Stephen Buetow
The University of Auckland, General Practice and Primary Health Care, Department Member
Aim: The aim of this study was to describe parent/caregiver-reported adverse reactions to food in children aged 0-5 years in New Zealand. Method: A cross-sectional survey was undertaken in clinics conducted by the Royal New Zealand... more
Aim: The aim of this study was to describe parent/caregiver-reported adverse reactions to food in children aged 0-5 years in New Zealand. Method: A cross-sectional survey was undertaken in clinics conducted by the Royal New Zealand Plunket Society, which is the major healthcare provider for New Zealand's Well Child programme. Parents/caregivers of 110 (65%) children participated. Results: Of the 44 children who experienced an adverse reaction to food, only four were clinically evaluated and had undergone diagnostic testing. Two other children were hospitalised following systemic symptoms. Neither was tested for food allergy. 18 (16%) children had physician diagnosed eczema. Conclusion: Within the limitations of this small study, the data indicated adverse reactions to foods are a public health concern in New Zealand and may be under investigated even in children with severe symptoms. These children remain at increased risk of continued morbidity. Based on this preliminary study further research on food allergy in New Zealand is warranted.
Research Interests: Pediatrics, Public Health, Medicine, Food Allergy, Humans, and 15 moreFemale, Male, New Zealand, Infant, Risk factors, Parents, Age Factors, Health surveys, Risk Factors, Cross sectional Study, Cross Sectional Studies, Cohort Studies, Child preschool, Medical and Health Sciences, and food hypersensitivity
The existential task of managing the fear of, or apprehension toward, death is a challenge for palliative care health professionals. This paper aims to build on current strategies that professionals in this field use to explore their own... more
The existential task of managing the fear of, or apprehension toward, death is a challenge for palliative care health professionals. This paper aims to build on current strategies that professionals in this field use to explore their own fear of death and, by logical extension, to engage with and understand their patients, and to benefit them as well. We draw on ideas from the history of philosophy and our own experience in a discussion of six possible reasons to fear death less or not at all. We argue not for the logical correctness of these reasons but, pragmatically, for their potential usefulness as ways to support professionals and patients. However, our partial approach is non-evidence-based. Professionals have unmet educational needs relevant to putting our ideas into practice, and there will likely be situations in which our approach is not applicable.
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Not required because the manuscript is an invited commentary.
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ABSTRACT
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1which reports that “patients make errors too”. Indeed, at fi rst glance it seems nonsensical to suggest otherwise, not least since the same observation has been made several times over the past half century. 2–4 Yet the contribution of... more
1which reports that “patients make errors too”. Indeed, at fi rst glance it seems nonsensical to suggest otherwise, not least since the same observation has been made several times over the past half century. 2–4 Yet the contribution of patients (and their caregivers) to medical error has been discussed only rarely. This reluctance to consider patient fallibility and, as a result, to identify and manage the errors that patients make, could threaten patient safety. Does this silence indicate an unwillingness to analyse such a sensitive issue? Or, despite claims to the contrary, is patient error merely a false construction: can patients, by defi nition, not make mistakes? In this Viewpoint, we discuss, and draw attention to, the concept and context of patient errors. We also consider how analysis of the errors to which patients contribute could aid in the development of strategies to avoid such mistakes, and whether such processes could benefi t from active participation by patients. We focus on concerns raised by consumer groups about the quality and safety of health care, 5
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As evidence grows that organisational characteristics can influence patient outcomes in general practice (1,2), many health systems are demonstrating increased interest in externally assessing and improving the quality of practice... more
As evidence grows that organisational characteristics can influence patient outcomes in general practice (1,2), many health systems are demonstrating increased interest in externally assessing and improving the quality of practice management. This development has coincided with European unification and the opportunity to develop a common set of quality indicators to organise and manage practices across Europe. For instance, a European Practice Assessment (EPA) instrument has been developed and validated (3,4). Key questions now are how best to refine and use such instruments for assessing organisational performance in general practice. For almost a decade, New Zealand (NZ) has been developing a programme to accredit general practices while supporting their quality improvement and achievement of organisational excellence (5,6). This paper considers potential lessons for Europe. Comparing the NZ experience with Europe (rather than with one European country) is consistent with the development of European instruments for quality assessment, maximises our target audience, and respects the ability of readers in different European countries to assess the applicability of our discussion to their own health system. In NZ (and, for example, the United Kingdom [UK] and the Netherlands), the profession leads the accreditation process for the voluntary development of practice organisations. This contrasts with the trend in some insurance-based health systems in Europe towards contracting for the ‘‘regulation’’ of health providers (7,8). As these systems signal using accreditation that is more summative than formative, it is appropriate to look at accreditation systems, such as in NZ and the Netherlands, with a formative commitment to quality improvement. First, therefore, we describe the experience of NZ and Europe in measuring performance at the practice level, using the EPA instrument as a reference. Then, we recommend possible directions for further development of the accreditation process, regarding what to assess and how.
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There is little evidence that treatment advances have improved the prognosis of heart failure in the community. One explanation is the failure of doctors to undertake necessary prescribing. Reports elsewhere how a modified Delphi... more
There is little evidence that treatment advances have improved the prognosis of heart failure in the community. One explanation is the failure of doctors to undertake necessary prescribing. Reports elsewhere how a modified Delphi approach, based on the RAND Health Services utilisation study method, was used to produce audit criteria for necessary prescribing for systolic heart failure in New Zealand
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Research Interests: Psychology, Evidence Based Medicine, Medicine, Empathy, Humans, and 10 moreFemale, Male, Patient Satisfaction, Feeling, Public health systems and services research, Patient Centered Care, Action (Physics), Practice Education/Clinical Evaluation, Physician-Patient Relations, and Outcome Assessment Health Care
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Research Interests: Sociology, Epistemology, Communication, Health Informatics, Evidence Based Medicine, and 11 morePhilosophy of Medicine, Argumentation Theory, Conversation, Medicine, Communicative action, Humans, Health Care Productivity Analysis, Professional Practice, Public health systems and services research, Patient Centered Care, and Physician-Patient Relations
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The expressions 'high quality... more
The expressions 'high quality care' and 'low quality care' are cognitive and linguistic artefacts that help to structure people's lives and thinking; for example, moves are now afoot internationally to pay bonuses to health professionals for delivering high quality care. United States programmes, most conspicuously, are assuming that high quality care can be validly distinguished from low quality care, and incentivised through bonuses. This distinction is always at least implicit, for high quality care has no meaning without low quality care. Through a 'deconstructionist reading,' this article discusses limitations of categorising the quality of care as either high or low. The limitations of this 'binary opposition' can include a lack of defining attributes; vagueness and fuzziness at the 'boundaries' between high quality care and low quality care; concealment of quality as a continuum; and use of the binary opposition to effect social order and control. Health policy implications of our analysis are discussed. Drawing upon the general medical services contract in the United Kingdom, we suggest an approach to overcoming the oversimplification and imprecision that categorisation tends to produce.
Research Interests: Philosophy of Medicine, Health Care, Deconstruction, Medical Theory and Philosophy, Health Policy, and 12 moreMedicine, United Kingdom, Quality of Care, United States, Health Professionals, Health Care Productivity Analysis, Social Order, Opposition Politics, Public health systems and services research, Formal Social Control, attitude to health, and Quality of health care
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Background Austria has high health resource use compared to similar countries. Reclassifying (switching) medicines from prescription to non-prescription can reduce pressure on health resources and aid timely access to medicines. Since... more
Background Austria has high health resource use compared to similar countries. Reclassifying (switching) medicines from prescription to non-prescription can reduce pressure on health resources and aid timely access to medicines. Since Austria is less progressive in this area than many other countries, this research aimed to elucidate enablers and barriers to it reclassifying medicines and make recommendations for change in the context of similar research conducted elsewhere. Methods Qualitative research using a heuristic approach was conducted in Austria in 2018. Informed by their own “insider” and “outsider” knowledge, the authors identified themes from personal interviews with 24 participants, including reclassification committee members, government officials and stakeholders, before comparing these themes with earlier research findings. Results Significant barriers to reclassification included committee conservatism, minimal political support, medical negativity and few company a...
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Background Austria has high health resource use compared to similar countries. Reclassifying (switching) medicines from prescription to non-prescription can reduce pressure on health resources and aid timely access to medicines. Since... more
Background Austria has high health resource use compared to similar countries. Reclassifying (switching) medicines from prescription to non-prescription can reduce pressure on health resources and aid timely access to medicines. Since Austria is less progressive in this area than many other countries, this research aimed to elucidate enablers and barriers to it reclassifying medicines and make recommendations for change in the context of similar research conducted elsewhere. Methods Qualitative research using a heuristic approach was conducted in Austria in 2018. Informed by their own “insider” and “outsider” knowledge, the authors identified themes from personal interviews with 24 participants, including reclassification committee members, government officials and stakeholders, before comparing these themes with earlier research findings. Results Significant barriers to reclassification included committee conservatism, minimal political support, medical negativity and few company a...
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Stable, healthy families are the loto or heart of strong Pacific communities. This paper addresses the problem of a decline in the strength of Pacific families. It introduces and discusses the Tongan concept of O’ofaki, as the way in... more
Stable, healthy families are the loto or heart of strong Pacific communities. This paper addresses the problem of a decline in the strength of Pacific families. It introduces and discusses the Tongan concept of O’ofaki, as the way in which shared, core relational commitments can bring Pasifika peoples together to support one another for health and community development. This process is based on a reciprocal sharing of social capital to promote cultural solidarity and social justice. We describe two studies by the lead author, through which the concept of O’ofaki emerged. The first study utilized an action research model while the second study focused on two Pasifika-centric research approaches: talanga, which is a Tongan word for interactive talking for a purpose, and the kakala (Tongan garland) research approach. The latter approach is incorporated within a general inductive methodology as well as luva—the dissemination of the results. Finally, the paper focuses on the components o...
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There is little evidence that treatment advances have improved the prognosis of heart failure in the community. One explanation is the failure of doctors to undertake necessary prescribing. Reports elsewhere how a modified Delphi... more
There is little evidence that treatment advances have improved the prognosis of heart failure in the community. One explanation is the failure of doctors to undertake necessary prescribing. Reports elsewhere how a modified Delphi approach, based on the RAND Health Services utilisation study method, was used to produce audit criteria for necessary prescribing for systolic heart failure in New Zealand
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There is now broad agreement that ideas like person‐centred care, patient expertise and shared decision‐making are no longer peripheral to health discourse, fine ideals or merely desirable additions to sound, scientific clinical practice.... more
There is now broad agreement that ideas like person‐centred care, patient expertise and shared decision‐making are no longer peripheral to health discourse, fine ideals or merely desirable additions to sound, scientific clinical practice. Rather, their incorporation into our thinking and planning of health and social care is essential if we are to respond adequately to the problems that confront us: they need to be seen not as “ethical add‐ons” but core components of any genuinely integrated, realistic and conceptually sound account of healthcare practice.This, the tenth philosophy thematic edition of the journal, presents papers conducting urgent research into the social context of scientific knowledge and the significance of viewing clinical knowledge not as something that “sits within the minds” of researchers and practitioners, but as a relational concept, the product of social interactions. It includes papers on the nature of reasoning and evidence, the on‐going problems of how...
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ABSTRACT The widely-observed behavior of holding losing stocks longer than winning ones, is known as the disposition effect. This failure to realise paper losses is a major cause of eventual loss in investing. There is increasing evidence... more
ABSTRACT The widely-observed behavior of holding losing stocks longer than winning ones, is known as the disposition effect. This failure to realise paper losses is a major cause of eventual loss in investing. There is increasing evidence that financial choices, particularly those where there is threat of loss, such as the disposition effect, could be related to elements of psychophysiology. There is a well-known relationship between the psychophysiological and behavioral responses to threat and aspects of autonomic nervous system function. This study investigates the relationship between failure to realise paper losses during simulated stock trading and autonomic nervous system function as indexed by heart rate variability (HRV). Resting HRV was measured before participants played a stock trading game. After playing, a disposition effect index (DEX) was calculated for each player, from the time spent in losing stocks, as a proportion of total time in the market. HRV, specifically, a high level of high frequency HRV (HFHRV), is known to be significantly associated with reduced inappropriate responsiveness to threat, and inhibition of arousal. The group showed a significant inverse correlation between HF HRV ( %HRV) and DEX. This was carried mostly by males. Men who had a faster heart rate at baseline also held losing stocks longer, as did those with a higher LF/HF ratio. Men who have high HFHRV are more able to exert parasympathetic control over arousal, and are less likely to stay in losing stocks in a stock market trading game. The gender difference in correlations may be related to gender-specific responses to threat.
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Safety events indicating medication-related errors in Parkinson's disease (PD) are common but seldom studied, particularly from lay perspectives. Our objective was to study the meaning and significance to people living... more
Safety events indicating medication-related errors in Parkinson's disease (PD) are common but seldom studied, particularly from lay perspectives. Our objective was to study the meaning and significance to people living with PD of their experience of safety events. Twenty qualitative interviews were conducted by telephone with purposively sampled individuals with PD, a proxy, or both, throughout New Zealand. Themes identified from the data included joint assessments of the objective and subjective severity of the individual safety events. Most of the events indicated minor objective errors, whose severity was sometimes perceived as major, especially in the face of callous communication. Variation between objective and subjective assessments of the severity of possible errors indicated by safety events highlight the importance of distinguishing between, and using, both forms of assessment.
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Aim The aim of this study was to describe parent/caregiver-reported adverse reactions to food in children aged 0–5 years in New Zealand. Method A cross-sectional survey was undertaken in clinics conducted by the Royal New Zealand Plunket... more
Aim The aim of this study was to describe parent/caregiver-reported adverse reactions to food in children aged 0–5 years in New Zealand. Method A cross-sectional survey was undertaken in clinics conducted by the Royal New Zealand Plunket Society, which is the major healthcare provider for New Zealand’s Well Child programme. Parents/caregivers of 110 (65%) children participated. Results Of the 44 children who experienced an adverse reaction to food, only four were clinically evaluated and had undergone diagnostic testing. Two other children were hospitalised following systemic symptoms. Neither was tested for food allergy. 18 (16%) children had physician diagnosed eczema. Conclusion Within the limitations of this small study, the data indicated adverse reactions to foods are a public health concern in New Zealand and may be under investigated even in children with severe symptoms. These children remain at increased risk of continued morbidity. Based on this preliminary study further ...
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Last year saw the 20th anniversary edition of JECP, and in the introduction to the philosophy section of that landmark edition, we posed the question: apart from ethics, what is the role of philosophy 'at the bedside'? The purpose... more
Last year saw the 20th anniversary edition of JECP, and in the introduction to the philosophy section of that landmark edition, we posed the question: apart from ethics, what is the role of philosophy 'at the bedside'? The purpose of this question was not to downplay the significance of ethics to clinical practice. Rather, we raised it as part of a broader argument to the effect that ethical questions - about what we should do in any given situation - are embedded within whole understandings of the situation, inseparable from our beliefs about what is the case (metaphysics), what it is that we feel we can claim to know (epistemology), as well as the meaning we ascribe to different aspects of the situation or to our perception of it. Philosophy concerns fundamental questions: it is a discipline requiring us to examine the underlying assumptions we bring with us to our thinking about practical problems. Traditional academic philosophers divide their discipline into distinct ar...
Research Interests: Philosophy, Metaphysics, Ontology, Ethics, Epistemology, and 15 moreEvidence Based Medicine, Health Care, Causation, Health, Medical Theory and Philosophy, Clinical Reasoning, Medicine, Knowledge, Humans, Disease, Classification, Value, Public health systems and services research, Medicine and Health Sciences, and Person Centered
This paper describes the development, implementation and validation of general practice standards, supported by a continuous quality improvement (CQI) process that teaches practice teams how to work together to identify and enhance the... more
This paper describes the development, implementation and validation of general practice standards, supported by a continuous quality improvement (CQI) process that teaches practice teams how to work together to identify and enhance the quality of care they provide. Practice standards were developed through consensus by key stakeholders in general practice, pre-tested in four practices, and refined and piloted in 20 practices throughout New Zealand during 1999. A further field trial was undertaken to validate the standards and test the process of practice assessment. During 2000-2001, 74 practices volunteered to be assessed against the standards. Sixty one general practitioners, practice nurses and practice managers, nominated from independent practitioner associations (IPAs) or primary care organisations (PCOs), were trained to undertake the assessments. On five of 13 variables, no statistically significant differences at the 0.05 level were identified between the practices in the f...
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Research Interests: Decision Making, Evidence Based Medicine, Evaluation, Treatment Outcome, Evidence, and 10 moreMedicine, Criticism, Humans, Empirical Research, Harm, Public health systems and services research, Patient Centered Care, Practice Education/Clinical Evaluation, Constructive, and Randomized Controlled Trials as Topic
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Research Interests: Emotion, Ethics, Epistemology, Empiricism, Evidence Based Medicine, and 15 moreEvaluation, Autonomy, Evidence, Health Services Research, Knowledge, Criticism, Humans, Biomedical Research, Justification, Clinical Practice Guidelines, Clinical Medicine, Judgement, Challenge, Good Practice, and Medical Imperialism
Editors' introduction to 4th Philosophy of Medicine thematic issue of JECP