1
|
Shen L, Wang T, Yin J, Sun Q, Dyar OJ. Clinical Uncertainty Influences Antibiotic Prescribing for Upper Respiratory Tract Infections: A Qualitative Study of Township Hospital Physicians and Village Doctors in Rural Shandong Province, China. Antibiotics (Basel) 2023; 12:1027. [PMID: 37370346 DOI: 10.3390/antibiotics12061027] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/21/2023] [Accepted: 06/06/2023] [Indexed: 06/29/2023] Open
Abstract
OBJECTIVE This study aimed to explore how clinical uncertainty influences antibiotic prescribing practices among township hospital physicians and village doctors in rural Shandong Province, China. METHODS Qualitative semi-structured interviews were conducted with 30 township hospital physicians and 6 village doctors from rural Shandong Province, China. A multi-stage random sampling method was used to identify respondents. Conceptual content analysis together with Colaizzi's method were used to generate qualitative codes and identify themes. RESULTS Three final thematic categories emerged during the data analysis: (1) Incidence and treatment of Upper Respiratory Tract Infections (URTIs) in township hospitals and village clinics; (2) Antibiotic prescribing practices based on the clinical experience of clinicians; (3) Influence of clinical uncertainty on antibiotic prescribing. Respondents from both township hospitals and village clinics reported that URTIs were the most common reason for antibiotic prescriptions at their facilities and that clinical uncertainty appears to be an important driver for the overuse of antibiotics for URTIs. Clinical uncertainty was primarily due to: (1) Diagnostic uncertainty (establishing a relevant diagnosis is hindered by limited diagnostic resources and capacities, as well as limited willingness of patients to pay for investigations), and (2) Insufficient prognostic evidence. As a consequence of the clinical uncertainty caused by both diagnostic and prognostic uncertainty, respondents stated that antibiotics are frequently prescribed for URTIs to prevent both prolonged courses or recurrence of the disease, as well as clinical worsening, hospital admission, or complications. CONCLUSION Our study suggests that clinical uncertainty is a key driver for the overuse and misuse of prescribing antibiotics for URTIs in both rural township hospitals and village clinics in Shandong province, China, and that interventions to reduce clinical uncertainty may help minimize the unnecessary use of antibiotics in these settings. Interventions that use clinical rules to identify patients at low risk of complications or hospitalization may be more feasible in the near-future than laboratory-based interventions aimed at reducing diagnostic uncertainty.
Collapse
Affiliation(s)
- Liyan Shen
- Center for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan 250012, China
- NHC Key Lab of Health Economics and Policy Research (Shandong University), Jinan 250012, China
| | - Ting Wang
- Center for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan 250012, China
- NHC Key Lab of Health Economics and Policy Research (Shandong University), Jinan 250012, China
| | - Jia Yin
- Center for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan 250012, China
- NHC Key Lab of Health Economics and Policy Research (Shandong University), Jinan 250012, China
| | - Qiang Sun
- Center for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan 250012, China
- NHC Key Lab of Health Economics and Policy Research (Shandong University), Jinan 250012, China
| | - Oliver James Dyar
- Department of Public Health and Caring Sciences, Uppsala University, 75122 Uppsala, Sweden
| |
Collapse
|
2
|
Cusatis R, Litovich C, Spellecy R, Liang A, D'Souza A. Navigating the perils and pitfalls throughout the consent process in hematopoietic cell transplantation. Blood Rev 2023; 59:101037. [PMID: 36577602 PMCID: PMC10548336 DOI: 10.1016/j.blre.2022.101037] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 11/29/2022] [Accepted: 12/15/2022] [Indexed: 12/25/2022]
Abstract
Hematopoietic cell transplantation (HCT) is a complex treatment used in malignancies and some non-malignant diseases. The informed consent process for HCT can also be complex due to patient- and process-related barriers. The informed consent process needs to be a dynamic and ongoing process, not simply a checklist. As a result of the realities of HCT, we highlight some potential pitfalls to the informed consent process including uncertainty, sociocultural and communication barriers, and decisional regret. The purpose of this comprehensive review is to highlight unique situations which can result in failure of the informed consent process. We also offer potential solutions to these pitfalls, primarily making the informed consent more patient focused through dynamic and continuous processes to mitigate decisional regret.
Collapse
Affiliation(s)
- Rachel Cusatis
- Center for International Blood & Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, United States of America.
| | - Carlos Litovich
- Center for International Blood & Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, United States of America
| | - Ryan Spellecy
- Center for Bioethics and Medical Humanities, Medical College of Wisconsin, United States of America
| | - Andrew Liang
- Student-centered Program to Advance Research in Cancer Careers (SPARCC) Program, Department of Obstetrics & Gynecology, Medical College of Wisconsin, United States of America; Molecular Cell Developmental Biology, University of California, Los Angeles, United States of America
| | - Anita D'Souza
- Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, United States of America.
| |
Collapse
|
3
|
Moulder G, Harris E, Santhosh L. Teaching the science of uncertainty. Diagnosis (Berl) 2023; 10:13-18. [PMID: 36087299 DOI: 10.1515/dx-2022-0045] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 08/16/2022] [Indexed: 11/15/2022]
Abstract
As we increasingly acknowledge the ubiquitous nature of uncertainty in clinical practice (Meyer AN, Giardina TD, Khawaja L, Singh H. Patient and clinician experiences of uncertainty in the diagnostic process: current understanding and future directions. Patient Educ Counsel 2021;104:2606-15; Han PK, Klein WM, Arora NK. Varieties of uncertainty in health care: a conceptual taxonomy. Med Decis Making 2011;31:828-38) and strive to better define this entity (Lee C, Hall K, Anakin M, Pinnock R. Towards a new understanding of uncertainty in medical education. J Eval Clin Pract 2020; Bhise V, Rajan SS, Sittig DF, Morgan RO, Chaudhary P, Singh H. Defining and measuring diagnostic uncertainty in medicine: a systematic review. J Gen Intern Med 2018;33:103-15), as educators we should also design, implement, and evaluate curricula addressing clinical uncertainty. Although frequently encountered, uncertainty is often implicitly referred to rather than explicitly discussed (Gärtner J, Berberat PO, Kadmon M, Harendza S. Implicit expression of uncertainty - suggestion of an empirically derived framework. BMC Med Educ 2020;20:83). Increasing explicit discussion of - and comfort with -uncertainty has the potential to improve diagnostic reasoning and accuracy and improve patient care (Dunlop M, Schwartzstein RM. Reducing diagnostic error in the intensive care unit. Engaging. Uncertainty when teaching clinical reasoning. Scholar;1:364-71). Discussion of both diagnostic and prognostic uncertainty with patients is central to shared decision-making in many contexts as well, (Simpkin AL, Armstrong KA. Communicating uncertainty: a narrative review and framework for future research. J Gen Intern Med 2019;34:2586-91) from the outpatient setting to the inpatient setting, and from undergraduate medical education (UME) trainees to graduate medical education (GME) trainees. In this article, we will explore the current status of how the science of uncertainty is taught from the UME curriculum to the GME curriculum, and describe strategies how uncertainty can be explicitly discussed for all levels of trainees.
Collapse
Affiliation(s)
- Glenn Moulder
- Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Emily Harris
- Department of Medicine, University of California-San Francisco, San Francisco, CA, USA
| | - Lekshmi Santhosh
- Department of Medicine, University of California-San Francisco, San Francisco, CA, USA
| |
Collapse
|
4
|
Rodríguez-Arbolí E, Othus M, Orvain C, Zarling LC, Sandmaier BM, Milano F, Schoch G, Davis C, Deeg HJ, Appelbaum FR, Storb R, Walter RB. Contribution of measurable residual disease status to prediction accuracy of relapse and survival in adults with acute myeloid leukemia undergoing allogeneic hematopoietic cell transplantation. Haematologica 2023; 108:273-277. [PMID: 36134457 PMCID: PMC9827162 DOI: 10.3324/haematol.2022.281631] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 09/14/2022] [Indexed: 02/05/2023] Open
Affiliation(s)
- Eduardo Rodríguez-Arbolí
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA; Department of Hematology, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla (IBIS/CSIC/CIBERONC), University of Seville, Seville
| | - Megan Othus
- Public Health Science Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Corentin Orvain
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Lucas C Zarling
- Department of Medicine, Residency Program, University of Washington, Seattle, WA
| | - Brenda M Sandmaier
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA; Department of Medicine, Division of Medical Oncology, University of Washington, Seattle, WA
| | - Filippo Milano
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA; Department of Medicine, Division of Medical Oncology, University of Washington, Seattle, WA
| | - Gary Schoch
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Chris Davis
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - H Joachim Deeg
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA; Department of Medicine, Division of Medical Oncology, University of Washington, Seattle, WA
| | - Frederick R Appelbaum
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA; Department of Medicine, Division of Medical Oncology, University of Washington, Seattle, WA
| | - Rainer Storb
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA; Department of Medicine, Division of Medical Oncology, University of Washington, Seattle, WA
| | - Roland B Walter
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA; Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA; Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA.
| |
Collapse
|
5
|
Bigdeli S, Baradaran HR, Ghanavati S, Soltani Arabshahi SK. A qualitative approach to identify clinical uncertainty in practicing physicians and clinical residents. JOURNAL OF EDUCATION AND HEALTH PROMOTION 2022; 11:278. [PMID: 36325214 PMCID: PMC9621374 DOI: 10.4103/jehp.jehp_14_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 02/21/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Clinical decision-making is not only stressful to physicians, but also to patients and even their companions. Thus, managing uncertainty in clinical decision-making is essential which requires knowing its origins. Therefore, this study aimed to understand determinants of uncertainty in clinical decision-making from the perspective of clinical physicians. MATERIALS AND METHODS This is a qualitative study which is done during October to November 2020. An in-depth interview is performed with 24 specialists of clinical groups including obstetrics, surgery, internal medicine, and pediatrics, working in teaching hospitals affiliated to Iran University of Medical Sciences. All the interviews were recorded, transcribed and analyzed according to the steps suggested by Graneheim and Lundman. The interviews were analyzed through comparative method. Then, the interviewer created initial codes, categories, and key concepts and sent them to fourteen physicians for member check. RESULTS According to the participants' view, determinants of uncertainty in clinical decision-making consisted of three themes: individual determinants, dynamics of medical sciences, and diagnostic and instrumental constraint. Individual determinants can be related to the physician or patient. The dynamics of medical sciences could be explained in two categories: variation of medical science and complexity. Diagnostic and instrumental constraint category could be also explained in subcategories such as lack of efficient diagnostic tests and unknown etiology. CONCLUSION To curb uncertainty, the more accessible way is considering interventional programs with a focus on individual determinants related to physicians, such as strengthening doctor-patient relationships, and considering related mandatory retraining courses to reduce insufficient knowledge of physicians.
Collapse
Affiliation(s)
- Shoaleh Bigdeli
- Center for Educational Research in Medical Sciences, Department of Medical Education, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Hamid Reza Baradaran
- Center for Educational Research in Medical Sciences, Department of Medical Education, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Shirin Ghanavati
- Center for Educational Research in Medical Sciences, Department of Medical Education, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Seyed Kamran Soltani Arabshahi
- Center for Educational Research in Medical Sciences, Department of Medical Education, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
6
|
Ghanavati S, Baradaran HR, Kamran Soltani Arabshahi S, Bigdeli S. Developing and validating of the Clinical Uncertainty Measurement Questionnaire (CUMQ) among practicing physicians and clinical residents in Iran. BMC MEDICAL EDUCATION 2022; 22:462. [PMID: 35710546 PMCID: PMC9202180 DOI: 10.1186/s12909-022-03444-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 05/11/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Despite the fact that clinicians face uncertainty in their decisions, there is no comprehensive framework to measure it in medical practices which is the knowledge gap especially for Iran. Therefore, this study aimed to evaluate the reliability and validity of a Persian questionnaire which is designed to measure different determining aspects of uncertainty from clinical physicians' perspectives in Iran. METHODS Clinical Uncertainty Measurement Questionnaire (CUMQ) has been derived from a mixed method study since March 2019 to January 2021. To exclude raw items of the questionnaire, the literature was reviewed and in-depthinterviews were implemented with 24 residents,specialists and sub-specialists in all major clinical fields which resulted in the first theoretical uncertainty in clinical decision making framework. CUMQ content validity has been evaluated using content validity index (CVI) and content validity ratio (CVR). The structural validity of the questionnaire was assessed using confirmatory factor analysis and factor loading and t-value for each indicator of uncertainty is reported. Moreover, to analyze the research model we used the Partial Least Squares (PLS) technique using the SmartPLS software. Convergent (using Average Variance Extracted (AVEs) for each latent variable) and discriminant validity (using the criteria of Fornell and Larckerand cross loading) of the model was also evaluated. After that, the quality of the model was evaluated adjustment through predictive validity (Q2) and effect size (f2). In addition, the reliability was also assessed using Cronbach's alpha and composite reliability. RESULTS The CVR and CVI ranged from 0. 80 to 1. 00 which illustrates high content validity. Out of 30 items, 24 items had acceptable factor loading and remained in the questionnaire which have been categorized as five main clinical uncertainty dimensions; general determinants, individual determinants of the physician, individual determinants of patient, dynamics of medical sciences, diagnostic and instrumental limitations. The value of composite reliability and Cronbach's alpha for all dimensions were above the threshold value of 0. 7 and the reliability has been confirmed. As AVE values were greater than 0. 5, convergent validity is confirmed. The result of Fornell-Larcker and cross-loadings also indicated that discriminant validity is well established. CONCLUSION This CUMQ is as avalid and reliable instrument and a suitable tool to measure clinical uncertainty in the Iranian Medical community. However, the reliability of this questionnaire can be studied in other languages and in other countries.
Collapse
Affiliation(s)
- Shirin Ghanavati
- Center for Educational Research in Medical Sciences (CERMS), Department of Medical Education, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Hamid Reza Baradaran
- Center for Educational Research in Medical Sciences (CERMS), Department of Medical Education, School of Medicine, Iran University of Medical Sciences, Tehran, Iran.
| | - Seyed Kamran Soltani Arabshahi
- Center for Educational Research in Medical Sciences (CERMS), Department of Medical Education, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Shoaleh Bigdeli
- Center for Educational Research in Medical Sciences (CERMS), Department of Medical Education, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
7
|
Karboub K, Tabaa M. A Machine Learning Based Discharge Prediction of Cardiovascular Diseases Patients in Intensive Care Units. Healthcare (Basel) 2022; 10:healthcare10060966. [PMID: 35742018 PMCID: PMC9222879 DOI: 10.3390/healthcare10060966] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 05/03/2022] [Accepted: 05/09/2022] [Indexed: 01/12/2023] Open
Abstract
This paper targets a major challenge of how to effectively allocate medical resources in intensive care units (ICUs). We trained multiple regression models using the Medical Information Mart for Intensive Care III (MIMIC III) database recorded in the period between 2001 and 2012. The training and validation dataset included pneumonia, sepsis, congestive heart failure, hypotension, chest pain, coronary artery disease, fever, respiratory failure, acute coronary syndrome, shortness of breath, seizure and transient ischemic attack, and aortic stenosis patients’ recorded data. Then we tested the models on the unseen data of patients diagnosed with coronary artery disease, congestive heart failure or acute coronary syndrome. We included the admission characteristics, clinical prescriptions, physiological measurements, and discharge characteristics of those patients. We assessed the models’ performance using mean residuals and running times as metrics. We ran multiple experiments to study the data partition’s impact on the learning phase. The total running time of our best-evaluated model is 123,450.9 mS. The best model gives an average accuracy of 98%, highlighting the location of discharge, initial diagnosis, location of admission, drug therapy, length of stay and internal transfers as the most influencing patterns to decide a patient’s readiness for discharge.
Collapse
Affiliation(s)
- Kaouter Karboub
- FRDISI, Hassan II University Casablanca, Casablanca 20000, Morocco
- LRI-EAS, ENSEM, Hassan II University Casablanca, Casablanca 20000, Morocco
- LGIPM, Lorraine University, 57000 Metz, France
- Correspondence: (K.K.); (M.T.); Tel.: +212-661-943-174 (M.T.)
| | - Mohamed Tabaa
- LPRI, EMSI, Casablanca 23300, Morocco
- Correspondence: (K.K.); (M.T.); Tel.: +212-661-943-174 (M.T.)
| |
Collapse
|
8
|
Negarandeh R, Khoobi M, Ahmadihedayat M, Marks D. Critical care nurses' experiences on dishonesty: A qualitative content analysis. Nurs Ethics 2022; 29:1209-1219. [PMID: 35505630 DOI: 10.1177/09697330211020422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Providing information to patients is an essential aspect of care. The way in which such information is transmitted is also important and is affected by different variables. The perceptions of dishonest nursing staff have not been sufficiently discussed to date. AIM The purpose is to explore the reasons for dishonesty in transmitting information to patients. DESIGN AND METHOD In this qualitative content analysis study, data were collected using semi-structured interviews with Twelve Iranian Critical Care Nurses from January 2020 till August 2020. Data were analyzed according to Graneheim and Lundman approach. ETHICAL CONSIDERATION The research protocol was authorized by the Ethics Committee of the Medical Sciences University of Tehran (Register number: 95-04-99-33485). RESULTS The findings indicated that dishonesty in giving information to the patients has many reasons. Although lying is not compatible with ethical care, working conditions sometimes forced nurses to hide the truth. DISCUSSION AND CONCLUSION Nurses believed honesty was an integral aspect of professional practice, but situational specifics have an effect on whether the truth is told or withheld. Finally, the nurses noticed a big gap between what they want to tell and what they were doing in practice.
Collapse
Affiliation(s)
- Reza Negarandeh
- Tehran University of Medical Sciences, Iran; Nursing & Midwifery Care Research Center, Tehran university of Medical Sciences, Iran
| | - Mitra Khoobi
- Faculty of Medical Sciences, Tarbiat Modares University, Iran
| | - Majid Ahmadihedayat
- Applied Sciences University; Ebn-e Sina Apllied and Science and Technology Institute; Ebn-e-Sina Hospital, Iran
| | | |
Collapse
|
9
|
Deeg HJ. Not all patients with AML over 60 years of age should be offered early allogeneic stem cell transplantation. Blood Adv 2022; 6:1623-1627. [PMID: 34607346 PMCID: PMC8905709 DOI: 10.1182/bloodadvances.2021004799] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- H. Joachim Deeg
- Fred Hutchinson Cancer Research Center and the University of Washington School of Medicine, Seattle, WA
| |
Collapse
|
10
|
Bartley N, Best MC, Biesecker BB, Fisher A, Goldstein D, Meiser B, Thomas DM, Ballinger ML, Butow P. Effectively communicating comprehensive tumor genomic profiling results: Mitigating uncertainty for advanced cancer patients. PATIENT EDUCATION AND COUNSELING 2022; 105:452-459. [PMID: 34016496 DOI: 10.1016/j.pec.2021.05.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/07/2021] [Accepted: 05/11/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To understand advanced cancer patients' experience of uncertainty when receiving comprehensive tumor genomic profiling (CTGP) results, and their perceptions of how healthcare provider (HCP) communication impacts uncertainty. METHODS Thirty-seven semi-structured interviews with advanced cancer patients were conducted within two weeks of patients receiving CTGP results. Transcripts were thematically analyzed, using an inductive approach. RESULTS We identified three themes that illustrate patient experience of uncertainties when receiving CTGP results: 1. Type and degree of uncertainty fluctuates along with changing illness circumstances and the nature of the CTGP results; 2. HCPs' co-ordination of care and communication shapes uncertainty, with immediate, clearer and simpler information promoting certainty; and 3. Patients felt that communicating results to reduce relatives' uncertainty is important, with patients choosing the time and process for achieving this and desiring HCPs support. CONCLUSION Oncology patients are confronted with an array of uncertainties. Clear, simple communication from HCPs about results and their implications, and support to manage uncertainty, will be of benefit. PRACTICE IMPLICATIONS If CTGP is to become routine clinical practice, clear communication will be crucial in reducing uncertainty. Awareness of potential uncertainties experienced by patients when receiving results, will assist HCPs to address uncertainties, reduce uncertainty where possible, and offer targeted support to patients struggling with uncertainty.
Collapse
Affiliation(s)
- Nicci Bartley
- School of Psychology, The University of Sydney, Sydney, Australia.
| | - Megan C Best
- School of Psychology, The University of Sydney, Sydney, Australia; Institute of Ethics and Society, The University of Notre Dame, Sydney, Australia.
| | | | - Alana Fisher
- School of Psychology, The University of Sydney, Sydney, Australia.
| | - David Goldstein
- Prince of Wales Clinical School, University of NSW, Sydney, Australia.
| | - Bettina Meiser
- Psychosocial Research Group, Prince of Wales Clinical School, University of NSW, Sydney, Australia.
| | - David M Thomas
- Cancer Theme, Garvan Institute of Medical Research, Sydney, Australia; St Vincent's Clinical School, University of NSW, Sydney, Australia.
| | - Mandy L Ballinger
- Cancer Theme, Garvan Institute of Medical Research, Sydney, Australia; St Vincent's Clinical School, University of NSW, Sydney, Australia.
| | - Phyllis Butow
- School of Psychology, The University of Sydney, Sydney, Australia.
| |
Collapse
|
11
|
Brotzman LE, Crookes DM, Austin JD, Neugut AI, Shelton RC. Patient perspectives on treatment decision-making under clinical uncertainty: chemotherapy treatment decisions among stage II colon cancer patients. Transl Behav Med 2021; 11:1905-1914. [PMID: 34042154 PMCID: PMC8541697 DOI: 10.1093/tbm/ibab040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The decision to use adjuvant chemotherapy (ACT) after surgical resection for stage II colon cancer remains an area of clinical uncertainty. Many patients diagnosed with stage II colon cancer receive ACT, despite inconclusive evidence of long-term clinical benefit. This study investigates patient experiences and perceptions of treatment decision-making and shared decision making (SDM) for ACT among patients diagnosed with stage II colon cancer. Stage II colon cancer patients engaged in treatment or follow-up care aged >18 years were recruited from two large NYC health systems. Patients participated in 30-60-min semi-structured interviews. All interviews were transcribed, translated, coded, and analyzed using a thematic analysis approach. We interviewed 31 patients, of which 42% received ACT. Overall, patient perspectives indicate provider inconsistency in communicating ACT harms, benefits, and uncertainties, and poor elicitation of patient preferences and values. Patients reported varying perceptions and understanding of personal risk and clinical benefits of ACT. For many patients, receiving a clear treatment recommendation from the provider limited their participation in the decision-making process, whether it aligned with their decisional support preferences or not. Findings advance understanding of perceived roles and preferences of patients in SDM processes for cancer treatment under heightened clinical uncertainty, and indicate a notable gap in understanding for decisions made using SDM models in the context of clinical uncertainty. Educational and communication strategies and training are needed to support providers in communicating uncertainty, risk, treatment options, and implementing clinical guidelines to support patient awareness and informed decisions.
Collapse
Affiliation(s)
- Laura E Brotzman
- Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Danielle M Crookes
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Jessica D Austin
- Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, NY, USA
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Alfred I Neugut
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY, USA
| | - Rachel C Shelton
- Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, NY, USA
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY, USA
| |
Collapse
|
12
|
Lee C, Hall K, Anakin M, Pinnock R. Towards a new understanding of uncertainty in medical education. J Eval Clin Pract 2021; 27:1194-1204. [PMID: 33089607 DOI: 10.1111/jep.13503] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 09/27/2020] [Accepted: 09/28/2020] [Indexed: 12/21/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES Uncertainty is a complex and constant phenomenon in clinical practice. How medical students recognize and respond to uncertainty impacts on their well-being, career choices, and attitudes towards patients. It has been suggested that curricula should do more to prepare medical students for an uncertain world. In order to teach medical students about uncertainty, we need to understand how uncertainty has been conceptualized in the literature to date. The aim of this article is to explore existing models of uncertainty and to develop a framework of clinical uncertainty to aid medical education. METHOD A scoping literature review was performed to identify conceptual models of uncertainty in healthcare. Content and inductive analyses were performed to explore three dimensions of clinical uncertainty: sources of uncertainty, subjective influencers and responses to uncertainty. RESULTS Nine hundred one references were identified using our search strategy, of which, 24 met our inclusion criteria. It was possible to classify these conceptual models using one or more of three dimensions of uncertainty; sources, subjective influencers, and responses. Exploration and further classification of these dimensions led to the development of a framework of uncertainty for medical education. CONCLUSION The developed framework of clinical uncertainty highlights sources, subjective influencers, responses to uncertainty, and the dynamic relationship among these elements. Our framework illustrates the different aspects of knowledge as a source of uncertainty and how to distinguish between those aspects. Our framework highlights the complexity of sources of uncertainty, especially when including uncertainty arising from relationships and systems. These sources can occur in combination. Our framework is also novel in how it describes the impact of influencers such as personal characteristics, experience, and affect on perceptions of and responses to uncertainty. This framework can be used by educators and curricula developers to help understand and teach about clinical uncertainty.
Collapse
Affiliation(s)
- Ciara Lee
- Department of General Practice and Rural Health, Otago Medical School, University of Otago, Dunedin, New Zealand
| | - Katherine Hall
- Department of General Practice and Rural Health, Otago Medical School, University of Otago, Dunedin, New Zealand
| | - Megan Anakin
- Education Unit, Otago Medical School, University of Otago, Dunedin, New Zealand
| | - Ralph Pinnock
- Education Unit, Otago Medical School, University of Otago, Dunedin, New Zealand
| |
Collapse
|
13
|
A Baby at All Costs? Exploring the Use and Provision of Unproven Adjuvant Treatments in the Context of IVF. Semin Reprod Med 2021; 39:220-226. [PMID: 34500475 DOI: 10.1055/s-0041-1731789] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The year 2018 marked 40 years since the birth of Louise Brown, the first baby born as a result of pioneering in vitro fertilization (IVF) treatment. Since then, advances have seen a wide range of reproductive technologies emerge into clinical practice, including adjuvant treatments often referred to as IVF "add-ons." However, these "optional extras" have faced growing criticism, especially when they have often come at additional financial cost to the patient and have little evidence supporting their efficacy to improve pregnancy or birth rates. Despite this, according to the latest national patient survey by the Human Fertilisation and Embryology Authority, three quarters of patients who had fertility treatment in the United Kingdom in the past two years had at least one type of treatment add-on highlighting the growing demand for these interventions. This article uses a psychosocial perspective to consider the motivations behind patient and clinician behavior along with the wider societal and economic factors that may be impacting upon the increase in the use of adjuvant treatments in fertility clinics more widely. It suggests the reasons fertility patients use unproven "optional extras" are complex, with interpersonal, psychological, and social factors intertwining to generate an increase in the use of IVF add-ons.
Collapse
|
14
|
Banerjee R, Shah N, Dicker AP. Next-Generation Implementation of Chimeric Antigen Receptor T-Cell Therapy Using Digital Health. JCO Clin Cancer Inform 2021; 5:668-678. [PMID: 34110929 DOI: 10.1200/cci.21.00023] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Chimeric antigen receptor T-cell (CAR-T) therapy is a paradigm-shifting immunotherapy modality in oncology; however, unique toxicities such as cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome limit its ability to be implemented more widely in the outpatient setting or at smaller-volume centers. Three operational challenges with CAR-T therapy include the following: (1) the logistics of toxicity monitoring, ie, with frequent vital sign checks and neurologic assessments; (2) the specialized knowledge required for toxicity management, particularly with regard to CRS and immune effector cell-associated neurotoxicity syndrome; and (3) the need for high-quality symptomatic and supportive care during this intensive period. In this review, we explore potential niches for digital innovations that can improve the implementation of CAR-T therapy in each of these domains. These tools include patient-facing technologies and provider-facing platforms: for example, wearable devices and mobile health apps to screen for fevers and encephalopathy, electronic patient-reported outcome assessments-based workflows to assist with symptom management, machine learning algorithms to predict emerging CRS in real time, clinical decision support systems to assist with toxicity management, and digital coaching to help maintain wellness. Televisits, which have grown in prominence since the novel coronavirus pandemic, will continue to play a key role in the monitoring and management of CAR-T-related toxicities as well. Limitations of these strategies include the need to ensure care equity and stakeholder buy-in, both operationally and financially. Nevertheless, once developed and validated, the next-generation implementation of CAR-T therapy using these digital tools may improve both its safety and accessibility.
Collapse
Affiliation(s)
- Rahul Banerjee
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Nina Shah
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Adam P Dicker
- Department of Radiation Oncology, Jefferson University, Philadelphia, PA.,Jefferson Center for Digital Health, Jefferson University, Philadelphia, PA
| |
Collapse
|
15
|
Langford AT, Maayan E, Lad M, Orellana K, Buderer N. Perceived involvement in health care decisions among US adults: Sociodemographic and medical condition correlates. PATIENT EDUCATION AND COUNSELING 2021; 104:1317-1320. [PMID: 33176979 DOI: 10.1016/j.pec.2020.11.004] [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: 05/03/2020] [Revised: 10/05/2020] [Accepted: 11/01/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE To explore factors associated with how often US adults perceived that they were "always" involved in decisions about health care to the degree that they desired. METHODS We examined cross-sectional, nationally representative data from the 2018 Health Information National Trends Survey. There were 3504 responses in the full HINTS dataset; 2499 remained after eliminating respondents with missing data for any factor of interest. Sociodemographic factors included age, gender, race/ethnicity, and education. Medical conditions included diabetes, hypertension, heart disease, lung disease, arthritis, cancer, and depression. Participants were asked to think about communication with health professionals during the last 12 months and how often health professionals involved them in decisions about health care. RESULTS In univariate analyses, Asian and Hispanic race were associated with lower odds of always being involved in decisions about health care; whereas higher education and a history of cancer were associated with higher odds of "always" being involved in decisions about health care, p < 0.05. In multivariate analyses, race and education both remained significant; however, history of cancer did not. CONCLUSION Differences by race/ethnicity and educational attainment exist regarding perceived involvement in decisions about health care. PRACTICE IMPLICATIONS Findings may inform future shared decision making interventions.
Collapse
Affiliation(s)
- Aisha T Langford
- Department of Population Health, NYU Langone Health, 227 East 30th Street, New York, NY, 10016, USA.
| | - Eli Maayan
- Department of Population Health, NYU Langone Health, 227 East 30th Street, New York, NY, 10016, USA.
| | - Meeki Lad
- Department of Population Health, NYU Langone Health, 227 East 30th Street, New York, NY, 10016, USA.
| | - Kerli Orellana
- Department of Population Health, NYU Langone Health, 227 East 30th Street, New York, NY, 10016, USA.
| | | |
Collapse
|
16
|
Examining the patterns of uncertainty across clinical reasoning tasks: effects of contextual factors on the clinical reasoning process. Diagnosis (Berl) 2020; 7:299-305. [DOI: 10.1515/dx-2020-0019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 04/20/2020] [Indexed: 11/15/2022]
Abstract
AbstractObjectivesUncertainty is common in clinical reasoning given the dynamic processes required to come to a diagnosis. Though some uncertainty is expected during clinical encounters, it can have detrimental effects on clinical reasoning. Likewise, evidence has established the potentially detrimental effects of the presence of distracting contextual factors (i.e., factors other than case content needed to establish a diagnosis) in a clinical encounter on clinical reasoning. The purpose of this study was to examine how linguistic markers of uncertainty overlap with different clinical reasoning tasks and how distracting contextual factors might affect physicians’ clinical reasoning process.MethodsIn this descriptive exploratory study, physicians participated in a live or video recorded simulated clinical encounter depicting a patient with unstable angina with and without contextual factors. Transcribed think-aloud reflections were coded using Goldszmidt’s clinical reasoning task typology (26 tasks encompassing the domains of framing, diagnosis, management, and reflection) and then those coded categories were examined using linguistic markers of uncertainty (e.g., probably, possibly, etc.).ResultsThirty physicians with varying levels of experience participated. Consistent with expectations, descriptive analysis revealed that physicians expressed more uncertainty in cases with distracting contextual factors compared to those without. Across the four domains of reasoning tasks, physicians expressed the most uncertainty in diagnosis and least in reflection.ConclusionsThese results highlight how linguistic markers of uncertainty can shed light on the role contextual factors might play in uncertainty which can lead to error and why it is essential to find ways of managing it.
Collapse
|
17
|
Shifting therapeutic paradigms in induction and consolidation for older adults with acute myeloid leukemia. Curr Opin Hematol 2020; 26:51-57. [PMID: 30585895 DOI: 10.1097/moh.0000000000000480] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
PURPOSE OF REVIEW As the age and life expectancy of the general population rise, the number of acute myeloid leukemia (AML) patients suitable for therapy is expected to dramatically increase. The population of older adults with AML, while already comprising the vast majority of AML patients, has not been specifically addressed in terms of unique age-related features, such as existence of comorbidities, frailty, and disease biology. RECENT FINDINGS Over the past decade, major improvements in the approach to the management of older adults with AML included: incorporation of new comorbidity scores specifically oriented to this patient population that can predict individual fitness to treatment, refined knowledge of the unique mutational landscape, and incorporating new combinations and novel agents designed to target the AML biology. Particularly, the recent exciting description of age-related clonal hematopoiesis and its evolution to AML may open new avenues for intervention prior to development of full-blown leukemia. SUMMARY The rising awareness of the unique biology and special needs of older adults with AML has resulted in the design of new studies aiming to target the aberrant mutations and clinical characteristics in this patient population.
Collapse
|
18
|
Hill DL, Walter JK, Szymczak JE, DiDomenico C, Parikh S, Feudtner C. Seven Types of Uncertainty When Clinicians Care for Pediatric Patients With Advanced Cancer. J Pain Symptom Manage 2020; 59:86-94. [PMID: 31425822 PMCID: PMC6942218 DOI: 10.1016/j.jpainsymman.2019.08.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 08/05/2019] [Accepted: 08/08/2019] [Indexed: 11/18/2022]
Abstract
CONTEXT Clinicians deciding whether to refer a patient or family to specialty palliative care report facing high levels of uncertainty. Most research on medical uncertainty has focused on prognostic uncertainty. As part of a pediatric palliative referral intervention for oncology teams we explored how uncertainty might influence palliative care referrals. OBJECTIVES To describe distinct meanings of the term "uncertainty" that emerged during the qualitative evaluation of the development and implementation of an intervention to help oncologists overcome barriers to palliative care referrals. METHODS We conducted a phenomenological qualitative analysis of "uncertainty" as experienced and described by interdisciplinary pediatric oncology team members in discussions, group activities and semistructured interviews regarding the introduction of palliative care. RESULTS We found that clinicians caring for patients with advanced cancer confront seven broad categories of uncertainty: prognostic, informational, individual, communication, relational, collegial, and inter-institutional. Each of these kinds of uncertainty can contribute to delays in referring patients to palliative care. CONCLUSION Various types of uncertainty arise in the care of pediatric patients with advanced cancer. To manage these forms of uncertainty, providers need to develop strategies and techniques to handle professionally challenging situations, communicate bad news, manage difficult interactions with families and colleagues, and collaborate with other organizations.
Collapse
Affiliation(s)
- Douglas L Hill
- Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jennifer K Walter
- Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Julia E Szymczak
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Concetta DiDomenico
- Division of Pediatric Oncology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Shefali Parikh
- Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Chris Feudtner
- Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
| |
Collapse
|
19
|
Subramani S. The Rhetoric of the 'Passive Patient' in Indian Medical Negligence Cases. Asian Bioeth Rev 2019; 11:349-366. [PMID: 33717322 PMCID: PMC7747317 DOI: 10.1007/s41649-019-00106-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 11/18/2019] [Accepted: 11/19/2019] [Indexed: 12/30/2022] Open
Abstract
In this paper, I examine the rhetoric employed by court judgements, with a particular emphasis on the narrative construct of the 'passive patient'. This construction advances and reinforces paternalistic values, which have scant regard for the patients' preferences, values, or choices within the legal context. Further, I critique the rhetoric employed and argue that the use of this rhetoric is the basis for a precedent that limits the understanding and respect of patients. Through this paper, I present the contemporary use of the 'passive patient' construct in the context of the Indian legal system and describe how such constructions have become a source of normative justification for legal reasoning that jeopardizes the patient's agency. I argue for the primacy of 'respect for persons' within Indian law and the need to treat each patient as a person who has agency, preferences, and values during clinical interactions. I conclude by suggesting that laws that adopt narratives that acknowledging the significance of patient engagement and the relevance of effective communication during clinical encounters would help cultivate a culture of patient-centred care, by moving beyond the rhetoric of 'passive patient' and the 'health/choice' dichotomy.
Collapse
Affiliation(s)
- Supriya Subramani
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zurich, Switzerland
| |
Collapse
|
20
|
Habib AR, Cronin AM, Earle CC, Tulsky JA, Mack JW, Abel GA, Odejide OO. How Do Blood Cancer Doctors Discuss Prognosis? Findings from a National Survey of Hematologic Oncologists. J Palliat Med 2019; 22:677-684. [PMID: 30907686 DOI: 10.1089/jpm.2018.0441] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Although blood cancers are accompanied by a high level of prognostic uncertainty, little is known about when and how hematologic oncologists discuss prognosis. Objectives: Characterize reported practices and predictors of prognostic discussions for a cohort of hematologic oncologists. Design: Cross-sectional mailed survey in 2015. Setting/Subjects: U.S.-based hematologic oncologists providing clinical care for adult patients with blood cancers. Measurements: We conducted univariable and multivariable analyses assessing the association of clinician characteristics with reported frequency of initiation of prognostic discussions, type of terminology used, and whether prognosis is readdressed. Results: We received 349 surveys (response rate = 57.3%). The majority of respondents (60.3%) reported conducting prognostic discussions with "most" (>95%) of their patients. More than half (56.8%) preferred general/qualitative rather than specific/numeric terms when discussing prognosis. Although 91.3% reported that they typically first initiate prognostic discussions at diagnosis, 17.7% reported routinely never readdressing prognosis or waiting until death is imminent to revisit the topic. Hematologic oncologists with ≤15 years since medical school graduation (odds ratio [OR] 0.51; confidence interval (95% CI) 0.30-0.88) and those who considered prognostic uncertainty a barrier to quality end-of-life care (OR 0.57; 95% CI 0.35-0.90) had significantly lower odds of discussing prognosis with "most" patients. Conclusions: Although the majority of hematologic oncologists reported discussing prognosis with their patients, most prefer general/qualitative terms. Moreover, even though prognosis evolves during the disease course, nearly one in five reported never readdressing prognosis or only doing so near death. These findings suggest the need for structured interventions to improve prognostic communication for patients with blood cancers.
Collapse
Affiliation(s)
- Anand R Habib
- 1 Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,2 Harvard Medical School, Boston, Massachusetts
| | - Angel M Cronin
- 1 Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Craig C Earle
- 3 Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| | - James A Tulsky
- 2 Harvard Medical School, Boston, Massachusetts.,4 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.,5 Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jennifer W Mack
- 1 Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,2 Harvard Medical School, Boston, Massachusetts
| | - Gregory A Abel
- 1 Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,2 Harvard Medical School, Boston, Massachusetts
| | - Oreofe O Odejide
- 1 Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,2 Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
21
|
The complexity of physicians' understanding and management of prognostic uncertainty in neonatal hypoxic-ischemic encephalopathy. J Perinatol 2019; 39:278-285. [PMID: 30568164 DOI: 10.1038/s41372-018-0296-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Prognosis of Hypoxic-Ischemic Encephalopathy (HIE) remains challenging and uncertain. This paper investigates how physicians understand and address the ethical challenges of prognostic uncertainty in the case of neonatal HIE, contextualized within the social science literature. STUDY DESIGN Semi-structured interviews were conducted with 12 Canadian neurologists and neonatologists, addressing their perspectives and clinical experiences concerning neonatal HIE prognostication. Interviews were analyzed using thematic content analysis. RESULTS Participants unanimously recognized uncertainty in their prognostication. They identified several sources contributing to uncertainty in HIE prognostication, including etiology and underlying pathophysiologic mechanisms, statistical limitations, variable clinical data, the dynamic process of neurodevelopment, or the impact of hypothermia treatment. Unlike in some other literature, some physicians in this study talked about ways to render uncertainty explicit rather than hide it. CONCLUSION Results from this study support the call for recognition of the ubiquitous uncertainty surrounding this act in medical education and training.
Collapse
|
22
|
Therapeutic Schedule Evaluation for Brain-Metastasized Non-Small Cell Lung Cancer with A Probabilistic Linguistic ELECTRE II Method. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:ijerph15091799. [PMID: 30134591 PMCID: PMC6163449 DOI: 10.3390/ijerph15091799] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 08/06/2018] [Accepted: 08/14/2018] [Indexed: 12/29/2022]
Abstract
With the rapid development of modern medicine, therapeutic schedules of brain-metastasized non-small cell lung cancer (NSCLC) are expanding. To assist a patient who suffers from brain-metastasized NSCLC to select the most suitable therapeutic schedule, firstly, we establish an indicator system for evaluating the therapeutic schedules; then, we propose a probabilistic linguistic ELECTRE II method to handle the corresponding evaluation problem for the following reasons: (1) probabilistic linguistic information is effective to depict the uncertainty of the therapeutic process and the fuzziness of an expert’s cognition; (2) the ELECTRE II method can deal with evaluation indicators that do not meet a fully compensatory relationship. Simulation tests on the parameters in the proposed method are provided to discuss their impacts on the final rankings. Furthermore, we apply the proposed method to help a patient with brain-metastasized NSCLC at the Sichuan Cancer Hospital and Institute to choose the optimal therapeutic schedule, and we present some sensitive analyses and comparative analyses to demonstrate the stability and applicability of the proposed method.
Collapse
|
23
|
Bories P, Lamy S, Simand C, Bertoli S, Delpierre C, Malak S, Fornecker L, Moreau S, Récher C, Nebout A. Physician uncertainty aversion impacts medical decision making for older patients with acute myeloid leukemia: results of a national survey. Haematologica 2018; 103:2040-2048. [PMID: 30006448 PMCID: PMC6269286 DOI: 10.3324/haematol.2018.192468] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 07/12/2018] [Indexed: 12/11/2022] Open
Abstract
Elderly patients with acute myeloid leukemia can be treated with intensive chemotherapy, low-intensity therapy such as low-dose aracytine or hypomethylating agents, or best supportive care. The choice between these treatments is a function of many patient-related and disease-related factors. We investigated how physicians’ behavioral characteristics affect medical decision-making between intensive and non-intensive therapy in this setting. A nationwide cross-sectional online survey of hematologists collected data on medical decision-making for 6 clinical vignettes involving older acute myeloid leukemia patients that were representative of routine practice. Questionnaires elicited physicians’ demographic and occupational characteristics along with their individual behavioral characteristics according to a decision theory framework. From the pattern of responses to the vignettes, a K-means clustering algorithm was used to distinguish those who were likely to prescribe more intensive therapy and those who were likely to prescribe less intensive or no therapy. Multivariate analyses were used to identify physician’s characteristics predictive of medical decision-making. We obtained 230 assessable answers, which represented an adjusted response rate of 45.4%. A multivariate model (n=210) revealed that physicians averse to uncertainty recommend significantly more intensive chemotherapy: Odds Ratio (OR) [95% Confidence Interval (CI)]: 1.15 [1.01;1.30]; P=0.039. Male physicians who do not conform to the expected utility model (assumed as economically irrational) recommend more intensive chemotherapy [OR (95% CI) = 3.45 (1.34; 8.85); P=0.01]. Patient volume per physician also correlated with therapy intensity [OR (95% CI)=0.98 (0.96; 0.99); P=0.032]. The physicians’ medical decision-making was not affected by their age, years of experience, or hospital facility. The significant association between medical decision and individual behavioral characteristics of the physician identifies a novel non-biological factor that may affect acute myeloid leukemia patients’ outcomes and explain variations in clinical practice. It should also encourage the use of validated predictive models and the description of novel bio-markers to best select patients for intensive chemotherapy or low-intensity therapy.
Collapse
Affiliation(s)
- Pierre Bories
- Regional Cancer Network Onco-Occitanie, Toulouse University Institute of Cancer-Oncopole .,Department of Hematology, Toulouse University Institute of Cancer-Oncopole
| | - Sébastien Lamy
- INSERM Unit 1027, Faculty of Medicine, Toulouse.,Department of Clinical Pharmacology, Toulouse University Hospital
| | | | - Sarah Bertoli
- Department of Hematology, Toulouse University Institute of Cancer-Oncopole
| | | | - Sandra Malak
- Department of Hematology, Rene Huguenin Hospital, Curie Institute, Saint-Cloud
| | - Luc Fornecker
- Department of Hematology, Strasbourg University Hospital
| | | | - Christian Récher
- Department of Hematology, Toulouse University Institute of Cancer-Oncopole
| | | |
Collapse
|