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Valentine KD, Leavitt L, Sepucha KR, Atlas SJ, Simmons L, Siegel L, Richter JM, Han PKJ. Uncertainty tolerance among primary care physicians: Relationship to shared decision making-related perceptions, practices, and physician characteristics. PATIENT EDUCATION AND COUNSELING 2024; 123:108232. [PMID: 38458091 PMCID: PMC10997439 DOI: 10.1016/j.pec.2024.108232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 02/20/2024] [Accepted: 02/26/2024] [Indexed: 03/10/2024]
Abstract
OBJECTIVE Understand how physicians' uncertainty tolerance (UT) in clinical care relates to their personal characteristics, perceptions and practices regarding shared decision making (SDM). METHODS As part of a trial of SDM training about colorectal cancer screening, primary care physicians (n = 67) completed measures of their uncertainty tolerance in medical practice (Anxiety subscale of the Physician's Reactions to Uncertainty Scale, PRUS-A), and their SDM self-efficacy (confidence in SDM skills). Patients (N = 466) completed measures of SDM (SDM Process scale) after a clinical visit. Bivariate regression analyses and multilevel regression analyses examined relationships. RESULTS Higher UT was associated with greater physician age (p = .01) and years in practice (p = 0.015), but not sex or race. Higher UT was associated with greater SDM self-efficacy (p < 0.001), but not patient-reported SDM. CONCLUSION Greater age and practice experience predict greater physician UT, suggesting that UT might be improved through training, while UT is associated with greater confidence in SDM, suggesting that improving UT might improve SDM. However, UT was unassociated with patient-reported SDM, raising the need for further studies of these relationships. PRACTICE IMPLICATIONS Developing and implementing training interventions aimed at increasing physician UT may be a promising way to promote SDM in clinical care.
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Affiliation(s)
- K D Valentine
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Lauren Leavitt
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Karen R Sepucha
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Steven J Atlas
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Leigh Simmons
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Lydia Siegel
- Harvard Medical School, Boston, MA, USA; Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - James M Richter
- Harvard Medical School, Boston, MA, USA; Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
| | - Paul K J Han
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, USA.
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Navanandan N, McNulty MC, Suresh K, Freeman J, Scherer LD, Tyler A. Factors Associated With Clinician Self-Reported Resource Use in Acute Care and Ambulatory Pediatrics. Clin Pediatr (Phila) 2022; 62:329-337. [PMID: 36199256 PMCID: PMC10073349 DOI: 10.1177/00099228221128074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The objective of this study is to determine predictors of resource use among pediatric providers for common respiratory illnesses. We surveyed pediatric primary care, emergency department (ED)/urgent care (UC), and hospital medicine providers at a free-standing children's hospital system. Five clinical vignettes assessed factors affecting resource use for upper respiratory infections, bronchiolitis, and pneumonia, including provider-type, practice location, tolerance to uncertainty, and medical decision-making behaviors. The response rate was 75.3% (168/223). The ED/UC and primary care providers had higher vignette scores, indicating higher resource use, compared with inpatient providers; advanced practice providers (APPs) had higher vignette scores compared with physicians. In multivariate analysis, being an ED/UC provider, an APP, and greater concern for bad outcomes were associated with higher vignette scores. Overall, provider type and location of practice may predict resource use for children with respiratory illnesses. Interventions targeted at test-maximizing providers may improve quality of care and reduce resource burden.
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Affiliation(s)
- Nidhya Navanandan
- Section of Pediatric Emergency Medicine, Children's Hospital Colorado, Aurora, CO, USA.,Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Monica C McNulty
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, CO, USA
| | - Krithika Suresh
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, CO, USA.,Department of Biostatistics and Informatics, University of Colorado School of Public Health, Aurora, CO, USA
| | - Julia Freeman
- Section of Pediatric Emergency Medicine, Children's Hospital Colorado, Aurora, CO, USA.,Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Laura D Scherer
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, CO, USA.,Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Amy Tyler
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA.,Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, CO, USA.,Section of Pediatric Hospital Medicine, Children's Hospital of Colorado, Aurora, CO, USA
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3
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Begin AS, Hidrue M, Lehrhoff S, Del Carmen MG, Armstrong K, Wasfy JH. Factors Associated with Physician Tolerance of Uncertainty: an Observational Study. J Gen Intern Med 2022; 37:1415-1421. [PMID: 33904030 PMCID: PMC8074695 DOI: 10.1007/s11606-021-06776-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 03/29/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Physicians need to learn and work amidst a plethora of uncertainties, which may drive burnout. Understanding differences in tolerance of uncertainty is an important research area. OBJECTIVE To examine factors associated with tolerance of uncertainty, including well-being metrics such as burnout. DESIGN Online confidential survey. SETTING The Massachusetts General Physicians Organization (MGPO). PARTICIPANTS All 2172 clinically active faculty in the MGPO. MAIN MEASURES We examined associations for tolerance of uncertainty with demographic information, personal and professional characteristics, and physician well-being metrics. KEY RESULTS Two thousand twenty (93%) physicians responded. Multivariable analyses identified significant associations of lower tolerance of uncertainty with female gender (OR, 1.23; 95% CI, 1.03-1.48); primary care practice (OR, 1.56; 95% CI, 1.22-2.00); years since training (OR, 0.99; 95% CI, 0.98-0.995); and lacking a trusted advisor (OR, 1.25; 95% CI, 1.03-1.53). Adjusting for demographic and professional characteristics, physicians with low tolerance of uncertainty had higher likelihood of being burned-out (OR, 3.06; 95% CI, 2.41-3.88), were less likely to be satisfied with career (OR, 0.37; 95% CI, 0.26-0.52), and less likely to be engaged at work (RR, 0.87; 95% CI, 0.84-0.90). CONCLUSION At a time when concern about physician well-being is high, with much speculation about causes of burnout, we found a strong relationship between tolerance of uncertainty and physician well-being, across specialties. Particular attention likely needs to be paid to those with less experience, those in specialties with high rates of undifferentiated illness and uncertainty, such as primary care, and ensuring all physicians have access to a trusted advisor. These results generate the potential hypothesis that efforts focused in understanding and embracing uncertainty could be potentially effective for reducing burnout. This concept should be tested in prospective trials.
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Affiliation(s)
- Arabella Simpkin Begin
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA. .,Harvard Medical School, Boston, MA, USA. .,Department of Pharmacology, University of Oxford, Oxford, UK. .,Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.
| | - Michael Hidrue
- Massachusetts General Physicians Organization, Boston, USA
| | - Sara Lehrhoff
- Massachusetts General Physicians Organization, Boston, USA
| | - Marcela G Del Carmen
- Harvard Medical School, Boston, MA, USA.,Massachusetts General Physicians Organization, Boston, USA.,Division of Gynecologic Oncology, Department of Obstetrics and Gynecology and Reproductive Biology, Massachusetts General Hospital, Boston, MA, USA
| | - Katrina Armstrong
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Jason H Wasfy
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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4
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Borracci RA, Ciambrone G, Arribalzaga EB. Tolerance for Uncertainty, Personality Traits and Specialty Choice Among Medical Students. JOURNAL OF SURGICAL EDUCATION 2021; 78:1885-1895. [PMID: 34001460 DOI: 10.1016/j.jsurg.2021.03.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 01/20/2021] [Accepted: 03/25/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE The objective was to explore the tolerance for uncertainty in its different aspects (risk, ambiguity and complexity) in medical students at different times of their careers, and to relate these tolerance levels with their predominant personality traits and specialty choices. A secondary objective was to build a hypothetical model aimed at explaining the potential relationships of dependency between gender, personality traits, tolerance for uncertainty and specialty choice using a structural equation modeling (SEM) analysis. DESIGN/SETTING/PARTICIPANTS A prospective cross-sectional study including two cohorts of second-year (n = 155) and sixth-year (n = 157) medical students was performed during 2017 at the Buenos Aires University School of Medicine. Both student cohorts completed instruments assessing tolerance for different types of uncertainty: (1) complexity (Tolerance for Ambiguity scale); (2) risk (Pearson Risk Attitude scale); and (3) ambiguity (Ambiguity Aversion in Medicine scale). Information on age, gender and specialty choice in sixth-year medical students was included, plus the Big Five Inventory-10 (BFI-10) personality test. RESULTS Sixth-year students showed significantly lower scores than second-year students at tolerance for complexity (p = 0.0003) and ambiguity (p = 0.008). Sixth-year students choosing a surgical specialty were associated with low tolerance for risk and ambiguity, and moderate for complexity. Conversely, students choosing a clinical specialty were related with high tolerance for risk, moderate for ambiguity, and low for complexity. Logistic regression analysis including the uncertainty questionnaires plus BFI-10 categories demonstrated that only the "neuroticism" personality trait was independently associated with a surgical specialty choice (OR: 1.31, 95%CI: 1.03-1.67). The final SEM that best represented the data showed good fit statistics: chi-square (p = 0.108), and RMSEA (p = 0.047). CONCLUSIONS Tolerance for uncertainty in its different dimensions was associated with personality traits and specialty choice among medical students. A SEM analysis could satisfactorily explain the hypothetical relationships of dependency between gender, personality traits, tolerance for uncertainty, and specialty choice.
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Affiliation(s)
- Raúl A Borracci
- School of Medicine, Buenos Aires University, Buenos Aires, Argentina; Medical Education Research Laboratory, Deutsches Hospital, Buenos Aires, Argentina.
| | - Graciana Ciambrone
- Medical Education Research Laboratory, Deutsches Hospital, Buenos Aires, Argentina
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5
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Geller G, Grbic D, Andolsek KM, Caulfield M, Roskovensky L. Tolerance for Ambiguity Among Medical Students: Patterns of Change During Medical School and Their Implications for Professional Development. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2021; 96:1036-1042. [PMID: 33149092 DOI: 10.1097/acm.0000000000003820] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
PURPOSE Tolerance for ambiguity (TFA) is important for physicians, with implications for ethical behavior and patient care. This study explores how medical students' TFA changes from matriculation to graduation and how change in empathy and openness to diversity are associated with this change. METHOD Data for students who took the Matriculating Student Questionnaire (MSQ) in 2013 or 2014 and the Medical School Graduation Questionnaire (GQ) in 2017 or 2018 were drawn from the Association of American Medical Colleges (n = 17,221). Both the MSQ and GQ included a validated TFA scale and a shortened version of the Interpersonal Reactivity Index; the MSQ also included an openness to diversity scale. Tercile groups were used to assess how TFA changed from the MSQ to GQ, and regression analyses were used to assess associations between change in TFA and openness to diversity and between change in TFA and change in empathy. RESULTS Mean TFA scores decreased (d = -.67) among students with the highest TFA at matriculation but increased (d = .60) among students with the lowest TFA at matriculation. Regression results showed that change in TFA was significantly and positively associated with change in empathy (beta = .05, P < .001) and that openness to diversity (as reported at matriculation) was significantly and positively associated with TFA at graduation (beta = .05, P < .001). CONCLUSIONS This is the first nationally representative study to suggest that medical students' TFA changes over time, but in different directions depending on TFA at matriculation. TFA over time was also associated with change in empathy and openness to diversity. Medical schools should consider strategies to assess TFA in their admissions processes and for cultivating TFA throughout the learning process.
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Affiliation(s)
- Gail Geller
- G. Geller is professor, Johns Hopkins University Berman Institute of Bioethics, School of Medicine, Bloomberg School of Public Health, and Department of Sociology, Johns Hopkins University, Baltimore, Maryland; ORCID: https://orcid.org/0000-0003-4856-1942
| | - Douglas Grbic
- D. Grbic is lead research analyst, Medical Education, Association of American Medical Colleges, Washington, DC
| | - Kathyrn M Andolsek
- K.M. Andolsek is professor of family medicine and community health, Duke University School of Medicine, Durham, North Carolina
| | - Marie Caulfield
- M. Caulfield is manager of applicant, student, and resident data, Data Operations and Services, Association of American Medical Colleges, Washington, DC
| | - Lindsay Roskovensky
- L. Roskovensky is lead research and data analyst, Data Operations and Services, Association of American Medical Colleges, Washington, DC
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Saposnik G, Bueno-Gil G, Sempere ÁP, Rodríguez-Antigüedad A, Del Río B, Baz M, Terzaghi M, Ballesteros J, Maurino J. Regret and Therapeutic Decisions in Multiple Sclerosis Care: Literature Review and Research Protocol. Front Neurol 2021; 12:675520. [PMID: 34234734 PMCID: PMC8256155 DOI: 10.3389/fneur.2021.675520] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 05/18/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Decisions based on erroneous assessments may result in unrealistic patient and family expectations, suboptimal advice, incorrect treatment, or costly medical errors. Regret is a common emotion in daily life that involves counterfactual thinking when considering alternative choices. Limited information is available on care-related regret affecting healthcare professionals managing patients with multiple sclerosis (MS). Methods: We reviewed identified gaps in the literature by searching for the combination of the following keywords in Pubmed: "regret and decision," "regret and physicians," and "regret and nurses." An expert panel of neurologists, a nurse, a psychiatrist, a pharmacist, and a psychometrics specialist participated in the study design. Care-related regret will be assessed by a behavioral battery including the standardized questionnaire Regret Intensity Scale (RIS-10) and 15 new specific items. Six items will evaluate regret in the most common social domains affecting individuals (financial, driving, sports-recreation, work, own health, and confidence in people). Another nine items will explore past and recent regret experiences in common situations experienced by healthcare professionals caring for patients with MS. We will also assess concomitant behavioral characteristics of healthcare professionals that could be associated with regret: coping strategies, life satisfaction, mood, positive social behaviors, occupational burnout, and tolerance to uncertainty. Planned Outcomes: This is the first comprehensive and standardized protocol to assess care-related regret and associated behavioral factors among healthcare professionals managing MS. These results will allow to understand and ameliorate regret in healthcare professionals. Spanish National Register (SL42129-20/598-E).
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Affiliation(s)
- Gustavo Saposnik
- Laboratory for Social and Neural Systems Research, Department of Economics, University of Zurich, Zurich, Switzerland.,Clinical Outcomes & Decision Neuroscience Unit, Li Ka Shing Institute, University of Toronto, Toronto, ON, Canada.,Division of Neurology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | | | - Ángel P Sempere
- Department of Neurology, Hospital General Universitario de Alicante, Alicante, Spain
| | | | - Beatriz Del Río
- Department of Neurology, Hospital Universitario de La Princesa, Madrid, Spain
| | - Mar Baz
- Department of Psychiatry, Hospital Universitari Vall d'Hebrón, Barcelona, Spain
| | - María Terzaghi
- Clinical Outcomes & Decision Neuroscience Unit, Li Ka Shing Institute, University of Toronto, Toronto, ON, Canada
| | - Javier Ballesteros
- Department of Neurosciences and CIBERSAM, University of the Basque Country (UPV/EHU), Leioa, Spain
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7
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Callen AL, Dupont SM, Price A, Laguna B, McCoy D, Do B, Talbott J, Kohli M, Narvid J. Between Always and Never: Evaluating Uncertainty in Radiology Reports Using Natural Language Processing. J Digit Imaging 2020; 33:1194-1201. [PMID: 32813098 DOI: 10.1007/s10278-020-00379-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 06/10/2020] [Accepted: 07/23/2020] [Indexed: 02/06/2023] Open
Abstract
The ideal radiology report reduces diagnostic uncertainty, while avoiding ambiguity whenever possible. The purpose of this study was to characterize the use of uncertainty terms in radiology reports at a single institution and compare the use of these terms across imaging modalities, anatomic sections, patient characteristics, and radiologist characteristics. We hypothesized that there would be variability among radiologists and between subspecialities within radiology regarding the use of uncertainty terms and that the length of the impression of a report would be a predictor of use of uncertainty terms. Finally, we hypothesized that use of uncertainty terms would often be interpreted by human readers as "hedging." To test these hypotheses, we applied a natural language processing (NLP) algorithm to assess and count the number of uncertainty terms within radiology reports. An algorithm was created to detect usage of a published set of uncertainty terms. All 642,569 radiology report impressions from 171 reporting radiologists were collected from 2011 through 2015. For validation, two radiologists without knowledge of the software algorithm reviewed report impressions and were asked to determine whether the report was "uncertain" or "hedging." The relationship between the presence of 1 or more uncertainty terms and the human readers' assessment was compared. There were significant differences in the proportion of reports containing uncertainty terms across patient admission status and across anatomic imaging subsections. Reports with uncertainty were significantly longer than those without, although report length was not significantly different between subspecialities or modalities. There were no significant differences in rates of uncertainty when comparing the experience of the attending radiologist. When compared with reader 1 as a gold standard, accuracy was 0.91, sensitivity was 0.92, specificity was 0.9, and precision was 0.88, with an F1-score of 0.9. When compared with reader 2, accuracy was 0.84, sensitivity was 0.88, specificity was 0.82, and precision was 0.68, with an F1-score of 0.77. Substantial variability exists among radiologists and subspecialities regarding the use of uncertainty terms, and this variability cannot be explained by years of radiologist experience or differences in proportions of specific modalities. Furthermore, detection of uncertainty terms demonstrates good test characteristics for predicting human readers' assessment of uncertainty.
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Affiliation(s)
- Andrew L Callen
- Department of Radiology, University of Colorado Anschutz Medical Campus, Denver, CO, USA.
| | | | - Adi Price
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Ben Laguna
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - David McCoy
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Bao Do
- Department of Radiology, Stanford University Medical Center, Stanford, CA, USA
| | - Jason Talbott
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Marc Kohli
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Jared Narvid
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
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Woodruff JN. Accounting for complexity in medical education: a model of adaptive behaviour in medicine. MEDICAL EDUCATION 2019; 53:861-873. [PMID: 31106901 DOI: 10.1111/medu.13905] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 02/07/2019] [Accepted: 04/04/2019] [Indexed: 06/09/2023]
Abstract
CONTEXT Medicine is practised in complex systems. Physicians engage in clinical and operational problems that are dynamic and lack full transparency. As a consequence, the behaviour of medical systems and diseases is often unpredictable. Medical science has equipped physicians with powerful tools to favourably impact health, but a reductionist approach alone is insufficient to optimally address the complex challenges posed by illness and public health. Concepts from complexity science, such as continuous quality improvement and teamwork, strive to fill the gap between biomedical knowledge and the realities of practice. However, the superficial treatment of these systems-thinking concepts in medical education has distorted their implementation and undermined their impact. 'Systems thinking' has been conflated with 'systematic thinking'; concepts which are adaptive in nature are being taught as standardised, reductionist tools. METHODS Using concepts from complexity science, the history of science and psychology, this problem is outlined and a theoretical model of professional development is proposed. RESULTS This model proposes that complex problem solving and adaptive behaviour, not technical expertise, are distinguishing features of professionalism. DISCUSSION The impact of this model on our understanding of physician autonomy, professionalism, teamwork and continuous quality improvement is discussed. This model has significant implications for the structure and content of medical education. Strategies for enhancing medical training, including interventions in recruitment, the curriculum and evaluation, are reviewed. Such adjustments would prepare trainees to more effectively utilise biomedical knowledge and tools in the complex high-stakes reality of medical practice.
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Affiliation(s)
- James N Woodruff
- Department of Medicine, The University of Chicago, Chicago, Illinois, USA
- The Pritzker School of Medicine, Chicago, Illinois, USA
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Strout TD, Hillen M, Gutheil C, Anderson E, Hutchinson R, Ward H, Kay H, Mills GJ, Han PKJ. Tolerance of uncertainty: A systematic review of health and healthcare-related outcomes. PATIENT EDUCATION AND COUNSELING 2018; 101:1518-1537. [PMID: 29655876 DOI: 10.1016/j.pec.2018.03.030] [Citation(s) in RCA: 111] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 03/28/2018] [Accepted: 03/30/2018] [Indexed: 05/06/2023]
Abstract
BACKGROUND Uncertainty tolerance (UT) is thought to be a characteristic of individuals that influences various outcomes related to health, healthcare, and healthcare education. We undertook a systematic literature review to evaluate the state of the evidence on UT and its relationship to these outcomes. METHODS We conducted electronic and bibliographic searches to identify relevant studies examining associations between UT and health, healthcare, or healthcare education outcomes. We used standardized tools to assess methodological quality and analyzed the major findings of existing studies, which we organized and classified by theme. RESULTS Searches yielded 542 potentially relevant articles, of which 67 met inclusion criteria. Existing studies were heterogeneous in focus, setting, and measurement approach, were largely cross-sectional in design, and overall methodological quality was low. UT was associated with various trainee-centered, provider-centered, and patient-centered outcomes which were cognitive, emotional, and behavioral in nature. UT was most consistently associated with emotional well-being. CONCLUSIONS Uncertainty tolerance is associated with several important trainee-, provider-, and patient-centered outcomes in healthcare and healthcare education. However, low methodological quality, study design limitations, and heterogeneity in the measurement of UT limit strong inferences about its effects, and addressing these problems is a critical need for future research.
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Affiliation(s)
- Tania D Strout
- Department of Emergency Medicine, Maine Medical Center, Tufts University School of Medicine, 47 Bramhall Street, Portland, ME, 04102, USA.
| | - Marij Hillen
- Department of Medical Psychology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Caitlin Gutheil
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, ME, USA
| | - Eric Anderson
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, ME, USA
| | - Rebecca Hutchinson
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, ME, USA; Hospice and Palliative Medicine, Maine Medical Center, Portland, ME, USA
| | - Hannah Ward
- University of Rochester, School of Medicine & Dentistry, Rochester, NY, USA
| | - Hannah Kay
- Dell Medical School, University of Texas at Austin, Austin, TX, USA
| | | | - Paul K J Han
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, ME, USA
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10
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Reiner BI. Quantifying Analysis of Uncertainty in Medical Reporting: Creation of User and Context-Specific Uncertainty Profiles. J Digit Imaging 2018; 31:379-382. [PMID: 29427140 PMCID: PMC6113141 DOI: 10.1007/s10278-018-0057-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
While uncertainty is ubiquitous in medical practice, minimal work to date has been performed to analyze the cause and effect relationship between uncertainty and patient outcomes. In medical imaging practice, uncertainty in the radiology report has been well documented to be a source of clinician dissatisfaction. Before one can effectively create intervention strategies aimed at reducing uncertainty, it must first be better understood through context- and user-specific analysis. One strategy for accomplishing this task is to characterize the source of uncertainty and create user-specific uncertainty profiles which take into account a number of provider-specific variables which may contribute to report uncertainty. The resulting data can in turn be used to create real-time report uncertainty metrics aimed at providing uncertainty analytics at the point of care, for the combined purposes of decision support, improved communication, and enhanced clinical/economic outcomes.
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Affiliation(s)
- Bruce I Reiner
- Maryland VA Healthcare System, 10 North Greene Street, Baltimore, MD, 21201, USA.
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11
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Radick AC, Phipps AI, Piepkorn MW, Nelson HD, Barnhill RL, Elder DE, Reisch LM, Frederick PD, Elmore JG. Characteristics and diagnostic performance of pathologists who enjoy interpreting melanocytic lesions. Dermatol Online J 2018; 24:13030/qt96g5q3sz. [PMID: 30142708 PMCID: PMC6463485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 08/22/2018] [Indexed: 06/08/2023] Open
Abstract
Diagnostic discrepancy among pathologists interpreting melanocytic skin lesions (MSL) is an ongoing concern for patient care. Given that job satisfaction could impact patient care, this study aimed to characterize which pathologists enjoy interpreting MSL and estimate the association between enjoyment and diagnostic accuracy. Pathologists' demographics, training, and experience were obtained by a cross-sectional survey. Associations between these characteristics and self-reported enjoyment when interpreting MSL were estimated by Pearson's Chi-square tests. Diagnostic accuracy was determined by comparing pathologists' MSL interpretations with reference standard diagnoses. Associations between enjoyment and diagnostic accuracy were evaluated by generalized estimating equations (GEE) models. One hundred and eighty-seven (90%) pathologists completed the study. Seventy percent agreed that interpreting MSL is enjoyable. Pathologists who enjoyed interpreting MSL were more likely to be board certified and/or fellowship trained in dermatopathology (P=0.008), have ?10 years of experience (P=0.010) and have an MSL caseload of ?60 per month (P=<0.001). After adjustment, there was no association between enjoyment and diagnostic accuracy. Our data suggest that job dissatisfaction does not adversely affect diagnostic accuracy in the interpretation of melanocytic lesions, which is of importance given the progressive increase in annual biopsy rates and the attendant work demands imposed on pathologists.
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Affiliation(s)
- Andrea C Radick
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington.
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12
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Bowden WP, Morse A. The Mechanism of Heartbreak. J Physician Assist Educ 2018; 29:122-125. [PMID: 29787511 DOI: 10.1097/jpa.0000000000000195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- W Patrick Bowden
- W. Patrick Bowden, MMS, PA-C, is an assistant professor in the Division of Physician Assistant Education at Oregon Health and Science University, Portland, Oregon. Annie Morse, MA (art history), MLIS, is an independent curator and educator in Chicago, Chicago, Illinois
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Helmich E, Diachun L, Joseph R, LaDonna K, Noeverman-Poel N, Lingard L, Cristancho S. 'Oh my God, I can't handle this!': trainees' emotional responses to complex situations. MEDICAL EDUCATION 2018; 52:206-215. [PMID: 29044675 DOI: 10.1111/medu.13472] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Revised: 05/12/2017] [Accepted: 09/04/2017] [Indexed: 05/28/2023]
Abstract
CONTEXT Dealing with emotions is critical for medical trainees' professional development. Taking a sociocultural and narrative approach to understanding emotions, we studied complex clinical situations as a specific context in which emotions are evoked and influenced by the social environment. We sought to understand how medical trainees respond to emotions that arise in those situations. METHODS In an international constructivist grounded theory study, 29 trainees drew two rich pictures of complex clinical situations, one exciting and one frustrating. Rich pictures are visual representations that capture participants' perceptions about the people, situations and factors that create clinical complexity. These pictures were used to guide semi-structured, individual interviews. We analysed visual materials and interviews in an integrated way, starting with looking at the drawings, doing a 'gallery walk', and using the interviews to inform the aesthetic analysis. RESULTS Participants' drawings depicted a range of personal emotions in response to complexity, and disclosed unsettling feelings and behaviours that might be considered unprofessional. When trainees felt confident, they were actively participating, engaged in creative problem-solving strategies, and emphasised their personal involvement. When trainees felt the situation was beyond their control, they described how they were running away from the situation, hiding themselves behind others or distancing themselves from patients or families. CONCLUSIONS A sense of control seems to be a key factor influencing trainees' emotional and behavioural responses to complexity. This is problematic, as complex situations are by their nature emergent and dynamic, which limits possibilities for control. Following a social performative approach to emotions, we should help students understand that feeling out of control is an inherent property of participating in complex clinical situations, and, by extension, that it is not something they will 'grow out of' with expertise.
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Affiliation(s)
- Esther Helmich
- University Medical Center Groningen, Groningen, the Netherlands
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Pelletier E, Daigle JM, Defay F, Major D, Guertin MH, Brisson J. Frequency and Determinants of a Short-Interval Follow-up Recommendation After an Abnormal Screening Mammogram. Can Assoc Radiol J 2016; 67:322-329. [PMID: 27209218 DOI: 10.1016/j.carj.2015.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 10/28/2015] [Accepted: 11/10/2015] [Indexed: 11/17/2022] Open
Abstract
PURPOSE After imaging assessment of an abnormal screening mammogram, a follow-up examination 6 months later is recommended to some women. Our aim was to identify which characteristics of lesions, women, and physicians are associated to such short-interval follow-up recommendation in the Quebec Breast Cancer Screening Program. METHODS Between 1998 and 2008, 1,839,396 screening mammograms were performed and a total of 114,781 abnormal screens were assessed by imaging only. Multivariate analysis was done with multilevel Poisson regression models with robust variance and generalized linear mixed models. RESULTS A short-interval follow-up was recommended in 26.7% of assessments with imaging only, representing 2.3% of all screens. Case-mix adjusted proportion of short-interval follow-up recommendations varied substantially across physicians (range: 4%-64%). Radiologists with high recall rates (≥15%) had a high proportion of short-interval follow-up recommendation (risk ratio: 1.82; 95% confidence interval: 1.35-2.45) compared to radiologists with low recall rates (<5%). The adjusted proportion of short-interval follow-up was high (22.8%) even when a previous mammogram was usually available. CONCLUSIONS Short-interval follow-up recommendation at assessment is frequent in this Canadian screening program, even when a previous mammogram is available. Characteristics related to radiologists appear to be key determinants of short-interval follow-up recommendation, rather than characteristics of lesions or patient mix. Given that it can cause anxiety to women and adds pressure on the health system, it appears important to record and report short-interval follow-up and to identify ways to reduce its frequency. Short-interval follow-up recommendations should be considered when assessing the burden of mammography screening.
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Affiliation(s)
- Eric Pelletier
- Bureau d'information et d'études en santé des populations, Institut national de santé publique du Québec, Québec City, Québec, Canada.
| | - Jean-Marc Daigle
- Bureau d'information et d'études en santé des populations, Institut national de santé publique du Québec, Québec City, Québec, Canada
| | - Fannie Defay
- Bureau d'information et d'études en santé des populations, Institut national de santé publique du Québec, Québec City, Québec, Canada
| | - Diane Major
- Bureau d'information et d'études en santé des populations, Institut national de santé publique du Québec, Québec City, Québec, Canada
| | - Marie-Hélène Guertin
- Bureau d'information et d'études en santé des populations, Institut national de santé publique du Québec, Québec City, Québec, Canada
| | - Jacques Brisson
- Bureau d'information et d'études en santé des populations, Institut national de santé publique du Québec, Québec City, Québec, Canada; Centre de recherche du Centre hospitalier universitaire de Québec, Département de médecine sociale et préventive, Université Laval, Québec City, Québec, Canada
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15
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Waddimba AC, Scribani M, Krupa N, May JJ, Jenkins P. Frequency of satisfaction and dissatisfaction with practice among rural-based, group-employed physicians and non-physician practitioners. BMC Health Serv Res 2016; 16:613. [PMID: 27770772 PMCID: PMC5075400 DOI: 10.1186/s12913-016-1777-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 09/21/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Widespread dissatisfaction among United States (U.S.) clinicians could endanger ongoing reforms. Practitioners in rural/underserved areas withstand stressors that are unique to or accentuated in those settings. Medical professionals employed by integrating delivery systems are often distressed by the cacophony of organizational change(s) that such consolidation portends. We investigated the factors associated with dis/satisfaction with rural practice among doctors/non-physician practitioners employed by an integrated healthcare delivery network serving 9 counties of upstate New York, during a time of organizational transition. METHODS We linked administrative data about practice units with cross-sectional data from a self-administered multi-dimensional questionnaire that contained practitioner demographics plus valid scales assessing autonomy/relatedness needs, risk aversion, tolerance for uncertainty/ambiguity, meaningfulness of patient care, and workload. We targeted medical professionals on the institutional payroll for inclusion. We excluded those who retired, resigned or were fired during the study launch, plus members of the advisory board and research team. Fixed-effects beta regressions were performed to test univariate associations between each factor and the percent of time a provider was dis/satisfied. Factors that manifested significant fixed effects were entered into multivariate, inflated beta regression models of the proportion of time that practitioners were dis/satisfied, incorporating clustering by practice unit as a random effect. RESULTS Of the 473 eligible participants. 308 (65.1 %) completed the questionnaire. 59.1 % of respondents were doctoral-level; 40.9 % mid-level practitioners. Practitioners with heavier workloads and/or greater uncertainty intolerance were less likely to enjoy top-quintile satisfaction; those deriving greater meaning from practice were more likely. Higher meaningfulness and gratified relational needs increased one's likelihood of being in the lowest quintile of dissatisfaction; heavier workload and greater intolerance of uncertainty reduced that likelihood. Practitioner demographics and most practice unit characteristics did not manifest any independent effect. CONCLUSIONS Mutable factors, such as workload, work meaningfulness, relational needs, uncertainty/ambiguity tolerance, and risk-taking attitudes displayed the strongest association with practitioner satisfaction/dissatisfaction, independent of demographics and practice unit characteristics. Organizational efforts should be dedicated to a redesign of group-employment models, including more equitable division of clinical labor, building supportive peer networks, and uncertainty/risk tolerance coaching, to improve the quality of work life among rural practitioners.
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Affiliation(s)
- Anthony C Waddimba
- Bassett Healthcare Network, Research Institute, 1 Atwell Road, Cooperstown, NY, 13326, USA. .,Columbia University College of Physicians and Surgeons, 630 West 168th St, New York, NY, 10032, USA.
| | - Melissa Scribani
- Bassett Healthcare Network, Research Institute, 1 Atwell Road, Cooperstown, NY, 13326, USA
| | - Nicole Krupa
- Bassett Healthcare Network, Research Institute, 1 Atwell Road, Cooperstown, NY, 13326, USA
| | - John J May
- Bassett Healthcare Network, Research Institute, 1 Atwell Road, Cooperstown, NY, 13326, USA.,Columbia University Mailman School of Public Health, 722 West 168th St, New York, NY, 10032, USA
| | - Paul Jenkins
- Bassett Healthcare Network, Research Institute, 1 Atwell Road, Cooperstown, NY, 13326, USA
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16
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Waddimba AC, Scribani M, Hasbrouck MA, Krupa N, Jenkins P, May JJ. Resilience among Employed Physicians and Mid-Level Practitioners in Upstate New York. Health Serv Res 2016; 51:1706-34. [PMID: 27620116 DOI: 10.1111/1475-6773.12499] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE To investigate the factors associated with resilience among medical professionals. DATA SOURCES/STUDY SETTING Administrative information from a rural health care network (1 academic medical center, 6 hospitals, 31 clinics, and 20 school health centers) was triangulated with self-report data from 308 respondents (response rate = 65.1 percent) to a 9/2013-1/2014 survey among practitioners serving a nine-county 5,600-square-mile area. STUDY DESIGN A cross-sectional questionnaire survey comprising valid measures of resilience, practice meaningfulness, satisfaction, and risk/uncertainty intolerance, nested within a prospective, community-based project. DATA COLLECTION/EXTRACTION METHODS The sampling frame included practitioners on institutional payroll, excluding voluntary/involuntary attritions and advisory board/research team members. In multivariable mixed-effects models, we regressed full-range and high-/low-resilience scores on demographics, professional satisfaction, workplace needs, risk/uncertainty intolerance, and service unit characteristics. PRINCIPAL FINDINGS Relational needs, uncertainty intolerance, satisfaction ≥75 percent of the time, number of practitioners on a unit, and workload were significantly associated with resilience. Higher scores were most strongly associated with uncertainty tolerance, satisfaction, and practitioner numbers. Practitioner/unit demographics were mostly nonsignificant. CONCLUSIONS More resilient practitioners experienced frequent satisfaction, relational needs gratification, better uncertainty tolerance, lighter workloads, and practiced on units with more colleagues. Further studies should investigate well-being interventions based on these mutable factors.
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Affiliation(s)
- Anthony C Waddimba
- Health Services Research Scientist, Bassett Healthcare Network, Research Institute, Cooperstown, NY. .,Assistant Professor of Pediatrics, Columbia University College of Physicians & Surgeons, Cooperstown, NY.
| | - Melissa Scribani
- Biostatistics and Computing Center, Bassett Healthcare Network, Research Institute, Cooperstown, NY
| | - Melinda A Hasbrouck
- Health Services Research Scientist, Bassett Healthcare Network, Research Institute, Cooperstown, NY
| | - Nicole Krupa
- Biostatistics and Computing Center, Bassett Healthcare Network, Research Institute, Cooperstown, NY
| | - Paul Jenkins
- Biostatistics and Computing Center, Bassett Healthcare Network, Research Institute, Cooperstown, NY
| | - John J May
- Health Services Research Scientist, Bassett Healthcare Network, Research Institute, Cooperstown, NY.,Department of Epidemiology, Columbia University Mailman School of Public Health, Cooperstown, New York
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17
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Bertschy S, Pannek J, Meyer T. Delivering care under uncertainty: Swiss providers' experiences in caring for women with spinal cord injury during pregnancy and childbirth - an expert interview study. BMC Pregnancy Childbirth 2016; 16:181. [PMID: 27443838 PMCID: PMC4957428 DOI: 10.1186/s12884-016-0976-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 07/16/2016] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND When different health problems such as pregnancy and spinal cord injury (SCI) occur together, providing adequate care becomes even more challenging. Women with SCI may encounter a variety of specific problems and symptoms during pregnancy and childbirth, including urinary tract infections, pressure ulcers, constipation, autonomic dysreflexia, and preterm labour. Therefore, expertise from different medical specialties, especially spinal cord medicine and gynaecology are required. What is totally normal for experts of one specialty could cause a problem for experts from another specialty. Therefore, this study aimed to reconstruct the perceptions and experiences of healthcare providers in Switzerland in caring for women with SCI during pregnancy and childbirth. METHODS The perception and experience of healthcare professionals toward providing care for women with SCI during pregnancy and labour were elicited using qualitative expert interviews and analysed using grounded theory techniques. Fifteen health professionals were interviewed, including gynaecologists (n = 4), midwives (n = 3), physical medicine and rehabilitation professionals (n = 4), urologists (n = 3), and a peer counselor (n = 1). RESULTS Care delivery experiences of health professionals could be described as a forced reaction to decision making under uncertainty. However, health professionals seemed to express three different attitudes while handling the situation: (i) protective concerned attitude, (ii) 'no big deal' attitude, or (iii) precautionary attitude. The applied strategies were influenced by the conditions of the healthcare system, policies in place, and health professionals' behaviours. Consequently, health professionals faced with uncertainty felt like actors in a fragmented treatment process and called for interdisciplinary collaborations. CONCLUSIONS Our findings highlight the diversity of perspectives among different healthcare professionals with respect to the approach to care and delivery services for pregnant women with SCI. A need for more specific services, information, guidance, and guidelines for health professionals caring for woman with SCI during pregnancy and childbirth was identified. We strongly recommend further research on the development of integrated care concepts as well as clinical studies for establishing a more profound knowledge base.
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Affiliation(s)
- Sue Bertschy
- />Swiss Paraplegic Research (SPF), Guido A. Zäch-Strasse 4, CH-6207 Nottwil, Switzerland
- />Department of Health Sciences and Health Policy, University of Lucerne and SPF, Nottwil, Switzerland
| | - Jürgen Pannek
- />Swiss Paraplegic Centre (SPZ), Neuro-Urology, Guido A. Zäch-Strasse 2, CH-6207 Nottwil, Switzerland
| | - Thorsten Meyer
- />Hannover Medical School, Institute for Epidemiology, Social Medicine and Health Systems Research, Carl-Neuberg-Str. 1, D-30625 Hannover, Germany
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18
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Dalton AF, Golin CE, Esserman D, Pignone MP, Pathman DE, Lewis CL. Relationship between Physicians' Uncertainty about Clinical Assessments and Patient-Centered Recommendations for Colorectal Cancer Screening in the Elderly. Med Decis Making 2015; 35:458-66. [PMID: 25712448 DOI: 10.1177/0272989x15572828] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Accepted: 01/19/2015] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The goal of this study was to examine associations between physicians' clinical assessments, their certainty in these assessments, and the likelihood of a patient-centered recommendation about colorectal cancer (CRC) screening in the elderly. METHODS Two hundred seventy-six primary care physicians in the United States read 3 vignettes about an 80-year-old female patient and answered questions about her life expectancy, their confidence in their life expectancy estimate, the balance of benefits/downsides of CRC screening, their certainty in their benefit/downside assessment, and the best course of action regarding CRC screening. We used logistic regression to determine the relationship between these variables and patient-centered recommendations about CRC screening. RESULTS In bivariate analyses, physicians had higher odds of making a patient-centered recommendation about CRC screening when their clinical assessments did not lead to a clear screening recommendation or when they experienced uncertainty in their clinical assessments. However, in a multivariate regression model, only benefit/downside assessment and best course of action remained statistically significant predictors of a patient-centered recommendation. CONCLUSIONS Our findings demonstrate that when the results of clinical assessments do not lead to obvious screening decisions or when physicians feel uncertain about their clinical assessments, they are more likely to make patient-centered recommendations. Existing uncertainty frameworks do not adequately describe the uncertainty associated with patient-centered recommendations found in this study. Adapting or modifying these frameworks to better reflect the constructs associated with uncertainty and the interactions between uncertainty and the complexity inherent in clinical decisions will facilitate a more complete understanding of how and when physicians choose to include patients in clinical decisions.
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Affiliation(s)
- Alexandra F Dalton
- Department of Medicine, Division of General Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO (AFD, CLL)
| | - Carol E Golin
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC (CG),Department of Health Behavior and Health Education, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC (CG)
| | - Denise Esserman
- Department of Biostatistics, Yale University School of Public Health, New Haven, CT (DE)
| | - Michael P Pignone
- Department of Medicine, Division of General Medicine and Clinical Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC (MPP, DEP)
| | - Donald E Pathman
- Department of Medicine, Division of General Medicine and Clinical Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC (MPP, DEP),Department of Family Medicine, University of North Carolina School of Medicine, Chapel Hill, NC (DEP)
| | - Carmen L Lewis
- Department of Medicine, Division of General Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO (AFD, CLL)
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Raglan GB, Babush M, Farrow VA, Kruglanski AW, Schulkin J. Need to know: the need for cognitive closure impacts the clinical practice of obstetrician/gynecologists. BMC Med Inform Decis Mak 2014; 14:122. [PMID: 25540033 PMCID: PMC4297425 DOI: 10.1186/s12911-014-0122-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 12/11/2014] [Indexed: 12/02/2022] Open
Abstract
Background Need for cognitive closure (NFCC) has been shown to be a consistent and measurable trait. It has effects on decision making and has been associated with more rapid decision making, higher reliance on heuristics or biases for decision making, reduced tolerance for ambiguity, and reduced interest in searching for alternatives. In medical practice, these tendencies may lead to lower quality of decision making. Methods This study measured NFCC in 312 obstetrician/gynecologists using a survey-style approach. Physicians were administered a short NFCC scale and asked questions about their clinical practice. Results Obstetrician/gynecologists with high NFCC were found to be less likely to address a number of clinical questions during well-woman exams, and were more likely to consult a greater number of sources when prescribing new medications. Conclusions NFCC of physicians may have an important impact on practice. It is possible that increased training during residency or medical school could counteract the detrimental effects of NFCC, and steps can be taken through increased use of electronic reminder systems could orient physicians to the appropriate questions to ask patients. Electronic supplementary material The online version of this article (doi:10.1186/s12911-014-0122-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Greta B Raglan
- Department of Research, American College of Obstetricians and Gynecologists, 409 12th St, SW, Washington, DC, 20024, USA. .,Department of Psychology, American University, Washington, DC, 20016, USA.
| | - Maxim Babush
- Department of Psychology, University of Maryland, College Park, MD, 20742, USA.
| | - Victoria A Farrow
- Department of Research, American College of Obstetricians and Gynecologists, 409 12th St, SW, Washington, DC, 20024, USA.
| | - Arie W Kruglanski
- Department of Psychology, University of Maryland, College Park, MD, 20742, USA.
| | - Jay Schulkin
- Department of Research, American College of Obstetricians and Gynecologists, 409 12th St, SW, Washington, DC, 20024, USA.
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20
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Cunningham BA, Bonham VL, Sellers SL, Yeh HC, Cooper LA. Physicians' anxiety due to uncertainty and use of race in medical decision making. Med Care 2014; 52:728-33. [PMID: 25025871 PMCID: PMC4214364 DOI: 10.1097/mlr.0000000000000157] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND The explicit use of race in medical decision making is contested. Researchers have hypothesized that physicians use race in care when they are uncertain. OBJECTIVES The aim of this study was to investigate whether physician anxiety due to uncertainty (ADU) is associated with a higher propensity to use race in medical decision making. RESEARCH DESIGN This study included a national cross-sectional survey of general internists. SUBJECTS A national sample of 1738 clinically active general internists drawn from the SK&A physician database were included in the study. MEASURES ADU is a 5-item measure of emotional reactions to clinical uncertainty. Bonham and Sellers Racial Attributes in Clinical Evaluation (RACE) scale includes 7 items that measure self-reported use of race in medical decision making. We used bivariate regression to test for associations between physician characteristics, ADU, and RACE. Multivariate linear regression was performed to test for associations between ADU and RACE while adjusting for potential confounders. RESULTS The mean score on ADU was 19.9 (SD=5.6). Mean score on RACE was 13.5 (SD=5.6). After adjusting for physician demographics, physicians with higher levels of ADU scored higher on RACE (+β=0.08 in RACE, P=0.04, for each 1-point increase in ADU), as did physicians who understood "race" to mean biological or genetic ancestral, rather than sociocultural, group. Physicians who graduated from a US medical school, completed fellowship, and had more white patients scored lower on RACE. CONCLUSIONS This study demonstrates positive associations between physicians' ADU, meanings attributed to race, and self-reported use of race in medical decision making. Future research should examine the potential impact of these associations on patient outcomes and health care disparities.
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Affiliation(s)
| | - Vence L. Bonham
- Social and Behavioral Research Branch, National Human Genome Research Institute, Bethesda, MD, United States
| | - Sherrill L. Sellers
- Department of Family Studies & Social Work, Miami University, Oxford, OH, United States
| | - Hsin-Chieh Yeh
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Lisa A. Cooper
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States
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Weissenstein A, Ligges S, Brouwer B, Marschall B, Friederichs H. Measuring the ambiguity tolerance of medical students: a cross-sectional study from the first to sixth academic years. BMC FAMILY PRACTICE 2014; 15:6. [PMID: 24405525 PMCID: PMC3897997 DOI: 10.1186/1471-2296-15-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Accepted: 12/30/2013] [Indexed: 11/10/2022]
Abstract
BACKGROUND Tolerance of ambiguity, or the extent to which ambiguous situations are perceived as desirable, is an important component of the attitudes and behaviors of medical students. However, few studies have compared this trait across the years of medical school. General practitioners are considered to have a higher ambiguity tolerance than specialists. We compared ambiguity tolerance between general practitioners and medical students. METHODS We designed a cross-sectional study to evaluate the ambiguity tolerance of 622 medical students in the first to sixth academic years. We compared this with the ambiguity tolerance of 30 general practitioners. We used the inventory for measuring ambiguity tolerance (IMA) developed by Reis (1997), which includes three measures of ambiguity tolerance: openness to new experiences, social conflicts, and perception of insoluble problems. RESULTS We obtained a total of 564 complete data sets (return rate 90.1%) from medical students and 29 questionnaires (return rate 96.7%) from general practitioners. In relation to the reference groups defined by Reis (1997), medical students had poor ambiguity tolerance on all three scales. No differences were found between those in the first and the sixth academic years, although we did observe gender-specific differences in ambiguity tolerance. We found no differences in ambiguity tolerance between general practitioners and medical students. CONCLUSIONS The ambiguity tolerance of the students that we assessed was below average, and appeared to be stable throughout the course of their studies. In contrast to our expectations, the general practitioners did not have a higher level of ambiguity tolerance than the students did.
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Affiliation(s)
- Anne Weissenstein
- Department of Gastroenterology and Hepatology, University Hospital of Cologne, Kerpener Strasse 62, Cologne, 50937 Germany.
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22
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Geller G. Tolerance for ambiguity: an ethics-based criterion for medical student selection. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2013; 88:581-4. [PMID: 23524934 DOI: 10.1097/acm.0b013e31828a4b8e] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
Planned changes to the MCAT exam and the premedical course requirements are intended to enable the assessment of humanistic characteristics and, thus, to select students who are more likely to become physicians who can communicate and relate with patients and engage in ethical decision making. Identifying students who possess humanistic and communication skills is an important goal, but the changes being implemented may not be sufficient to evaluate key personality traits that characterize well-rounded, thoughtful, empathic, and respectful physicians. The author argues that consideration should be given to assessing prospective students' tolerance for ambiguity as part of the admission process. Several strategies are proposed for implementing and evaluating such an assessment. Also included in this paper is an overview of the conceptual and empirical literature on tolerance for ambiguity among physicians and medical students, its impact on patient care, and the attention it is given in medical education. This evidence suggests that if medical schools admitted students who possess a high tolerance for ambiguity, quality of care in ambiguous conditions might improve, imbalances in physician supply and practice patterns might be reduced, the humility necessary for moral character formation might be enhanced, and the increasing ambiguity in medical practice might be better acknowledged and accepted.
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Affiliation(s)
- Gail Geller
- School of Medicine, Department of Medicine and Berman Institute of Bioethics, Johns Hopkins University, Baltimore, Maryland 21205, USA.
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Carney PA, Cook AJ, Miglioretti DL, Feig SA, Bowles EA, Geller BM, Kerlikowske K, Kettler M, Onega T, Elmore JG. Use of clinical history affects accuracy of interpretive performance of screening mammography. J Clin Epidemiol 2012; 65:219-30. [PMID: 22000816 PMCID: PMC3253253 DOI: 10.1016/j.jclinepi.2011.06.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2010] [Revised: 06/15/2011] [Accepted: 06/18/2011] [Indexed: 10/16/2022]
Abstract
OBJECTIVE To examine how use of clinical history affects radiologist's interpretation of screening mammography. STUDY DESIGN AND SETTING Using a self-administered survey and actual interpretive performance, we examined associations between use of clinical history and sensitivity, false-positive rate, recall rate, and positive predictive value, after adjusting for relevant covariates using conditional logistic regression. RESULTS Of the 216 radiologists surveyed (63.4%), most radiologists reported usually or always using clinical history when interpreting screening mammography. Compared with radiologists who rarely use clinical history, radiologists who usually or always use it had a higher false-positive rate with younger women (10.7 vs. 9.7), denser breast tissue (10.1 for heterogeneously dense to 10.9 for extremely dense vs. 8.9 for fatty tissue), or longer screening intervals (> prior 5 years) (12.5 vs. 10.5). Effect of current hormone therapy (HT) use on false-positive rate was weaker among radiologists who use clinical history compared with those who did not (P=0.01), resulting in fewer false-positive examinations and a nonsignificant lower sensitivity (79.2 vs. 85.2) among HT users. CONCLUSION Interpretive performance appears to be influenced by patient age, breast density, screening interval, and HT use. This influence does not always result in improved interpretive performance.
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Affiliation(s)
- Patricia A Carney
- Department of Family Medicine, Oregon Health & Science University, Portland, OR 97239-3098, USA.
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van Breest Smallenburg V, Setz-Pels W, Groenewoud JH, Voogd AC, Jansen FH, Louwman MWJ, Tielbeek AV, Duijm LEM. Malpractice claims following screening mammography in The Netherlands. Int J Cancer 2012; 131:1360-6. [PMID: 22173962 DOI: 10.1002/ijc.27398] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2011] [Accepted: 11/28/2011] [Indexed: 01/12/2023]
Abstract
Although malpractice lawsuits are frequently related to a delayed breast cancer diagnosis in symptomatic patients, information on claims at European screening mammography programs is lacking. We determined the type and frequency of malpractice claims at a Dutch breast cancer screening region. We included all 85,274 women (351,009 screens) who underwent biennial screening mammography at a southern breast screening region in The Netherlands between 1997 and 2009. Two screening radiologists reviewed the screening mammograms of all screen detected cancers and interval cancers and determined whether the cancer had been missed at the previous screen or at the latest screen, respectively. We analyzed all correspondence between the screening organization, clinicians and screened women, and collected complaints and claims until September 2011. At review, 20.9% (308/1,475) of screen detected cancers and 24.3% (163/670) of interval cancers were considered to be missed at a previous screen. A total of 19 women (of which 2, 6 and 11 women had been screened between 1997 and 2001 (102,439 screens), 2001 and 2005 (114,740 screens) and 2005 and 2009 (133,830 screens), respectively) had contacted the screening organization for additional information about their screen detected cancer or interval cancer, but filed no claim. Three other women directly initiated an insurance claim for financial compensation of their interval cancer without previously having contacted the screening organization. We conclude that screening-related claims were rarely encountered, although many screen detected cancers and interval cancers had been missed at a previous screen. A small but increasing proportion of women sought additional information about their breast cancer from the screening organization.
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Abstract
Uncertainty is a pervasive and important problem that has attracted increasing attention in health care, given the growing emphasis on evidence-based medicine, shared decision making, and patient-centered care. However, our understanding of this problem is limited, in part because of the absence of a unified, coherent concept of uncertainty. There are multiple meanings and varieties of uncertainty in health care that are not often distinguished or acknowledged although each may have unique effects or warrant different courses of action. The literature on uncertainty in health care is thus fragmented, and existing insights have been incompletely translated to clinical practice. This article addresses this problem by synthesizing diverse theoretical and empirical literature from the fields of communication, decision science, engineering, health services research, and psychology and developing a new integrative conceptual taxonomy of uncertainty. A 3-dimensional taxonomy is proposed that characterizes uncertainty in health care according to its fundamental sources, issues, and locus. It is shown how this new taxonomy facilitates an organized approach to the problem of uncertainty in health care by clarifying its nature and prognosis and suggesting appropriate strategies for its analysis and management.
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Affiliation(s)
- Paul K J Han
- Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, Maine (PKJH)
| | - William M P Klein
- Division of Cancer Control and Population Sciences, National CancerInstitute, Bethesda, Maryland (WMPK, NKA)
| | - Neeraj K Arora
- Division of Cancer Control and Population Sciences, National CancerInstitute, Bethesda, Maryland (WMPK, NKA)
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Luther VP, Crandall SJ. Commentary: ambiguity and uncertainty: neglected elements of medical education curricula? ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2011; 86:799-800. [PMID: 21715991 DOI: 10.1097/acm.0b013e31821da915] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Despite significant advances in scientific knowledge and technology, ambiguity and uncertainty are still intrinsic aspects of contemporary medicine. To practice confidently and competently, a physician must learn rational approaches to complex and ambiguous clinical scenarios and must possess a certain degree of tolerance of ambiguity. In this commentary, the authors discuss the role that ambiguity and uncertainty play in medicine and emphasize why openly addressing these topics in the formal medical education curriculum is critical. They discuss key points from original research by Wayne and colleagues and their implications for medical education. Finally, the authors offer recommendations for increasing medical student tolerance of ambiguity and uncertainty, including dedicating time to attend candidly to ambiguity and uncertainty as a formal part of every medical school curriculum.
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Abstract
Uncertainty is a pervasive and important problem that has attracted increasing attention in health care, given the growing emphasis on evidence-based medicine, shared decision making, and patient-centered care. However, our understanding of this problem is limited, in part because of the absence of a unified, coherent concept of uncertainty. There are multiple meanings and varieties of uncertainty in health care that are not often distinguished or acknowledged although each may have unique effects or warrant different courses of action. The literature on uncertainty in health care is thus fragmented, and existing insights have been incompletely translated to clinical practice. This article addresses this problem by synthesizing diverse theoretical and empirical literature from the fields of communication, decision science, engineering, health services research, and psychology and developing a new integrative conceptual taxonomy of uncertainty. A 3-dimensional taxonomy is proposed that characterizes uncertainty in health care according to its fundamental sources, issues, and locus. It is shown how this new taxonomy facilitates an organized approach to the problem of uncertainty in health care by clarifying its nature and prognosis and suggesting appropriate strategies for its analysis and management.
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Affiliation(s)
- Paul K. J. Han
- Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, Maine (PKJH)
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland (WMPK, NKA)
| | - William M. P. Klein
- Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, Maine (PKJH)
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland (WMPK, NKA)
| | - Neeraj K. Arora
- Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, Maine (PKJH)
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland (WMPK, NKA)
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The patient–physician relationship in surgical students. Am J Surg 2010; 200:624-7. [DOI: 10.1016/j.amjsurg.2010.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2010] [Revised: 07/07/2010] [Accepted: 07/07/2010] [Indexed: 11/13/2022]
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Politi MC, Légaré F. Physicians' reactions to uncertainty in the context of shared decision making. PATIENT EDUCATION AND COUNSELING 2010; 80:155-7. [PMID: 19948387 DOI: 10.1016/j.pec.2009.10.030] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2009] [Revised: 09/21/2009] [Accepted: 10/26/2009] [Indexed: 05/22/2023]
Abstract
OBJECTIVE Physicians' reactions towards uncertainty may influence their willingness to engage in shared decision making (SDM). This study aimed to identify variables associated with physician's anxiety from uncertainty and reluctance to disclose uncertainty to patients. METHODS We conducted a cross-sectional secondary analysis of longitudinal data of an implementation study of SDM among primary care professionals (n=122). Outcomes were anxiety from uncertainty and reluctance to disclose uncertainty to patients. Hypothesized factors that would be associated with outcomes included attitude, social norm, perceived behavioral control, intention to implement SDM in practice, and socio-demographics. Stepwise linear regression was used to identify predictors of anxiety from uncertainty and reluctance to disclose uncertainty to patients. RESULTS In multivariate analyses, anxiety from uncertainty was influenced by female gender (beta=0.483; p=0.0039), residency status (1st year: beta=0.600; p=0.001; 2nd year: beta=0.972; p<0.001), and number of hours worked per week (beta=-0.012; p=0.048). Reluctance to disclose uncertainty to patients was influenced by having more years in formal education (beta=-1.996; p=0.012). CONCLUSION Variables associated with anxiety from uncertainty differ from those associated with reluctance to disclose uncertainty to patients. PRACTICE IMPLICATIONS Given the importance of communicating uncertainty during SDM, measuring physicians' reactions to uncertainty is essential in SDM implementation studies.
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Affiliation(s)
- Mary C Politi
- Department of Surgery, Washington University School of Medicine, St. Louis, MO 63112-1408, USA.
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Lown BA, Roy E, Gorman P, Sasson JP. Women's and residents' experiences of communication in the diagnostic mammography suite. PATIENT EDUCATION AND COUNSELING 2009; 77:328-337. [PMID: 19819097 DOI: 10.1016/j.pec.2009.09.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2008] [Revised: 07/18/2009] [Accepted: 09/13/2009] [Indexed: 05/28/2023]
Abstract
OBJECTIVE To gain understanding of radiology residents' and women's experiences, concerns, information needs, coping strategies and perspectives about optimal communication during diagnostic mammography. METHODS Qualitative analysis of focus groups of radiology residents and women who had undergone diagnostic mammograms. RESULTS Five categories of themes emerged from our analysis: information needs, perspectives and ideals, emotional experiences and observations, working together, individual experiences, and others' roles. Women preferred continuous orientation, clear explanations and emotional support by physicians and radiology technologists throughout diagnostic processes. Communication about diagnostic mammogram results evoked the threat of breast cancer and was experienced as "bad news" by women, but not necessarily by all radiology residents. Lack of collaboration among radiologists, technologists and other healthcare professionals engendered confusion and anxiety in patients. Radiology residents felt inadequately prepared to meet the communication challenges of providing information and emotional support tailored to women's needs in this context. CONCLUSION Women's experiences are influenced by the extent to which they receive clear information and support, and perceive collaboration among professionals involved in the diagnostic mammography process. PRACTICE IMPLICATIONS Radiology education must address communication with patients and among healthcare professionals involved in the care of patients undergoing diagnostic procedures and interventions.
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Affiliation(s)
- Beth A Lown
- Harvard Medical School, Mount Auburn Hospital, Department of Medicine, 300 Mount Auburn Street, Cambridge, MA 02138, USA
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Predictors of radiologists' perceived risk of malpractice lawsuits in breast imaging. AJR Am J Roentgenol 2009; 192:327-33. [PMID: 19155390 DOI: 10.2214/ajr.07.3346] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The shortage of radiologists in breast imaging may be related to heightened malpractice lawsuit concerns. Our objective was to examine radiologists' reported experiences and perceptions of future lawsuit risk and explore personal and professional factors that may be associated with elevated perceptions of risk. MATERIALS AND METHODS Radiologists who routinely interpret mammography examinations in diverse regions of the United States (Washington, Colorado, and New Hampshire) completed a mailed survey in 2002 and 2006, including questions on demographics, practice characteristics, and medicolegal experience and perceptions as well as a validated scale measuring reactions to uncertainty in clinical situations. A survey assessing the radiologists' work facilities was also completed in 2002. RESULTS Participation by eligible radiologists was 77% (139 of 181) in 2002 and 71% (84 of 118) in 2006. The percentage of radiologists reporting malpractice claims related to mammography in the previous 5 years was 8% on the 2002 survey and 10% on the 2006 survey. Radiologists' mean estimate of the probability of being sued for malpractice in the next 5 years (41% in 2002 and 35% in 2006) was markedly higher than the actual reported risk. Radiologists' age, sex, clinical experience, and workload were not associated with a higher perceived risk of being sued. Radiologists who reported higher perceived risk of lawsuits were more likely to have experienced a prior malpractice claim, to report knowing colleagues with prior lawsuits, and to score higher on a scale measuring anxiety caused by uncertainty in clinical situations. Radiologists working at facilities that did not use double reading reported higher perceived risk, but the difference was not statistically significant. CONCLUSION Radiologists working in breast imaging substantially overestimate their risk of a future malpractice lawsuit. Radiologists with higher risk perceptions show more negative reactions to uncertainty in a clinical setting. Understanding that their actual risk of malpractice lawsuits may be substantially lower than anticipated may help reduce radiologists' fears and alleviate the manpower shortage in mammography. Programs to address the shortage of breast imagers could be targeted toward radiologists with heightened malpractice lawsuit concerns.
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