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Radiography Managers’ Perspectives on the Strategies to Mitigate Disruptive Behaviours: A Qualitative Exploratory Study. Healthcare (Basel) 2022; 10:healthcare10091742. [PMID: 36141354 PMCID: PMC9498484 DOI: 10.3390/healthcare10091742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 09/01/2022] [Accepted: 09/07/2022] [Indexed: 12/05/2022] Open
Abstract
Disruptive behaviours (DBs) are not normally in the scope of legal sanctions, notwithstanding their undesirable effects. Hence, many healthcare organizations still have difficulty in dealing with them in an effective manner. Several studies suggest that few organizations have tailor-made policies or procedures for evaluating, proving and mitigating these behaviours. However, evidence shows that mitigating DBs is critical to empowering healthcare workers to focus on providing superior, affordable and safe patient care. The aim of this study was to explore radiography managers’ perspectives on the strategies to mitigate DBs involving radiographers. An exploratory qualitative study employing one-on-one semi-structured in-depth interviews was carried out between March and April 2021. Eleven radiography managers at central hospitals in Harare Metropolitan Province were selected by criterion-purposive sampling. The interview data were analyzed using Tesch’s method of qualitative analysis. The data were first manually coded and then entered into Nvivo (QSR International Version 11) for further analysis. Three themes emerged from the interview data including awareness of DBs, willingness to address DBs, and conflict resolution. Context-specific strategies to mitigate DBs should be identified and implemented to guarantee a healthy work environment for radiographers so that they focus on providing excellent and safe patient care.
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Disruptive behavior in the operating room: Systemic over individual determinants. INTERNATIONAL JOURNAL OF SURGERY OPEN 2022. [DOI: 10.1016/j.ijso.2022.100492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Abstract
PURPOSE OF REVIEW This review addresses the importance of some of the human factors for intraoperative patient safety with particular focus on the active failures. These are the mishaps or sentinel events related to decisons taken and actions performed by the individual at the delivery end of a system. Such sentinel events may greatly affect intraoperative patient safety. RECENT FINDINGS Intimidating, aggressive and disruptive communication is a cause of adverse staff interaction, which may then represent an important patient safety threat. Also, anaesthesiologist's physical and mental state and limitations may interfere with patient safety. SUMMARY The concept of physician well being is multidimensional and includes factors related to each physician as an individual as well as to the working environment. Creating optimal safe conditions for patients, therefore, requires actions at both the personal level and the working conditions. Also, initiatives to ban rude and dismissive communication should be implemented in order to further improve intraoperative patient safety.
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Affiliation(s)
- Stefan De Hert
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, Ghent University, Ghent, Belgium
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Abstract
PURPOSE OF REVIEW The disruptive physician is a growing problem in medicine. All too often, physician behavior negatively impacts the delivery of quality patient care. The hostile environment that certain behaviors create makes it difficult for team members advocate for their patients. It is imperative that physician practices develop and an understanding of how to identify the disruptive physician to maintain patient safety. RECENT FINDINGS Disruptive physicians can damage team morale by creating a psychologically unsafe working environment. Healthcare organizations must be committed to ensuring that all team members can function effectively in their work environments. The leaders of healthcare organizations must be acutely aware of what constitutes disruptive behavior and act proactively to eliminate such behaviors. Disruptive physicians should be made acutely aware that their behavior is deemed unacceptable and efforts at correcting such behavior are imperative. SUMMARY The practice of medicine is multifaceted. It is imperative that the assurance of psychological safety is met to meet the standards of high quality and safe care for patients.
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Affiliation(s)
- Crystal Wright
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Vaughan L, Bardsley M, Bell D, Davies M, Goddard A, Imison C, Melnychuk M, Morris S, Rafferty AM. Models of generalist and specialist care in smaller hospitals in England: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2021. [DOI: 10.3310/hsdr09040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
The increasing number of older, complex patients who require emergency admission to hospital has prompted calls for better models of medical generalist care, especially for smaller hospitals, whose size constrains resources and staffing.
Objective
To investigate the strengths and weaknesses of the current models of medical generalism used in smaller hospitals from patient, professional and service perspectives.
Methods
The design was a mixed-methods study. Phase 1 was a scoping and mapping exercise to create a typology of models of care, which was then explored further through 11 case studies. Phase 2 created a classification using the Hospital Episode Statistics of acute medical ‘generalist’ and ‘specialist’ work and described differences in workload and explored the links between case mix, typology and length of stay and between case mix and skill mix. Phase 3 analysed the relationships between models of care and patient-level costs. Phase 4 examined the strengths and weaknesses of the models of care through focus groups, a discrete choice experiment and an exploration of the impact of typology on other outcomes.
Results
In total, 50 models of care were explored through 48 interviews. A typology was constructed around generalist versus specialist patterns of consultant working. Twenty-five models were deployed by 48 hospitals, and no more than four hospitals used any one model of care. From the patient perspective, analysis of Hospital Episode Statistics data of 1.9 million care episodes found that the differences in case mix between hospitals were relatively small, with 65–70% of episodes accounted for by 20 case types. The skill mix of hospital staff varied widely; there were no relationships with case mix. Patients exhibited a preference for specialist care in the discrete choice experiment but indicated in focus groups that overall hospital quality was more important. From a service perspective, qualitative work found that models of care were contingent on complex constellations of factors, including staffing, the local hospital environment and policy imperatives. Neither the model of care nor the case mix accounted for variability in the length of stay (no associations were significant at p < 0.05). No significant differences were found in the costs of the models. Professionally, the preferences of doctors for specialist versus generalist work depended on their experiences of providing care and were associated with a healthy organisational culture and a co-operative approach to managing emergency work. Concepts of medical generalism were found to be complex and difficult to define, with theoretical models differing markedly from models in action.
Limitations
Smaller hospitals in multisite trusts were excluded, potentially leading to sample bias. The rapidly changing nature of the models limited the analysis of typology against outcomes.
Conclusions
The case mix of smaller hospitals was dominated by patients with presentations amenable to generalist approaches to care; however, there was no evidence to support any particular pattern of consultant working. Matching hospital staff to better meet local need and the creation of more collaborative working environments appear more likely to improve care in smaller hospitals than changing models.
Future work
The exploration of the relationships between workforce, measures of hospital culture, models of care, costs and outcomes in both smaller and larger hospitals is urgently required to underpin service reforms.
Study registration
This study is registered as Integrated Research Application System project ID 191393.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 4. See the NIHR Journals Library website for further project information.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Anne Marie Rafferty
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King’s College London, London, UK
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Roizenblatt M, Fidalgo TM, Polizelli M, Cruz NFSD, Roizenblatt A, Jiramongkolchai K, Gehlbach PL, Farah ME, Belfort R, Maia M. Effect of chronic cocaine use on fine motor coordination tested during ophthalmic vitreoretinal simulated performance. J Psychiatr Res 2021; 132:7-12. [PMID: 33035762 DOI: 10.1016/j.jpsychires.2020.09.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 09/06/2020] [Accepted: 09/25/2020] [Indexed: 10/23/2022]
Abstract
We conducted a case-control study using the Eyesi simulator to assess the surgical performance of 24 chronic cocaine users (CCUs) and 24 sex-/age-matched controls to numerically quantify ophthalmic microsurgical simulator performance and fine motor deficiencies. The inclusion criteria were no exposure to illicit drugs other than cocaine, marijuana, or alcohol within the previous month and no health conditions that could impact manual task performance. The outcomes included surgical scores (0-100, worst-best) and task completion time (minutes). Fisher's exact test, analysis of variance, Mann-Whitney U test, and Kruskal-Wallis test followed by Dunn-Bonferroni post-hoc were conducted for statistical analysis. The Eyesi scores were lower among CCUs compared to controls for bimanual tasks (4.50 ± 14.30 vs. 18.46 ± 26.64, p = 0.012), for exercises demanding upper and lower limb coordination (both hands and two foot pedals, respectively) (74.13 ± 35.01 vs. 85.21 ± 24.1, p = 0.045), and in the overall score for all three tasks (27.38 ± 15.06 vs. 39.5 ± 18.66, p = 0.021). CCUs took longer to complete tasks when performing exercises demanding upper and lower limb coordination compared to controls (1.26 ± 0.38 vs. 1.02 ± 0.44 min, p = 0.006). Individuals who used cocaine during the previous month had an independent lower bimanual score compared to controls (1.42 ± 4.91 vs. 18.46 ± 26.64, p = 0.018). No differences in performance among the CCUs were attributable to sporadic cannabis or alcohol use. Chronic use of cocaine negatively impacted fine dexterity as measured by bimanual tasks or maneuvers that required simultaneous coordination of the upper and lower limbs. This was most notable among individuals who used cocaine during the 1-month period before the simulation.
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Affiliation(s)
- Marina Roizenblatt
- Department of Ophthalmology, Universidade Federal de São Paulo, 821, Botucatu Street, 1st floor, 04023-062, Administrative Office, São Paulo, Brazil; Vision Institute, IPEPO, Paulista Medical School, 1083, 11 floor, Borges Lagoa Street, 04038-032, Administrative Office, São Paulo, Brazil; Wilmer Eye Institute, Johns Hopkins University, 600 N. Broadway, Maumenee 724, 21287, Baltimore, MD, USA.
| | - Thiago Marques Fidalgo
- Department of Psychiatry, Universidade Federal de São Paulo, 570, Borges Lagoa Street, 04038-000, Administrative Office, São Paulo, Brazil.
| | - Murilo Polizelli
- Department of Ophthalmology, Universidade Federal de São Paulo, 821, Botucatu Street, 1st floor, 04023-062, Administrative Office, São Paulo, Brazil.
| | - Natasha Ferreira Santos da Cruz
- Department of Ophthalmology, Universidade Federal de São Paulo, 821, Botucatu Street, 1st floor, 04023-062, Administrative Office, São Paulo, Brazil.
| | - Arnaldo Roizenblatt
- Department of Ophthalmology, Universidade Federal de São Paulo, 821, Botucatu Street, 1st floor, 04023-062, Administrative Office, São Paulo, Brazil.
| | - Kim Jiramongkolchai
- Wilmer Eye Institute, Johns Hopkins University, 600 N. Broadway, Maumenee 724, 21287, Baltimore, MD, USA.
| | - Peter Louis Gehlbach
- Wilmer Eye Institute, Johns Hopkins University, 600 N. Broadway, Maumenee 724, 21287, Baltimore, MD, USA.
| | - Michel Eid Farah
- Department of Ophthalmology, Universidade Federal de São Paulo, 821, Botucatu Street, 1st floor, 04023-062, Administrative Office, São Paulo, Brazil; Vision Institute, IPEPO, Paulista Medical School, 1083, 11 floor, Borges Lagoa Street, 04038-032, Administrative Office, São Paulo, Brazil.
| | - Rubens Belfort
- Department of Ophthalmology, Universidade Federal de São Paulo, 821, Botucatu Street, 1st floor, 04023-062, Administrative Office, São Paulo, Brazil; Vision Institute, IPEPO, Paulista Medical School, 1083, 11 floor, Borges Lagoa Street, 04038-032, Administrative Office, São Paulo, Brazil.
| | - Mauricio Maia
- Department of Ophthalmology, Universidade Federal de São Paulo, 821, Botucatu Street, 1st floor, 04023-062, Administrative Office, São Paulo, Brazil; Vision Institute, IPEPO, Paulista Medical School, 1083, 11 floor, Borges Lagoa Street, 04038-032, Administrative Office, São Paulo, Brazil.
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Barthélemy EJ, Thango NS, Höhne J, Lippa L, Kolias A, Germano IM. Resilience in the Face of the COVID-19 Pandemic: How to Bend and not Break. World Neurosurg 2020; 146:280-284. [PMID: 33249221 PMCID: PMC7836866 DOI: 10.1016/j.wneu.2020.11.105] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 11/12/2020] [Indexed: 12/24/2022]
Affiliation(s)
- Ernest J Barthélemy
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Nqobile S Thango
- Division of Neurosurgery, Department of Surgery, University of Cape Town, Cape Town, South Africa
| | - Julius Höhne
- Department of Neurosurgery, University Medical Center Regensburg, Regensburg, Germany
| | - Laura Lippa
- Department of Neurosurgery, Ospedali Riuniti, Livorno, Italy
| | - Angelos Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge, United Kingdom; NIHR Global Health Research Group on Neurotrauma, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | | | - Isabelle M Germano
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Pharasi S, Patra S. Burnout in medical students of a tertiary care Indian medical center: How much protection does resilience confer? Indian J Psychiatry 2020; 62:407-412. [PMID: 33165365 PMCID: PMC7597710 DOI: 10.4103/psychiatry.indianjpsychiatry_681_19] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 12/24/2019] [Accepted: 04/10/2020] [Indexed: 01/07/2023] Open
Abstract
CONTEXT Medical profession continues to grapple with burnout; even medical students are not spared of this self-destructive psychological experience. Attempts are being made to control and contain burnout in medical students by the medical fraternity. AIMS We intend to study the prevalence and determinants of burnout in medical students in a tertiary medical center and also to study the relationship of resilience with the experience of burnout. SETTINGS AND DESIGN This was a cross-sectional anonymous survey method. MATERIALS AND METHODS Randomized stratified sampling method was used wherein roll numbers of MBBS students belonging to four different semesters were chosen using randomization software. Based on prevailing prevalence of burnout, sample size calculation was done, and 196 completed questionnaires were included in analysis. The Maslach Burnout Inventory (MBI) and the Resilience Scale for Adults (RSA) were used. Two-dimensional approach toward diagnosing burnout was used. STATISTICAL ANALYSIS Association tests were carried out to analyze the association between means, and Spearman's rho was used to assess the correlation of MBI subscales with RSA subscales. We also used binary logistic regression to assess the relationship of burnout with resilience. RESULTS The prevalence of burnout was 16.84%, and high scores on depersonalization (DP) subscale were seen in males. Personal accomplishment (PA) scores were lower in the fifth and seventh semesters. A statistically significant correlation was observed between MBI and RSA subscales. Binary regression analysis revealed higher resilience scores were significantly associated with decreased likelihood of burnout in emotional exhaustion (odds ratio [OR] = 0.95; 95% confidence interval [CI] = 0.93-0.97), DP (OR = 0.95; 95% CI = 0.93-0.98), and PA (OR = 0.91; 95% CI = 0.84-0.98). CONCLUSIONS Burnout prevalence in our sample lies at the lower range of global prevalence rates. Resilience is protective from burnout.
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Affiliation(s)
| | - Suravi Patra
- Department of Psychiatry, AIIMS, Bhubaneswar, Odisha, India
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Summers SM, Nagy CJ, April MD, Kuiper BW, Rodriguez RG, Jones WS. The Prevalence of Faculty Physician Burnout in Military Graduate Medical Education Training Programs: A Cross-Sectional Study of Academic Physicians in the United States Department of Defense. Mil Med 2019; 184:e522-e530. [DOI: 10.1093/milmed/usz055] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 02/25/2019] [Accepted: 02/28/2019] [Indexed: 11/12/2022] Open
Abstract
Abstract
Introduction
In military populations, physician burnout has potential to adversely affect medical readiness to deploy in support of joint operations. Burnout among Graduate Medical Education (GME) faculty may further threaten the welfare of the medical force given the central role these officers have in training and developing junior physicians. The primary aim of this investigation was to estimate the prevalence of burnout among faculty physicians in United States (US) Army, Navy, and Air Force GME programs.
Materials and Methods
We conducted a cross-sectional study of faculty physicians at US military GME training programs between January 2018 and July 2018. Through direct coordination with Designated Institutional Officials, we administered the Maslach Burnout Inventory Health Services Survey (MBI-HSS) via online web link to faculty physicians listed in Accreditation Data System at each sponsoring institution. In addition to the MBI-HSS, we collected demographic data and queried physicians about common occupational stressors in order to assist institutional leaders with identifying at-risk physicians and developing future interventions to address burnout.
Results
Sixteen of 21 institutions that currently sponsor military GME programs agreed to distribute the MBI-HSS survey to core faculty. We received completed assessments from 622 of the 1,769 (35.1%) reported physician core faculty at these institutions. Of the 622 physician respondents, 162 demonstrated high levels of emotional exhaustion and depersonalization for an estimated 26% prevalence of burnout. We identified only one independent risk factor for burnout: increasing numbers of deployments (OR 1.38, 95% CI 1.07–1.77). Physicians in our cohort who reported a desire to stay beyond their initial active duty service obligation were less likely to be classified with burnout (OR 0.45, 95% CI 0.26–0.77). The most common drivers of occupational distress were cumbersome bureaucratic tasks, insufficient administrative support, and overemphasis on productivity metrics.
Conclusions
We estimate that 26% of physician faculty in military GME programs are experiencing burnout. No specialty, branch of service, or specific demographic was immune to burnout in our sample. Institutional leaders in the MHS should take action to address physician burnout and consider using our prevalence estimate to assess effectiveness of future interventions.
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Affiliation(s)
- Shane M Summers
- San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr., JBSA Fort Sam Houston, TX 78234
| | - Christopher J Nagy
- San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr., JBSA Fort Sam Houston, TX 78234
| | - Michael D April
- San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr., JBSA Fort Sam Houston, TX 78234
| | - Brandon W Kuiper
- San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr., JBSA Fort Sam Houston, TX 78234
| | - Rechell G Rodriguez
- Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814
| | - Woodson S Jones
- University of Texas Health Sciences Center San Antonio, 8300 Floyd Curl Dr, San Antonio, TX 78229
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Clemons M, Mazzarello S, Pond G, Amir E, Asmis T, Berry S, Brackstone M, Brule S, Goodwin R, Hilton JF, Julião M, Nicholas G, Stewart DJ, Wheatley-Price P, Cholmsky L, Krentel A, Hutton B, Joy AA. A prospective intervention to improve happiness and reduce burnout in oncologists. Support Care Cancer 2018; 27:1563-1572. [PMID: 30506102 DOI: 10.1007/s00520-018-4567-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 11/20/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND There is a paucity of data about effective interventions to improve happiness and reduce burnout in oncologists. Benjamin Franklin developed a 13-week program of "necessary activities" or "virtues" (temperance, silence, order, resolution, frugality, industry, sincerity, justice, moderation, cleanliness, tranquility, chastity, and humility) to follow, in his attempt at self-improvement. In this pilot study, we explored whether using a modified version of this was associated with any discernable impact on physician happiness, burnout, or compliance with each of the virtues. METHODS Self-reported happiness (Oxford happiness scores) and burnout (Abbreviated Maslach Burnout Inventory) were completed at baseline (pre-study), week 13, and 1 month after completion of the program. Each day during the 13-week program, oncologists were emailed a list of virtues to focus on and scored how they felt they were complying with them. The oncologist's spouses also assessed how they felt the oncologist was complying with the virtues. RESULTS Thirteen physicians completed the baseline scores, 11 completed Maslach/Oxford scores at the end of the study, and 8 the 1-month post-study assessment. No significant improvements in happiness and burnout (emotional exhaustion, depersonalization, personal accomplishment) scores were observed. Statistically significant changes in self-rated virtue scores were observed for temperance (p = 0.046), order (p = 0.049), and resolution (p = 0.014). Additionally, although not reaching statistical significance, 11 of 13 virtues (excepting sincerity and chastity) assessed by spouses indicated a positive change over time. CONCLUSION In this hypothesis generating study, daily reflection on personal virtues was not associated with any statistically significant change in happiness or burnout scores. Alternative strategies should be considered.
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Affiliation(s)
- Mark Clemons
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and University of Ottawa, 501 Smyth Road, Box 912, Ottawa, ON, K1H 8L6, Canada.
- Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Canada.
| | - Sasha Mazzarello
- Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Canada
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Canada
| | - Gregory Pond
- Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Canada
| | - Eitan Amir
- Princess Margaret Cancer Centre, Toronto, Canada
| | - Timothy Asmis
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and University of Ottawa, 501 Smyth Road, Box 912, Ottawa, ON, K1H 8L6, Canada
- Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Canada
| | - Scott Berry
- Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Canada
| | | | - Stephanie Brule
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and University of Ottawa, 501 Smyth Road, Box 912, Ottawa, ON, K1H 8L6, Canada
| | - Rachel Goodwin
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and University of Ottawa, 501 Smyth Road, Box 912, Ottawa, ON, K1H 8L6, Canada
| | - John F Hilton
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and University of Ottawa, 501 Smyth Road, Box 912, Ottawa, ON, K1H 8L6, Canada
- Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Canada
| | - Miguel Julião
- Equipa Comunitária de Suporte em Cuidados Paliativos ACES Sintra, Sintra, Portugal
| | - Garth Nicholas
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and University of Ottawa, 501 Smyth Road, Box 912, Ottawa, ON, K1H 8L6, Canada
| | - David J Stewart
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and University of Ottawa, 501 Smyth Road, Box 912, Ottawa, ON, K1H 8L6, Canada
- Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Canada
| | - Paul Wheatley-Price
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and University of Ottawa, 501 Smyth Road, Box 912, Ottawa, ON, K1H 8L6, Canada
- Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Canada
| | - Laurel Cholmsky
- Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Canada
| | | | - Brian Hutton
- Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Canada
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Canada
| | - Anil A Joy
- Division of Medical Oncology, Department of Oncology, University of Alberta, Cross Cancer Institute, Edmonton, Canada
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