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This qualitative study aimed to describe, from the perspective of domestic violence survivors, what helped victims in health care encounters improve their situation and thus their health, and how disclosure to and identification by health care providers were related to these helpful experiences. Semi-structured, open-ended interviews were conducted with a purposeful sample of survivors in the San Francisco Bay Area. Data were analyzed using constant comparative techniques and interpretative processes. Twenty-five women were interviewed, the majority being white and middle-class, with some college education. Two overlapping phenomena related to helpful experiences emerged: (1) the complicated dance of disclosure by victims and identification by health care providers, and (2) the power of receiving validation (acknowledgment of abuse and confirmation of patient worth) from a health care provider. The women described a range of disclosure and identification behaviors from direct to indirect or tacit. They also described how-with or without direct identification or disclosure-validation provided "relief," "comfort," "planted a seed," and "started the wheels turning" toward changing the way they perceived their situations, and moving them toward safety. Our data suggest that if health care providers suspect domestic violence, they should not depend on direct disclosure, but rather assume that the patient is being battered, acknowledge that battering is wrong, and confirm the patient's worth. Participants described how successful validation may take on tacit forms that do not jeopardize patient safety. After validating the patient's situation and worth, we suggest health care providers document the abuse and plan with the patient for safety, while offering ongoing validation, support, and referrals.

Physicians who treat HIV-seropositive patients can and should help them become more involved in their healthcare. This qualitative study investigated HIV-seropositive persons' perspectives regarding when and how physicians could have a pronounced effect on their involvement. Sixty-four HIV-seropositive patients, diverse in gender, ethnicity, and risk factors, were purposefully selected from three San Francisco Bay Area healthcare delivery settings. A combined interview-guide approach with a standardized open-ended interview was used to elicit participants' healthcare and physician relationship experiences. Data analysis revealed the themes that (1) involvement led to improved health outcomes and quality of life, (2) three life circumstances served as "opportune moments" for persons becoming more involved with their healthcare (a diagnosis of HIV/AIDS, the onset of symptoms, and beginning drug treatment intervention), and (3) participants became more involved when their physicians used a relationship-centered approach to healthcare. The results of the study suggest that physicians should be aware of opportune moments to intervene with their HIV-seropositive patients and of the helpful effect a personal, caring, relationship-centered approach can have on these individuals' involvement in their care. The recognition of opportune moments also may have implications for treating other chronic illnesses.

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Electronic advice and guidance (A&G) was implemented in our trust in April 2016. Referrals to this service steadily increased with weekly requests up to 313 (average 261) in 2022. We noticed that, increasingly, requests were being sent from allied health professionals or junior medical staff often for quite rudimentary dermatology. A survey was constructed to understand who is using our service, their level of dermatology training, whether there is discussion prior to sending A&G and to examine user satisfaction. A survey link comprising 16 questions was attached to A&G replies within a 12-week period from October 2022. In total, 144 responses were received. Most responders were regular users of the service, with 20% sending over six requests a month. Of those responding, 94 were fully trained general practitioners (GPs), with the others a mix of junior doctors, nurses and allied health professionals. Only 27.8% of referrers had discussed the case within primary care prior to sending the request; this included one-third of non-GPs. Levels of formal dermatology training among requestors are low, with 10.4% stating they have no formal dermatology training and 35.4% having training only within primary care. Eighty-five per cent stated they would like more dermatology training. Our department has developed online management guidelines for use in primary care. While 75.7% of those responding were aware of these guidelines, only 30.3% looked at these prior to sending the A&G request. Most requesters found the A&G process very easy, and 99.3% felt they received a satisfactory A&G response. Only 28.4% of requests were converted to a referral. Additional comments from the responders were universally positive with the service repeatedly described as ‘excellent’. We have created an easy-to-use, valued and quick service, but this creates extra work within secondary care if cases are not discussed locally before requesting specialist input. Many may not have been referred to secondary care prior to electronic A&G being established. We will discuss the issues this presents and ways we can address this to ensure we are providing the optimal A&G service for those who really need it.