Physicians’ views on men's mental health and the role of counselling services – a pilot study

This pilot study aimed to explore how physicians understand men's avoidance of mental health counselling services and to elicit physicians’ views on pairing mental health assessment with routine physical examination. Initially, physicians’ views on men's avoidance of mental health counselling services were explored through a focus group. A short survey exploring views on pairing mental health assessment with a routine physical examination was then developed and sent to 125 physicians at a local medical centre. Physicians discussions indicated that male socialisation processes, the stigma of needing help, and ignorance about counselling sessions, all contribute to men's avoidance of mental health counselling services. The survey results suggest that combining a mental health assessment with an annual physical examination was viewed positively by most physicians (80%), that they would encourage this approach (75%), and would appreciate the support of counselling services in this process (80%). However, these survey results were influenced by the age and sex of the physician. The focus group suggestion to pair mental health assessments with routine medical examinations, with support from counselling services, was viewed by most physicians as a positive way to engage men. Preliminary services could be established that utilise this approach and examine its efficacy.     

Attitudes of Muslim Physicians and Nurses Toward Religious Issues

There is a growing body of evidence that suggests a positive role for religious involvement in physical and mental health. Studies have shown that attitudes of physicians toward religion affect their relationship with patients and their medical decisions, and in this way may ultimately affect treatment outcomes. Attitudes of nurses toward religion could also influence whether or not they address patients’ unmet spiritual needs. To assess attitudes of physicians and nurses toward religion and how these attitudes vary by education level and demographic characteristics, a total of 800 physicians, medical students, and nurses from some of the largest hospitals in Tehran, Iran, were approached, of whom 720 completed questionnaires (148 nurses, 572 medical students and physicians). The survey questionnaire included the Duke University Religion Index (DUREL), Hoge Intrinsic Religiosity Scale, a brief measure of Negative Religious Coping (NRCOPE), and the brief Trust/Mistrust in God Scale. Religious attitudes and practices were compared between physicians (medical students and physicians) and nurses. Regression analysis revealed that except for intrinsic religiosity, physicians were not less religious than nurses on any other dimension of religiosity. Training level (year of training) was a predictor of religiosity, with those having less training being the most religious. The findings suggest that there are few religious differences between nurses and physicians in Iran. However, religiosity may become less as the training level increases. Lack of emphasis in training on the important role that religion plays in health care may result in a decrease in religious involvement and the development of negative attitudes toward religion over time (displaced by a focus on the technological aspects of health care).     

Patient autonomy and the challenge of clinical uncertainty

Bioethicists have articulated an ideal of shared decision making between physician and patient, but in doing so the role of clinical uncertainty has not been adequately confronted. In the face of uncertainty about the patient's prognosis and the best course of treatment, many physicians revert to a model of nondisclosure and nondiscussion, thus closing off opportunities for shared decision making. Empirical studies suggest that physicians find it more difficult to adhere to norms of disclosure in situations where there is substantial uncertainty. They may be concerned that acknowledging their own uncertainty will undermine patient trust and create additional confusion and anxiety for the patient. We argue, in contrast, that effective disclosure will protect patient trust in the long run and that patients can manage information about uncertainty. In situations where there is substantial uncertainty, extra vigilance is required to ensure that patients are given the tools and information they need to participate in cooperative decision making about their care.     

Physician Beliefs about Physical and Mental Competency of Patients Applying for Concealed Weapon Permits

Law enforcement officials have asked health care providers to evaluate patient applications for concealed weapon permits. The current study was designed to examine physician beliefs regarding competency to carry a concealed weapon for patients with specific physical and mental conditions. Among 222 North Carolina physicians who participated in this survey (40% response rate), large variation and uncertainty existed for determining competency. Physicians most frequently chose mild dementia, post-traumatic stress disorder, and recent depression as conditions that would render a patient not competent to carry a concealed weapon. Male physicians and those owning a gun were more likely to deem a patient competent. Almost a third of physicians were unsure about competence for most conditions. Physicians asked to assess competency of patients to carry a concealed weapon have quite disparate views on competency and little confidence in their decisions. If physicians are expected to assess patient competence to carry a concealed weapon, more objective criteria and training are needed. Copyright © 2015 John Wiley & Sons, Ltd.     

Fragility,uncertainty, and healthcare

Medicine seeks to overcome one of the most fundamental fragilities of being human, the fragility of good health. No matter how robust our current state of health, we are inevitably susceptible to future illness and disease, while current disease serves to remind us of various frailties inherent in the human condition. This article examines the relationship between fragility and uncertainty with regard to health, and argues that there are reasons to accept rather than deny at least some forms of uncertainty. In situations of current ill health, both patients and doctors seek to manage this fragility through diagnoses that explain suffering and provide some certainty about prognosis as well as treatment. However, both diagnosis and prognosis are inevitably uncertain to some degree, leading to questions about how much uncertainty health professionals should disclose, and how to manage when diagnosis is elusive, leaving patients in uncertainty. We argue that patients can benefit when they are able to acknowledge, and appropriately accept, some uncertainty. Healthy people may seek to protect the fragility of their good health by undertaking preventative measures including various tests and screenings. However, these attempts to secure oneself against the onset of biological fragility can cause harm by creating rather than eliminating uncertainty. Finally, we argue that there are good reasons for accepting the fragility of health, along with the associated uncertainties.     

Investigation and its discontents: Some constraints on progress in psychological research

This article examines a number of prominent trends in the conduct of psychological research and considers how they may limit progress in our field. Failure to appreciate important differences in temperament among researchers, as well as differences in the particular talents researchers bring to their work, has prevented the development in psychology of a vigorous tradition of fruitful theoretical inquiry. Misplaced emphasis on quantitative “productivity,” a problem for all disciplines, is shown to have particularly unfortunate results in psychology. Problems associated with the distorting effects of seeking grant support are shown to interact with the first two difficulties. Finally, the distorting effects of certain kinds of experimental studies are discussed, together with their implications for progress in this field.     

The hazards of underspecified models: the case of symmetry in everyday predictions

Should one be more confident when predicting the whole (or an event based on a larger sample) from the part (or an event based on a smaller sample) than when predicting the reverse? The relevant literature on judgment under uncertainty argues that such predictions are symmetrical but that, as an empirical matter, people often fail to appreciate this symmetry. The authors show that symmetry in prediction does not necessarily hold. In addition to an empirical study involving predictions about soccer games, they develop a theoretical model showing that, at least for the ranges of numerical values usually found in everyday judgment problems, symmetry in predictions is uncommon when 2 different sample sizes are involved. The complexity of the theoretical model used in this analysis raises questions about model specification in judgmental research.     

A Survey of Ethical and Professional Challenges Experienced by Spanish Health-Care Professionals that Provide Genetic Counseling Services

Genetic testing is increasingly applied for diagnosis and clinical treatment. In some countries, genetic counseling services are provided by professionals with specific training in this discipline, whereas other countries have no teaching programs and counseling is offered by physicians, nurses, pharmacists or biochemists. This counseling raises more and more ethical dilemmas for health professionals at their clinics. The purpose of this study was to analyze the characteristics of Spanish professionals devoted to providing genetic counseling services and to investigate the frequency of the ethical dilemmas they face. Results from 72 survey respondents revealed this counseling is provided by an almost even number of male and female professionals, mostly physicians with many years of professional experience. The overall frequency of the ethical dilemmas encountered was not high. The most frequent dilemmas corresponded to emotional responses by patients, informed consent, uncertainty about test results, and limitations on health-care resources. The frequency of dilemmas involving discrimination and provider directiveness was very low. Additional findings, practice implications, and research recommendations are presented.     

Satisficing rationality: In praise of folly

Conclusion From a psychological point of view, human wants and desires form a multitiered structure. If values are related in any way to human affectivity or desire - and this is something most maximizing theorists would certainly not dispute - then we are forced to recognize that human values also form a multi-tiered structure. Failure to appreciate this connection leads maximization theorists seriously astray, both in their interpretation of human behavior and in their postulates of rationality. Optimizing involves satisficing, not strictly maximization; satisficing is truly rational.I thank David Schmidtz and Jan Narveson, and the participants of a colloquium at the University of British Columbia, for helpful comments on earlier drafts of this essay.     

Voluntary Control of Behavior and Responsibility

Malpractice insurance rates have created a crisis in American medicine. Rates are rising and reimbursements are not keeping pace. In response, physicians in the states hardest hit by this crisis are feeling compelled to take political action, and the current action of choice seems to be physician strikes. While the malpractice insurance crisis is acknowledged to be severe, does it justify the extreme action of a physician walkout? Should physicians engage in this type of collective action, and what are the costs to patients and the profession when such action is taken? I will offer three related arguments against physician strikes that constitute a prima facie prohibition against such action: first, strikes are intended to cause harm to patients; second, strikes are an affront to the physician-patient relationship; and, third, strikes risk decreasing the public's respect for the medical profession. As with any prima facie obligation, there are justifying conditions that may override the moral prohibition, but I will argue that the current malpractice crisis does not rise to the level of such a justifying condition. While the malpractice crisis demands and justifies a political response on the part of the nation's physicians, strikes and slow-downs are not an ethically justified means to the legitimate end of controlling insurance costs.     

Physicians and strikes: can a walkout over the malpractice crisis be ethically justified?

Malpractice insurance rates have created a crisis in American medicine. Rates are rising and reimbursements are not keeping pace. In response, physicians in the states hardest hit by this crisis are feeling compelled to take political action, and the current action of choice seems to be physician strikes. While the malpractice insurance crisis is acknowledged to be severe, does it justify the extreme action of a physician walkout? Should physicians engage in this type of collective action, and what are the costs to patients and the profession when such action is taken? I will offer three related arguments against physician strikes that constitute a prima facie prohibition against such action: first, strikes are intended to cause harm to patients; second, strikes are an affront to the physician-patient relationship; and, third, strikes risk decreasing the public's respect for the medical profession. As with any prima facie obligation, there are justifying conditions that may override the moral prohibition, but I will argue that the current malpractice crisis does not rise to the level of such a justifying condition. While the malpractice crisis demands and justifies a political response on the part of the nation's physicians, strikes and slow-downs are not an ethically justified means to the legitimate end of controlling insurance costs.     

Emotional inhibition in essential hypertension: obstacle to communication during medical visits?

A substantial literature on the "hypertensive personality" links essential hypertension (EH) with the suppression of negative emotions, implying that suppression may elevate blood pressure. Yet affective inhibition might also impair communication with health care providers and exacerbate EH by limiting therapeutic collaboration. We studied 542 patient-physician interviews from a national sample to see if patients with EH (n = 203) were less likely to exhibit negative emotions than normotensive patients (n = 339) as rated by their physicians and independent observers. EH patients did not differ from others on self-rated emotional or physical health. However, physicians were less accurate in characterizing the emotional states of EH patients than those of normotensive patients, and they rated EH patients as exhibiting fewer signs of distress during the visit. Independent observers also judged the EH patients as less distressed than normotensives, thereby validating the physicians' appraisals. Content analysis disclosed that physicians paid less attention to psychosocial concerns and concentrated on biomedical matters to a greater degree with hypertensive patients than with their normotensive patients. EH patients, particularly those experiencing emotional distress, appear to have patterns of self-presentation that could present an obstacle to effective communication with their physicians, and this difficulty may be amplified by physicians' disinclination to probe for emotional difficulty.     

Portrayals of Global Health Worker Migration in Canadian Print News Media: Domestic Concerns vs. Global Awareness

The global migration of physicians and nurses has implications for health human resources in both source and recipient countries. Of particular concern to academics and policy experts is the “brain drain” of health professionals from under-resourced nations to developed countries, which promote immigration of physicians and nurses to solve their own health worker shortages. How does the general public in these destination countries understand and respond to concerns over migration and immigration of health professionals? This understanding is likely to be influenced in large part by how the issues are portrayed in the news media. News media treatment of this issue was explored by surveying news articles; newspaper columns/editorials; and op-ed pieces; and letters to the editor published in four prominent Canadian newspapers between May 2004 and January 2009, a time frame that included two federal elections in which physician immigration was highlighted as a political issue. Despite the prominence among academics of concern over the brain drain of physicians and nurses from developing countries to Canada and other Western nations, this issue received little attention in print news media discussions, which focused on domestic physician shortages and the role of international medical graduates in filling Canadian needs. While recent federal elections brought concerns about immigrant physicians into the political spotlight in Canada, they did so by focusing on Canadians' health care provision needs to the exclusion of promoting a broader, global awareness that the immigration of health professionals to developed nations such as Canada exacerbates global health disparities.     

Observations of Muslim Physicians Regarding the Influence of Religion on Health and Their Clinical Approach

Although most patients report wanting their physicians to address the religious aspects of their lives, most physicians do not initiate questions concerning religion with their patients. Although religion plays a major role in every aspect of the life of a Muslim, most of the data on the role of religion in health have been conducted in populations that are predominantly non-Muslim. The objectives of this study were to assess Muslim physicians' beliefs and behaviours regarding religious discussions in clinical practice and to understand the factors that facilitate or impede discussion of religion in clinical settings. The study is based on a cross-sectional survey. Muslim physicians working in a tertiary care hospital in Saudi Arabia were invited to complete a questionnaire that included demographic data; intrinsic level of religiosity; beliefs about the impact of religion on health; and observations, attitudes, behaviours, and barriers to attending to patients' religious needs. Out of 225 physicians, 91% agreed that religion had a positive influence on health, but 62.2% thought that religion could lead to the refusal of medically indicated therapy. Over half of the physicians queried never asked about religious issues. Family physicians were more likely to initiate religious discussions, and physicians with high intrinsic religiosity were more likely to share their own religious views. Residents and staff physicians tended to avoid such discussions. The study results highlight the fact that many physicians do not address patients' religious issues and that there is a need to clarify ethically sound means by which to address such needs in Islamic countries. Medical institutions should work to improve the capacity of medical personnel to appropriately address religious issues. The training of clinical religious advisors is a promising solution to this dilemma.     

Health care responsibility

The general and deep dissatisfaction with the present-day status of health care is of such intensity that one speaks of a health care crisis. What is most disturbing to the physicians is that society directs its accusation mainly at the health care professional for being responsible for this crisis. If we want to abolish the crisis we must try to get a renewed look at its source, i.e., to answer the questions “where did health care go wrong primarily?” and “with whom lies the ultimate responsibility for health care?”. In the following discourse these questions are discussed. Based on the assumption that every human being is a free rational agent the ultimate health care responsibility is assigned to the citizen. Of course, whether such an approach will in fact solve the problems inherent in present-day health systems cannot be predicted.     

Ethical evaluation of "retainer fee" medical practice

This article examines the reasons that some physicians have recently opted to reduce the size of their practice rosters to allow more time for each patient in exchange for a retainer fee from patients. These physicians also offer supplementary, nonmedical amenities to patients as part of their service. Because physicians have reduced the size of their practice rosters and have increased the price tag for their services, some patients have lost access to their care. We have tried to assess the ethical propriety of such a change in the design of medical practices by weighing plausible, ethically relevant arguments favoring and opposing RFMP. Physicians are ethically obligated first and foremost to promote and protect the health of their patients. RFMP fulfills this duty directly by ensuring prompt and ample professional time for the care of patients. It does so indirectly by allowing time for physicians' continuing education, which in turn should upgrade the quality of care. It also advances the ethical goals of autonomy as it allows patients to choose their own physicians and to spend their money as they please. On the other hand, these ethical positives are offset by the cost of retainer fees that may exclude access of patients to their physicians' care. Even if ethical tradition obligates physicians primarily to patients under their specific care, as professionals and as private citizens, they also have a responsibility to support the health of the entire community. RFMP does little to advance this cause, except that by optimizing the conditions under which their own private patients receive healthcare, they call attention to shortcomings in prevailing public healthcare policies, which by comparison fall short of that standard. An assumption that health is not properly a market commodity, and that all people should receive healthcare on equal terms, would expose RFMP to moral reproof. From an ethical perspective, we find sufficient cause for concern and caution in this innovative style of practice. Nevertheless, the weight of arguments presented here does not seem to justify unequivocal moral condemnation of RFMP. As neither pro nor con views seem to have settled the ethical question, definitive moral judgment on RFMP will probably depend on the outcome of future experience and ongoing evaluation. The implications of RFMP for any future healthcare system are not clear, at least to us.     

Physician-assisted suicide: the role of mental health professionals

A review of the literature was conducted to better understand the (potential) role of mental health professionals in physician-assisted suicide. Numerous studies indicate that depression is one of the most commonly encountered psychiatric illnesses in primary care settings. Yet, depression consistently goes undetected and undiagnosed by nonpsychiatrically trained primary care physicians. Noting the well-studied link between depression and suicide, it is necessary to question giving sole responsibility of assisting patients in making end-of-life treatment decisions to these physicians. Unfortunately, the use of mental health consultation by these physicians is not a common occurrence. Greater involvement of mental health professionals in this emerging and debated area is advocated. Beyond describing mental health professionals' role in the assessment of patient competency or decision making capacity, other areas of potential involvement are described. A discussion of ethical principles relevant to this area follows, along with comments on the training necessary to adequately serve patient needs.     

The Morality of Refusing to Treat HIV-positive Patients

ABSTRACT Do physicians and nurses have an obligation to treat patients who are HIV-positive? Although an initial review of the possible sources of such an obligation yields equivocal results, a closer examination reveals a clear obligation to treat. The current risk of job-caused HIV-infection is not sufficient to warrant a refusal to treat. This is so because there exist rationally justified, general social, as well as specific peer expectations, that health care professionals treat HIV-positive patients. These expectations impose moral obligations on doctors and nurses. Moreover there is no sound libertarian argument entitling doctors and nurses to refuse to treat HIV-positive patients. A morally appropriate identification with his or her role would disincline a health care professional to refuse treatment to an HIV-positive patient. The likely source of such refusal is occupational alienation and an irrational reaction to AIDS symbolism.     

A Method for Introducing the Concepts of Chaos Theory to Medical Students

Chaos theory is beginning to find applications in the field of medicine. The theory of chaos should be introduced to students to help them as they make the transition from learning the scientific literature to actually applying this newly acquired knowledge in clinical situations. Chaos theory will give the students a powerful conceptual framework from which they can better understand the limits of predictability in clinical situations. Failure to understand the limits of predictability in chaotic natural systems will invariably lead to frustration in both patients and physicians.