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Stephens GC, Lazarus MD, Sarkar M, Karim MN, Wilson AB. Identifying validity evidence for uncertainty tolerance scales: A systematic review. MEDICAL EDUCATION 2023; 57:844-856. [PMID: 36576391 DOI: 10.1111/medu.15014] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 12/14/2022] [Accepted: 12/17/2022] [Indexed: 06/17/2023]
Abstract
PURPOSE Uncertainty tolerance (UT) is increasingly valued as a medical graduate attribute and broadly measured among medical student populations. However, the validity evidence underpinning UT scale implementation has not been summarised across studies. The present work evaluates UT scale validity evidence to better inform when, why and how UT scales ought to be used and to identify remaining validity evidence gaps. METHODS A literature search for psychometric studies of UT scales was completed in 2022. Records were included if they implemented one of the four most cited UT scales (i.e. Physicians' Reactions to Uncertainty scale 1990 [PRU1990] or 1995 [PRU1995], Tolerance for Ambiguity [TFA] scale or Tolerance of Ambiguity in Medical Students and Doctors scale [TAMSAD]) in a population of physicians and/or medial students and presented validity evidence according to the Standards for Educational and Psychological Testing framework. Included studies were rated and analysed according to evidence for test content, response processes, internal structure, relations to other variables and consequences of testing. RESULTS Among the investigated scales, 'relations to other variables' and 'internal structure' were the most commonly reported forms of validity evidence. No evidence of 'response processes' or 'consequences of testing' was identified. Overall, the PRU1990 and PRU1995 demonstrated the strongest validity evidence, although evidence primarily related to physician populations. CONCLUSIONS None of the studied scales demonstrated evidence for all five sources of validity. Future research would benefit from assessing validity evidence for 'response processes' and 'consequences of testing' among physicians and medical students at different training/career stages to better understand UT construct conceptualisation in these populations. Until further and stronger validity evidence for UT scales is established, we caution against implementing UT scales outside of research settings (e.g. for higher stakes decision making).
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Affiliation(s)
- Georgina C Stephens
- Centre for Human Anatomy Education, Monash University, Clayton, Victoria, Australia
| | - Michelle D Lazarus
- Centre for Human Anatomy Education Director and Monash Centre for Scholarship in Health Education Curriculum Integration Lead, Monash University, Clayton, Victoria, Australia
| | - Mahbub Sarkar
- Monash Centre for Scholarship in Health Education, Monash University, Clayton, Victoria, Australia
| | - M Nazmul Karim
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Adam B Wilson
- Department of Anatomy and Cell Biology, Rush University, Chicago, Illinois, USA
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Shashar S, Codish S, Ellen M, Davidson E, Novack V. Determinants of Medical Practice Variation Among Primary Care Physicians: Protocol for a Three Phase Study. JMIR Res Protoc 2020; 9:e18673. [PMID: 33079069 PMCID: PMC7609196 DOI: 10.2196/18673] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 06/04/2020] [Accepted: 06/14/2020] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND One of the greatest challenges of modern health systems is the choice and use of resources needed to diagnose and treat patients. Medical practice variation (MPV) is a broad term which entails the differences between health care providers inclusive of both the overuse and underuse. In this paper, we describe a 3-phase research protocol examining MPV in primary care. OBJECTIVE We aim to identify the potential targets for behavioral modification interventions to reduce the variation in practice patterns and thus improve health care, decrease costs, and prevent disparities in care. METHODS The first phase will delineate the variation in primary care practice over a wide range of services and long follow-up period (2003-2017), the second will examine the 3 determinants of variation (ie, patient, physician, and clinic characteristics), and attempt to derive the unexplained variance. In the third phase, we will assess a novel component that might contribute to the previously unexplained variance - the physicians' personal behavioral characteristics (such as risk aversion, fear of malpractice, stress from uncertainty, empathy, and burnout). RESULTS This work was supported by the research grant from Israel National Institute for Health Policy Research (Grant No. 2014/134). Soroka University Medical Center Institutional Ethics Committee has approved the updated version of the study protocol (SOR-14-0063) in February 2019. All relevant data for phases 1 and 2, including patient, physician, and clinic, were collected from the Clalit Health Services data set in 2019 and are currently being analyzed. The evaluation of the individual physician characteristics (eg, risk aversion) by the face-to-face questionnaires was started on 2018 and remains in progress. We intend to publish the results during 2020-2021. CONCLUSIONS Based on the results of our study, we aim to propose a list of potential targets for focused behavioral intervention. Identifying new targets for such an intervention can potentially lead to a decrease in the unwarranted variation in the medical practice. We suggest that such an intervention will result in optimization of the health system, improvement of health outcomes, reduction of disparities in care and savings in cost. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/18673.
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Affiliation(s)
- Sagi Shashar
- Clinical Research Center, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Shlomi Codish
- Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Moriah Ellen
- Department of Health Services Management, Guilford Glazer Faculty of Business and Management, Ben Gurion University, Beer-Sheva, Israel.,Institute of Health Policy Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,McMaster Health Forum, McMaster University, Hamilton, ON, Canada
| | - Ehud Davidson
- General Management, Clalit Health Services, Tel Aviv, Israel
| | - Victor Novack
- Clinical Research Center, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Kline JA, Lin MP, Hall CL, Puskarich MA, Dehon E, Kuehl DR, Wang RC, Hess EP, Runyon MS, Wang H, Courtney DM. Perception of Physician Empathy Varies With Educational Level and Gender of Patients Undergoing Low-Yield Computerized Tomographic Imaging. J Patient Exp 2020; 7:386-394. [PMID: 32821799 PMCID: PMC7410137 DOI: 10.1177/2374373519838529] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE Lack of empathic communication between providers and patients may contribute to low value diagnostic testing in emergency care. Accordingly, we measured the perception of physician empathy and trust in patients undergoing low-value computed tomography (CT) in the emergency department (ED). METHODS Multicenter study of ED patients undergoing CT scanning, acknowledged by ordering physicians as unlikely to show an emergent condition. Near the end of their visit, patients completed the Jefferson Scale of Patient Perception of Physician Empathy (JSPPPE), Trust in Physicians Survey (TIPS), and the Group Based Medical Mistrust Scale (GBMMS). We stratified results by patient demographics including gender, race, and education. RESULTS We enrolled 305 participants across 9 sites with diverse geographic, racial, and ethnic representation. The median scores (interquartile ranges) for the JSPPPE, TIPS, and GBMMS for all patients were 29 (24-33.5), 55 (47-62), and 18 (12-29). Compared with white patients, nonwhite patients had similar JSPPPE and TIPS scores but had higher (worse) GBMMS scores. Females had significantly lower JSPPPE and TIPS scores than males, and scores were lower (worse) in females with college degrees. Patients in the lowest tier of educational status had the highest (better) JSPPPE and TIPS scores. Scores were invariant with physician characteristics. CONCLUSION Among patients undergoing low-value CT scanning in the ED, the degree of patient perception of physician empathy and trust varied based on the patients' level of education and gender. Given this variation, an intervention to increase patient perception of physician empathy should contain individualized strategies to address these subgroups, rather than a one-size-fits-all approach.
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Affiliation(s)
- Jeffrey A Kline
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Michelle P Lin
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Cassandra L Hall
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Erin Dehon
- Department of Emergency Medicine, University of Mississippi, Jackson, MS, USA
| | - Damon R Kuehl
- Department of Emergency Medicine, Virginia Tech-Carilion, Roanoke, VA, USA
| | - Ralph C Wang
- Department of Emergency Medicine, University of California, San Francisco, CA, USA
| | - Erik P Hess
- Department of Emergency Medicine, University of Alabama, Birmingham, AL, USA
| | - Michael S Runyon
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC, USA
| | - Hao Wang
- Department of Emergency Medicine, John Peter Smith Hospital, Ft. Worth, TX, USA
| | - D Mark Courtney
- Department of Emergency Medicine, Northwestern University School of Medicine, Chicago, IL, USA
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Pettit KE, Rattray NA, Wang H, Stuckey S, Mark Courtney D, Messman AM, Kline JA. Coming in Warm: Qualitative Study and Concept Map to Cultivate Patient-centered Empathy in Emergency Care. AEM EDUCATION AND TRAINING 2019; 3:136-144. [PMID: 31008425 PMCID: PMC6457357 DOI: 10.1002/aet2.10328] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 01/21/2019] [Accepted: 02/04/2019] [Indexed: 06/09/2023]
Abstract
BACKGROUND Increased empathy may improve patient perceptions and outcomes. No training tool has been derived to teach empathy to emergency care providers. Accordingly, we engaged patients to assist in creating a concept map to teach empathy to emergency care providers. METHODS We recruited patients, patient caretakers and patient advocates with emergency department experience to participate in three separate focus groups (n = 18 participants). Facilitators guided discussion about behaviors that physicians should demonstrate to rapidly create trust; enhance patient perception that the physician understood the patient's point of view, needs, concerns, and fears; and optimize patient/caregiver understanding of their experience. Verbatim transcripts from the three focus groups were read by the authors, and by consensus, five major themes with 10 minor themes were identified. After creating a codebook with thematic definitions, one author reviewed all transcripts to a library of verbatim excerpts coded by theme. To test for inter-rater reliability, two other authors similarly coded a random sample of 40% of the transcripts. Authors independently chose excerpts that represented consensus and strong emotional responses from participants. RESULTS Approximately 90% of opinions and preferences fell within 15 themes, with five central themes: provider transparency, acknowledgment of patient's emotions, provider disposition, trust in physician, and listening. Participants also highlighted the need for authenticity, context, and individuality to enhance empathic communication. For empathy map content, patients offered example behaviors that promote perceptions of physician warmth, respect, physical touch, knowledge of medical history, explanation of tests, transparency, and treating patients as partners. The resulting concept map was named the "Empathy Circle." CONCLUSIONS Focus group participants emphasized themes and tangible behaviors to improve empathy in emergency care. These were incorporated into the Empathy Circle, a novel concept map that can serve as the framework to teach empathy to emergency care providers.
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Affiliation(s)
- Katie E. Pettit
- Department of Emergency MedicineIndiana University School of MedicineIndianapolisIN
| | - Nicholas A. Rattray
- VA HSR&D Center for Health Information and CommunicationRoudebush VA Medical Center and Regenstrief Institute, Inc.IndianapolisIN
| | - Hao Wang
- Department of Emergency MedicineJohn Peter Smith Health NetworkFt. WorthTX
| | - Shanna Stuckey
- Center for Urban and Multicultural Education (CUME)School of Education at Indiana University–Purdue University IndianapolisIndianapolisIN
| | - D. Mark Courtney
- Department of Emergency MedicineFeinberg School of MedicineNorthwestern UniversityChicagoIL
| | - Anne M. Messman
- Department of Emergency MedicineWayne State University School of MedicineDetroitMI
| | - Jeffrey A. Kline
- Department of Emergency MedicineIndiana University School of MedicineIndianapolisIN
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Emergency physician empathy does not explain variation in admission rates. Am J Emerg Med 2019; 37:767-768. [DOI: 10.1016/j.ajem.2018.08.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Revised: 08/07/2018] [Accepted: 08/07/2018] [Indexed: 11/18/2022] Open
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The Impact of Risk Standardization on Variation in CT Use and Emergency Physician Profiling. AJR Am J Roentgenol 2018; 211:392-399. [PMID: 29975119 DOI: 10.2214/ajr.17.19188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study is to use detailed electronic health record data to profile the use of condition-specific, risk-standardized imaging by emergency physicians. MATERIALS AND METHODS CT utilization in four emergency departments in a single health care system was retrospectively analyzed. The primary outcome for analysis was indication-specific, risk-standardized CT utilization. We constructed seven clinical cohorts on the basis of the presence or absence of a traumatic indication for the most frequently performed CT studies. Risk standardization was performed using machine learning algorithms and hierarchic logistic regression models. Variation in CT utilization for each cohort was analyzed using coefficients of variation and box plots, the effect of risk standardization on physician profiling was determined using slope diagrams and kappa values, and within-physician correlation was assessed using correlation coefficients and matrices. RESULTS For the seven cohorts, the number of physicians ordering more than 25 CT studies for a particular indication ranged from 70 to 88, and the number of ED visits ranged from 17,458 to 117,489. The unadjusted variation was large for each indication (coefficient of variation, 30.2-57.9). Risk standardization resulted in reduced but persistent variation for all indications (coefficient of variation, 12.3-22.3). Among indication-specific models, risk standardization resulted in reclassification by two or more deciles for 14.0-39.1% of physicians. The R value for within-physician correlation varied from 0.02 to 0.80 and was highest between chest and abdominal imaging for trauma. CONCLUSION In this multisite study of CT utilization, risk standardization had a substantial impact on variation in CT utilization and emergency physician profiling. Administrators and payers should include risk standardization in future measures of physician imaging to ensure valid assessment of performance and achieve improvements in emergency care value.
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Lin MP, Probst MA, Puskarich MA, Dehon E, Kuehl DR, Wang RC, Hess EP, Butler K, Runyon MS, Wang H, Courtney DM, Muckley B, Hobgood CD, Hall CL, Kline JA. Improving perceptions of empathy in patients undergoing low-yield computerized tomographic imaging in the emergency department. PATIENT EDUCATION AND COUNSELING 2018; 101:717-722. [PMID: 29173841 DOI: 10.1016/j.pec.2017.11.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 11/17/2017] [Accepted: 11/19/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE We assessed emergency department (ED) patient perceptions of how physicians can improve their language to determine patient preferences for 11 phrases to enhance physician empathy toward the goal of reducing low-value advanced imaging. METHODS Multi-center survey study of low-risk ED patients undergoing computerized tomography (CT) scanning. RESULTS We enroled 305 participants across nine sites. The statement "I have carefully considered what you told me about what brought you here today" was most frequently rated as important (88%). The statement "I have thought about the cost of your medical care to you today" was least frequently rated as important (59%). Participants preferred statements indicating physicians had considered their "vital signs and physical examination" (86%), "past medical history" (84%), and "what prior research tells me about your condition" (79%). Participants also valued statements conveying risks of testing, including potential kidney injury (78%) and radiation (77%). CONCLUSION The majority of phrases were identified as important. Participants preferred statements conveying cognitive reassurance, medical knowledge and risks of testing. PRACTICE IMPLICATIONS Our findings suggest specific phrases have the potential to enhance ED patient perceptions of physician empathy. Further research is needed to determine whether statements to convey empathy affect diagnostic testing rates.
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Affiliation(s)
- Michelle P Lin
- Icahn School of Medicine at Mount Sinai, Department of Emergency Medicine, New York, NY, United States
| | - Marc A Probst
- Icahn School of Medicine at Mount Sinai, Department of Emergency Medicine, New York, NY, United States
| | - Michael A Puskarich
- University of Mississippi, Department of Emergency Medicine, Jackson, MS, United States
| | - Erin Dehon
- University of Mississippi, Department of Emergency Medicine, Jackson, MS, United States
| | - Damon R Kuehl
- Virginia Tech-Carilion, Department of Emergency Medicine, Roanoke, VA, United States
| | - Ralph C Wang
- University of California San Francisco Department of Emergency Medicine, San Francisco, CA, United States
| | - Erik P Hess
- Mayo Clinic, Department of Emergency Medicine, Rochester, MN, United States
| | - Katie Butler
- Carolinas Medical Center, Department of Emergency Medicine, Charlotte, NC, United States
| | - Michael S Runyon
- Carolinas Medical Center, Department of Emergency Medicine, Charlotte, NC, United States
| | - Hao Wang
- John Peter Smith Hospital, Department of Emergency Medicine, Ft. Worth, TX, United States
| | - D Mark Courtney
- Northwestern University School of Medicine, Department of Emergency Medicine, Chicago, IL, United States
| | - Brandon Muckley
- Indiana University School of Medicine, Department of Emergency Medicine, Indianapolis, IN, United States
| | - Cherri D Hobgood
- Indiana University School of Medicine, Department of Emergency Medicine, Indianapolis, IN, United States
| | - Cassandra L Hall
- Indiana University School of Medicine, Department of Emergency Medicine, Indianapolis, IN, United States
| | - Jeffrey A Kline
- Indiana University School of Medicine, Department of Emergency Medicine, Indianapolis, IN, United States.
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Yuguero O, Forné C, Esquerda M, Pifarré J, Abadías MJ, Viñas J. Empathy and burnout of emergency professionals of a health region: A cross-sectional study. Medicine (Baltimore) 2017; 96:e8030. [PMID: 28906390 PMCID: PMC5604659 DOI: 10.1097/md.0000000000008030] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
The objective of this study is to assess the association between levels of empathy and burnout of emergency professionals in all the assistance levels.A cross-sectional observational study was conducted in the health region of Lleida and the Pyrenees with 100 professionals from the field of Urgency. Participation reached 40.8%. Empathy and burnout were measured using the Spanish versions of the Jefferson Scale of Physician Empathy (JSPE) and Maslach Burnout Inventory (MBI) respectively. The total MBI score and its 3 dimensions (emotional exhaustion, depersonalization, and personal accomplishment) were analyzed. The JSPE and MBI scores were categorized into tertiles that were identified as "low," "moderate," and "high" levels.The median (interquartile range) was 112 (102-123) and 37 (27-53.5) for the JSPE and MBI scores respectively. Professionals with high burnout (MBI≥47) showed the lowest levels of empathy, that is, JSPE score of 105 (98-114); those with moderate burnout (31≤MBI < 47) had a JSPE score of 114 (104.5-120.5); and those with low burnout (MBI < 31) had a JSPE score of 120.5 (105.8-127.2). In addition, the highest levels of empathy were associated with the lowest levels of burnout, especially in depersonalization, and to a lesser extent in personal accomplishment. There were no differences in empathy and burnout for any of the other study variables.Our findings suggest that the empathy of emergency professionals is associated with burnout. Hence, reducing professional burnout could help keep emergency professionals' empathy levels high, which in turn would ensure a better quality of care. Nevertheless, it would be necessary to carry out prospective studies to describe the profiles of burnout and empathy as well as their association and evolution.
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Affiliation(s)
- Oriol Yuguero
- Emergency Service, University Hospital Arnau de Vilanova, Lleida
- Biomedical Research Institute of Lleida (IRBLleida)
| | - Carles Forné
- Biostatistics Unit, Biomedical Research Institute of Lleida (IRBLleida)
- Department of Basic Medical Sciences, University of Lleida, Lleida
| | - Montserrat Esquerda
- Biomedical Research Institute of Lleida (IRBLleida)
- Borja Institute of Bioethics, Barcelona
| | - Josep Pifarré
- Biomedical Research Institute of Lleida (IRBLleida)
- Mental Health Service, University Hospital Santa Maria
| | | | - Joan Viñas
- Faculty of Medicine, University of Lleida, Lleida, Spain
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