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Doctor–patient relationship he doctor–patient relationship is central to the practice of healthcare and is essential for the delivery of high-quality health care in the diagnosis and treatment of disease. The doctor–patient relationship forms one of the foundations of contemporary medical ethics. Most universities teach students from the beginning, even before they set foot in hospitals, to maintain a professional rapport with patients, uphold patients’ dignity, and respect their privacy. Importance A medical officer explains an x-ray to the patient. The doctor is providing medical advice to this patient. A physician performs a standard physical examination on his patient. A patient must have confidence in the competence of their physician and must feel that they can confide in him or her. For most physicians, the establishment of good rapport with a patient is important. Some medical specialties, such as psychiatry and family medicine, emphasize the physician–patient relationship m... Query Text: Doctor–patient relationship he doctor–patient relationship is central to the practice of healthcare and is essential for the delivery of high-quality health care in the diagnosis and treatment of disease. The doctor–patient relationship forms one of the foundations of contemporary medical ethics. Most universities teach students from the beginning, even before they set foot in hospitals, to maintain a professional rapport with patients, uphold patients’ dignity, and respect their privacy. Importance A medical officer explains an x-ray to the patient. The doctor is providing medical advice to this patient. A physician performs a standard physical examination on his patient. A patient must have confidence in the competence of their physician and must feel that they can confide in him or her. For most physicians, the establishment of good rapport with a patient is important. Some medical specialties, such as psychiatry and family medicine, emphasize the physician–patient relationship more than others, such as pathology or radiology. The quality of the patient–physician relationship is important to both parties. The better the relationship in terms of mutual respect, knowledge, trust, shared values and perspectives about disease and life, and time available, the better will be the amount and quality of information about the patient's disease transferred in both directions, enhancing accuracy of diagnosis and increasing the patient's knowledge about the disease. Where such a relationship is poor the physician's ability to make a full assessment is compromised and the patient is more likely to distrust the diagnosis and proposed treatment, causing decreased compliance to actually follow the medical advice. In these circumstances and also in cases where there is genuine divergence of medical opinions, a second opinion from another physician may be sought or the patient may choose to go to another physician. Michael Balint pioneered the study of the physician patient relationship in the UK with his wife Enid Balint resulting in the publication of the seminal book "The Doctor, His Patient and the Illness." Balint's work is continued by the Balint Society, The International Balint Federation[1] and other national Balint societies in other countries. In terms of efficacy (i.e. the outcome of treatment), the doctor–patient relationship seems to have a small, but statistically significant impact on healthcare outcomes.[2] Recognising that patients receive the best care when they work in partnership with doctors, the UK General Medical Council issued guidance for patients "What to expect from your doctor" in April 2013.[3][4] Aspects of relationship The following aspects of the doctor–patient relationship are the subject of commentary and discussion. Informed consent Main article: Informed consent The default medical practice for showing respect to patients is for the doctor to be truthful in informing the patient of their health and to be direct in asking for the patient's consent before giving treatment. Historically in many cultures there has been a shift from paternalism, the view that the "doctor always knows best," to the idea that patients must have a choice in the provision of their care and be given the right to provide informed consent to medical procedures.[5] There can be issues with how to handle informed consent in a doctor–patient relationship;[6] for instance, with patients who do not want to know the truth about their condition. Furthermore, there are ethical concerns regarding the use of placebo. Does giving a sugar pill lead to an undermining of trust between doctor and patient? Is deceiving a patient for his or her own good compatible with a respectful and consent-based doctor–patient relationship?[7] Shared decision making Health advocacy messages such as this one encourage patients to talk with their doctors about their healthcare. Main article: Shared decision making Shared decision making is the idea that as a patient gives informed consent to treatment, that person also is given an opportunity to choose among the treatment options according to their own treatment goals and wishes. A practice which is an alternative to this is for the doctor to make a person's health decisions without considering that person's treatment goals or having that person's input into the decision-making process. The spectrum of a physician’s inclusion of a patient into treatment decisions is well represented in Ulrich Beck’s World at Risk. At one end of this spectrum is Beck’s Negotiated Approach to risk communication, in which the communicator maintains an open dialogue with the patient and settles on a compromise on which both patient and physician agree. A majority of physicians employ a variation of this communication model to some degree, as it is only with this technique that a doctor can maintain the open cooperation of his or her patient. At the opposite end of this spectrum is the Technocratic Approach to risk communication, in which the physician exerts authoritarian control over the patient’s treatment and pushes the patient to accept the treatment plan with which they are presented. This communication model places the physician in a position of omniscience and omnipotence over the patient and leaves little room for patient contribution to a treatment plan. [8] Physician superiority The physician may be viewed as superior to the patient simply because the physician has the knowledge and credentials and is most often the one that is on home ground. The physician–patient relationship is also complicated by the patient's suffering (patient derives from the Latin patior, "suffer") and limited ability to relieve it on his or her own, potentially resulting in a state of desperation and dependency on the physician. A physician should at least be aware of these disparities in order to establish a good rapport and optimize communication with the patient. It may be further beneficial for the doctor–patient relationship to have a form of shared care with patient empowerment to take a major degree of responsibility for her or his care. Benefiting or pleasing A dilemma may arise in situations where determining the most efficient treatment, or encountering avoidance of treatment, creates a disagreement between the physician and the patient, for any number of reasons. In such cases, the physician needs strategies for presenting unfavorable treatment options or unwelcome information in such a way that minimizes strain on the doctor-patient relationship while benefiting the patient's overall physical health and best interests. Formal or casual There may be differences in opinion between the doctor and patient in how formal or casual the doctor–patient relationship should be. For instance, according to a Scottish study,[9] patients want to be addressed by their first name more often than is currently the case. In this study, most of the patients either liked (223) or did not mind (175) being called by their first names. Only 77 disliked it, most of whom were aged over 65.[9] On the other hand, most patients don't want to call the doctor by his or her first name.[9] Some familiarity with the doctor generally makes it easier for patients to talk about intimate issues such as sexual subjects, but for some patients, a very high degree of familiarity may make the patient reluctant to reveal such intimate issues.[10] Transitional care Transitions of patients between health care practitioners may decrease the quality of care in the time it takes to reestablish proper doctor-patient relationships. Generally, the doctor–patient relationship is facilitated by continuity of care in regard to attending personnel. Special strategies of integrated care may be required where multiple health care providers are involved, including horizontal integration (linking similar levels of care, e.g. multiprofessional teams) and vertical integration (linking different levels of care, e.g. primary, secondary and tertiary care).[11] Other people present An example of where other people present in a doctor-patient encounter may influence their communication is one or more parents present at a minor's visit to a doctor. These may provide psychological support for the patient, but in some cases it may compromise the doctor–patient confidentiality and inhibit the patient from disclosing uncomfortable or intimate subjects. When visiting a health provider about sexual issues, having both partners of a couple present is often necessary, and is typically a good thing, but may also prevent the disclosure of certain subjects, and, according to one report, increases the stress level.[10] Bedside manner The medical doctor, with a nurse by his side, is performing a blood test at a hospital in 1980. A good bedside manner is typically one that reassures and comforts the patient while remaining honest about a diagnosis. Vocal tones, body language, openness, presence, honesty, and concealment of attitude may all affect bedside manner. Poor bedside manner leaves the patient feeling unsatisfied, worried, frightened, or alone. Bedside manner becomes difficult when a healthcare professional must explain an unfavorable diagnosis to the patient, while keeping the patient from being alarmed. An example of how body language affects patient perception of care is that the time spent with the patient in the emergency department is perceived as longer if the doctor sits down during the encounter.[12] Physician–patient privilege Physician–patient privilege is a legal concept, related to medical confidentiality, that protects communications between a patient and his or her doctor from being used against the patient in court. It is a part of the rules of evidence in many common law jurisdictions. Almost every jurisdiction that recognizes physician–patient privilege not to testify in court, either by statute or though case law, limits the privilege to knowledge acquired during the course of providing medical services. In some jurisdictions, conversations between a patient and physician may be privileged in both criminal and civil courts. Scope The privilege may cover the situation where a patient confesses to a psychiatrist that he or she committed a particular crime. It may also cover normal inquiries regarding matters such as injuries that may result in civil action. For example, any defendant that the patient may be suing at the time cannot ask the doctor if the patient ever expressed the belief that his or her condition had improved. However, the rule generally does not apply to confidences shared with physicians when they are not serving in the role of medical providers. The rationale behind the rule is that a level of trust must exist between a physician and the patient so that the physician can properly treat the patient. If the patient were fearful of telling the truth to the physician because he or she believed the physician would report such behavior to the authorities, the treatment process could be rendered far more difficult, or the physician could make an incorrect diagnosis. For example, a below-age of consent patient came to a doctor with a sexually transmitted disease. The doctor is usually required to obtain a list of the patient's sexual contacts to inform them that they need treatment. This is an important health concern. However, the patient may be reluctant to divulge the names of his/her older sexual partners, for fear that they will be charged with statutory rape. In some jurisdictions, the doctor cannot be forced to reveal the information revealed by his patient to anyone except to particular organizations, as specified by law, and they too are required to keep that information confidential. If, in the case, the police become aware of such information, they are not allowed to use it in court as proof of the sexual conduct, except as provided by express intent of the legislative body and formalized into law.[1] The law in Ontario, Canada, requires that physicians report patients who, in the opinion of the physician, may be unfit to drive for medical reasons as per Section 203 of the Highway Traffic Act (Ontario).[2] The law in New Hampshire places physician–patient communications on the same basis as attorney–client communications, except in cases where law enforcement officers seek blood or urine test samples and test results taken from a patient who is being investigated for driving while intoxicated.[3] United States In the United States, the Federal Rules of Evidence do not recognize doctor–patient privilege. At the state level, the extent of the privilege varies depending on the law of the applicable jurisdiction. For example, in Texas there is only a limited physician–patient privilege in criminal proceedings, and the privilege is limited in civil cases as wel Patient participation Patient participation, also called shared decision making, is a process in which both the patient and physician contribute to the medical decision-making process. Under this operating system, health care providers explain treatments and alternatives to patients in order to provide the necessary resources for patients to choose the treatment option that most closely aligns with their unique cultural and personal beliefs.[1] In contrast, the current dominant form of medicine, the biomedical care system, places physicians in a position of authority with patients playing a passive role in care.[2] Under this paradigm, known as medical paternalism, physicians instruct patients about what to do, and the patients often follow the physicians' advice.[3] Relatively recently, however, a general shift has occurred in which patients are more involved in medical decision-making than before.[4] A recent review of 115 patient participation studies, for example, found that the majority of respondents preferred to participate in medical-decision making in only 50% of studies prior to 2000, while 71% of studies after 2000 found a majority of respondents who wanted to participate.[5] Variations of each method, including medical paternalism and patient participation, may be preferred by different patients. Many health agencies, including the American Cancer Society[6] and the American College of Physicians,[7] recommend a shared decision model in their medical practices. Patient Autonomy and Informed Consent In recognition of the fact that many factors influence medical decisions, the basic premise of patient participation emphasizes patient autonomy. The model recognizes that patients have personal values that influence the interpretation of risks and benefits differently from a physician. Frequently, there is more than one option with no clear choice of which option is best; this occurs when the decision at hand is about a preference-sensitive condition.[8] In certain situations, for example, the physician's point of view may differ from the decision that aligns most with the patient's values, judgments, and opinions. For this reason, informed consent is at the core of shared decision making.[9] That is, without fully understanding the advantages and disadvantages of all treatment options, patients cannot engage in making decisions based on their personal values and beliefs. The Ecological Model The ecological model of patient participation, proposed by researcher and professor Donald J. Cegala and based on previous research by Richard Street,[10] includes four main components of patient participation.[11] The first of these is termed information seeking. Assessment for this component includes the number of health-related questions the patient asks, along with the number of times the patient asks for the physician to verify information. Examples of information verifying may include asking a physician to repeat information, or summarizing what the physician said in order to ensure that the patient understood the information. The second facet of patient participation, as proposed by this model, is assertive utterances, which may include making recommendations to physicians, expressing an opinion or preference, or expressing disagreement. The third component of the model is information provision of symptoms and medical history with or without prompting from the physician. The final component of patient participation is expressions of concern, including affective responses such as anxiety, worry, or negative feelings. The extent of participation can be determined based on how often a patient displays these four overarching behaviors. Factors that Predict Participation There are certain patient characteristics that influence the extent of involvement.[12] Research shows that female patients who are younger, more educated, and who have a less severe illness than other patients are more likely to participate in medical decisions.[12] That is, an increase in age leads to a decrease in desire to participate, while higher levels of education increase participation levels. However, other research has offered conflicting evidence for the effect of age on level of participation. One study found that age did not inversely relate to participation levels.[13] In addition, numeracy levels may play an important role in patient participation. Recent research has shown that, in general, low-numeracy individuals in both Germany and the United States prefer to play a more passive role than their high-numeracy counterparts.[13] That is, individuals who are not as fluent with numbers and statistics tended to let their physicians make medical decisions without much input from the patients. In general, however, Americans play a more active role in the physician-patient relationship, by performing activities like asking follow-up questions and researching treatment options, than do Germans.[13] Furthermore, research shows that race plays an important role in whether a patient participates. Though African American patients report that they participate less in shared decision-making than whites,[14] studies have shown that African American patients desire to participate just as much as their white counterparts and are more likely to report initiating conversation about their health care with their physicians.[15] Interestingly, individuals who place a higher value on their health are more likely to play a passive role when it comes to medical decision-making than those who placed a lower value on health.[12] Researchers Arora and McHorney posit that this finding may be the result of apprehension when it comes to health-related concerns among those who place a high value on health, leading to a tendency to let an expert, rather than themselves, make important medical decisions. The Role of Physicians Physicians, of course, play an important role in the patient participation model. Researchers have developed specific measures to evaluate the effectiveness of a physician-patient relationship. One such measure explores the following three components of patient-centered behavior: physician's general ability to conceptualize both illness and disease in relation to a patient's life; physicians exploring the full context of illness in the patient's life setting (e.g., work, social supports, family) and personal development; physicians' ability to reach common ground with the participants in which the treatment goals and management strategies, nature of the problems and priorities, and roles of both the physician and patient are addressed.[16] Previous research has demonstrated that increased patient-centered behavior by physicians leads to greater compliance of patients' at-home medical care, such as taking pills.[17] It is important to note that, generally, physicians engage in more patient-centered communication when speaking with high participation patients rather than with low participation patients.[11] However, when a patient sees a physician of the same race, the patient perceives that physician as involving the patient more so than a physician of a different race.[14] Patient empowerment Patient empowerment is the granting of patients to take an active role in the decisions made about his or her own healthcare. Patient empowerment requires a patient to take responsibility for aspects of care such as respectful communications with one's doctors and other providers, patient safety, evidence gathering, smart consumerism (making care cost decisions in the United States), shared decision-making and more.[18] To ease patients’ empowerment, different countries have made laws and run multiple campaigns to raise awareness of these matters. For example, the French Act of 2 March 2002 aims for a ‘‘health democracy’’ in which patients’ rights and responsibilities are revisited, and which gives patients an opportunity to take control of their health. Similar enactments have been passed in countries such as Croatia, Hungary and the Catalan region. The same year, the UK passed The Penalty Charge for Patients to remind them of their responsibility in healthcare. In 2009, British and Australian campaigns were launched to highlight the costs of unhealthy lifestyles and the need for a culture of responsibility. The European Union took this issue seriously and since 2005, has regularly reviewed the question of patients’ rights through various policies with the cooperation of the World Health Organisation. Various Medical Associations have also followed the path of patients’ empowerment through different Bill of Rights or Declarations Consequences Benefits A recent study found that individuals who participate in shared decision-making are more likely to feel secure and may feel a stronger sense of commitment to recover.[20] Also, research has shown that patient participation leads to higher judgments of the quality of care.[21] Furthermore, patient participation leads to greater self-efficacy in patients, which in turn, leads to better health outcomes.[22] When a patient participates more in the decision-making process, the frequency of self-management behaviors increases, as well.[23] Self-management behaviors fall into three broad categories: health behaviors (e.g., exercise); consumeristic behaviors (e.g., reading the risks about a new treatment); and disease-specific management strategies.[24] In a similar vein, a recent study found that among patients with diabetes, the more an individual remembers information given by a physician, the more the patient participated in self-care behaviors at home.[25] Previous research has demonstrated that providing patients with personal coronary risk information may assist patients in improving cholesterol levels.[26] These findings are most likely attributed to an improvement in self-management techniques in response to the personalized feedback from physicians. Additionally, the findings of another study indicate that the use of a cardiovascular risk calculator led to increased patient participation and satisfaction with the treatment decision process and outcome, and reduced decisional regret.[27] Disadvantages Some patients do not find the patient participation model to be the best approach to care. A qualitative study found that barriers to patient participation may include: a patient's desire to avoid participation due to lack of perceived control over the situation, a medical professional's inability to make an emotional connection with the patient, an interaction with an overconfident and overly assertive medical professional, and general structural deficits in care that may undermine opportunities for a patient to exert control over the situation.[28] Furthermore, dispositional factors may play an important role in the extent to which a patient feels comfortable with a participating in medical decisions. Individuals who exhibit high trait anxiety, for example, prefer not to participate in medical decision-making.[29] For those who do participate in decision-making, there are potential disadvantages. As patients take part in the decision process, physicians may communicate uncertain or unknown evidence about the risks and benefits of a decision.[30] The communication of scientific uncertainty may lead to decision dissatisfaction.[30] Critics of the patient participation model assert that physicians who choose not to question and challenge the assumptions of patients do a medical disservice to patients, who are overall less knowledgeable and skilled than the physician.[31] Physicians who encourage patient participation can help the patient make a decision that is aligned with the patients' values and preferences. Decision Aids Patient participation increasingly relies on the use of decision aids in assisting the patients in choosing the best treatment option. Patient decision aids, which may include leaflets, video or audio tapes, or interactive media, supplement the patient-physician relationship and assist patients in making medical decisions that most closely aligns with their values and preferences.[32] Recently, interactive software or internet websites have helped bridge the divide between physician and patients.[33][34][35] Recent research has shown that the use of decision aids may increase patients' trust in physicians, thereby facilitating the shared decision-making process.[36] The International Patient Decision Aid Standards (IPDAS) Collaboration, a group of researchers led by professors Annette O'Connor in Canada and Glyn Elwyn in England, has published a set of standards, representing the efforts of more than 100 participants from fourteen countries around the world, that will help determine the quality of patient decision aids.[37] The report determined that there are certain components of an aid, such as providing information about options, using patient stories, and disclosing conflicts of interest, that will assist patients and health practitioners to assess the content, development process and effectiveness of decision aids. A health professional is an individual who provides preventive, curative, promotional or rehabilitative health care services in a systematic way to people, families or communities. A health professional may operate within medicine, surgery, midwifery, dentistry, nursing, pharmacy, psychology or allied health professions. A health professional may also be a public/community health expertee working for the common good of the society. Practitioners and professionals Health practitioners and professionals • Athletic trainer • Audiologist • Chiropractor • Clinical nurse specialist • Clinical officer • Community health worker • Dentist • Dietitian and nutritionist • Emergency medical technician • Feldsher • Health administrator • Medical assistant • Medical technologist • Midwife • Nurse anesthetist • Nurse • Paramedic • Pharmacist • Pharmaconomist • Pharmacy technician • Phlebotomist • Physician • Physician assistant • Podiatrist • Psychologist • Psychotherapist • Physical therapist (physiotherapist) • Radiographer • Respiratory therapist • Speech-language pathologist • Surgeon • Surgeon's assistant • Surgical technologist Related health care This box: • view • talk • edit Health care practitioners include physicians, dentists, pharmacists, physician assistants, nurses, advanced practice registered nurses, surgeons, surgeon's assistant, athletic trainers, surgical technologist, midwives, dietitians, therapists, psychologists, chiropractors, clinical officers, social workers, phlebotomists, occupational therapist, physical therapists, radiographer, respiratory therapists, audiologists, speech pathologists, optometrists, emergency medical technicians, paramedics, medical laboratory scientists, medical prosthetic technicians and a wide variety of other human resources trained to provide some type of health care service. They often work in hospitals, health care centres, and other service delivery points, but also in academic training, research, and administration. Some provide care and treatment services for patients in private homes. Many countries have a large number of community health workers who work outside formal health care institutions. Managers of health care services, health information technicians, and other assistive personnel and support workers are also considered a vital part of health care teams.[1] Health care practitioners are commonly grouped into a number of professions: • Medical (including generalist practitioners and specialists) • Nursing (including various professional titles) • Midwifery (including Obstetrics) • Dentistry (including dental team members) • Allied health professions • Health Scientists Within each field of expertise, practitioners are often classified according to skill level and skill specialization. “Health professionals” are highly skilled workers, in professions that usually require extensive knowledge including university-level study leading to the award of a first degree or higher qualification.[2] This category includes physicians, physician assistants, dentists, midwives, registered nurses, pharmacists, physiotherapists, optometrists, and others. Allied health professionals, also referred to as "health associate professionals" in the International Standard Classification of Occupations, support implementation of health care, treatment and referral plans usually established by medical, nursing, and other health professionals, and usually require formal qualifications to practice their profession. In addition, unlicensed assistive personnel assist with providing health care services as permitted. Another way to categorize health care practitioners is according to the sub-field in which they practice, such as mental health care, pregnancy and childbirth care, surgical care, rehabilitation care, or public health. Mental health practitioners Main article: Mental health professional A mental health practitioner is a health worker who offers services for the purpose of improving the mental health of individuals or treating mental illness. These include psy Mental health practitioners Main article: Mental health professional A mental health practitioner is a health worker who offers services for the purpose of improving the mental health of individuals or treating mental illness. These include psychiatrists, clinical psychologists, clinical social workers, psychiatric-mental health nurse practitioners, marriage and family therapists, as well as other health professionals and allied health professions. These health care providers often deal with the same illnesses, disorders, conditions, and issues; however their scope of practice often differs. The most significant difference across categories of mental health practitioners is education and training.[3] Maternal and newborn health practitioners Main articles: Obstetrics and Birth attendant A maternal and newborn health practitioner is a health worker who deals with the care of women and their children before, during and after pregnancy and childbirth. Such health practitioners include obstetricians, midwives, obstetrical nurses and many others. One of the main differences between these professions is in the training and authority to provide surgical services and other life-saving interventions.[4] In some developing countries, traditional birth attendants, or traditional midwives, are the primary source of pregnancy and childbirth care for many women and families, although they are not certified or licensed. Geriatric care practitioners Main articles: Geriatrics and Geriatric care management A geriatric care practitioner plans and coordinates the care of the elderly and/or disabled to promote their health, improve their quality of life, and maintain their independence for as long as possible. They include geriatricians, adult-gerontology nurse practitioners, clinical nurse specialists, geriatric clinical pharmacists, geriatric nurses, geriatric care managers, geriatric aides, and others who focus on the health and psychological care needs of older adults. Surgical practitioners A surgical practitioner is a healthcare professional who specializes in the planning and delivery of a patient's perioperative care, including during the anaesthetic, surgical and recovery stages. They may include general and specialist surgeons, surgeon's assistant, assistant surgeon, surgical assistant, anesthesiologists, anesthesiologist assistant, nurse anesthetists, surgical nurses, clinical officers, operating department practitioners, anaesthetic technicians, perioperative nursing, surgical technologists, and others. Rehabilitation care practitioners A rehabilitation care practitioner is a health worker who provides care and treatment which aims to enhance and restore functional ability and quality of life to those with physical impairments or disabilities. These include physiatrists, rehabilitation nurses, clinical nurse specialists, nurse practitioners, physiotherapists, orthotists, prosthetists, occupational therapists, recreational therapists, audiologists, speech and language pathologists, respiratory therapists, rehabilitation counsellors, physical rehabilitation therapists, physiotherapy technicians, orthotic technicians, prosthetic technicians, personal care assistants, and others.[5] Eye care practitioners Main articles: Ophthalmology and Optometry Care and treatment for the eye and the adnexa may be delivered by ophthalmologists specializing in surgical/medical care, or optometrists specializing in refractive management and medical/therapeutic care. Oral health practitioners Main article: Dentistry A dental care practitioner is a health worker who provides care and treatment to promote and restore oral health. These include dentists and dental surgeons, dental assistants, dental auxiliaries, dental hygienists, dental nurses, dental technicians, dental therapists, and related professionals. Foot care practitioners Care and treatment for the foot, ankle, and lower leg may be delivered by podiatrists, pedorthists, foot health practitioners, podiatric medical assistants, podiatric nurse and others. Public health practitioners A public health practitioner focuses on improving health among individuals, families and communities through the prevention and treatment of diseases and injuries, surveillance of cases, and promotion of healthy behaviors. This category includes community and preventive medicine specialists, public health nurses, clinical nurse specialists, dietitians, environmental health officers, paramedics, epidemiologists, health inspectors, and others. Alternative medicine practitioners In many societies, practitioners of alternative medicine have contact with a significant number of people, either as integrated within or remaining outside the formal health care system. These include practitioners in acupuncture, Ayurveda, herbalism, homeopathy, naturopathy, Siddha medicine, traditional Chinese medicine, traditional Korean medicine, and Unani. In some countries such as Canada, chiropractors and osteopaths (not to be confused with doctors of osteopathic medicine in the United States) are considered alternative medicine practitioners. Practice conditions and regulations Shortages of health professionals See also: Health workforce, Doctor shortage and Nursing shortage Many jurisdictions report shortfalls in the number of trained health human resources to meet population health needs and/or service delivery targets, especially in medically underserved areas. For example, in the United States, the 2010 federal budget invested $330 million to increase the number of doctors, nurses, and dentists practicing in areas of the country experiencing shortages of health professionals. The Budget expands loan repayment programs for physicians, nurses, and dentists who agree to practice in medically underserved areas. This funding will enhance the capacity of nursing schools to increase the number of nurses. It will also allow states to increase access to oral health care through dental workforce development grants. The Budget’s new resources will sustain the expansion of the health care workforce funded in the Recovery Act.[6] There were 15.7 million health care professionals in the US as of 2011.[7] In Canada, the 2011 federal budget announced a Canada Student Loan forgiveness programme to encourage and support new family physicians, nurse practitioners and nurses to practise in underserved rural or remote communities of the country, including communities that provide health services to First Nations and Inuit populations.[8] In Uganda, the Ministry of Health reports that as many as 50% of staffing positions for health workers in rural and underserved areas remain vacant. As of early 2011, the Ministry was conducting research and costing analyses to determine the most appropriate attraction and retention packages for medical officers, nursing officers, pharmacists, and laboratory technicians in the country’s rural areas.[9] At the international level, the World Health Organization estimates a shortage of almost 4.3 million doctors, midwives, nurses, and support workers worldwide to meet target coverage levels of essential primary health care interventions.[10] The shortage is reported most severe in 57 of the poorest countries, especially in sub-Saharan Africa. Occupational hazards A healthcare professional wears an air sampling device to investigate exposure to airborne influenza Occupational stress and occupational burnout are highly prevalent among health professionals.[11] Some studies suggest that workplace stress is pervasive in the health care industry because of inadequate staffing levels, long work hours, exposure to infectious diseases and hazardous substances leading to illness or death, and in some countries threat of malpractice litigation. Other stressors include the emotional labor of caring for ill people and high patient loads. The consequences of this stress can include substance abuse, suicide, major depressive disorder, and anxiety, all of which occur at higher rates in health professionals than the general working population. Elevated levels of stress are also linked to high rates of burnout, absenteeism and diagnostic errors, and to reduced rates of patient satisfaction.[11][12] In Canada, a national report (Canada's Health Care Providers) also indicated higher rates of absenteeism due to illness or disability among health care workers compared to the rest of the working population, although those working in health care reported similar levels of good health and fewer reports of being injured at work.[13] There is some evidence that cognitive-behavioral therapy, relaxation training and therapy (including meditation and massage), and modifying schedules can reduce stress and burnout among multiple sectors of health-care providers. Research is ongoing in this area, especially with regards to physicians, whose occupational stress and burnout is less researched compared to other health professions.[11] Exposure to respiratory infectious diseases like tuberculosis (caused by Mycobacterium tuberculosis) and influenza can be reduced with the use of respirators; this exposure is a significant occupational hazard for health care professionals.[14] Exposure to dangerous chemicals, including chemotherapy drugs, is another potential occupational risk. These drugs can cause cancer and other health conditions.[15] Healthcare workers are also at risk for diseases that are contracted through extended contact with a patient, including scabies.[16] Female health care workers may face specific types of workplace-related health conditions and stress. According to the World Health Organization, women predominate in the formal health workforce in many countries, and are prone to musculoskeletal injury (caused by physically demanding job tasks such as lifting and moving patients) and burnout. Female health workers are exposed to hazardous drugs and chemicals in the workplace which may cause adverse reproductive outcomes such as spontaneous abortion and congenital malformations. In some contexts, female health workers are also subject to gender-based violence including from coworkers and patients.[17][18] Health professionals are also at risk for contracting blood-borne diseases like hepatitis B, hepatitis C, and HIV/AIDS through needlestick injuries or through contact with bodily fluids.[19][20] This risk can be mitigated with vaccination when there is a vaccine available, like with hepatitis B.[20] Healthcare workers are at higher risk of on-the-job injury due to violence. Drunk, confused, and hostile patients and visitors are a continual threat to providers attempting to treat patients. Frequently, assault and violence in a healthcare setting goes unreported and is wrongly assumed to be part of the job.[21] Violent incidents typically occur during one-on-one care; being alone with patients increases healthcare workers' risk of assault.[22] In the United States, healthcare workers suffer 2/3 of nonfatal workplace violence incidents.[21] Psychiatric units represent the highest proportion of violent incidents, at 40%; they are followed by geriatric units (20%) and the emergency department (10%). Workplace violence can also cause psychological trauma.[22] The Occupational Health Safety Network is a system developed by the National Institute for Occupational Safety and Health (NIOSH) to address health and safety risks among health care providers. Hospitals and other healthcare facilities can upload the occupational injury data they already collect to the secure database for analysis and benchmarking with other de-identified facilities from throughout the U.S. NIOSH works with OHSN participants in identifying and implementing timely and targeted interventions. OHSN modules currently focus on three high risk and preventable events that can lead to injuries or musculoskeletal disorders among healthcare providers: musculoskeletal injuries from patient handling activities; slips, trips, and falls; and workplace violence.[21] Slips, trips, and falls are the second-most common cause of worker's compensation claims in the US, and cause 21% of work absences due to injury. These injuries most commonly result in strains and sprains; women , those older than 45, and those who have been working less than a year in a healthcare setting are at the highest risk.[7] Health care professionals are also likely to experience sleep deprivation due to their jobs. Many health care professionals are on a shift work schedule, and therefore experience misalignment of their work schedule and their circadian rhythm. In 2007, 32% of healthcare workers were found to get fewer than 6 hours of sleep a night. Sleep deprivation also predisposes healthcare professionals to make mistakes that may potentially endanger a patient.[23] Regulation and registration of professionals Main article: Health professional requisites Practicing without a license that is valid and current is typically illegal. In most jurisdictions, the provision of health care services is regulated by the government. Individuals found to be providing medical, nursing or other professional services without the appropriate certification or license may face sanctions and criminal charges leading to a prison term. The number of professions subject to regulation, requisites for individuals to receive professional licensure, and nature of sanctions that can be imposed for failure to comply vary across jurisdictions. In the United States, under Michigan state laws, an individual is guilty of felony if identified as practicing in the health profession without a valid personal license or registration. Health professionals can also be imprisoned if found guilty of practicing beyond the limits allowed by their licences and registration. The state laws define the scope of practice for medicine, nursing, and a number of allied health professions.[24][unreliable source?] In Florida, practicing medicine without the appropriate license is a crime classified as a third degree felony,[25] which may give imprisonment up to five years. Practicing a health care profession without a license which results in serious bodily injury classifies as a second degree felony,[25] providing up to 15 years' imprisonment. In the United Kingdom, healthcare professionals are regulated by the state; the UK Health and Care Professions Council (HCPC) protects the 'title' of each profession it regulates. For example, it is illegal for someone to call himself an Occupational Therapist or Radiographer if they are not on the register held by the HCPC.