Informed consent and patient decision making: two decades of research

Exploring the Impact of Education Strategies on Individuals' Attitude Towards Telemental Health Service: Findings from a Survey Experiment Study

While COVID-19 has caused significant mental health consequences, telemental health services have the potential to mitigate this problem. But due to the sensitive nature of mental health issues, such services are seriously underutilized. Based on an integrated variance-process theoretical framework, this study examines the impact of applying different education strategies on individuals' attitude toward telemental health and subsequently their intention to adopt telemental health. Two different education videos on telemental health (peer- or professional-narrated) were developed based on social identity theory. A survey experiment study was conducted at a major historically black university, with 282 student participants randomly assigned to the two education videos. Individual perceptions of the telemental health service (usefulness, ease of use, subjective norms, relative advantage, trust, and stigma) and their attitude and usage intention data were collected. The results show that ease of use, subjective norms, trust, relative advantage, and stigma significantly influence individuals' attitude toward telemental health in the peer-narrated video group. Only trust and relative advantage were found to be significant factors toward attitude in the professional-narrated video group. This study highlights the importance of designing education strategies and builds a theoretical foundation for understanding the nuanced differences in individuals' responsiveness to different educational materials.

Invoking death: How oncologists discuss a deadly outcome

Existing sociological research documents patient and physician reticence to discuss death in the context of a patient's end of life. This study offers a new approach to analyzing how death gets discussed in medical interaction. Using a corpus of 90 video-recorded oncology visits and conversation analytic (CA) methods, this analysis reveals that when existing parameters are expanded to look at mentions of death outside of the end-of-life context, physicians do discuss death with their patients. Specifically, the most frequent way physicians invoke death is in a persuasive context during treatment recommendation discussions. When patients demonstrate active or passive resistance to a recommendation, physicians invoke the possibility of the patient's death to push back against this resistance and lobby for treatment. Occasionally, physicians invoke death in instances where resistance is anticipated but never actualized. Similarly, death invocations function for treatment advocacy. Ultimately, this study concludes that physicians in these data invoke death to leverage their professional authority for particular treatment outcomes.

The consent process: Enabling or disabling patients' active participation?

Standards expected by doctors' regulatory bodies in respect of the process of consent to treatment have arguably sought to restructure the nature of the doctor-patient relationship from one of the paternalism to that of shared decision-making. Yet, few studies have explored empirically, from patients' perspectives, the extent to which the process of consent to treatment enables or disables patients' participation in medical decision-making. Our article examines patients' attitudes towards the consent process, exploring how and why these attitudes influence patients' active participation in decision-making and considering possible consequent medico-legal issues. Data were collected longitudinally using semi-structured interviews and field observations involving 35 patients and 19 of their caregivers, in an English hospital between February and November 2014. These indicate that generally patients defer to the doctor in respect of treatment decision-making. Although most patients and their caregivers wanted detailed information and discussion, they did not necessarily expect that this would be provided. Furthermore, patients perceived that signing the consent form was an obligatory routine principally to protect doctors from legal action should something go wrong. Our study suggests that patients' predominantly paternalistic perceptions of the consent process can not only undermine attempts by doctors to involve them in decision-making but, as patients are now considered in law as informed actors, their perceptions of the consent form as not being in their interests could be a self-fulfilling prophecy if signing is undertaken without due consideration to the content.

Roles for Mental Health Consumers in Self-Help Group Research

This article describes emerging roles of mental health consumers in self-help group research. Examples taken from recent empirical studies of self-help group activities among people with long-term and serious mental health disabilities illustrate new roles that transcend traditional relationships in research. A working typology for these roles include informed participant, key informant, advisor, staff member, and co-investigator as practical additions to the more traditional role of the research subject. Current guidelines for the protection of human subjects in research are limited in their ability to address ethical and procedural issues that arise out of these new role relationships. Self-help group research should address ethical issues that are not currently addressed by the established requirements of informed consent and IRB oversight. The author recommends that consumer review and approval be included as an integral part of the development and evaluation of human subject issues in clinical services research.

Informed Consent: The Politics of Intent and Practice in Medical Research Ethics

Informed consent is a key feature of risk management in medical research. This review outlines the history of the consent requirement and describes its diverse forms through a review of anthropological studies of consent practices. We make a distinction between the politics of intent and the politics of practice to show how the consent requirement has become entrenched in practices through insistence on particular morally sanctioned intentions regardless of whether these intentions are ever realized. We draw attention to the importance of socioeconomic contexts, material practices, and the ethicopolitical dynamics that undergird the resilience of informed consent. We conclude that informed consent has become so ubiquitous thanks to an ability to conjure a stable image of a recognizable and manageable procedure with a particular moral appeal, while simultaneously serving as an empty signifier: an image onto which people can project very different hopes, concerns, and expectations.

Informed Consent: Its History, Meaning, and Present Challenges

The practice of obtaining informed consent has its history in, and gains its meaning from, medicine and biomedical research. Discussions of disclosure and justified nondisclosure have played a significant role throughout the history of medical ethics, but the term “informed consent” emerged only in the 1950s. Serious discussion of the meaning and ethics of informed consent began in medicine, research, law, and philosophy only around 1972.

Informed Consent: The Making of a Ubiquitous Rule in Medical Practice

During the past few decades the rule of informed consent has thoroughly changed everyday decision-making in the healthcare sector. This paper explores the dissemination of informed consent from the perspective of organizational fashion studies. It is argued that this approach can be employed to stimulate renewed reflections on what informed consent procedures do as well as when and how such procedures become endorsed by various organizational actors. A history of the agencies involved in formulating the consent requirement is presented and related to the implications of this new emphasis on the autonomous choice of patients and research participants.

Proposing modesty for informed consent

The extension of informed consent into social science research has met with considerable opposition. The history and concept of informed consent, however, is based on a substantive ethical notion of the research relationship as informed and voluntary that is appropriate for social science research relationships. Yet social science research might sometimes be different from health research in ways that justify a different approach to informed consent and research relationships. Social science research tends to have a lower magnitude of risk, usually does not need to disrupt the therapeutic assumption common in health research contexts or when researchers are health professionals, and recruitment is sometimes incremental and reflects a building of trust and development of the research participant's role. These differences may sometimes justify novel approaches to the research relationship and require case-by-case evaluation to determine their relevance to establishing the informed and voluntary nature of the relationship through the use of informed consent procedures. Ultimately, respect for research participants requires social research into practices that can support or replace informed consent. The institutional role of informed consent and the goal of informed and voluntary research participation serve modest but important roles in health and social research. Their proper role in health and social research requires flexibility and experimentation, but does not justify abdication of informed consent or the notion of informed and voluntary participation.

Optimizing the HIV/AIDS informed consent process in India

BACKGROUND

While the basic ethical issues regarding consent may be universal to all countries, the consent procedures required by international review boards which include detailed scientific and legal information, may not be optimal when administered within certain populations. The time and the technicalities of the process itself intimidate individuals in societies where literacy and awareness about medical and legal rights is low.

METHODS

In this study, we examined pregnant women's understanding of group education and counseling (GEC) about HIV/AIDS provided within an antenatal clinic in Maharashtra, India. We then enhanced the GEC process with the use of culturally appropriate visual aids and assessed the subsequent changes in women's understanding of informed consent issues.

RESULTS

We found the use of visual aids during group counseling sessions increased women's overall understanding of key issues regarding informed consent from 38% to 72%. Moreover, if these same visuals were reinforced during individual counseling, improvements in women's overall comprehension rose to 96%.

CONCLUSIONS

This study demonstrates that complex constructs such as informed consent can be conveyed in populations with little education and within busy government hospital settings, and that the standard model may not be sufficient to ensure true informed consent.

How do women make decisions about hormone replacement therapy?

Although clinicians are often expected to include patients in medical decision making, there is little data to assist clinicians in this process. The objective of this study was to investigate how patients make decisions and the role clinicians can play in this process in the context of how women decide about hormone replacement therapy.Twenty-three women who were deciding whether to take hormone replacement therapy, but who had not begun treatment, were interviewed individually using a semistructured protocol with open-ended questions. The interviews were audiotaped, transcribed, and converted into a database. The transcripts were labeled according to their content, and the database was used to identify common themes. The content of the women's statements were organized into nine descriptive categories. A common set of processes involved in patient decision making was identified and organized into a model of patient decision making. Four areas where clinicians might influence or assist patients in making decisions include the provision of information, the process by which patients selectively pay attention to some information, the patients' perception of their own health, and the patients' development of an explanatory narrative. This new model describes some of the complexity of the patient decision-making process and contributes to our understanding of the clinician's role. To examine its generalizability, the model should be tested on other types of patients making other medical decisions.

Understanding patient preferences for the treatment of lupus nephritis with adaptive conjoint analysis

BACKGROUND

Incorporation of patient preferences into treatment decisions is an essential component of medical care. Conjoint analysis is an established method of eliciting consumer preferences in market research and is being increasingly used to study patient preferences for health care.

OBJECTIVE

To examine the value of Adaptive Conjoint Analysis (ACA), a unique method of performing conjoint analysis, and to evaluate patient treatment preferences.

RESEARCH DESIGN

Interactive computer survey.

SUBJECTS

Consecutive women (n = 103) with lupus followed in three community rheumatology practices.

MEASURES

ACA was used to assess patients' relative preferences for specific cytotoxic medication characteristics, and to estimate the percentage of women preferring cyclophosphamide over azathioprine for different risk-benefit scenarios.

RESULTS

All participants were able to complete the conjoint task in 14 +/-5 minutes. Of the nine medication characteristics studied, efficacy and risk for infection had the greatest impact on preference (each accounting for 20% of the variation in preferences), suggesting that patients consider differences in the risk for infection equally as important as differences in the probability of renal survival. Premenopausal women wanting more children were less likely to choose cyclophosphamide compared with their counterparts (56% vs. 80%, P = 0.04). Modest changes in the probability of renal survival or risk for major toxicity lowered the percentage of women preferring cyclophosphamide by more than 20%, irrespective of their desire for more children.

CONCLUSIONS

ACA is a feasible method of assessing how patients consider specific medication characteristics and predicting treatment preferences under different risk-benefit scenarios. ACA may be a valuable tool to incorporate patient preferences into medical decision-making.

'Let mum have her say': turntaking in doctor-parent-child communication

Recent legislation in the Netherlands requires that children should play a part in decision making regarding their own health care. So far, however, little attention has been given to the child's participation in medical interviews. In order to get a grip on aspects of asymmetry and control in doctor-parent-child communication, the present study explores the turntaking patterns in this triad at the general practitioner's surgery, and makes a comparison over the years. Videotaped observations of 106 medical interviews taken over a period of almost 20 years have been analyzed by means of the Turn Allocation System. The results show that the child's control in the medical consultation is rather limited, though, over the years, the child participates more actively. The child's conversational contribution appears to be strongly related to the age of the child. An important finding is the difference in the way GP and parent accommodate their turntaking patterns to the child; parental control appears to be constant over the years, and is not related to the age of the child, whereas the GP is considering the child's age. The results are discussed in terms of implications for medical practice and health education.

Evaluation of therapeutic strategies: a new method for balancing risk and benefit

OBJECTIVE

A patient-specific drug safety-efficacy index was developed that combined objective clinical trial information about dose-related efficacy and toxicity with subjective perspectives on efficacy-toxicity trades.

METHODS

Patient preferences were systematically assessed using the probability tradeoff technique (PTT). Toxicity ranges over which a drug's efficacy exceeded the patient's minimally acceptable efficacy represented ranges of "surplus efficacy." These can be related to the dose interval in which a drug delivers this surplus efficacy. Seventy surplus efficacy functions (for 7 hypothetical drugs and 10 hypothetical preference curves) were simulated.

RESULTS

The analysis showed that index values change markedly by dose and patient preference, suggesting that different patients will benefit from different drugs depending on the dose prescribed and each patient's subjective assessment of the efficacy/toxicity tradeoff. In most situations, drugs achieve positive surplus efficacy only over limited dose ranges. The model was sensitive to different preference curves and discriminated well among drugs with different efficacy or safety profiles.

CONCLUSION

This index provides a new, systematic approach to choosing a specific therapeutic intervention and dosage, when known risks and benefits are reconciled against patient-specific preferences among an array of therapeutic alternatives.

Medical decision-making and the patient: understanding preference patterns for growth hormone therapy using conjoint analysis

OBJECTIVES

This study examines two questions that relate to patients' role in medical decision making: (1) Do patients utilize multiple attributes in evaluating different treatment options?, and (2) Do patient treatment preferences evidence heterogeneity and disparate patterns? Although research has examined these questions by using either individual- or aggregate-level approaches, the authors demonstrate an intermediate level approach (ie, relating to patient subgroups).

METHODS

The authors utilize growth augmentation therapy (GAT) as a context for analyzing these questions because GAT reflects a class of nonemergency treatments that (1) are based on genetic technology, (2) aim to improve the quality (rather than quantity) of life, and (3) offer useful insights for the patient's role in medical decision making. Using conjoint analysis, a methodology especially suited for the study of patient-consumer preferences but largely unexplored in the medical field, data were obtained from 154 parents for their decision to pursue GAT for their child.

RESULTS

In all, six attributes were utilized to study GAT, including risk of long-term side effects (1:10,000 or 1:100,000), certainty of effect (50% or 100% of cases), amount of effect (1-2 inches or 4-5 inches in adult height), out-of-pocket cost ($100, $2,000, or $10,000/year) and child's attitude (likes or not likes therapy). An experimental design using conjoint analysis procedures revealed five preference patterns that reflect clear disparities in the importance that parents attach to the different attributes of growth therapy. These preference patterns are (1) child-focused (23%), (2) risk-conscious (36%), (3) balanced (23%), (4) cost-conscious (14%), and (5) ease-of-use (4%) oriented. Additional tests provided evidence for the validity of these preference patterns. Finally, this preference heterogeneity related systematically to parental characteristics (eg, demographic, psychologic).

CONCLUSIONS

The study results offer additional insights into medical decision making with the consumer as the focal point and extend previous work that has tended to emphasize either an individual- or aggregate-based analysis. Implications for researchers and health care delivery in general and growth hormone management in particular are provided.

The use of multimedia in the informed consent process

OBJECTIVE

The goal of the project was to create recommendations and design specifications for a multimedia tool to enhance the informed consent process for clinical trials. The authors focused on the needs of patients with potential cognitive impairment.

DESIGN

The authors first performed a needs assessment using focus groups and interviews with health care researchers, institutional review board members, and three groups of patients (who had depression, breast cancer, or schizophrenia). Their feedback was incorporated into the design of a prototype multimedia tool. The design included general modules with information about clinical trials and informed consent as well as trial-specific modules. The authors then used the resulting prototype multimedia tool for informed consent in follow-up focus groups and interviews to obtain feedback on the feasibility and potential effectiveness of using such a tool routinely for clinical trials.

RESULTS

The authors showed that it was feasible to adapt a structured multimedia informed consent system to a specific clinical trial and to incorporate techniques to improve the understandability of informed consent content. Patients generally felt the prototype system was useful and could replace the paper document. They felt using the system would be less stressful, because they would have a greater sense of control and could proceed at their own pace. They liked the hierarchic and modular approach to providing information and felt that the use of video made information more understandable. Researchers and institutional review board members also found the system to be valuable in these ways but had concerns about how to review the system for potential biases in presentation and about the legal issues associated with replacing the paper document.

Informed consent: ideal or reality?

Is it ever possible to give informed consent to treatment or research? Are the standards of consent set by ethicists and lawyers too high for ordinary people to reach? Should these standards be abandoned or modified? These questions are discussed in this paper mainly in relation to the extensive literature on consent in medicine, with examples about consent to children's treatment and research which raise extra dilemmas. Paradoxical meanings are considered: consent as an informed correct choice or a courageous best guess, and autonomy as isolated, uncompromised freedom or reasonably uncoerced self-realisation. Beyond being informed, consent involves evaluating, making and signifying a decision. It is better understood as a process than an event, in which reasoned understandings can be complemented by emotional insights. Ethical and legal standards of voluntary consent, although partly an unrealistic ideal, provide important guidelines for people who request and give consent to research.

Resist and redirect: physicians respond to breast cancer informed consent legislation

During the 1980s, former breast cancer patients initiated efforts to introduce Breast Cancer Informed Consent legislation in twenty-two state legislatures. Their general intent in proposing this legislation was to insure that women patients were included in the decision-making process regarding their breast cancer treatment. A qualitative analysis of the reactions of medical professional organizations to these efforts revealed a pattern of change over time. Because professionals were not aware of early efforts for Breast Cancer Informed Consent, these met little or no resistance. Subsequent efforts in the early 1980s were met with organized resistance; physicians' organizations responded to the legislation as if it were a threat to their professional autonomy. By the middle of the decade, professionals had co-opted the efforts, shaping the legislation to their benefit. The challenge to physician authority that former breast cancer patients mounted had mixed results, but ultimately illustrated that professions are quite effective at retaining power.

Patient education for the millennium: beyond control and emancipation?

This paper reports on a study carried out in Nottinghamshire, UK, which focused upon patient education for low back pain in general (family) practice. This study found that patient education could not be viewed simply as either a repressive social control mechanism or as a vehicle for patient empowerment and social change. The paper suggests that a new theoretical and practical orientation to patient education is required which transcends binary categorizations. The existing control/empowerment dichotomy offers a persuasive, yet restrictive conceptualization of patient education which has created rival camps of theoreticians and practitioners intent on demonizing each other. In the light of presented findings, the study suggests a new trajectory for patient education focusing on local possibilities for change.

Informed consent in clinical trials

A review is provided in this paper on the empirical literature on informed consent from 1979 to 1995 referring to information disclosure and trial participation in clinical trials. Articles being reviewed focus upon information disclosure, reactions to disclosure and recall, features of consent and perceptions of informed consent, both in hypothetical and in real life situations. It is concluded that further research is needed to study the process of informed consent in clinical trials, to obtain a better insight into the myth and reality of informed consent in daily practice. Future studies should come forward on the limitations of previous empirical research on informed consent. Additional research should focus on the perspectives of patients who accept or decline trial participation.

Parental perceptions and attitudes about informed consent in clinical research involving children

We interviewed 64 parents by questionnaire after completion of a clinical trial involving their children for their perceptions and attitudes about informed consent. The results show that only a small minority realized that drug trials are designed to assess not only efficacy but safety as well. More worrisome was the majority of parents who felt that drug trials conducted by hospitals are of no or low risks. Moreover, a significant minority offered the view that the strict informed consent procedures we followed were unnecessary because they would do what the doctor advised. Even more worrisome was the small percentage of parents who realized that a signed consent form was primarily meant to protect their rights, and only one-third of the parents knew of their right to withdraw their child unconditionally from the trial at any time. These findings suggest that there may be significant attitudinal barriers to parental understanding of the informed consent process.

Parental perceptions and attitudes about informed consent in clinical research involving children

We interviewed 64 parents by questionnaire after completion of a clinical trial involving their children for their perceptions and attitudes about informed consent. The results show that only a small minority realised that drug trials are designed to assess not only efficacy but safety as well. More worrisome was the majority of parents who felt that drug trials conducted by hospitals are of no or low risks. Moreover, a significant minority offered the view that the strict informed consent procedures we followed were unnecessary because they would do what the doctor advised. Even more worrisome was the small percentage of parents who realised that a signed consent form was primarily meant to protect their rights, and only one-third of the parents knew of their right to withdraw their child unconditionally from the trial at any time. These findings suggest that there may be significant attitudinal barriers to parental understanding of the informed consent process.

Presenting clinical trial information: a comparison of methods

The study objective was to assess the relative effects of 2 approaches to teaching about a clinical trial, in terms of patients' satisfaction, information understanding, and whether or not they would enter such a trial. One hundred patients receiving radiation therapy for a variety of cancer diagnoses were randomized to receive information about a hypothetical trial, either by audio tape or interactive computer program. A day later, information understanding was assessed. One week later, method satisfaction and whether respondents would enter such a trial were assessed. There were no differences in understanding or satisfaction. Members of the computer program group tended to report a more positive attitude towards trial entry (chi 2 = 4.0; 1 df; P = 0.05). Overall, refusers tended to be women with higher understanding scores. The results suggest that teaching with interactive components might not adversely affect trial accrual. Further work involving an actual trial entry decision is merited; the sex of the respondent should be controlled in designing this future work.

Social pharmacology: unresolved critical issues

This article describes and analyzes decision-making by patients, physicians, and drug information providers about registered medical drugs. Based on a cognitive psychology perspective, cognitive variables (the individual's mediating system) are assumed to be critical factors determining both patient and physician behavior. The individual's psychological functioning is seen as a continuous reciprocal interaction between behavioral, cognitive, and environmental influences; i.e., an interactional paradigm is applied. The importance of research models including cognitive and situation variables to guide the search for appropriate research methods is stressed. An intensive research strategy with a small sample of respondents will often be necessary. Also, respondents should be asked to describe their reactions to specific medical situations. The drug information sender has to select a set of goals for disseminating information to patients. Among the goals most often selected are: message comprehension, receiver satisfaction, changes in knowledge, attitudes, and drug behavior, as well as health effects. More research is needed on how the patient's mediating system, the actual situation, and the perceived situation steer his search for the use of new drug information. A different set of factors influence the patient's decision to start a medicinal or drug treatment than the factors that influence his decision to continue a treatment. The latter factors include forgetfulness, misunderstandings, and the patient's interpretation of physiological signs. More cognitive-oriented research about drug compliance must be undertaken. In such studies the mediating systems of a group of patients could be considered before and after intervention. There are a great number of types of inappropriate (irrational) prescribing. However, a physician may prescribe rationally in one area but irrationally in another. Face-to-face education of physicians has been shown to be effective in reducing inappropriate prescribing in a number of studies. "Overprescribing" of benzodiazepine has been an issue of intensive professional debate during the last decades. The two groups who criticize and defend the existing use of benzodiazepines build their views on different assumptions about the interaction between mind and brain as well as making different value assumptions regarding the use of a psychotropic drug. There is a need for prescription studies where a cognitive and interactional perspective is combined with an information-processing and a normative perspective. The benzodiazepines dependency problem has provoked lively discussion among professionals and the general public. Long-term benzodiazepine use and personality disorders increase the risk of the patient becoming dependent. A great number of research models have been suggested for the analysis of prescription drug dependency and as guides to the treatment of dependency.(ABSTRACT TRUNCATED AT 400 WORDS)

Practical problems of conducting patient-satisfaction surveys

OBJECTIVE

Patient-satisfaction surveys have been used frequently to assess the humanistic behaviors and skills of internal medicine housestaff. In conducting their first such survey, the authors found that many practical problems affected the progress and outcome of the project. This discussion of the authors' experiences is intended to be helpful to others considering patient-satisfaction surveys as part of their housestaff-evaluation process.

DESIGN

A description of the practical aspects of conducting a patient-satisfaction survey as well as the problems that the authors encountered.

SETTING

Both inpatient and outpatient settings at a major university internal medicine residency program.

PATIENTS/PARTICIPANTS

Ambulatory and hospitalized patients under the care of categorical internal medicine interns were eligible for participation in the study.

INTERVENTIONS

An established, validated patient-satisfaction questionnaire with high reported reliability was given to patients.

MEASUREMENTS AND MAIN RESULTS

Although well over 90% of patients were willing to participate, 10% of participating outpatients and 16% of participating hospital patients could not provide a usable patient-satisfaction questionnaire even with assistance. Certain patient characteristics were responsible for these decreased completion rates. Among the hospitalized patients, 42% of all eligible patients were either too ill or too cognitively impaired to even be approached for participation in the study.

CONCLUSIONS

Patient-satisfaction surveys are labor-intensive, require significant resources, and are temporally demanding. Results from them must be viewed with certain caveats.

Patients' willingness to enter clinical trials: measuring the association with perceived benefit and preference for decision participation

Patients who agree and those who refuse clinical trial entry may differ in attitudes towards decision control and the benefits associated with the trial arms. These differences, if they exist, have implications for the process of obtaining informed consent and for the generalization of the results of a clinical trial. This paper describes the development and initial application of methods designed to detect such differences. Developmental work involved creating an inventory of instruments designed to determine patients' attitudes towards participating in treatment decision making, permitting random selection of treatment, and undertaking the risks and benefits associated with the various treatments in a trial. Initial application involved modifying these instruments in terms of an actual chemotherapeutic trial for colonic adenocarcinoma, seeking responses to these measures from 60 non-eligible colorectal cancer patients, then determining whether those who would agree to trial entry differed systematically on these measures from those who indicated that they would refuse such a trial. Twenty-five of the respondents reported that, if faced with the actual decision, they would agree to trial entry: 35 would refuse. Refusers demanded more participation in decision making (Chi-square; P = 0.01) and a greater increment in treatment benefit (t-test; P = 0.0001). Twenty-two of the 35 refusers reported aversion to randomization as their primary reason for trial refusal. Since their particular content can be modified, these measures may be applicable to all clinical trials. They could be used to study the reasons patients accept or refuse trial entry and to determine if agreer-refuser attitude differences undermine the generalizability of a trials results.

Overconfidence among physicians and nurses: the 'micro-certainty, macro-uncertainty' phenomenon

Overconfidence in clinicians was examined in two independently designed studies, each using a different research approach. The first study examined treatment choices of physicians in treating breast cancer, and the second rapid decision making among nurses working in Intensive Care Units. In both studies, individual respondents were highly confident they had made the right choice ('micro-certainty'), although there was no consensus across respondents as to what the optimal treatment would be ('macro-uncertainty'). The difference between micro-certainty of individuals and macro-uncertainty within the clinical community may cast some light on the persistence of practice variation. The implications of overconfidence in clinical treatment for patients, practitioners, and professional regulation are discussed.

Consent in medical decision making: the role of communication

Informed participation in medical decisions is important because it demonstrates respect for the ethical principle of individual autonomy and increases the likelihood of reaching therapeutic goals. Twenty hospitalized patients were randomly selected and observed for six and a half hours to assess the degree to which informed participation was possible with diagnostic and therapeutic procedures. Resident physicians and patients were then interviewed about the rationale, benefit, risk, and alternative for each observed procedure. Commonly observed activities were injecting and giving oral medications, and performing invasive diagnostic procedures. Clinicians' communication involved rationale (43%) more often than benefits (34%), risks (14%), and alternatives (12%). Communication was similar when the procedures proposed were important and risky. Residents' and patients' interviews demonstrated limited congruence in shared understanding of rationale (57%), benefit (45%), risk (19%), and alternatives (25%). These results suggest that clinicians selectively impart information essential for informed patient participation, and highlight areas of clinician-patient communication in need of attention.

The activated patient: dogma, dream, or desideratum?

In this paper we critically review the active patient concept and place it in a broader social and historical context. We argue that as a reflection of core, Western European values, the active patient concept has not been adequately scrutinized. Very little research has been done that explicitly tests the claims that have been advanced on behalf of this ideal model of the clinician-patient relationship. The research that is available is far from definitive and does not support many of the assertions made by advocates of this approach to patienthood. We urge investigators to substitute theory driven research programs for those motivated by advocacy of a particular ideological stance.