Guidelines and mindlines: Why do clinical staff over-diagnose malaria in Tanzania? A qualitative study
Guidelines and mindlines: Why do clinical staff over-diagnose malaria in Tanzania? A qualitative study
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DOI：
10.1186/1475-2875-7-53
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发表时间：
2008-04-02
期刊：
影响因子：
3
通讯作者：
Whitty, Christopher J. M.
中科院分区：
文献类型：
--
作者：
Chandler, Clare I. R.;Jones, Caroline;Whitty, Christopher J. M.
背景：疟疾过度诊断在非洲很普遍，而且在经济上和漏诊造成的发病率和死亡率方面都代价高昂。迫切需要了解疟疾过度诊断背后的原因，以便为更好地靶向抗疟疾药物的战略提供信息。方法：在坦桑尼亚两家医院临床实践的人种学研究中，在每家医院观察了34名临床医生的2,082名患者咨询，为期三个月。所有临床医生也接受了单独访谈，并在与同事的日常工作活动中进行了观察。随后对附近一所临床医生培训学院的5名导师和10名临床医生学生进行了访谈。结果：确定了四个影响疟疾过度诊断的领域，主要是社会领域。首先，在大力宣传疟疾重要性的背景下，初步培训的影响。其次，同伴的影响，符合同事的预期。第三，符合患者偏好的压力。最后，诊断支持的质量，包括资源管理、激励和监督。临床医生的行为似乎遵循“思维线”，而不是遵循国家诊断发热性疾病的指导方针：从这些不同的影响范围构建的共同的基本原理。在这种情况下确定了三种思路：疟疾比其他疾病更容易诊断；疟疾是一种更容易被接受的诊断；错过疟疾是站不住脚的。这些思路在培训阶段以及整个临床生涯中都很明显。结论：临床医生被发现遵循思维线，而不是指导方针，其中包括在决策的直接和更广泛的背景下运作的多种社会影响。使思维方式更接近指导方针的干预措施需要考虑到各种社会影响。
Background: Malaria over-diagnosis in Africa is widespread and costly both financially and in terms of morbidity and mortality from missed diagnoses. An understanding of the reasons behind malaria over-diagnosis is urgently needed to inform strategies for better targeting of antimalarials.Methods: In an ethnographic study of clinical practice in two hospitals in Tanzania, 2,082 patient consultations with 34 clinicians were observed over a period of three months at each hospital. All clinicians were also interviewed individually as well as being observed during routine working activities with colleagues. Interviews with five tutors and 10 clinical officer students at a nearby clinical officer training college were subsequently conducted.Results: Four, primarily social, spheres of influence on malaria over-diagnosis were identified. Firstly, the influence of initial training within a context where the importance of malaria is strongly promoted. Secondly, the influence of peers, conforming to perceived expectations from colleagues. Thirdly, pressure to conform with perceived patient preferences. Lastly, quality of diagnostic support, involving resource management, motivation and supervision. Rather than following national guidelines for the diagnosis of febrile illness, clinician behaviour appeared to follow 'mindlines': shared rationales constructed from these different spheres of influence. Three mindlines were identified in this setting: malaria is easier to diagnose than alternative diseases; malaria is a more acceptable diagnosis; and missing malaria is indefensible. These mindlines were apparent during the training stages as well as throughout clinical careers.Conclusion: Clinicians were found to follow mindlines as well as or rather than guidelines, which incorporated multiple social influences operating in the immediate and the wider context of decision making. Interventions to move mindlines closer to guidelines need to take the variety of social influences into account.