Walking a tightrope: oncologists' perspective on providing information to women with recurrent ovarian cancer (ROC) during the medical encounter.

PURPOSE: Women with ovarian cancer (OC) must make treatment decisions. The first step in this process involves information giving about potential management choices. In this study, our objectives were to (1) describe the key issues that are reviewed by the oncologist when a woman presents with recurrent OC and (2) understand the extent to which physicians have different methods of giving information to patients. METHODS: A descriptive qualitative study of 19 gynecologic and medical oncologists in Ontario, Canada was undertaken using a semi-structured interview guide. RESULTS: Oncologists felt that the process of information giving was an important part of the medical encounter. The main themes that emerged from our data were (1) Oncologists varied in their approach to giving information about the disease and management; (2) oncologists felt that giving management choices to the patients helped engage patients in dealing with their disease and moving forward; (3) oncologists felt it was important to foster patient's hope; and (4) oncologists struggled with how much clinical outcome information to give to patients. CONCLUSIONS: Oncologists tried to achieve a difficult balance between providing patients with several management choices in order to help them keep hope alive and providing them with realistic clinical information suggesting poor patient outcomes. Areas for future research include exploring (1) how physicians can best walk this tightrope of information giving, (2) how to assess physician "success" in doing so, and (3) the meaning of fostering hope to patients and physicians in the context of treatment decision making.

Managing under managed community care: the experiences of clients, providers and managers in Ontario's competitive home care sector.

In 1996, a newly elected government in the Province of Ontario, Canada, introduced a managed competition environment into the home care sector through the establishment of a competitive contracting process for home care services. Through 65 in-depth, semi-structured interviews conducted between November 1999 and January 2001, we trace the implementation of this competitive contracting policy within Ontario's newly established managed community care environment and assess the effects of competitive contracting against two sets of goals: (1). quality of care goals that consider continuity of care of paramount importance in the provision of home care; and (2). the managed competition goal of increased efficiency. In assessing the implementation of this policy against these goals, we highlight the conflicts that can arise in pursuing different policy goals in response to different formulations of the policy problem that underpin them. We map stakeholder experiences with the competitive contracting policy onto relevant contracting and managed competition literatures. When measured against the goals of quality of care and efficiency, the findings presented here offer a mixed review of the experiences to date with the competitive contracting process introduced in Ontario's home care sector and suggest improvements for managing future competitive contracting processes.