Marie-Thérèse Lussier

Therapeutic privilege: between the ethics of lying and the practice of truth

The ‘right to the truth’ involves disclosing all the pertinent facts to a patient so that an informed decision can be made. However, this concept of a ‘right to the truth’ entails certain ambiguities, especially since it is difficult to apply the concept in medical practice based mainly on current evidence-based data that are probabilistic in nature. Furthermore, in some situations, the doctor is confronted with a moral dilemma, caught between the necessity to inform the patient (principle of autonomy) and the desire to ensure the patients well-being by minimising suffering (principle of beneficence). To comply with the principle of beneficence as well as the principle of non-maleficence ‘to do no harm’, the doctor may then feel obliged to turn to ‘therapeutic privilege’, using lies or deception to preserve the patients hope, and psychological and moral integrity, as well as his self-image and dignity. There is no easy answer to such a moral dilemma. This article will propose a process that can fit into reflective practice, allowing the doctor to decide if the use of therapeutic privilege is justified when he is faced with these kinds of conflicting circumstances. We will present the conflict arising in practice in the context of the various theoretical orientations in ethics, and then we will suggest an approach for a ‘practice of truth’. Last, we will situate this reflective method in the broader clinical context of medical practice viewed as a dialogic process.

A cluster randomized controlled Trial to Evaluate an Ambulatory primary care Management program for patients with dyslipidemia: the TEAM study

Background: Few studies have reported the efficacy of collaborative care involving family physicians and community pharmacists for patients with dyslipidemia. Methods: We randomly assigned clusters consisting of at least two physicians and at least four pharmacists to provide collaborative care or usual care. Under the collaborative care model, pharmacists counselled patients about their medications, requested laboratory tests, monitored the effectiveness and safety of medications and patients’ adherence to therapy, and adjusted medication dosages. After 12 months of follow-up, we assessed changes in low-density lipoprotein (LDL) cholesterol (the primary outcome), the proportion of patients reaching their target lipid levels and changes in other risk factors. Results: Fifteen clusters representing a total of 77 physicians and 108 pharmacists were initially recruited, and a total of 51 physicians and 49 pharmacists were included in the final analyses. The collaborative care teams followed a total of 108 patients, and the usual care teams followed a total of 117 patients. At baseline, mean LDL cholesterol level was higher in the collaborative care group (3.5 v. 3.2 mmol/L, p = 0.05). During the study, patients in the collaborative care group were less likely to receive high-potency statins (11% v. 40%), had more visits with health care professionals and more laboratory tests, were more likely to have their lipid-lowering treatment changed and were more likely to report lifestyle changes. At 12 months, the crude incremental mean reduction in LDL cholesterol in the collaborative care group was −0.2 mmol/L (95% confidence interval [CI] −0.3 to −0.1), and the adjusted reduction was −0.05 (95% CI −0.3 to 0.2). The crude relative risk of achieving lipid targets for patients in the collaborative care group was 1.10 (95% CI 0.95 to 1.26), and the adjusted relative risk was 1.16 (95% CI 1.01 to 1.34). Interpretation: Collaborative care involving physicians and pharmacists had no significant clinical impact on lipid control in patients with dyslipidemia. International Standard Randomized Controlled Trial register no. ISRCTN66345533.

Determinants of the diagnosis of psychological problems by primary care physicians in patients with normal GHQ-28 scores.

In studies comparing the performance of psychometric instruments and general practitioners in the identification of psychological disorders, authors usually treat the psychometric instrument as the gold standard. Some patients may have no psychiatric diagnosis and normal scores on self-report measures of distress, but still benefit from detection and treatment of their psychosocial problems. However, physicians may be spending valuable time identifying problems in patients who have no disability. The extent and implications of the discrepancy between clinician assessment and standard instruments requires further exploration. Adult patients of 40 family physicians completed the General Health Questionnaire (GHQ-28) before their visit. Immediately following the visit, physicians, who were blind to the patients GHQ score, indicated whether they had detected any signs or symptoms of anxiety, depression, somatization, or other psychosocial problems. Of the 1,011 primary care patients that participated, 439 had normal GHQ-28 scores. Physicians detected psychological problems in 177 (38.3%) of the 439. In bivariate analyses, poorer general and mental health (as measured by SF-36) was associated with higher detection rates. The patients belief that there was a psychological component of his or her problem (OR=2.50), being in a marital relationship (OR=1.87), and the physicians perception of the seriousness of the problem (OR=1.84) were associated with detection. Detection was less frequent when the physician did not know the patient well (OR=0.69), and when the physician was a woman (OR=0.46). For the 28% of patients who themselves perceived a psychological element of their problem, physician detection was probably appropriate. However, it is unlikely that detection of the remaining patients was beneficial to the patients.

The content of talk about health conditions and medications during appointments involving interpreters.

INTRODUCTION Interpreters often join immigrants and physicians to permit communication. OBJECTIVE To describe the content of talk about health problems and medications during clinical encounters involving interpreters [professionals (PI) or family members (FI)]. METHODS We analysed one regularly scheduled encounter for each of 16 adult patients with his family physician and their usual interpreter (10 with a PI and 6 with a FI). A different PI, not involved in the consultations, translated the non-English or French parts. We coded all utterances about each medical problem and each medication using six health problem and 16 medication topics from MEDICODE, a validated coding scheme. RESULTS Physicians and patients addressed an average of 3.6 problems and 3 medications per encounter. No psychosocial problems were discussed in encounters involving FIs. On average, three topics were discussed per problem. In order of frequency, they were follow-up, explanations of the condition, non-drug management, consequences, self-management and emotions about the problem. Encounters involving PIs were more likely than encounters with FIs to include discussions of emotions about the problem (42% versus 4%, P = 0.001) and indications for follow-up (88% versus 28%, P < 0.001). An average of 6.5 topics was discussed per medication. Commonest topics discussed were medication class, how the drug was being used, achieved effect and expected effect. CONCLUSIONS One can address multiple problems and share vital information even in the presence of a language barrier. When FIs are interpreting, physicians would do well to make a particular effort to bring the patients psychological and emotional issues into the interaction.

Discussion of lifestyle-related issues in family practice during visits with general medical examination as the main reason for encounter: an exploratory study of content and determinants.

The aim of this study was to describe the frequency and content of discussions on lifestyle issues during an annual examination and to identify characteristics of patients, physicians, and visits associated with lifestyle discussions. Audio-recordings of the visits of 35 family physicians with 148 of their patients were analyzed. Bivariate descriptive and multivariate analyses were used. On average, the visits contained discussions of 3.6 different issues for a total time of 2.9 min. Of the 11 topics of interest, weight, diet and nutrition, physical activity, and tobacco use were the most frequently discussed. Consultation with a female physician and perception by the physician of a poorer patient mental health status were associated with the number of themes discussed and the duration of exchanges. Results suggest that although, discussions on lifestyle issues are frequently observed during these visits, they remain limited in scope. Physicians appear to concentrate their energy on targeted patients, and female doctors are more active in this domain.

GHQ-28 and cGHQ-28: implications of two scoring methods for the GHQ in a primary care setting

Abstract.Background:The General Health Questionnaire allows for distinguishing patients suffering from psychiatric problems from those in good mental health. There is some controversy as to the best scoring method. Two different methods have been proposed: GHQ and cGHQ. The present study aims at verifying whether there is confirmation of the hypothesis that the population resulting from the cGHQ calculation presents greater chronicity.Method:A total of 40 general practitioners and 1145 of their patients in the Greater Montreal area, Québec, Canada participated in the original study. A sub-group of 313 patients were followed over a 3-month period. The patients were asked to complete a set of questionnaires, including the GHQ-28. The traditional method of calculating the GHQ score and the alternative cGHQ method were used.Results:Two discordant groups of patients were identified: Group 1 (acute cases only), positive on the GHQ, but negative on the cGHQ (n = 124), and Group 2 (chronic cases only), negative on the GHQ and positive on the cGHQ (n = 64).Patients in Group 2 were older (p<0.001), were more worried about their health (p = 0.06) and their health problem had lasted for a longer time (p = 0.02). Patients in Group 2 were twice as likely to remain positive on the GHQ and/or the cGHQ as those in Group 1 in the 1- and 3-month follow-ups.Conclusions:The results suggest the presence of notable differences between the two groups, generally explainable by the hypothesis of greater chronicity in the cGHQ patients. The results confirm the impact of the choice of calculation method on the composition of the two groups. Finally, the authors suggest using the two calculation methods simultaneously.

Priorities for action to improve cardiovascular preventive care of patients with multimorbid conditions in primary care--a participatory action research project.

BACKGROUND Cardiovascular disease (CVD) prevention in patients with multimorbid conditions is not always optimal in primary care (PC). Interactive collaborative processes involving PC community are recommended to develop new models of care and to successfully reshape clinical practices. OBJECTIVE To identify challenges and priorities for action in PC to improve CVD prevention among patients with multimorbid conditions. METHODS Physicians (n = 6), nurses (n = 6), community pharmacists (n = 6), other health professionals (n = 6), patients (n = 6) and family members (n = 6), decision makers (n = 6) and researchers (n = 6) took part in a 1-day workshop. Using the Chronic Care Model (CCM) as a framework, participants in focus groups and nominal groups identified the challenges and priorities for action. RESULTS Providing appropriate support to lifestyle change in patients and implementing collaborative practices are challenging. Priorities for action relate to three CCM domains: (i) improve the clinical information system by providing computerized tools for interprofessional and interinstitutional communication, (ii) improve the organization of health care and delivery system design by enhancing interprofessional collaboration, especially with nurses and pharmacists, and creating care teams that include a case manager and (iii) improve self-management support by giving patients access to nutritionists, to personalized health care plans including lifestyle recommendations and to other resources (community resources, websites). CONCLUSIONS To optimize CVD prevention, PC actors recommend focussing mainly on three CCM domains. Electronic medical records, collaborative practices and self-management support are perceived as pivotal aspects of successful PC prevention programme. Developing and implementing such models are challenging and will require the mobilization of the whole PC community.

Facilitating Implementation of Interprofessional Collaborative Practices Into Primary Care: A Trilogy of Driving Forces.

EXECUTIVE SUMMARY Implementing interprofessional collaborative practices in primary care is challenging, and research about its facilitating factors remains scarce. The goal of this participatory action research study was to better understand the driving forces during the early stage of the implementation process of a community‐driven and patient‐focused program in primary care titled “TRANSforming InTerprofessional cardiovascular disease prevention in primary care” (TRANSIT). Eight primary care clinics in Quebec, Canada, agreed to participate by creating and implementing an interprofessional facilitation team (IFT). Sixty‐three participants volunteered to be part of an IFT, and 759 patients agreed to participate. We randomized six clinics into a supported facilitation (“supported”) group, with an external facilitator (EF) and financial incentives for participants. We assigned two clinics to an unsupported facilitation (“unsupported”) group, with no EF or financial incentives. After 3 months, we held one interview for the two EFs. After 6 months, we held eight focus groups with IFT members and another interview with each EF. The analyses revealed three key forces: (1) opportunity for dialogue through the IFT, (2) active role of the EF, and (3) change implementation budgets. Decisionmakers designing implementation plans for interprofessional programs should ensure that these driving forces are activated. Further research should examine how these forces affect interprofessional practices and patient outcomes.

Development of an interprofessional program for cardiovascular prevention in primary care: A participatory research approach:

Background: The chronic care model provides a framework for improving the management of chronic diseases. Participatory research could be useful in developing a chronic care model–based program of interventions, but no one has as yet offered a description of precisely how to apply the approach. Objectives: An innovative, structured, multi-step participatory process was applied to select and develop (1) chronic care model–based interventions program to improve cardiovascular disease prevention that can be adapted to a particular regional context and (2) a set of indicators to monitor its implementation. Methods: Primary care clinicians (n = 16), administrative staff (n = 2), patients and family members (n = 4), decision makers (n = 5), researchers, and a research coordinator (n = 7) took part in the process. Additional primary care actors (n = 26) validated the program. Results: The program targets multimorbid patients at high or moderate risk of cardiovascular disease with uncontrolled hypertension, dyslipidemia or diabetes. It comprises interprofessional follow-up coordinated by case-management nurses, in which motivated patients are referred in a timely fashion to appropriate clinical and community resources. The program is supported by clinical tools and includes training in motivational interviewing. A set of 89 process and clinical indicators were defined. Conclusion: Through a participatory process, a contextualized interventions program to optimize cardiovascular disease prevention and a set of quality indicators to monitor its implementation were developed. Similar approach might be used to develop other health programs in primary care if program developers are open to building on community strengths and priorities.

How to help patients manage their dyslipidemia: A primary care physician-pharmacist team intervention

Dyslipidemia treatment in primary care is far from optimal — adherence and persistence to pharmacotherapy are low, and physicians tend not to titrate statin dosages. Consequently, a large proportion of patients do not attain their recommended lipid targets. This has serious clinical and economic consequences. Several studies have shown that community-pharmacist interventions and collaborative management of pharmacotherapy by physicians and pharmacists improve dyslipidemia treatment. In Quebec, as a result of legislative changes (Bill 90) made in 2002, community pharmacists may initiate and adjust drug therapy in accordance with a physician’s prescription and request laboratory analyses when needed. This new legislation increases the potential for a physician-pharmacist team approach to the management of dyslipidemic patients. In Quebec, in order to implement these collaborative practices, a treatment protocol has to be approved by members of a hospital’s Conseil des Medecins, Dentistes et Pharmaciens (Council of Doctors, Dentists, and Pharmacists). In this article, we present a treatment protocol for the management of statin therapy that was developed by pharmacists (LL, JV, DL, MCV, SP), family physicians (MTL, EH), and a cardiologist (JG) as part of a randomized controlled trial. The treatment protocol describes a physician-pharmacist team intervention for the management of patients with dyslipidemia in a primary care setting.