Academic literature on the topic 'Medical / General'

This thesis explores the role of technology as a resource in the structure of medical domination of birth and death, stressing technology's pivotal position at the intersection of control and uncertainty. Based in Intensive Care and Obstetrics (between which the health status of patients diverges sharply), it notes the convergence of technology used and examines the contest for control within the labour process. This includes using technology to facilitate a 'standardized' birth or death; a more retrospectively defensible event. In general, the 'burden of proof' is concluded to lie with those wishing not to intervene rather than the reverse. Given the (cognitively male) biomedical model, mind-body dualism is an assumption embedded in medical technology: this is especially significant in childbirth, where it fractures the woman's ontological experience of giving birth. Its positivistic and pathological emphasis is associated with a reification of processes and a commodification of their 'solution': which becomes located in technology. It is argued that commodification in health provision will increase with the further application of market principles to the NHS. It is concluded that 'uncertainty', endemic to medicine and a possible challenge to control, is proactively manipulated and pressed into the service of medical domination. Technology is used to mask uncertainty and aid the medical profession's control of patients/relatives, and subordinate work groups. A technological fix may be viewed as the opposite to re-discovering societal dreams and myths, however, more paradoxically, it is concluded that dreams and myths have become attached to technology. Thus, the symbolic role of technology is: to provide hope of continued survival (or cure), the veiling of existential uncertainty and the offer of 'absolution' - should all efforts fail (a freedom from guilt in the assurance that "everything possible was tried"). Its 'heroic' project is viewed as an existentially 'masculine' health provision and 'feminized' health care is posited as an alternative.

In seeking to answer the research question, “What are the Decision Factors that Determine Choice of Medical Specialty Amongst Medical Students, Prevocational Doctors, General Practice Registrars and General Practitioners?”, this qualitative research utilised in-depth interviews to provide a unique perspective in an intergenerational study that explored key factors impacting on choice of medical specialty. Findings confirm that money and prestige are not important and that work-life balance and professional satisfaction are key to influence decisions.

Patient safety is as an increasingly active field of research and policy in the UK and around the world. The prevailing academic model for understanding the cause of patient safety incidents considers failures in cognitive and system aspects of care to playa role, with an emphasis on system factors in preventing harm. General practitioners (GPs) are the first port of call for a wide range of undifferentiated medical, psychological and social problems, presented by patients with whom they may form lasting relationships. The priorities and processes of care in general practice are consequently less clearly defined, more individualised and more strongly influenced by the people involved than in the hospital settings where the existing model was developed. Research in general practice has thus far been conducted from a professional standpoint, using doctors' reports to detect and understand safety incidents. Patients may bring a valuable new perspective to understanding the nature, incidence and cause of adverse events in general practice, allowing the existing model to be refined. This study aimed to provide a detailed description and analysis of patients' perspective on episodes of care they regarded as regrettable. A qualitative approach was used, conducting in-depth interviews with 34 patients whose healthcare experiences made them likely to be good key informants regarding patient safety issues in general practice. An adaptive theorising approach was used, to allow grounded insights arising from the empirical data to be interpreted in the light of, and to add to the development of, theories about the causation of adverse events. The results showed respondents' evaluations of GPs' medical performance to be contingent on their expectations, prior experiences and the doctor-patient relationship. They understood the quality and safety of GPs' care to be determined by their knowledge, skills and an attitude of professional commitment, using this understanding to inform the attribution of responsibility or blame for their experiences of care. This approach differed from the prevailing academic model in that it focussed on errors more than adverse outcomes, placed a strong emphasis on the importance of personal and relational factors in error causation and paid relatively little attention to the role of system factors. It identified diagnostic error as a significant issue in general practice, highlighting the dependence of technical aspects of care upon the GP's personal and interpersonal performance. Having sufficient professional commitment to choose to perform well was seen as a prerequisite for the safe application of knowledge and skills. Even where little or no physical harm was sustained, errors attributed to a failing in professional commitment could result in Significant psychological distress, loss of trust, and changes in future help-seeking behaviour. Interpersonal aspects of care and personal factors in GP performance appear to be key influences on safety in this context. This has implications for the focus of safety improvement efforts, which may need to take more account of the role of the individual professional, alongside issues of human factors and system design. A renewed emphasis is recommended on traditional values of altruistic professionalism and personal responsibility. Patients may make good partners in improving safety, provided it is acknowledged that their perspective is subject to socially patterned biases, and that they are sometimes hesitant to challenge medical authority.

General medical wards deliver the majority of inpatient care. Despite technological and therapeutic advances, these wards expose 10% of patients to preventable adverse events, and disproportionately contribute to preventable hospital deaths. Improving ward team performance is often proposed as a mechanism to improve patient outcomes. The overarching goal of this thesis is to identify effective strategies to improve interdisciplinary team care on the medical ward. Chapter 1 introduces key concepts in healthcare quality, and specific issues in the delivery and measurement of interdisciplinary ward care. The existing literature for ward improvement strategies is then described. A narrative review identifies common targets for ward interventions [chapter 2], and a systematic review evaluates interdisciplinary team care interventions, finding little evidence of significant impact on objective patient outcomes [chapter 3]. The development and evaluation of prospective clinical team surveillance (PCTS) is then reported. PCTS is a novel interdisciplinary team care intervention, engaging staff to identify barriers to care delivery, with facilitation and feedback. A programme theory and mixed methods evaluation are presented, using a stepped wedge, cluster controlled trial [chapter 4]. Mixed-effects models show a significant reduction in excess length of stay with high fidelity PCTS [chapter 5]. Surveys, focus groups and auto-ethnography identify PCTS' mechanisms of action, and its impact on incident reporting, safety and teamwork climates [chapter 6]. Implementation outcomes, facilitators and barriers are described in chapter 7. Other perspectives on improvement are also explored. A model of organisational alignment is developed [chapter 8], and an interview study with patients and carers elicits their priorities [chapter 9]. Finally, chapter 10 summarises the findings, highlighting opportunities to develop medical ward outcome sets and construct a model of interdisciplinary team effectiveness. These can be used to support improvements in interdisciplinary care, through changes in policy and practice.

This study aims to make a sociological contribution to understanding the experience of medical students from graduate-entry medicine degree programmes. In this study, I asked the research question ‘what are the challenges experienced by graduate-entry medicine degree programme students during their transition through medical school training?’ Medical students from the University of Warwick Medical School graduate-entry medicine degree programme were invited to take part in this interview-based study. A volunteer sample of 21 medical students took part in a stage one semi-structured one-to-one interview. Fourteen of 21 medical students took part in a follow-up stage two interview between four to thirteen months later. Their interview transcripts were transcribed verbatim and analysed using thematic analysis. Results showed there were three key transition periods within the University of Warwick Medical School’s graduate-entry medicine degree programme. Medical students encountered a range of challenging issues throughout their medical school journey that could be categorised under three conceptual themes: challenges associated with the curriculum, challenges associated with their social role and generic life challenges. Learning, professional identity development and managing coping strategies were the three key challenging issues dominating their transition experience. These challenging issues were in keeping with my findings from literature review on the medical school experience of undergraduate-entry and graduate-entry students. This study has made one original sociological contribution to understanding the professionalism issue about how medical students manage health advice requests from their family and friends. The findings from this study could be useful to educators and medical schools in enhancing their student support services. It could also be useful to prospective and existing medical students in understanding the realities of undertaking a graduate-entry medicine degree programme.

This thesis begins by considering that modern medicine as a profession has tremendous scope for both good and ill, and as an enterprise consumes a vast amount of the national wealth. Against this background, the thesis considers how and why medicine is regulated, and what the effects of this regulation are. The study aims to assess the regulation of the medical profession against the interests of the state, the profession, and the consumers of health care, to see whether the regulatory mechanisms adopted adequately safeguard the interests of all parties concerned with the practice of medicine. The methodology chapter spells out the analytical techniques which the bulk of the thesis utilises and delimits the scope of the research to cover only bodies having a legal genesis and which are universal in application. A series of "core evaluation criteria" are identified against which the four regulatory mechanisms are assessed. Chapters 3 to 6 contain the bulk of the actual research into the four main areas of regulatory endeavour which the study considers; each is analysed in turn in terms of the purpose, mechanism and effect of the regulatory machinery being considered and then assessed against the core evaluation criteria. Finally, the conclusions chapter draws together the different threads which the sector-specific analyses have identified as being points of concern, and the system as a whole is evaluated to see whether the interests of the relevant stakeholders are adequately safeguarded, to identify any regulatory gaps which exist in the present system, and to point out the direction which anyone seeking to improve the system should consider

The social construction of the discourse of medical institutions is analysed, drawing on both speech act and structural theories. Discourse is defined as a symbol system which has an ideological effect. This effect is linked to the maintenance of the interests of hegemonic social groups. Michel Foucault's archaeological method accords primacy to the relations which exist between institutional and social processes in the formation of discursive relations. Foucault's genealogical method also describes how the identity of the modern subject is constituted within the power nexus of coercive institutions. Medical discourse is paradigmatic of Basil Bernstein's model of pedagogic discourse. Pedagogic discourse is constructed according to the intrinsic grammar of the pedagogic device. This comprises distributive, recontextualizing and evaluative rules. These operate in three institutional contexts: the field of production, the field of reproduction and the recontextualizing field. M. A. K. Halliday's systemic linguistics defines three metafunctions of the text which operate in relation to its context of situation: the textual, ideational, and interpersonal. The textual characteristics of three principal modalities, or genres, of medical text are described in relation to their institutional contexts: the medical research report within the field of production, the medical interview within the field of reproduction and the medical textbook within the recontextualizing field. As a medical text shifts from the field of production to the recontextualizing field, certain transformations take place in the ideational options of tense, transitivity and process and the interpersonal options of modality. These syntactic transformations, organized by codes of the pedagogic device, symbolically authorize the recontextualized medical text.

Atlas-Based Segmentation of medical images is an image analysis task which involves labelling a desired anatomy or set of anatomy from images generated by medical imaging modalities. The overall goal of atlas-based segmentation is to assist radiologists in the detection and diagnosis of diseases. By extracting the relevant anatomy from medical images and presenting it in an appropriate view, their work-flow can be optimised. This portfolio-style thesis discusses the research projects carried out in order to evaluate the applicability of atlas-based methods to a variety of medical imaging problems. The thesis describes how atlas-based methods have been applied to heart segmentation, to extract the heart for further cardiac analysis from cardiac CT images, to kidney segmentation, to prepare the kidney for automated perfusion measurements, and to coronary vessel tracking, in order to improve on the quality of tracking algorithms. This thesis demonstrates how state of the art atlas-based segmentation techniques can be applied successfully to a range of clinical problems in different imaging modalities. Each application has been tested using not only standard experimentation principles, but also by clinically-trained personnel to evaluate its efficacy. The success of these methods is such that some of the described applications have since been deployed in commercial products. While exploring these applications, several techniques based on published literature were explored and tailored to suit each individual application. This thesis describes in detail the methods used for each application in turn, recognising the state of the art, and outlines the author's contribution in every application.