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Medicine by Alexandros G.Sfakianakis,Anapafseos 5 Agios Nikolao

Medicine by Alexandros G.Sfakianakis

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Τρίτη, 3 Ιανουαρίου 2017

Pediatric neurological surgery






Highlights

Strongest indicators of satisfactory clinical experience are cheerfulness of practice and ability to get desired appointment
High satisfaction requires that the clinic staff and providers work as a well integrated team
Patients are not as greatly affected by length of appointment or clinic wait times
Patients appreciate explanations and apologies for delays and time limitations

Abstract

Introduction

Patient and family satisfaction during outpatient visits is correlated with a continuance of care and likelihood to recommend the practice to others. Additionally, patient-family satisfaction can determine the success of the practice and influence medical outcomes. Utilizing a well-validated surveys instrument, patient and family satisfaction can be explored in the office setting.

Methods

During a consecutive 36 month period, a standardized and validated patient satisfaction survey instrument was provided to the family members of patients who presented to two pediatric neurosurgery clinics associated with Nemours Children's Health System. The completed surveys were analyzed statistically to identify correlations between overall satisfaction, defined as “Likelihood to Recommend (LTR) the Practice”, and relevant practice and provider variables.

Results

The factors that exhibited the greatest correlation to LTR were: ‘Cheerfulness of Practice’ (r = 0.74), ‘Ability to Get Desired Appointment’ (r = 0.70), ‘Likelihood of Recommending Care Provider’ (r = 0.65), ‘Staff Worked Together’ (r = 0.65), and ‘Waiting Area Comfort and Pleasantness’ (r = 0.60).

Discussion and conclusions

Patient and family satisfaction surveys are useful for gaining insight into pediatric neurosurgical practices. Data from this cohort suggest that the environment in which patient care is delivered, timeliness of appointments and positive perceptions of the healthcare team correlate most strongly with overall satisfaction.

1. Introduction

In a typical doctor's office, there could be hundreds of patient encounters daily. It is difficult to maintain the same level of care with each patient as well as meet every expectation that a patient may possess prior to seeing his physician. However, while it would be difficult for the staff to tailor their approach to every single patient's needs and expectations, certain qualities can ensure that each patient receives excellent quality of care and is satisfied with his visit. It is no surprise that patient satisfaction during a doctor's visit can have dramatic effects on the patient, his family, the practice and its staff. A great experience can mean that the patient will be compliant with the doctor's orders and medications [3] — therefore, requiring less healthcare in the future. On the other hand, a less than ideal experience may mean that the patient does not return to his doctor and does not seek the care he needs. For many years, the best way to assess the level of care that each patient receives has been to anonymously survey the patient at the end of his visit [2] and [7]. Several online programs allow this process, even without the physician's knowledge. These methods are ideal because without the patient's responses, the practice has no way of knowing how best to improve their care. The results of these surveys can have surprising effects on the physician and staff of the practice. For example, one aspect that the staff may believe is conducted exceedingly well may not resonate as such with the patients. Thus, the use of the results of these surveys can serve to provide identifiable targets for improvement.
Within pediatric neurosurgery, patient satisfaction can serve as a marker of quality of care[6]. Enhancement of neurosurgical patient satisfaction can lead to less emergency room visits by the patient [10]. Additionally, gaining a better understanding of patient and family expectations during a typical visit to a pediatric neurosurgeon will help pave the way for the new generation of healthcare that will implement technological advancements such as Telehealth, which serves to bring the expertise of physicians from all around the world to a patient's bedside via a live video feed [12]. Understanding the intricacies of the doctor-patient-family dynamics is a crucial element in the future of all of medicine, particularly the subspecialties, including pediatric neurosurgery. More physicians also are moving toward a shared decision approach to the treatment of their patients, in which the traditionally authoritative patient care approach is replaced by a cooperative approach with collaborative decision making [1]. This means that formidable communication between all members of a patient's healthcare team, including the family, is absolutely fundamental and increasingly imperative.
A pediatric neurosurgery office may experience an influx of patients ranging from normal post-op care to newly diagnosed devastating disorders. The care provider may see patients suffering from congenital abnormalities or neoplasms or accidents/recent trauma all in the same day. Throughout this day, the staff is faced with identifying seriousness of situations, available radiological information present on each patient, prepping the patient, answering questions, putting the patient at ease, etc. To better serve the patients, the office staff rely on the patient feedback, which is best attained through anonymous surveys conducted after the visit. Since the patient and family's interactions with the physician, nurses, and assistants are the majority of the patient experience while in office and, thus, carry the most weight in the satisfaction, we hypothesize that the patient's likelihood to recommend the care provider and rating of staffs' sensitivity to patient's needs should have the strongest effect on the patient's likelihood to recommend the practice.

2. Methods

During a consecutive 36 month period (12/2012–12/2014), patient-family satisfaction surveys were obtained from attendees at two pediatric neurological surgery clinics associated with Nemours Children's' Healthcare System. One is located in Orlando, Florida and the other in Wilmington, Delaware. The validated survey instrument was created by an independent healthcare improvement company, Press Ganey, Inc. It features 34 questions, which include questions relevant to ‘background, access, ‘moving through your visit’, nurse/assistant domains, care provider domains, Personal Issues’, and ‘overall assessment’. All questions were presented as 5 point Likert numeral scales equating ‘1′ with ‘very poor’ and 5 with ‘very good’. Data were accessed through the vendor's website and analyzed. Since Press Ganey, Inc. has validated the highest score (5, or “top box score”) as the most important metric, we used monthly percentages of “top box” scores to perform the correlational analysis. For example, in January 2012, 93.3% of respondents rated ‘Friendliness/Courtesy of Nurses and Assistants' as a ‘5′. However, only 46.2% rated the same in March 2012. Alternatively, in January 2012, 69.2% respondents rated ‘Care Provider's Information About Medications' as a ‘5′, but 81.8% did the same in March 2012.
“Likelihood to Recommend” the Practice, or LTR, was used as the indicator of overall patient-family satisfaction with an individual clinic encounter [8]. Pearson product-moment correlation coefficients were calculated for other variables to identify those that are most predictive of LTR. Correlation coefficients were calculated using Pearson Point in time correlation Microsoft Excel version 2007. The likelihood to recommend was the independent variable and the other questions on the Press Ganey medical practice patient satisfaction survey were the dependent variables. Those variables included: ‘Care Provider's concern for questions/worries’, ‘Care Provider's Information About Medications’, ‘Friendliness/Courtesy of Nurses and Assistants’, ‘Cleanliness of Practice’, ‘Information about Delays’, ‘Care Provider's Effort to Include in Decisions’, ‘Care Provider Spoke Using Clear Language’, ‘Care Provider's Instructions for Follow-up Care’, ‘Ease of Getting Clinic on Phone’, ‘Courtesy of Registration Staff’, ‘Concern for Patient Privacy’, ‘Courtesy of Person Scheduling Appointments’, ‘Time Care Provider Spent with Patient’, ‘Friendliness and Courtesy of Care Provider’, ‘Wait Time at Clinic’, ‘Convenience of Office Hours’, ‘Sensitivity to Patient's Needs’, ‘Care Provider's Explanation of Problem or Condition’, ‘Patient's Confidence in Care Provider’, ‘Extended Staff Introduced Themselves’, ‘Waiting Area Comfort and Pleasantness’, ‘Staff Worked Together’, ‘Concern of Nurses and Assistance for Problem’, ‘Likelihood of Recommending Care Provider’, ‘Ease of Scheduling Appointments’, ‘Ability to Get Desired Appointment’, ‘How Well Staff Protect Safety’, and ‘Cheerfulness of Practice’.

3. Results

A total of 458 respondents completed the survey. We identified a correlation coefficient (r) ≥ 0.6 as indicative of a strong relationship. A correlation coefficient (r) < 0.6 indicated a weaker relationship, which was considered inconclusive. The factors that exhibited the greatest correlation to LTR were: ‘Cheerfulness of Practice’ (r = 0.74), ‘Ability to Get Desired Appointment’ (r = 0.70), ‘Likelihood of Recommending Care Provider’ (r = 0.65), ‘Staff Worked Together’ (r = 0.65), and ‘Waiting Area Comfort and Pleasantness’ (r = 0.60). All factors with corresponding correlation factors are listed in Table 1.
Table 1.
Factors assessed on the survey with correlation coefficients (r) related to “likelihood of recommending practice” in order from strongest correlation to weakest. A correlation factor (r) of ≥ 0.6 indicates a strong relationship.
(CP = Care Provider).
Questionr
Likelihood of recommending practice
Cheerfulness of practice0.74
Ability to get desired appointment0.70
Likelihood of recommending CP0.65
Staff worked together0.65
Waiting area comfort/pleasantness0.60
Friendliness/courtesy of nurse/assistant0.59
Extent staff introduced themselves0.59
Patients' confidence in CP0.58
CP explanations of problem/condition0.55
Our sensitivity to patients' needs0.54
Concern of nurse/assistant for problem0.53
Ease of scheduling appointments0.53
How well staff protect safety0.52
Convenience of our office hours0.49
Wait time at clinic0.48
CP concern for questions/worries0.48
Cleanliness of our practice0.47
Information about delays0.47
CP efforts to include in decisions0.44
CP spoke using clear language0.44
CP instructions for follow-up care0.43
Ease of getting clinic on phone0.40
Courtesy of registration staff0.40
CP information about medications0.35
Our concern for patients' privacy0.34
Courtesy of person scheduling appointment0.33
Time CP spent with patient0.31
Friendliness/courtesy of CP0.30
Bold factors indicate a correlation coefficient of >0.6, which denotes a strong relationship.
Quantifying the extent to which each factor is predictive of LTR was presented through a r[2], goodness of fit linear regression (Fig. 1). The top four factors with a strong relationship to LTR are displayed.
Fig. 1
Fig. 1. 
Scatterplots depict the four factors with the strongest relationship to Likelihood of Recommending Practice. Each plot represents 36 data points that correlate to monthly percentages of those responding with a “top box” score of 5.

4. Discussion and conclusion

Achieving high patient-family satisfaction is a goal for all healthcare providers. Improvement requires a thorough and accurate assessment of the patient-family experience [5]. Fundamentally, the doctor-patient-family relationship is predicated on professionalism, courtesy, and compassion. In an attempt to identify specific elements of an encounter that produce the greatest satisfaction in the outpatient pediatric neurosurgery clinic, we analyzed the results of a standardized, validated survey methodology applied to two practices. The results were enlightening.
We hypothesized that the two strongest indicators of a highly satisfactory clinical experience would be high LTR scores for the provider and high ratings of staffs' sensitivity to patient's needs. While the former was true, the latter was not. This suggests that the provider plays the dominate role in eye of a patient and family. Cheerfulness and experiencing a pleasant office environment had a strong impact on satisfaction. Therefore, it can be deduced that the office environment and the attitude experienced by the patient and family play a significant role in the satisfaction.
In an era of rapid access to most products and services, patients and families expect timely appointments. Within our pediatric healthcare system, we have set a strategic goal of seeing clinic patients within 5 days of initial contact. Finally, high satisfaction requires that the clinic staff and providers work as a well integrated team. Quality data demonstrate this to be a dominate factor in producing safe and effective care. The lack of correlation with several other factors was surprising. For example, patients and families were not greatly affected by length of appointment nor clinic wait times. The perception of time is heavily influenced by the quality the healthcare experience; explaining and apologizing for delays and time limitations can have great impact. Similarly, the complexities of “front end” experience of registration can be buffered by a great encounter with the clinical team [11].
Interaction between the healthcare provider, office staff, patient and family can be impacted by several factors. For example, demographics and language barriers can serve to hinder proper communication or lead to a failure of meeting expectations [9] and [4]. One of the most debated aspects of current practice is the disparity in healthcare quality felt by different races and socioeconomic distributions. Correlating the differences with patient satisfaction may result in a different approach to interactions. Similarly, with regards to a language barrier, while interpreters can satisfactorily relay information to and from the patient and family, subtleties may be lost in translation. It is unclear whether these barriers were contributory to our results, but may be evaluated in future surveys to further identify areas of patient satisfaction improvement.
Lastly, compared to several published cross-sectional studies, the n value was relatively small and may have contributed to the surprising results. It is, therefore, recommended that the survey be made available to other pediatric neurosurgery patients throughout the country, with modified analyses that include the relationship between demographic, language barrier and past medical history.
In conclusion, we have employed a standardized survey methodology to seek understanding of the drivers of patient-family satisfaction in two pediatric neurosurgical clinics. We believe that these data are vital to improvement and optimization of the family-patient experience. We have been able to direct attention to the elements that have the greatest impact. We now employ this methodology throughout all clinics within our system, and the results are provided monthly to the clinic teams for their reflection. We encourage others to learn from their patients and families and improve overall healthcare and the patient-family experience.

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Tinnitus

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HIPPOCRATE'S OATH

"I swear by Apollo, the healer, Asclepius, Hygieia, and Panacea, and I take to witness all the gods, all the goddesses, to keep according to my ability and my judgment, the following Oath and agreement:

To consider dear to me, as my parents, him who taught me this art; to live in common with him and, if necessary, to share my goods with him; To look upon his children as my own brothers, to teach them this art.

I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.

I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not give a woman a pessaryto cause an abortion.

But I will preserve the purity of my life and my arts.

I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art.

In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction and especially from the pleasures of love with women or with men, be they free or slaves.

All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal.

If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all men and in all times; but if I swerve from it or violate it, may the reverse be my lot."

MAIMONIDE'S PRAYER

"Almighty God, Thou has created the human body with infinite wisdom. Ten thousand times ten thousand organs hast Thou combined in it that act unceasingly and harmoniously to preserve the whole in all its beauty the body which is the envelope of the immortal soul. They are ever acting in perfect order, agreement and accord. Yet, when the frailty of matter or the unbridling of passions deranges this order or interrupts this accord, then forces clash and the body crumbles into the primal dust from which it came. Thou sendest to man diseases as beneficent messengers to foretell approaching danger and to urge him to avert it.

"Thou has blest Thine earth, Thy rivers and Thy mountains with healing substances; they enable Thy creatures to alleviate their sufferings and to heal their illnesses. Thou hast endowed man with the wisdom to relieve the suffering of his brother, to recognize his disorders, to extract the healing substances, to discover their powers and to prepare and to apply them to suit every ill. In Thine Eternal Providence Thou hast chosen me to watch over the life and health of Thy creatures. I am now about to apply myself to the duties of my profession. Support me, Almighty God, in these great labors that they may benefit mankind, for without Thy help not even the least thing will succeed.

"Inspire me with love for my art and for Thy creatures. Do not allow thirst for profit, ambition for renown and admiration, to interfere with my profession, for these are the enemies of truth and of love for mankind and they can lead astray in the great task of attending to the welfare of Thy creatures. Preserve the strength of my body and of my soul that they ever be ready to cheerfully help and support rich and poor, good and bad, enemy as well as friend. In the sufferer let me see only the human being. Illumine my mind that it recognize what presents itself and that it may comprehend what is absent or hidden. Let it not fail to see what is visible, but do not permit it to arrogate to itself the power to see what cannot be seen, for delicate and indefinite are the bounds of the great art of caring for the lives and health of Thy creatures. Let me never be absent- minded. May no strange thoughts divert my attention at the bedside of the sick, or disturb my mind in its silent labors, for great and sacred are the thoughtful deliberations required to preserve the lives and health of Thy creatures.

"Grant that my patients have confidence in me and my art and follow my directions and my counsel. Remove from their midst all charlatans and the whole host of officious relatives and know-all nurses, cruel people who arrogantly frustrate the wisest purposes of our art and often lead Thy creatures to their death.

"Should those who are wiser than I wish to improve and instruct me, let my soul gratefully follow their guidance; for vast is the extent of our art. Should conceited fools, however, censure me, then let love for my profession steel me against them, so that I remain steadfast without regard for age, for reputation, or for honor, because surrender would bring to Thy creatures sickness and death.

"Imbue my soul with gentleness and calmness when older colleagues, proud of their age, wish to displace me or to scorn me or disdainfully to teach me. May even this be of advantage to me, for they know many things of which I am ignorant, but let not their arrogance give me pain. For they are old and old age is not master of the passions. I also hope to attain old age upon this earth, before Thee, Almighty God!

"Let me be contented in everything except in the great science of my profession. Never allow the thought to arise in me that I have attained to sufficient knowledge, but vouchsafe to me the strength, the leisure and the ambition ever to extend my knowledge. For art is great, but the mind of man is ever expanding.

"Almighty God! Thou hast chosen me in Thy mercy to watch over the life and death of Thy creatures. I now apply myself to my profession. Support me in this great task so that it may benefit mankind, for without Thy help not even the least thing will succeed."

Information for Health Professionals

Information for Patients

Modern challenged parts of the oath:

  1. To teach medicine to the sons of my teacher. In the past, medical schools gave preferential consideration to the children of physicians.
  2. To practice and prescribe to the best of my ability for the good of my patients, and to try to avoid harming them. This beneficial intention is the purpose of the physician. However, this item is still invoked in the modern discussions of euthanasia.
  3. I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan. Physician organizations in most countries have strongly denounced physician participation in legal executions. However, in a small number of cases, most notably the U.S. states of Oregon,[10] Washington,[11]Montana,[12] and in the Kingdom of the Netherlands,[13] a doctor can prescribe euthanasia with the patient's consent.
  4. Similarly, I will not give a woman a pessary to cause an abortion. Since the legalization of abortion in many countries, the inclusion of the anti-abortion sentence of the Hippocratic oath has been a source of contention.
  5. To avoid violating the morals of my community. Many licensing agencies will revoke a physician's license for offending the morals of the community ("moral turpitude").
  6. I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art. The "stones" referred to are kidney stones or bladder stones, removal of which was judged too menial for physicians, and therefore was left for barbers (the forerunners of modern surgeons). Surgery was not recognized as a specialty at that time. This sentence is now interpreted as acknowledging that it is impossible for any single physician to maintain expertise in all areas. It also highlights the different historical origins of the surgeon and the physician.
  7. To keep the good of the patient as the highest priority. There may be other conflicting 'good purposes,' such as community welfare, conserving economic resources, supporting the criminal justice system, or simply making money for the physician or his employer that provide recurring challenges to physicians
http://www.worldallergy.org/educational_programs/world_allergy_forum/barcelona2008/rabe/

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