Sharing research findings with research participants and communities.

In occupational and environmental health research, individual, group and community research participants have a unique and vested interest in the research findings. The ethical principles of autonomy, non-maleficence and beneficence are helpful in considering the ethical issues in the disclosure of research findings in occupational and environmental health research. Researchers need to include stakeholders, such as groups and communities, in these discussions and in planning for the dissemination of research findings. These discussions need to occur early in the research process.

Better governance in academic health sciences centres: moving beyond the Olivieri/Apotex Affair in Toronto.

The Toronto experience suggests that there may be several general lessons for academic health sciences complexes to learn from the Olivieri/Apotex affair (OAA) regarding the ethics, independence, and integrity of clinical research sponsored by for profit enterprises. From a local perspective, the OAA occurred when there already was a focus on the complex and changing relationships among the University of Toronto, its medical school, the fully affiliated teaching hospitals, and off campus faculty because of intertwined interests and responsibilities. The OAA became a catalyst that accelerated various systemic reforms, particularly concerning academic/industry relations. In this article, the evolving governance framework for the Toronto academic health sciences complex is reviewed and these policy and process reforms discussed. These reforms have created collaborative activity among research ethics boards and contract research offices of the partner institutions, and allowed the joint university/hospital ethics centre to play a role in governance and policy, while respecting the missions and mandates of the involved institutions. Although few of the policies are dramatically innovative, what is arguably novel is the elaboration of an overarching governance framework that aims to move ethics to a central focus in the academic complex. Time alone will tell how sustainable and effective these changes are.

Problems for clinical judgement: 4. Surviving in the report card era.

Health care report cards involve comparisons of health care systems, hospitals or clinicians on performance measures. They are going to be an important feature of medical care in Canada in the new millennium as patients demand more information about their medical care. Although many clinicians are aware of this growing trend, they may not be prepared for all of its implications. In this article, we provide some historical background on health care report cards and describe a number of strategies to help clinicians survive and thrive in the report card era. We offer a number of tips ranging from knowing your outcomes first to proactively getting involved in developing report cards.

Should Canadian physicians have a mandatory duty to report woman abuse?

As in other countries, woman abuse is a leading public health issue in Canada. In recognition of its seriousness and the need to interrupt the cycle of violence, several jurisdictions outside of Canada have enacted mandatory reporting laws for woman abuse that require health care workers to report cases. This article reviews the major debates surrounding mandatory reporting of woman abuse with an emphasis on where knowledge is incomplete but would be of benefit when weighing the pros and cons of such laws. We conclude with comments and recommendations with respect to Canada and its health legislation.

Problems for clinical judgement: 3. Thinking clearly in an emergency.

The resuscitation of a patient in extremis is frequently characterized by chaos and disorganization, and is one of the most stressful situations in medicine. We reviewed selected studies from the fields of anesthesia, emergency medicine and critical care that address the process of responding to a critically ill patient. Individual clinicians can improve their performance by increased exposure to emergencies during training and by the incorporation of teamwork, communication and crisis resource management principles into existing critical care courses. Team performance may be enhanced by assessing personality factors when selecting personnel for high-stress areas, explicit assignment of roles, ensuring a common "culture" in the team and routine debriefings. Over-reliance on technology and instinct at the expense of systematic responses should be avoided. Better training and teamwork may allow for clearer thinking in emergencies, so that knowledge can be translated into effective action and better patient outcomes.

Problems for clinical judgement: 1. Eliciting an insightful history of present illness.

This article presents the results of a review of studies of psychology that describe how ordinary human reasoning may lead patients to provide an unreliable history of present illness. Patients make errors because of mistakes in comprehension, recall, evaluation and expression. Comprehension of a question changes depending on ambiguities in the language used and conversational norms. Recall fails through the forgetting of relevant information and through automatic shortcuts to memory. Evaluation can be mistaken because of shifting social comparisons and faulty personal beliefs. Expression is influenced by moods and ignoble failures. We suggest that an awareness of how people report current symptoms and events is an important clinical skill that can be enhanced by knowledge of selected studies in psychology. These insights might help clinicians avoid mistakes when eliciting a patient's history of present illness.

Problems for clinical judgement: 2. Obtaining a reliable past medical history.

Ordinary human reasoning may lead patients to provide an unreliable history of past experiences because of errors in comprehension, recall, evaluation and expression. Comprehension of a question may change depending on the definition of periods of time and prior questions. Recall fails through the loss of relevant information, the fabrication of misinformation and distracting cues. Evaluations may be mistaken because of the "halo effect" and a reluctance to change personal beliefs. Expression is influenced by social culture and the environment. These errors can also occur when patients report a history of present illness, but they tend to be more prominent with experiences that are more remote. An awareness of these specific human fallibilities might help clinicians avoid some errors when eliciting a patient's past medical history.

Medical care use among women before and after sexual assault: a population study.

We set out to compare medical care utilisation patterns between women who were sexually assaulted and women who were not sexually assaulted in the year before and the year after the assault. Cases studied were 690 females aged 15 and over who had undergone a forensic evidence examination for sexual assault between April 1996 and March 1997 and the same number of female age-matched controls. This was a population-based, matched case-control study using administrative databases of medical encounters (only physician services). Outcomes included physician visits by physician specialty; clinic and hospital diagnoses and hospital discharges. Of the cases, 38.4% were aged 1519; 21.4% aged 2024; and 40.2% aged 25 or older. Before and after the sexual assault, cases were more frequent users of medical services than controls. Cases were seen more often, received more medical services and were more likely to be hospitalised than controls in both time periods. Cases were also more likely to be diagnosed with a vast range of physical and psychological problems during the period of study. The persistence of mental and physical health problems before and after a forensic examination for sexual assault presents a challenge. Of paramount concern are issues concerning informed consent to undergo the examination. Collection and documentation of evidence may be important for victims with severe mental illness who may have more difficulty testifying in court. Our study suggests the need for future research examining the reasons why women do not undergo the examination both in terms of whether it is offered and declined or not offered to them.

What the courts need to know about mental health diagnoses of abused women.

Abused women may appear before the courts because of family or criminal matters. It is not uncommon for an abused woman to be diagnosed as having a mental health condition, including a mental disorder. In this paper, we consider the implications of the use of mental health diagnoses in the court system. We discuss the diagnostic criteria in the DSM-IV and ICD-10 classification systems and examine what other information is needed by the courts to interpret the behaviour and thought processes of abused women. This other information includes: whether the abuse is continuing and the likely impact of its continuance, diagnosis and prognosis, as well as the woman's survival strategies, her coping mechanisms, her support systems, and the severity of the physical and/or psychological abuse. This information needs to be stated within the context of what we currently know about abuse, including up-to-date knowledge about its epidemiology (e.g., prevalence, physical and psychological manifestations, and complex psychological responses). Information about other intervening factors is essential for the courts; and in order to present meaningful testimony on these factors, it is critical for clinicians to have a thorough understanding of the complex dynamics of spousal abuse.

Clinical factors affecting physicians' management decisions in cases of female partner abuse.

BACKGROUND AND OBJECTIVES: This study determined which clinical factors influence Canadian primary care physicians' management decisions in cases of female partner abuse. METHODS: We used a cross-sectional survey design and randomly sampled (n = 2,014) English-speaking Canadian physicians with a primary interest in family or general practice who were practicing in any of the 12 provinces and territories in Canada and who were active in private practice and registered to prescribe. Respondents completed a questionnaire that required them to score management decision plans in response to case scenarios illustrating typical office-based situations that might involve domestic violence. RESULTS: The response rate was 50.7% (n = 1,022). Using forward stepwise regression analysis, the strongest predictor of whether a physician endorsed a management plan in response to violence was whether the woman acknowledged or revealed the abuse. Male physicians were more likely than females to endorse talking with the suspected abuser if he was known to them, regardless of the quality of this patient-physician relationship with the abuser. CONCLUSIONS: Decisions about whether to deal with the abuse or the selection of a management plan are not dependent on the severity of the physical abuse and the emotional consequences. Whether a woman acknowledges or reveals the abuse, as well as whether both the male and female patients are in the physician's practice, are predictive of whether a physician's response to a case scenario involves dealing with spousal abuse and how he/she will address it.

Factors influencing the delivery of abortion services in Ontario: a descriptive study.

CONTEXT: Although Canadian women have had the right to obtain legal induced abortions for the past decade, access to the procedure is still limited and controversial in many areas. METHODS: Chiefs of obstetrics and gynecology, chiefs of staff, directors of nursing and other health professionals at 163 general hospitals in Ontario, Canada, were asked to provide information on issues concerning the availability of abortion services of their facility. The hospital participation rate was 97% and the individual response rate was 75%. RESULTS: Nearly one-half (48%) of hospitals perform abortions. Approximately 36% of these hospitals do so up to a maximum gestational age of 12 weeks, 23% to a maximum of 13-16 weeks, 37% to a maximum of 17-20 weeks and 4% at greater than 20 weeks. Hospital factors, including resources and policies, did not significantly influence whether abortions are provided. However, these factors did affect the number performed, whether there were gestational limitations and the choice of procedure. About 13% of provider hospitals indicated that staff training contributes to the existence of gestational age limits, and 24% said that it directly influences procedure choice. Only 18% of hospitals reported that their physicians have received additional training outside of their medical school or medical residency education to learn abortion techniques or to gain new skills. Forty-five percent of hospitals that provide abortions had experienced harassment within the past two years, and 15% reported that this harassment has directly affected their staff members' willingness to provide abortions. CONCLUSION: Based upon the provision of obstetric care, many hospitals in Ontario that are capable of offering abortion services do not. Some of the reasons for this failure are related to the procedure itself, while others may be related to resource issues that affect the delivery of other medical services as well. Variation in the availability of abortions is due to a shortage of clinicians performing the procedure, and training directly influences gestational limits and procedural choices.

PIP: Although induced abortion was awarded the same status as any other medical procedure in 1991 in Canada, women's access to the procedure remains limited. To identify factors influencing the delivery of abortion services, a questionnaire was mailed to chiefs of obstetrics and gynecology, chiefs of staff, directors of nursing, and other health professionals at 163 general hospitals in Ontario, Canada, in 1994. The hospital participation rate was 97% and the individual response rate was 75%. Of the 158 responding hospitals, 76 (48%) perform abortions--36% up to 12 weeks' gestation, 23% to a maximum of 13-16 weeks, 37% up to 17-20 weeks, and 4% beyond 20 weeks. Staff preferences and training were significant determinants of both these age limits and the choice of procedures offered. 47% of provider hospitals had written guidelines or policies regulating abortion. 67% provided alternative work assignments for nurses unwilling to participate in pregnancy terminations. Only 18% of hospitals reported that their staff physicians have received training beyond that obtained in medical school or medical residencies to learn abortion techniques or gain new skills. 45% of hospitals that provide abortion had experienced harassment--primarily picketing--in the 2 years preceding the survey and, in 15% of hospitals, this harassment had reportedly affected the willingness of staff members to provide abortions. If provision of obstetric care is a marker for a hospital's capacity to provide abortion services, 59 general hospitals (72% of nonproviders) do not provide abortion despite the capacity to do so. The restructuring process currently underway in Canadian hospitals should include steps to ensure more widespread access to abortion services and more opportunities for physicians to become trained in this area.

Defining the physician's duty to warn: consensus statement of Ontario's Medical Expert Panel on Duty to Inform.

Ontario's Medical Expert Panel on Duty to Inform was formed to consider the duty of Ontario physicians in circumstances where a patient threatens to kill or cause serious bodily harm to a third party. The panel was concerned about the implications of any duty to inform on the integrity of the physician-patient relationship, particularly with respect to confidentiality. The panel agreed that regulations safeguarding the confidentiality of patient information ought to be changed only if there is a critical reason for doing so, but, after deliberation, the panel members concluded that the need to protect the public from serious risk of harm is a paramount concern that should supersede the duty of confidentiality. The recommendations reported here were endorsed in principle by the panelists and the groups they represented (the Royal College of Physicians and Surgeons of Canada, the Canadian Medical Protective Association, the College of Physicians and Surgeons of Ontario, the Ontario College of Family Physicians and the Ontario Medical Association) and are being implemented by the College of Physicians and Surgeons of Ontario.