ObjectiveTo study how doctors care for their patients, both medically and as fellow humans, through observing their conduct in patient–doctor encounters.DesignQualitative study in which 101 videotaped consultations were observed and analysed using a Grounded Theory approach, generating explanatory categories through a hermeneutical analysis of the taped consultations.SettingA 500-bed general teaching hospital in Norway.Participants71 doctors working in clinical non-psychiatric departments and their patients.ResultsThe doctors were concerned about their patients' health and how their medical knowledge could be of service. This medical focus often over-rode other important aspects of the consultations, especially existential elements. The doctors actively directed the focus away from their patients' existential concerns onto medical facts and rarely addressed the personal aspects of a patient's condition, treating them in a biomechanical manner. At the same time, however, the doctors attended to their patients with courteousness, displaying a polite and friendly attitude and emphasising the relationship between them.ConclusionsThe study suggests that the main failing of patient–doctor encounters is not a lack of courteous manners, but the moral offence patients experience when existential concerns are ignored. Improving doctors' social and communication skills cannot resolve this moral problem, which appears to be intrinsically bound to modern medical practice. Acknowledging this moral offence would, however, be the first step towards minimising the effects thereof.
While certain substantial moral dilemmas in health care have been given much attention, like abortion, euthanasia or gene testing, doctors rarely reflect on the moral implications of their daily clinical work. Yet, with its aim to help patients and relieve suffering, medicine is replete with moral decisions. In this qualitative study we analyse how doctors handle the moral aspects of everyday clinical practice. About one hundred consultations were observed, and interviews conducted with fifteen clinical doctors from different practices. It turned out that the doctors’ approach to clinical cases followed a rather strict pattern across specialities, which implied transforming patients’ diverse concerns into specific medical questions through a process of ‘essentialising’: Doctors broke the patient’s story down, concretised the patient’s complaints and categorised the symptoms into a medical sense. Patients’ existential meanings were removed, and the focus placed on the patients’ functioning. By essentialising, doctors were able to handle a complex and ambiguous reality, and establish a medically relevant problem. However, the process involved a moral as well as a practical simplification. Overlooking existential meanings and focusing on purely functional aspects of patients was an integral part of clinical practice and not an individual flaw. The study thus questions the value of addressing doctors’ conscious moral evaluations. Yet doctors should be aware that their daily clinical work systematically emphasises beneficence at the expense of others—that might be more important to the patient.
The principle of respect for autonomy has shaped much of the bioethics' discourse over the last 50 years, and is now most commonly used in the meaning of respecting autonomous choice. This is probably related to the influential concept of informed consent, which originated in research ethics and was soon also applied to the field of clinical medicine. But while available choices in medical research are well defined, this is rarely the case in healthcare. Consideration of ordinary medical practice reveals that the focus on patient choice does not properly grasp the moral aspects involved in healthcare. Medical decisions are often portrayed as if doctors and patients in confidence confront specific decisions about examinations or treatment, yet the reality often involves many different participants, with decisions being made over time and space. Indeed, most of the decisions are never even presented to patients, as it would be unethical to suggest something that is not medically justifiable. The options patients do confront are somewhat arbitrarily constructed within the narrow framework of both what is deemed to be medically appropriate and how the healthcare system is organised practically. While the autonomy discourse has proven valuable, a failure to distinguish between the fields of medical research and clinical medicine has generated a focus on patient choice that does not reflect what is really at stake in healthcare settings. This is alarming, because the current discourse misrepresents medical practice in a way that actually contributes to bioethical self-delusion.
Objective: The transfer of experiences gained after prehospital medical responses to major incidents has largely been nonsystematic, and better-structured reporting methods have been advocated. A consensus-based template was recently created and implemented as an open-access website. This qualitative study assessed the feasibility of using the template and reporting site. Methods: Informants who had used or who had been asked to use the template were interviewed. The semi-structured interviews were transcribed verbatim, and the transcripts were analyzed by using an inductive approach based on grounded theory methodology. Results: The major theme identified was a need for "defining purpose" as explained by the minor themes "relevance," "scope," "resources," and "usefulness." Informants reported that the template content needed to be revised and that the scope and rationale behind each question should be conveyed to the user. Resources necessary for reporting and clarity regarding the aim and outcome also need to be communicated to users and policy-makers. The interface between informants and the template is critical. Conclusions: Informants considered the template and website useful but reported that the workload exceeded their expectations. Despite pilot testing of the template before implementation, early revision of the template is recommended. (Disaster Med Public Health Preparedness. 2017;11:403-406)
Kari Milch Agledahl er spesialist i øyesykdommer, overlege og forsker ved Finnmarkssykehuset, Klinikk Hammerfest, og førsteamanuensis i medisinsk etikk ved UiT Norges arktiske universitet. Hun er leder av den nasjonale forskningsetiske komité for medisin og helsefag og medlem i Tidsskriftets redaksjonskomité. Forfatteren har fylt ut ICMJE-skjemaet og oppgir ingen interessekonflikter.Torben Wisborg er spesialist i anestesiologi, overlege ved Akuttavdelingen, Finnmarkssykehuset, Klinikk Hammerfest, professor ved UiT Norges arktiske universitet og forskningsleder ved Nasjonal kompetansetjeneste for traumatologi, Oslo universitetssykehus. Han er hovedtillitsvalgt for Overlegeforeningen ved Hammerfest sykehus. Forfatteren har fylt ut ICMJE-skjemaet og oppgir ingen interessekonflikter.
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