Charo Rodríguez

Partnership experiences: involving decision-makers in the research process.

Objectives To describe researchers’ experiences with involving health system managers and public policy-makers (i.e. decision-makers) in the research process, and decision-makers’ experiences with the research process, including their assessments of the benefits and costs of the involvement, and their recommendations for facilitating it. Methods We conducted semi-structured interviews with principal investigators and research staff for the seven research programmes funded by the Canadian Health Services Research Foundation in the 1999 and 2000 competition years, and with the decision-makers they involved in the research programmes. Results We identify three models of decision-maker involvement - formal supporter, responsive audience, and integral partner - each of which yielded important contributions to the research process. Four factors - the stage of the research process, time commitment required, alignment between decision-maker expertise and programme needs, and an existing relationship between the researcher and decision-maker - influenced the role played by decision-makers. Conclusions While on balance a beneficial experience, the further promotion of decision-maker involvement in the research process should involve helping researchers and decision-makers identify strategic opportunities for decision-maker involvement and support the costs associated with the involvement. Consideration should also be given to undertaking and evaluating interactions between researchers and decision-makers outside of the research process.

Governance, Power, and Mandated Collaboration in an Interorganizational Network

This article explores the challenges of mandated collaboration among public health care organizations. This in-depth longitudinal multiple case study examines the interests and values of various organizational actors in three collaborative initiatives, focusing on the mobilization of power within the governance frameworks available to them. The authors elaborate on three alternate readings of the processes examined: The managerialist views poor interorganizational collaboration as a failure to adequately manage the process; the symbolic focuses on the value of collaborative initiatives even in the absence of instrumental results; and the third examines the systemic web of power relationships reproduced over time.

Shared decision-making in palliative care: A systematic mixed studies review using narrative synthesis

The aim of this study is to synthesize knowledge about the process of shared decision-making (SDM) in palliative care. Medline, EMBASE, CINAHL, PsychInfo, Web of Science were searched with core concepts: shared decisions, patient participation in decision-making, and palliative care. Titles and abstracts were screened according to inclusion criteria (original research, adult patients, Western contexts, decision-making, palliative treatment or setting), yielding 37 articles for analysis. A narrative synthesis was created using the methods of thematic analysis, conceptual mapping, and critical reflection on the synthesis process. Results demonstrate that while a majority of patients want to participate in treatment decisions to some extent, most do not achieve their preferred levels of involvement because decisions are delayed and alternative treatment options are seldom discussed. The literature regarding the process of SDM itself remains scarce in palliative care. Further research is needed in order to better understand the longitudinal, interactive, and interdisciplinary process of decision-making in palliative care.

More than the sum of its parts? A qualitative research synthesis on multi-disciplinary primary care teams

This qualitative research synthesis reviews interpretive scholarly papers on multi-disciplinary primary care teams. A bibliographic search was conducted in electronic databases: Medline, Embase, and the Web of Science Citation Index, and in the references of retrieved papers. The research consists of a taxonomic analysis of 19 qualitative studies about primary care teams published in peer-reviewed journals between 2001 and July 2008 in English and French. Nineteen qualitative studies were synthesized. Two major concerns emerged: (1) strategies for organizational change toward effective co-operative practice, and (2) dimensions of team interactions and work relations. The authors conclude that qualitative results suggest common strategies to improve the development of primary care teams, while identifying dimensions of team interactions that remain problematic. A fundamental aspect of team formation appears to be overlooked, i.e., the construction of a collective identity, which would involve the whole team in a shared ideal of co-operative practice. The adoption of discourse analysis is suggested as a more sophisticated qualitative methodology to explore this issue.

Four levels of outcomes of information-seeking: A mixed methods study in primary health care

Primary health care practitioners routinely search for information within electronic knowledge resources. We proposed four levels of outcomes of information-seeking: situational relevance, cognitive impact, information use, and patient health outcomes. Our objective was to produce clinical vignettes for describing and testing these levels. We conducted a mixed methods study combining a quantitative longitudinal study and a qualitative multiple case study. Participants were 10 nurses, 10 medical residents, and 10 pharmacists. They had access to an online resource, and did 793 searches for treatment recommendations. Using the Information Assessment Method (IAM), participants rated their searches for each of the four levels. Rated searches were examined in interviews guided by log reports and a think-aloud protocol. Cases were defined as clearly described searches where clinical information was used for a specific patient. For each case, interviewees described the four levels of outcomes. Quantitative and qualitative data were merged into clinical vignettes. We produced 130 clinical vignettes. Specifically, 46 vignettes (35.4%) corresponded to clinical situations where information use was associated with one or more than one type of positive patient health outcome: increased patient knowledge (n = 28), avoidance of unnecessary or inappropriate intervention (n = 25), prevention of disease or health deterioration (n = 9), health improvement (n = 6), and increased patient satisfaction (n = 3). Results suggested information use was associated with perceived benefits for patients. This may encourage clinicians to search for information more often when they feel the need. Results supported the four proposed levels of outcomes, which can be transferable to other information-seeking contexts.

The reputation and professional identity of family medicine practice according to medical students: A Spanish case study

OBJECTIVE Over the last decade, family medicine has been progressively rejected by medical students as a career choice in many Western countries. Our objective is to contribute to a better understanding of this phenomenon by examining the reputation of and identification processes with family medicine by medical students. DESIGN A qualitative case study. METHODS Focus groups and document analysis were used for generating empirical material. Focus groups (n=6) were conducted (2008-2009). Thematic analysis was adopted as the technique for analyzing data gathered. SETTING A faculty of medicine of a Spanish university. PARTICIPANTS Second and sixth year undergraduate medical students (N=48). RESULTS Family medicine appears to be largely devalued as a professional activity, among medical students, being viewed as a monotonous and non-technological medical practice with no intellectual challenge. Such a negative view, which already appears in early stages of medical training, leads to a lack of identification with this medical practice by students. CONCLUSION Misconceptions about the practice of family medicine, created and reproduced in health care system and societal contexts, encourage the practice of specialized medicine. In addition, the academic environment appears to promote organ- and disease-based medical knowledge, which goes against the holistic and patient-centered approach characteristic of the practice of family medicine. In order to improve the reputation of family medicine and for it to be considered as an attractive career path by medical students, it is recommended that family medicine is developed as an academic medical field, and that improvements are made in the conditions and status of this medical practice within the health care system.

Influence of the DSM‐IV Outline for Cultural Formulation on multidisciplinary case conferences in mental health

The Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (DSM‐IV‐TR) includes an Outline for Cultural Formulation (CF) that identifies cultural information that can be used to modify diagnosis, clinical assessment and treatment plan. This study examined the use of the CF by a Cultural Consultation Service in the psychiatric assessment of patients referred by primary care providers. The study uses conversation analysis of 12 clinical case conferences to explore the ways in which the CF influenced the interaction of a multidisciplinary group of mental health professionals in conceptualizing the implications of patients’ cultural background and current context for diagnosis and treatment planning. The results suggest that the CF can be a useful tool for interdisciplinary collaboration and knowledge transfer by providing a framework to systematically introduce different disciplinary perspectives and levels of description that transcend the narrow frame of disorder‐centred psychiatric diagnosis, assessment and care.

The influence of academic discourses on medical students' identification with the discipline of family medicine.

Purpose To understand the influence of academic discourses about family medicine on medical students’ professional identity construction during undergraduate training. Method The authors used a multiple case study research design involving international medical schools, one each from Canada, France, Spain, and the United Kingdom (UK). The authors completed the fieldwork between 2007 and 2009 by conducting 18 focus groups (with 132 students) and 67 semistructured interviews with educators and by gathering pertinent institutional documents. They carried out discursive thematic analyses of the verbatim transcripts and then performed within- and cross-case analyses. Results The most striking finding was the diverging responses between those at the UK school and those at the other schools. In the UK case, family medicine was recognized as a prestigious academic discipline; students and faculty praised the knowledge and skills of family physicians, and students more often indicated their intent to pursue family medicine. In the other cases, family medicine was not well regarded by students or faculty. This was expressed overtly or through a paradoxical academic discourse that stressed the importance of family medicine to the health care system while decrying its lack of innovative technology and the large workload-to-income ratio. Students at these schools were less likely to consider family medicine. Conclusions These results stress the influence of academic discourses on medical students’ ability to identify with the practice of family medicine. Educators must consider processes of professional identity formation during undergraduate medical training as they develop and reform medical education.

Initiating decision-making conversations in palliative care: an ethnographic discourse analysis.

BackgroundConversations about end-of-life care remain challenging for health care providers. The tendency to delay conversations about care options represents a barrier that impedes the ability of terminally-ill patients to participate in decision-making. Family physicians with a palliative care practice are often responsible for discussing end-of-life care preferences with patients, yet there is a paucity of research directly observing these interactions. In this study, we sought to explore how patients and family physicians initiated decision-making conversations in the context of a community hospital-based palliative care service.MethodsThis qualitative study combined discourse analysis with ethnographic methods. The field research lasted one year, and data were generated through participant observation and audio-recordings of consultations. A total of 101 consultations were observed longitudinally between 18 patients, 6 family physicians and 2 pivot nurses. Data analysis consisted in exploring the different types of discourses initiating decision-making conversations and how these discourses were affected by the organizational context in which they took place.ResultsThe organization of care had an impact on decision-making conversations. The timing and origin of referrals to palliative care shaped whether patients were still able to participate in decision-making, and the decisions that remained to be made. The type of decisions to be made also shaped how conversations were initiated. Family physicians introduced decision-making conversations about issues needing immediate attention, such as symptom management, by directly addressing or eliciting patients’ complaints. When decisions involved discussing impending death, decision-making conversations were initiated either indirectly, by prompting the patients to express their understanding of the disease and its progression, or directly, by providing a justification for broaching a difficult topic.ConclusionsDecision-making conversations and the initiation thereof were framed by the organization of care and the referral process prior to initial encounters. While symptom management was taken for granted as part of health care professionals’ expected role, engaging in decisions regarding preparation for death implicitly remained under patients’ control. This work makes important clinical contributions by exposing the rhetorical function of family physicians’ discourse when introducing palliative care decisions.

Improving undergraduate medical education about pain assessment and management: A qualitative descriptive study of stakeholders’ perceptions

BACKGROUND Pain is one of the most common reasons for individuals to seek medical advice, yet it remains poorly managed. One of the main reasons that poor pain management persists is the lack of adequate knowledge and skills of practicing clinicians, which stems from a perceived lack of pain education during the training of undergraduate medical students. OBJECTIVE To identify gaps in knowledge with respect to pain management as perceived by students, patients and educators. METHODS A qualitative descriptive study was conducted. Data were generated through six focus groups with second- and fourth-year medical students, four focus groups with patients and individual semistructured interviews with nine educators. All interviews were audiotaped and an inductive thematic analysis was performed. RESULTS A total of 70 individuals participated in the present study. Five main themes were identified: assessment of physical and psychosocial aspects of pain; clinical management of pain with pharmacology and alternative therapies; communication and the development of a good therapeutic relationship; ethical considerations surrounding pain; and institutional context of medical education about pain. CONCLUSION Participating patients, students and pain experts recognized a need for additional medical education about pain assessment and management. Educational approaches need to teach students to gather appropriate information about pain, to acquire knowledge of a broad spectrum of therapeutic options, to develop a mutual, trusting relationship with patients and to become aware of their own biases and prejudice toward patients with pain. The results of the present study should be used to develop and enhance existing pain curricula content.