A Disclosure About Death Disclosure: Variability in Circulatory Death Determination

Introduction. Circulatory-respiratory death declaration is a common duty of physicians, but little is known about the amount of education and physician practice patterns in completing this examination. Methods. We conducted an online survey of physicians evaluating the rate of formal training and specific examination techniques used in the pronouncement of circulatory-respiratory death. Data, including level of practice, training received in formal death declaration, and examination components were collected. Results. Respondents were attending physicians (52.4%), residents (30.2%), fellows (10.7%), and interns (6.7%). The majority of respondents indicated they had received no formal training in death pronouncement, however, most reported self-perceived competence. When comparing examination components used by our cohort, 95 different examination combinations were used for death pronouncement. Conclusions. Formal training in death pronouncement is uncommon and clinical practice varies. Implementation of formal training and standardization of the examination are necessary to improve physician competence and reliability in death declarations.

In Search of Quality: Echocardiographic Mitral Regurgitation Evaluation Discrepancies

Introduction: Two-dimensional (2D) transthoracic echocardiography (TTE) for mitral regurgitation (MR) evaluation plays a vital role in choosing the adequate type of treatment. Considerable undertreatment prevalence suggests a possible knowledge gap. The aim of the present study was to assess physician diagnostic adherence according to clinical echocardiographic guidelines. Methods: 438 echocardiographically confirmed MR cases evaluated by 60 beginner, intermediate, or expert level physicians were enrolled. MR eyeballing tendencies, quantitative method application accuracy, and guideline adherence were analyzed. Results: Main discrepancies were unjustified eyeballing (66.95%; p<0.001), inaccurate application of methods (22.46%, p=0.002), and misinterpretation of diagnostic criteria (10.59%). Female patient gender (p=0.026) and lower physician competence levels (p<0.001) were identified as predictors for eyeballing discrepancy possibility. The latter was also a predictor quantitative method discrepancy (p=0.043). Method choice had the most substantial correlation to discrepancies when determining moderate–severe MR (p<0.001). Conclusions: Echocardiographic evaluation of hemodynamically significant MR discrepant in 53.88% of cases as non-quantitative evaluation of hemodynamically significant MR, methodological inaccuracies, and misinterpretation of diagnostic criteria compile the largest proportion of discrepancies. Female gender, lower physician competence, and downgraded diagnostic method application were the most substantial predictors of discrepancy occurrence.

Who Can I Trust? Ensuring Physician Competence

Gwyneth Vives, a scientist at Los Alamos National Laboratory in New Mexico, suffered a complication and bled to death 3 hours after giving birth to a healthy boy in 2001. It was 4 days before Christmas. Vives suffered a vaginal tear and other lacerations during the delivery that caused profuse bleeding. Her obstetrician, Pamela Johnson, was sued for failure to order a blood transfusion for Vives as well as abandonment since she had turned over repair of the vaginal tear to a midwife. Two other patients also sued Johnson. Jean Challacombe alleged that Johnson tore her bowel and uterus while doing a dilation and curettage the same day Vives died. Tanya Lewis accused Johnson of doing an unnecessary hysterectomy.

A Survey of Patient Perspectives on Approach to Health Care: Focus on Physician Competency and Compassion

We conducted a cross-sectional, survey study of 764 volunteers to gain insight into patients’ perceptions of physician qualities of compassion and competence. Among 651 (85% response rate) survey participants, mean age was 52.4 (SD 21.4) years, 70.8% (n = 458) were female, and 84% (n = 539) identified as white. Predictors of compassion over competence included female gender (adjusted odds ratio [aOR] = 1.4, 95% CI: 1.04-1.89) and whether the respondent had a personal connection to the vignette (aOR = 1.24, 95% CI: 1.0-1.53). Thematic analysis demonstrated that preferences were influenced by: (a) explicit beliefs regarding the value of physician compassion and physician competence; (b) impact of emotional and mental health on medical experiences; (c) the type and frequency of health care exposure; and (d) perceived role of the physician in various clinical vignettes. Patients had wide-ranging, complex opinions on the qualities they valued in their physicians. These findings suggest that patients are engaged and can provide critical thoughtful feedback on the practice and delivery of health care.

Anesthesiologist Age and Sex Influence Patient Perceptions of Physician Competence

Background Uncovering patients’ biases toward characteristics of anesthesiologists may inform ways to improve the patient–anesthesiologist relationship. The authors previously demonstrated that patients prefer anesthesiologists displaying confident body language, but did not detect a sex bias. The effect of anesthesiologists’ age on patient perceptions has not been studied. In this follow-up study, it was hypothesized that patients would prefer older-appearing anesthesiologists over younger-appearing anesthesiologists and male over female anesthesiologists. Methods Three hundred adult, English-speaking patients were recruited in the Preanesthesia Evaluation and Testing Center. Patients were randomized (150 per group) to view a set of four videos in random order. Each 90-s video featured an older female, older male, younger female, or younger male anesthesiologist reciting the same script describing general anesthesia. Patients ranked each anesthesiologist on confidence, intelligence, and likelihood of choosing the anesthesiologist to care for their family member. Patients also chose the one anesthesiologist who seemed most like a leader. Results Three hundred patients watched the videos and completed the questionnaire. Among patients younger than age 65 yr, the older anesthesiologists had greater odds of being ranked more confident (odds ratio, 1.92; 95% CI, 1.41 to 2.64; P &lt; 0.001) and more intelligent (odds ratio, 2.24; 95% CI, 1.62 to 3.11; P &lt; 0.001), and had greater odds of being considered a leader (odds ratio, 2.62; 95% CI, 1.72 to 4.00; P &lt; 0.001) when compared with younger anesthesiologists. The preference for older anesthesiologists was not observed in patients age 65 and older. Female anesthesiologists had greater odds of being ranked more confident (odds ratio, 1.46; 95% CI, 1.13 to 1.87; P = 0.003) and more likely to be chosen to care for one’s family member (odds ratio, 1.80; 95% CI, 1.40 to 2.31; P &lt; 0.001) compared with male anesthesiologists. The ranking preference for female anesthesiologists on these two measures was observed among white patients and not among nonwhite patients. Conclusions Patients preferred older anesthesiologists on the measures of confidence, intelligence, and leadership. Patients also preferred female anesthesiologists on the measures of confidence and likelihood of choosing the anesthesiologist to care for one’s family member. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

All hands on deck: Hand replantation versus transplantation

Objectives: Our hands play a remarkable role in our activities of daily living and the make-up of our identities. In the United States, an estimated 41,000 individuals live with upper limb loss. Our expanding experience in limb transplantation—including operative techniques, rehabilitation, and expected outcomes—has often been based on our past experience with replantation. Here, we undertake a systematic review of replantation with transplantation in an attempt to better understand the determinants of outcome for each and to provide a summary of the data to this point. Methods: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we conducted PubMed searches from 1964 to 2013 for articles in English. In total, 53 primary and secondary source articles were found to involve surgical repair (either replantation or transplantation) for complete amputations at the wrist and forearm levels. All were read and analyzed. Results: Hand replantations and transplantations were compared with respect to pre-operative considerations, surgical techniques, post-operative considerations and outcomes, including motor, sensation, cosmesis, patient satisfaction/quality of life, adverse events/side effects, financial costs, and overall function. While comparison of data is limited by heterogeneity, these data support our belief that good outcomes depend on patient expectations and commitment. Conclusion: When possible, hand replantation remains the primary option after acute amputation. However, when replantation fails or is not possible, hand transplantation appears to provide at least equal outcomes. Patient commitment, realistic expectations, and physician competence must coincide to achieve the best possible outcomes for both hand replantation and transplantation.

The Impact of Monetary Incentives on Physician Prosocial Behavior in Online Medical Consulting Platforms: Evidence From China

Background In online medical consulting platforms, physicians can get both economic and social returns by offering online medical services, such as answering questions or sharing health care knowledge with patients. Physicians’ online prosocial behavior could bring many benefits to the health care industry. Monetary incentives could encourage physicians to engage more in online medical communities. However, little research has studied the impact of monetary incentives on physician prosocial behavior and the heterogeneity of this effect. Objective This study aims to explore the effects of monetary incentives on physician prosocial behavior and investigate the moderation effects of self-recognition and recognition from others of physician competence. Methods This study was a fixed-effect specification-regression model based on a difference-in-differences design with robust standard errors clustered at the physician level using monthly panel data. It included 26,543 physicians in 3851 hospitals over 133 months (November 2006-December 2017) from a leading online health care platform in China. We used the pricing strategy of physicians and satisfaction levels to measure their own and patients’ degree of recognition, respectively. Physicians’ prosocial behavior was measured by free services offered. Results The introduction of monetary incentives had a positive effect on physician prosocial behavior (β=1.057, P<.01). Higher self-recognition and others’ recognition level of physician competence increased this promotion effect (γ=0.275, P<.01 and γ=0.325, P<.01). Conclusions This study explored the positive effect of the introduction of monetary incentives on physician prosocial behavior. We found this effect was enhanced for physicians with a high level of self-recognition and others’ recognition of their competence. We provide evidence of the effect of monetary incentives on physicians’ prosocial behaviors in the telemedicine markets and insight for relevant stakeholders into how to design an effective incentive mechanism to improve physicians’ prosocial engagements.

Analysis of Factors Influence Doctor's Decision in Choosing Patient's Referral to dr. Soepraoen Army Hospital Malang

The importance of the role of health services causes the quality of health services to be improved because of the needs of the community or individuals for health. Second-level health services can only be given for referral from first-level health services. Third-level health services can only be given for referral from second- or first-level health services, except in emergency situations. Based on this, it can be seen that the first level Health Service Provider (PPK) has a very important role in the health care system in Indonesia. The purpose of this study was to find out the factors underlying the doctors to refer their patients to the dr. Soepraoen Army Hospital Malang. The research design used is quantitative research with a cross sectional approach. The sampling technique used was saturated sampling by taking 100 doctors as the study sample. The data analysis technique of this study uses linear regression by using an α value of 0.05. The results showed that hospital facilities had a significant effect on choosing a referral with a p-value of 0,000 with a t-count of 4,300, the availability of drugs had a significant effect on choosing a referral with a p-value of 0,000 with a t-count of 2,557 , the type of disease has a significant effect on choosing a referral with a p-value of 0,000 with a t-count value of 2,435, and on physician competence has a significant effect on choosing a referral with a p-value of 0,000 and a t-count value of 2,327, and simultaneously for each facility variable, drug availability, type of disease and physician competence can have a significant effect on choosing a referral. and found that the dominant factor influencing the decision to choose referral is the facility factor. The low analysis of factors that influence the doctor's decision in choosing a patient's referral to dr. Soepraoen Army Hospital Malang can be minimized by further increasing the indicator indicators of each variable that is considered still low.

The Impact of Monetary Incentives on Physician Prosocial Behavior in Online Medical Consulting Platforms: Evidence From China (Preprint)

BACKGROUND In online medical consulting platforms, physicians can get both economic and social returns by offering online medical services, such as answering questions or sharing health care knowledge with patients. Physicians’ online prosocial behavior could bring many benefits to the health care industry. Monetary incentives could encourage physicians to engage more in online medical communities. However, little research has studied the impact of monetary incentives on physician prosocial behavior and the heterogeneity of this effect. OBJECTIVE This study aims to explore the effects of monetary incentives on physician prosocial behavior and investigate the moderation effects of self-recognition and recognition from others of physician competence. METHODS This study was a fixed-effect specification-regression model based on a difference-in-differences design with robust standard errors clustered at the physician level using monthly panel data. It included 26,543 physicians in 3851 hospitals over 133 months (November 2006-December 2017) from a leading online health care platform in China. We used the pricing strategy of physicians and satisfaction levels to measure their own and patients’ degree of recognition, respectively. Physicians’ prosocial behavior was measured by free services offered. RESULTS The introduction of monetary incentives had a positive effect on physician prosocial behavior (β=1.057, P<.01). Higher self-recognition and others’ recognition level of physician competence increased this promotion effect (γ=0.275, P<.01 and γ=0.325, P<.01). CONCLUSIONS This study explored the positive effect of the introduction of monetary incentives on physician prosocial behavior. We found this effect was enhanced for physicians with a high level of self-recognition and others’ recognition of their competence. We provide evidence of the effect of monetary incentives on physicians’ prosocial behaviors in the telemedicine markets and insight for relevant stakeholders into how to design an effective incentive mechanism to improve physicians’ prosocial engagements.

Women with Disabilities

Women with disabilities face challenges related to their disabilities of access and accommodation for infertility care. This chapter explores the societal and structural barriers to infertility care these women experience, including legal issues, training and attitudes of physicians, ability to pay, lack of adaptive equipment, inexperience of providers in treating these patient populations, and lack of access to health insurance coverage for infertility care. Ethical arguments respond to providers’ concerns about offering reproductive care to women with disabilities, including concerns about physician competence, physician choice, risks to the woman, inability to consent, risks to any offspring, conscientious objection, and ability to pay. It concludes that there is at best limited and partial justification for many of these concerns, especially in the context of background injustice. The chapter ends with an account of reasonable modifications and accommodations to allow women with disabilities to enjoy reproductive services on equal terms with other women.