2015) from the country's leading online physician rating website for this group, and for 751 matched controls according to gender, specialty, practice years, and location. We compared overall ratings (out of a score of 5) as well as mean ratings by the type of misconduct. We also compared ratings for each type of misconduct and punishment. RESULTS: There were 62.7% (471/751) of convicted and disciplined physicians (cases) with web-based ratings and 64.6% (485/751) of nondisciplined physicians (controls) with ratings. Of 312 matched case-control pairs, disciplined physicians were rated lower than controls overall (3.62 vs 4.00; P<.001). Disciplined physicians had lower ratings for all types of misconduct and punishment-except for physicians disciplined for sexual offenses (n=90 pairs; 3.83 vs 3.86; P=.81). Sexual misconduct was the only category in which mean ratings for physicians were higher than those for other disciplined physicians (3.63 vs 3.35; P=.003). CONCLUSIONS: Physicians convicted for disciplinary misconduct generally had lower web-based ratings. Physicians convicted of sexual misconduct did not have lower ratings and were rated higher than other disciplined physicians. These findings may have future implications for the identification of physicians providing poor-quality care.


Assuntos
Médicos/legislação & jurisprudência , Má Conduta Profissional/estatística & dados numéricos , Estudos de Casos e Controles , Feminino , Humanos , Internet , Masculino , Satisfação do Paciente , Estudos Retrospectivos
13.
PLoS One ; 15(5): e0230961, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32374737

RESUMO

Is it appropriate for scientists to engage in political advocacy? Some political critics of scientists argue that scientists have become partisan political actors with self-serving financial agendas. However, most scientists strongly reject this view. While social scientists have explored the effects of science politicization on public trust in science, little empirical work directly examines the drivers of scientists' interest in and willingness to engage in political advocacy. Using a natural experiment involving the U.S. National Science Foundation Graduate Research Fellowship (NSF-GRF), we causally estimate for the first time whether scientists who have received federal science funding are more likely to engage in both science-related and non-science-related political behaviors. Comparing otherwise similar individuals who received or did not receive NSF support, we find that scientists' preferences for political advocacy are not shaped by receiving government benefits. Government funding did not impact scientists' support of the 2017 March for Science nor did it shape the likelihood that scientists donated to either Republican or Democratic political groups. Our results offer empirical evidence that scientists' political behaviors are not motivated by self-serving financial agendas. They also highlight the limited capacity of even generous government support programs to increase civic participation by their beneficiaries.


Assuntos
Comportamento/ética , Financiamento Governamental , Pessoal de Laboratório/ética , Política , Política Ambiental/economia , Política Ambiental/legislação & jurisprudência , Financiamento Governamental/ética , Financiamento Governamental/normas , Programas Governamentais/economia , Programas Governamentais/ética , Programas Governamentais/normas , Política de Saúde/economia , Política de Saúde/legislação & jurisprudência , Humanos , Pessoal de Laboratório/economia , Pessoal de Laboratório/psicologia , Má Conduta Profissional/ética , Política Pública , Setor Público/ética , Publicações/economia , Publicações/ética , Publicações/legislação & jurisprudência , Publicações/normas , Ciência/economia , Ciência/ética , Confiança , Estados Unidos
14.
Educ. med. (Ed. impr.) ; 21(2): 100-105, mar.-abr. 2020. tab, graf
Artigo em Espanhol | IBECS | ID: ibc-194476

RESUMO

INTRODUCCIÓN: La deshonestidad académica se refiere a copiar en una prueba, plagiar, falsificar resultados de una investigación o conseguir anticipadamente resultados de actividades o exámenes; sin embargo, algunas conductas parecen no ser consideradas como deshonestas por los estudiantes. Se sabe que prevalecen dentro de muchos niveles y áreas del conocimiento, pero no se conocen las percepciones de estudiantes respecto al impacto en su aprendizaje. El objetivo del estudio fue evaluar la percepción que los estudiantes tienen sobre la deshonestidad académica observable cuando comparten el contenido de los casos y actividades de un curso con compañeros de generaciones posteriores. MATERIAL Y MÉTODO: El diseño fue cuantitativo y descriptivo, utilizando encuestas aplicadas a 3 generaciones (2014, 2016 y 2017) dentro de un curso de patología. Se incluyó ítems relacionados con deshonestidad académica y su impacto en la resolución de los casos. Para el análisis se utilizó una escala que determina las tendencias en las aseveraciones como honestos +1 y deshonestos como -1. RESULTADOS: La participación fue del 84%, 99% y 50%, respectivamente. A pesar de que la mayoría (40%) refirió no obtener beneficio en el aprendizaje al compartir el material, las generaciones más recientes demuestran una tendencia hacia el polo de conductas deshonestas (-0,124, -0,509 y -0,562). CONCLUSIONES: La intención de los alumnos al compartir las actividades fue disminuir el tiempo que sus compañeros invierten en buscar información del caso al comparar sus respuestas; sin embargo, refieren que el aprendizaje total del tema no aumenta como resultado de sus prácticas. Futuras intervenciones son necesarias para realizar difusión de ejemplos concretos relacionados con el concepto, para que interioricen los resultados sobre el beneficio en su aprendizaje y el significado de la integridad académica


INTRODUCTION: Academic dishonesty includes copying, plagiarising, or falsifying the results of an investigation, or obtaining the correct answers for activities or exams from peers that have already answered them. However, some of these behaviours do not appear to be considered as dishonest by students. Although it is known that this prevails within many levels and areas of knowledge, students' perceptions of the impact of this on their learning process are not known. The aim of this study was to evaluate the perception that students have about academic dishonesty when sharing course material with other students. MATERIAL AND METHOD: The design was quantitative and descriptive using questionnaires applied to students of 3 different years (2014, 2016 and 2017) during a pathology course. These included items related to academic dishonesty and its impact on the resolving of cases. A scale was used to classify the honest results as+1 and the dishonest ones as -1. RESULTS: Participation was 84%, 99% and 50%, respectively. Although the majority (40%) reported not benefiting from learning by sharing material, more recent generations show a greater tendency towards dishonesty (-0.124, -0.509, and -0.562). CONCLUSION: The intention of the students when sharing activities was to reduce the time that their classmates invest in looking for information by comparing their answers. However, they report that the total learning of the subject does not increase. Future interventions are necessary to transmit clear examples related to the concept so that they can internalise the results regarding the benefit to their learning, and the meaning of academic integrity


Assuntos
Humanos , Percepção , Avaliação Educacional/normas , Má Conduta Profissional/ética , Estudantes de Medicina/psicologia , Inquéritos e Questionários , 24960 , Má Conduta Profissional/psicologia
16.
Sao Paulo Med J ; 138(2): 140-145, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32159603

RESUMO

BACKGROUND: Nowadays, there is an ethical and moral necessity to establish rules that govern professional attitudes and conduct. In the medical field, these rules are multifaceted, given the health consequences inherent to medical procedures. Ethics is an even more delicate subject when it comes to plastic surgery, since one of the aims of this particular medical specialty is esthetic improvement of the body. OBJECTIVE: To survey and classify São Paulo State Medical Board investigations of plastic-surgery complaints that were treated as professional-misconduct cases between 2007 and 2016. DESIGN AND SETTING: Cross-sectional study conducted in a medical council. METHODS: A total of 360 cases were reviewed. Among these, 8 (2.23%) were dismissed, 1 (0.27%) became an administrative lawsuit and 351 (97.50%) were treated as professional-misconduct cases. RESULTS: A breakdown of the complaints filed over the nine-year period showed that complaints concerning malpractice were the most common (28.43%), followed by those regarding medical advertising (24.19%) and poor doctor-patient relationships (10.39%). CONCLUSION: Overall, the number of complaints lodged decreased over the last two years reviewed, although complaints regarding malpractice and poor doctor-patient relationships increased by 10% over the same period. In order to further reduce the number of medical board investigations, the medical establishment needs to carefully review the medical training of students and doctors at every stage of their careers.


Assuntos
Imperícia , Médicos , Cirurgia Plástica , Brasil , Estudos Transversais , Humanos , Má Conduta Profissional
18.
PLoS One ; 15(1): e0226677, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31896133

RESUMO

Overqualification has both positive and negative outcomes; however, extant literature exhibits a tilt in favor of its negative aspect against its positive side. This tilted approach results in derision of a condition which could produce positive results. We argue, through empirical evidence, that there might be some circumstances/conditions, like the intentions of employees about their current job, that may play an important role in enabling organizations to be benefitted from the surplus KSAs of the overqualified employees and overqualification can be used as a tool to mitigate the effects of its negative consequences. To empirically test this condition, a sample of 193 teachers and 193 students have been selected through cluster sampling technique. The results exhibited that if overqualified employees perceive their current job as a career job then there is a more likelihood that they will be involved in some innovative and creative behaviors instead of deviating negatively from the organization norms. The results provide some new research insights that could be used to better understand the phenomenon of overqualification. The results of the study have practical implications for HR managers.


Assuntos
Mobilidade Ocupacional , Escolaridade , Ocupações/normas , Poder Psicológico , Comportamento Problema/psicologia , Má Conduta Profissional/psicologia , Desempenho Profissional/normas , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade
20.
Ann Thorac Surg ; 109(2): 317-324, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31479640

RESUMO

BACKGROUND: The literature on unprofessional behavior is reviewed. It is well accepted that unprofessional behavior, including a lack of civility and respect, can have a negative impact on patient safety and quality of care. METHODS: We used a focused review in the context of 20 years of experience of assessing, treating, and remediating unprofessional behavior. The review highlights that unprofessional behavior can stem from a variety of sources, including health, psychological/psychiatric issues, social functioning or support, or a combination of these. The review covers the challenges in the work environment and the relationship between outcome, as experienced by the physician, and the likelihood the physician will repeat or modify his or her behavior. RESULTS: Based on the evidence provided in the review and our clinical and research experience, we offer a new framework for the assessment, treatment, and remediation of physicians with professionalism transgressions: the Environmentally Valid Learning Approach. The approach is related to and expands on Miller's Pyramid by adding bio-psycho-social functioning and professional identity to the Pyramid. It emphasizes the dynamic and environmental characteristics of professional identity. CONCLUSIONS: Effective intervention is possible. Consideration of contributory factors, addressing/treating those factors, teaching/remediating skill deficiencies, and determining elements that need to be in place to foster implementation and maintenance of the developing skills are necessary components for successful resolution. The behavior is fully remediated when a self-sustaining alternative to the unprofessional behavior is established and the desired behavior becomes a permanent part of the physician's behavioral repertoire.


Assuntos
Avaliação de Resultados em Cuidados de Saúde , Má Conduta Profissional/ética , Profissionalismo/ética , Cirurgiões/psicologia , Atitude do Pessoal de Saúde , Compreensão , Feminino , Humanos , Relações Interprofissionais , Masculino , Determinação de Necessidades de Cuidados de Saúde , Estados Unidos
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