Why are physicians not persuaded by scientific evidence? A grounded theory interview study

Evidence-Do Gap in Quality of Direct-To-Consumer Telemedicine: Cross-Sectional Standardized Patient Study in China

Background: The evidence-do gap between the availability of clinical guidelines and provider practice is well documented, resulting in low health care quality. With the rapid development of telemedicine worldwide, this study aimed to investigate the evidence-do gap and explore the factors for the evidence versus practice deficits as well as low quality in direct-to-consumer telemedicine. Methods: We adopted the standardized patient approach to evaluate the health worker performance and calculate the evidence-do gap in quality of the consultation process, diagnosis, and treatment in telemedicine based on China's national clinical guidelines. Moreover, we further explored the factors associated with the gap through multiple linear regression and logistic regressions. Results: Validated physician-patient interactions (N = 321) were included. On the one hand, the consultation process and treatment quality are less commendable with the huge evidence-do gap. More than three-quarters of the physicians provided low-quality care, as against standard clinical guidelines. On the other hand, the level I, specialized hospitals, doctor, associate chief physicians, and attending physicians, sponsored by Internet enterprises, more times of provider's responses and words were associated with high-quality processes; More total times of provider's responses, urticaria, and nonoffice hours of the visit were associated with high-quality diagnosis; Sponsored by Internet enterprises, more total words of provider's all responses, and urticaria were associated with high-quality treatment. Conclusions: Our findings have important implications in an era in which to better comprehend the evidence-do gap. Efforts to bridge the evidence-do gap should be focused on the important role of institutions and physicians.

Analysis of cataract-regulated genes using chemical DNA damage induction in a rat ex vivo model

Although cataracts affect almost all people at advanced age and carry a risk of blindness, the mechanisms of cataract development remain incompletely understood. Oxidative stress, which is a causative factor in cataract, results in DNA breakage, which suggests that DNA damage could contribute to the formation of cataracts. We developed an ex vivo experimental system to study changes in gene expression during the formation of opacities in the lens by culturing explanted rat lenses with Methylmethanesulfonate (MMS) or Bleomycin, which induce DNA damage. Lenses cultured using this experimental system developed cortical opacity, which increased in a concentration- and time-dependent manner. In addition, we compared expression profiles at the whole gene level using microarray analysis of lenses subjected to MMS or Bleomycin stress. Microarray findings in MMS-induced opacity were validated and gene expression was measured from Days 1-4 using RT-qPCR. Altered genes were classified into four groups based on the days of peak gene expression: Group 1, in which expression peaked on Day 1; Group 2, in which expression peaked on Day 2; Group 3, in which expression progressively increased from Days 1-4 or were upregulated on Day 1 and sustained through Day 4; and Group 4, in which expression level oscillated from Days 1-4. Genes involved in lipid metabolism were restricted to Group 1. DNA repair- and cell cycle-related genes were restricted to Groups 1 and 2. Genes associated with oxidative stress and drug efflux were restricted to Group 2. These findings suggest that in temporal changes of MMS-induced opacity formation, the activated pathways could occur in the following order: lipid metabolism, DNA repair and cell cycle, and oxidative stress and drug efflux.

The Possible Positive Mechanisms of Pirenoxine in Cataract Formation

Cataract is the leading cause of blindness worldwide. A diverse range of medication has been invented to prevent or treat cataract. Pirenoxine (PRX), a drug with strong antioxidant properties, has been used topically to treat cataract, and there is much evidence to demonstrate the beneficial effects of PRX on lens opacity from in vitro and in vivo models. In clinical use, PRX has been prescribed worldwide by ophthalmologists for over six decades; however, there is still controversy with regard to its efficacy, and thus PRX remains an off-label use for cataract treatment. This comprehensive review summarizes and discusses evidence pertinent to the mechanisms of PRX and its efficacy mainly on cataract models. The issues that have been deemed uncertain over the six-decade use of PRX are examined. The information summarized in this review should provide insights into contriving novel approaches for the treatment of cataract.

Biochemistry of Eye Lens in the Norm and in Cataractogenesis

The absence of cellular organelles in fiber cells and very high cytoplasmic protein concentration (up to 900 mg/ml) minimize light scattering in the lens and ensure its transparency. Low oxygen concentration, powerful defense systems (antioxidants, antioxidant enzymes, chaperone-like protein alpha-crystallin, etc.) maintain lens transparency. On the other hand, the ability of crystallins to accumulate age-associated post-translational modifications, which reduce the resistance of lens proteins to oxidative stress, is an important factor contributing to the cataract formation. Here, we suggest a mechanism of cataractogenesis common for the action of different cataractogenic factors, such as age, radiation, ultraviolet light, diabetes, etc. Exposure to these factors leads to the damage and death of lens epithelium, which allows oxygen to penetrate into the lens through the gaps in the epithelial layer and cause oxidative damage to crystallins, resulting in protein denaturation, aggregation, and formation of multilamellar bodies (the main cause of lens opacification). The review discusses various approaches to the inhibition of lens opacification (cataract development), in particular, a combined use of antioxidants and compounds enhancing the chaperone-like properties of alpha-crystallin. We also discuss the paradox of high efficiency of anti-cataract drugs in laboratory settings with the lack of their clinical effect, which might be due to the late use of the drugs at the stage, when the opacification has already formed. A probable solution to this situation will be development of new diagnostic methods that will allow to predict the emergence of cataract long before the manifestation of its clinical signs and to start early preventive treatment.

Analysis of UK eye casualty presentations

CLINICAL RELEVANCE

Optometrists upskilling and participating in enhanced optometric schemes has the potential to improve service accessibility and alleviate pressure on hospital eye services.

BACKGROUND

There is a growing demand for eye care in the UK with rising hospital attendances thought to be due in part to an ageing population and a shift in behaviour to favour emergency secondary care.

METHODS

Records of first-time presentations to the eye casualty department at the County Hospital (Wye Valley NHS Trust), Hereford, UK, over a month were analysed retrospectively and sequentially. The proportion of patients from optometrist referrals with conditions potentially requiring pharmacological intervention, that could have been retained within community optometry by an independent prescriber, was assessed. For general practitioner and self-referrals, the reasons for visit were compared to the Minor Eye Conditions Service criteria for inclusion. Patient conditions reviewed at the hospital following their initial presentation were grouped according to those who could have been discharged to a commissioned optometric service.

RESULTS

The records of 421 patients were organised by the source of referral and condition diagnosed by the hospital practitioner. Thirty-three percent of optometrist referrals could have been managed by an independent prescribing optometrist. Ninety-two percent of patients presenting from general practitioner referrals and 83 percent of self-referrals could have been assessed via the local optometric scheme. Sixty-six percent of patients attending hospital for follow-up could have been seen within the community.

CONCLUSION

The present analysis highlights the value of commissioned local optometric community services to address acute ocular symptoms and the value of an independent prescribing qualification in helping to further alleviate the burden on hospital emergency eye services. The large number of self-referrals suggests that the general public needs to be further educated on services that are available at a community optometry level.

Histone acetyltransferase and Polo-like kinase 3 inhibitors prevent rat galactose-induced cataract

Diabetic cataracts can occur at an early age, causing visual impairment or blindness. The detailed molecular mechanisms of diabetic cataract formation remain incompletely understood, and there is no well-documented prophylactic agent. Galactose-fed rats and ex vivo treatment of lenses with galactose are used as models of diabetic cataract. To assess the role of histone acetyltransferases, we conducted cataract prevention screening with known histone acetyltransferase (HAT) inhibitors. Ex vivo treatment with a HAT inhibitor strongly inhibited the formation of lens turbidity in high-galactose conditions, while addition of a histone deacetylase (HDAC) inhibitor aggravated turbidity. We conducted a microarray to identify genes differentially regulated by HATs and HDACs, leading to discovery of a novel cataract causative factor, Plk3. Plk3 mRNA levels correlated with the degree of turbidity, and Plk3 inhibition alleviated galactose-induced cataract formation. These findings indicate that epigenetically controlled Plk3 influences cataract formation. Our results demonstrate a novel approach for prevention of diabetic cataract using HAT and Plk3 inhibitors.

'Know-Can' gap: gap between knowledge and skills related to childhood diarrhoea and pneumonia among frontline workers in rural Uttar Pradesh, India

OBJECTIVES

In India, frontline workers (FLWs) - public accredited social health activists (ASHAs) and private rural medical providers (RMPs) - are important for early detection and treatment of childhood diarrhoea and pneumonia. This cross-sectional study aims to measure knowledge and skills, and the gap between the two ('know-can' gap), regarding assessment of childhood diarrhoea with dehydration and pneumonia among FLWs, and to explore factors associated with them.

METHODS

We surveyed 473 ASHAs and 447 RMPs in six districts of Uttar Pradesh. We assessed knowledge and skills using face-to-face interviews and video vignettes, respectively, about key signs of both conditions. The 'know-can' gap corresponds to absent skills among FLWs with correct knowledge. We used logistic regression to identify the correlates of knowledge and skills.

RESULTS

FLWs' correct knowledge ranged from 23% to 48% for dehydration signs and 27% to 37% for pneumonia signs. Their skills ranged from 3% to 42% for dehydration and 3% to 18% for pneumonia. There was a significant 'know-can' gap in all the signs, except 'sunken eyes'. Training and supervisory support was associated with better knowledge and skills for diarrhoea with dehydration, but only better knowledge for pneumonia.

CONCLUSIONS

FLWs are crucial to the Indian health system, and high-quality FLW services are necessary for continued progress against under-five deaths. The gap between FLWs' knowledge and skills warrants immediate attention. In particular, our results suggest that knowledge-focused trainings are insufficient for FLWs to convert knowledge into appropriate assessment skills.

Drug delivery to the lens for the management of cataracts

Cataracts are one of the most prevalent diseases of the lens, affecting its transparency and are the leading cause of reversible blindness in the world. The clarity of the lens is essential for its normal physiological function of refracting light onto the retina. Currently there is no pharmaceutical treatment for prevention or cure of cataracts and surgery to replace the affected lens remains the gold standard in the management of cataracts. Pharmacological treatment for prevention of cataracts is hindered by many physiological barriers that must be overcome by a therapeutic agent to reach the avascular lens. Various therapeutic agents and formulation strategies are currently being investigated to prevent cataract formation as access to surgery is limited. This review provides a summary of recent research in the field of drug delivery to the lens for the management of cataracts including models used to study cataract treatments and discusses the future perspectives in the field.

A bibliometric analysis of the citation classics of acute appendicitis

INTRODUCTION

Acute appendicitis is one of the most commonly encountered emergency surgical conditions. An understanding of the most highly cited research works in this field is key to good evidence based clinical practice.

AIMS

To perform a bibliometric analysis on the 100 most frequently cited articles in the field of acute appendicitis.

METHODS

The database of the Institute for Scientific Information (ISI) Web of Science Expanded citation index was searched to identify the 100 most frequently cited articles in the field of acute appendicitis. The web of science expanded citation index tracks article citations made since 1946.

RESULTS

The top 100 most frequently cited articles were selected for analysis in this series. The most frequently cited article was cited 649 times and the least cited three article 93 times. The average number of citations per article was 167.74. The top 100 cited articles originated from 17 countries. Over half of the papers originated from the USA. Fifty-one of the papers concentrated on diagnostics of acute appendicitis. Thirty-six papers looked at the treatment of acute appendicitis with 30 of these dealing with the surgical management of the disease. There were 6 studies at level 1a, 20 studies at level 1b and 43,5,17 and 9 studies at levels 2, 3, 4 and 5 respectively.

CONCLUSIONS

Bibliometric analysis of the citation classics in a given field can provide interesting insights into the relationship between the quality of research outputs and clinical practice. The study of acute appendicitis remains an active field of research with a growing body of higher quality evidence underpinning our clinical practice.

Meeting physicians' needs: a bottom-up approach for improving the implementation of medical knowledge into practice

Background

Multiple barriers to knowledge translation in medicine have been identified (ranging from information overload to abstraction of models), leading to important implementation gaps. This study aimed at assessing the suggestions of practicing physicians for possible improvements of knowledge translation (KT) effectiveness into clinical practice.

Methods

We used a mixed methods design. French- German- and Italian-speaking general practitioners, psychiatrists, orthopaedic surgeons, cardiologists, and diabetologists practicing in Switzerland were interrogated through semi-structured interviews, focus group discussions, and an online survey.

Results

A total of 985 physicians from three regions of Switzerland participated in the online survey, whereas 39 participated in focus group discussions and 14 in face-to-face interviews. Physicians expressed limitations and difficulties related to KT into their daily practice. Several barriers were identified, including influence and pressure of pharmaceutical companies, non-publication of negative results, mismatch between guidelines and practice, education gaps, and insufficient collaboration between research and practice. Suggestions to overcome barriers were improving education concerning the evaluation of scientific publications, expanding applicability of guidelines, having free and easy access to independent journals, developing collaborations between research and practice, and creating tools to facilitate access to medical information.

Conclusions

Our study provides suggestions for improving KT into daily medical practice, matching the views, needs and preferences of practicing physicians. Responding to suggestions for improvements brought up by physicians may lead to better knowledge translation, higher professional satisfaction, and better healthcare outcomes.

Electronic supplementary material

The online version of this article (doi:10.1186/s12961-016-0120-5) contains supplementary material, which is available to authorized users.

The clinical decision analysis using decision tree

The clinical decision analysis (CDA) has used to overcome complexity and uncertainty in medical problems. The CDA is a tool allowing decision-makers to apply evidence-based medicine to make objective clinical decisions when faced with complex situations. The usefulness and limitation including six steps in conducting CDA were reviewed. The application of CDA results should be done under shared decision with patients' value.

Validation of pre-operative patient self-assessment of cardiac risk for non-cardiac surgery: foundations for decision support

OBJECTIVES

To better characterize patient understanding of their risk of cardiac complications from non-cardiac surgery and to develop a patient driven clinical decision support system for preoperative patient risk management.

METHODS

A patient-driven preoperative self-assessment decision support tool for perioperative assessment was created. Patient' self-perception of cardiac risk and self-report data for risk factors were compared with gold standard preoperative physician assessment to evaluate agreement.

RESULTS

The patient generated cardiac risk profile was used for risk score generation and had excellent agreement with the expert physician assessment. However, patient subjective self-perception risk of cardiovascular complications had poor agreement with expert assessment.

CONCLUSION

A patient driven cardiac risk assessment tool provides a high degree of agreement with expert provider assessment demonstrating clinical feasibility. The limited agreement between provider risk assessment and patient self-perception underscores a need for further work including focused preoperative patient education on cardiac risk.

What, why, and how care protocols are implemented in Ontario nursing homes

The aim of this study was to better understand care protocol implementation, including the influence of organizational-contextual factors on implementation approaches, in long-term care homes operating in Ontario. We surveyed directors of care employed in all 547 Ontario LTC homes, and combined survey data with secondary organizational data on rural/urban location, nursing home size, chain membership, type of ownership, and accreditation status. Motivations for the use/selection of care protocols in nursing homes primarily derived from beliefs in continuous improvement and in evidence-based care. Protocol selection was largely participative, involving management and staff. External information sources were important for protocol implementation, and in-service education was the chief means of training and educating staff. Significant differences in approaches to implementation were evident in association with differences in ownership. Three key success factors for implementation were identified: contextualizing the practice change, adequately resourcing for implementation, and demonstrating connections between practice change and outcomes.

Role of pirenoxine in the effects of catalin on in vitro ultraviolet-induced lens protein turbidity and selenite-induced cataractogenesis in vivo

PURPOSE

In this study, we investigated the biochemical pharmacology of pirenoxine (PRX) and catalin under in vitro selenite/calcium- and ultraviolet (UV)-induced lens protein turbidity challenges. The systemic effects of catalin were determined using a selenite-induced cataractogenesis rat model.

METHODS

In vitro cataractogenesis assay systems (including UVB/C photo-oxidation of lens crystallins, calpain-induced proteolysis, and selenite/calcium-induced turbidity of lens crystallin solutions) were used to screen the activity of PRX and catalin eye drop solutions. Turbidity was identified as the optical density measured using spectroscopy at 405 nm. We also determined the in vivo effects of catalin on cataract severity in a selenite-induced cataract rat model. Sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE) was applied to analyze the integrity of crystallin samples.

RESULTS

PRX at 1,000 μM significantly delayed UVC-induced turbidity formation compared to controls after 4 h of UVC exposure (p<0.05), but not in groups incubated with PRX concentrations of <1,000 μM. Results were further confirmed by SDS-PAGE. The absolute γ-crystallin turbidity induced by 4 h of UVC exposure was ameliorated in the presence of catalin equivalent to 1~100 μM PRX in a concentration-dependent manner. Samples with catalin-formulated vehicle only (CataV) and those containing PRX equivalent to 100 μM had a similar protective effect after 4 h of UVC exposure compared to the controls (p<0.05). PRX at 0.03, 0.1, and 0.3 μM significantly delayed 10 mM selenite- and calcium-induced turbidity formation compared to controls on days 0~4 (p<0.05). Catalin (equivalent to 32, 80, and 100 μM PRX) had an initial protective effect against selenite-induced lens protein turbidity on day 1 (p<0.05). Subcutaneous pretreatment with catalin (5 mg/kg) also statistically decreased the mean cataract scores in selenite-induced cataract rats on post-induction day 3 compared to the controls (1.3±0.2 versus 2.4±0.4; p<0.05). However, catalin (equivalent to up to 100 μM PRX) did not inhibit calpain-induced proteolysis activated by calcium, and neither did 100 μM PRX.

CONCLUSIONS

PRX at micromolar levels ameliorated selenite- and calcium-induced lens protein turbidity but required millimolar levels to protect against UVC irradiation. The observed inhibition of UVC-induced turbidity of lens crystallins by catalin at micromolar concentrations may have been a result of the catalin-formulated vehicle. Transient protection by catalin against selenite-induced turbidity of crystallin solutions in vitro was supported by the ameliorated cataract scores in the early stage of cataractogenesis in vivo by subcutaneously administered catalin. PRX could not inhibit calpain-induced proteolysis activated by calcium or catalin itself, and may be detrimental to crystallins under UVB exposure. Further studies on formulation modifications of catalin and recommended doses of PRX to optimize clinical efficacy by cataract type are warranted.

Spanning the know-do gap: understanding knowledge application and capacity in long-term care homes

Using a multiple case study design, this article explores the translation process that emerges within Ontario long-term care (LTC) homes with the adoption and implementation of evidence-based clinical practice guidelines (CPGs). Within-organization knowledge translation is referred to as knowledge application. We conducted 28 semi-structured interviews with a range of administrative and care staff within 7 homes differentiated by size, profit status, chain membership, and rural/urban location. We further undertook 7 focus groups at 5 locations, involving a total of 35 senior clinical staff representing 15 homes not involved in earlier structured interviews. The knowledge application process that emerges across our participant organizations is highly complex, iterative, and reliant upon a facility's knowledge application capacity, or absorptive capacity to effect change through learning. Knowledge application capacity underpins the emergence of the application process and the advancement of knowledge through it. We find that different elements of capacity are important to different stages of the knowledge application process. Capacity can pre-exist, or can be acquired. The majority of the capacity elements required for successful knowledge application in the LTC contexts we studied were organizational. It is essential for managers and practitioners therefore to conceptualize and orchestrate knowledge application initiatives at the organization level; organizational leaders (including clinical leaders) have a vital role to play in the success of knowledge application processes.

Health decision making: lynchpin of evidence-based practice

Health decision making is both the lynchpin and the least developed aspect of evidence-based practice. The evidence-based practice process requires integrating the evidence with consideration of practical resources and patient preferences and doing so via a process that is genuinely collaborative. Yet, the literature is largely silent about how to accomplish integrative, shared decision making.

IMPLICATIONS

for evidence-based practice are discussed for 2 theories of clinician decision making (expected utility and fuzzy trace) and 2 theories of patient health decision making (transtheoretical model and reasoned action). Three suggestions are offered. First, it would be advantageous to have theory-based algorithms that weight and integrate the 3 data strands (evidence, resources, preferences) in different decisional contexts. Second, patients, not providers, make the decisions of greatest impact on public health, and those decisions are behavioral. Consequently, theory explicating how provider-patient collaboration can influence patient lifestyle decisions made miles from the provider's office is greatly needed. Third, although the preponderance of data on complex decisions supports a computational approach, such an approach to evidence-based practice is too impractical to be widely applied at present. More troublesomely, until patients come to trust decisions made computationally more than they trust their providers' intuitions, patient adherence will remain problematic. A good theory of integrative, collaborative health decision making remains needed.

A work force model to support the adoption of best practice care in chronic diseases - a missing piece in clinical guideline implementation

The development and implementation of an evidence-based approach to health workforce planning is a necessary step to achieve access to best practice chronic disease management. In its absence, the widely reported failure in implementation of clinical best practice guidelines is almost certain to continue. This paper describes a demand model to estimate the community-based primary care health workforce consistent with the delivery of best practice chronic disease management and prevention. The model takes a geographic region as the planning frame and combines data about the health status of the regional population by disease category and stage, with best practice guidelines to estimate the clinical skill requirement or competencies for the region. The translation of the skill requirement into a service requirement can then be modelled, incorporating various assumptions about the occupation group to deliver nominated competencies. The service requirement, when compared with current service delivery, defines the gap or surplus in services. The results of the model could be used to inform service delivery as well as a workforce supply strategy.

The use of evidence-based medicine in pediatrics: past, present and future

PURPOSE OF REVIEW

Evidence-based medicine is a process that seeks to integrate the best research evidence with clinical expertise and patient values in order to optimize clinical outcomes for our patients. This article will review the benefits of and barriers to the use of evidence-based medicine in pediatrics in the twenty-first century, discuss various implementation strategies and outline the resources that pediatricians could use to increase their knowledge and skills and apply them to their clinical practice.

RECENT FINDINGS

Although physicians have generally welcomed evidence-based medicine, the benefits and limitations are often debated, and studies reveal that physicians feel that practicing evidence-based medicine could be difficult in a busy clinical practice because they lack the time, knowledge and resources. There have been many recent developments to help pediatricians overcome these barriers and to use best evidence in their practice.

SUMMARY

Pediatricians must be able to use the evidence-based medicine process to identify, access, apply and integrate new knowledge into their practice to provide high-quality care for their patients. The resources discussed in this review will help pediatricians make clinical decisions about patient care that are based on the best, most current, valid, and relevant evidence available.

When is knowledge ripe for primary care? An exploratory study on the meaning of evidence

The objectives of this study were to explore the meaning of scientific evidence as it is understood by primary care physicians. Individual interviews were conducted with actors chosen for their roles in the production and use of knowledge: 22 family physicians, 13 specialist physicians, and 6 researchers. Two situations served as points of reference for these discussions: screening for genetic breast cancer and treatment of hypertension. The results suggest that there may be a misunderstanding between the producers of knowledge and primary care practitioners with respect to what constitutes "evidence"--knowledge ready for integration into the clinical practice of primary care. These potential differences go beyond the issues of how information is disseminated. Rather, many of the questions raised by family physicians concern how knowledge is developed. In the interests of fostering better dissemination of new knowledge and encouraging its adoption, new links should be created between knowledge "producers" and potential users.

Adjuvant therapy for resected gastric cancer--rapid, yet incomplete adoption following results of intergroup 0116 trial

PURPOSE

The Southwest Oncology Group/Intergroup 0116 (INT-0116) trial showed that adjuvant chemoradiotherapy improves survival in high-risk gastric adenocarcinoma patients. This study examined the adoption of adjuvant treatment following the trial results and the factors associated with its use.

METHODS AND MATERIALS

Between 1996 and 2003, patients aged 18-85 years with resected gastric adenocarcinoma were identified in the Surveillance, Epidemiology, and End Results (SEER) database and classified as diagnosed before (January 1996 to April 2000) or after (May 2000 to December 2003) presentation of the INT-0116 trial findings. Univariate and multivariable models were used to determine the factors associated with use of adjuvant radiotherapy (RT).

RESULTS

Of 10,230 patients studied, 14.6% were given adjuvant RT before the INT-0116 trial, increasing to 30.4% afterward (p<0.001). Significant increases in adjuvant RT from before to after INT-0116 were seen in all demographic categories. Younger patients were significantly more likely to receive adjuvant RT (44.5%, 18-59 years; 31.0%, 60-74 years; and 12.6%, 75-85 years, p<0.0001). Married patients were significantly more likely to receive adjuvant RT (30.9%) than were unmarried patients (23.6%, p<0.001). A greater depth of tumor invasion, worse nodal status, and more lymph nodes assessed were associated with adjuvant RT (p<0.0001). The rate of adjuvant RT varied from 22.9-44.2% across SEER regions. On multiple logistic regression analysis, age, SEER region, marital status, assessed lymph nodes, tumor depth, and nodal status were all significant independent predictors of the use of adjuvant RT.

CONCLUSION

Use of adjuvant RT doubled after the INT-0116 trial results became public; however, the fraction of patients receiving adjuvant RT is still low. Additional examination of the statistically significant and clinically relevant variability between different SEER regions, tumor characteristics, and patient demographics is warranted.

Proximity morality in medical school--medical students forming physician morality "on the job": grounded theory analysis of a student survey

BACKGROUND

The value of ethics education have been questioned. Therefore we did a student survey on attitudes about the teaching of ethics in Swedish medical schools.

METHODS

Questionnaire survey on attitudes to ethics education with 409 Swedish medical students participating. We analyzed > 8000 words of open-ended responses and multiple-choice questions using classic grounded theory procedures.

RESULTS

In this paper we suggest that medical students take a proximity morality stance towards their ethics education meaning that they want to form physician morality "on the job". This involves comprehensive ethics courses in which quality lectures provide "ethics grammar" and together with attitude exercises and vignette reflections nurture tutored group discussions. Goals of forming physician morality are to develop a professional identity, handling diversity of religious and existential worldviews, training students described as ethically naive, processing difficult clinical experiences, and desisting negative role modeling from physicians in clinical or teaching situations, some engaging in "ethics suppression" by controlling sensitive topic discussions and serving students politically correct attitudes.

CONCLUSION

We found that medical students have a proximity morality attitude towards ethics education. Rather than being taught ethics they want to form their own physician morality through tutored group discussions in comprehensive ethics courses.

Reincentivizing--a new theory of work and work absence

Background

Work capacity correlates weakly to disease concepts, which in turn are insufficient to explain sick leave behavior. With data mainly from Sweden, a welfare state with high sickness absence rates, our aim was to develop an explanatory theory of how to understand and deal with work absence and sick leave.

Methods

We used classic grounded theory for analyzing data from >130 interviews with people working or on sick leave, physicians, social security officers, and literature. Several hundreds of typed and handwritten memos were the basis for writing up the theory.

Results

In this paper we present a theory of work incentives and how to deal with work absence. We suggest that work disability can be seen as hurt work drivers or people caught in mode traps. Work drivers are specified as work capacities + work incentives, monetary and non-monetary. Also, people can get trapped in certain modes of behavior through changed capacities or incentives, or by inertia. Different modes have different drivers and these can trap the individual from reincentivizing, ie from going back to work or go on working. Hurt drivers and mode traps are recognized by driver assessments done on several different levels. Mode driver calculations are done by the worker. Then follows employer, physician, and social insurance officer assessments. Also, driver assessments are done on the macro level by legislators and other stakeholders. Reincentivizing is done by different repair strategies for hurt work drivers such as body repair, self repair, work-place repair, rehumanizing, controlling sick leave insurance, and strengthening monetary work incentives. Combinations of these driver repair strategies also do release people from mode traps.

Conclusion

Reincentivizing is about recognizing hurt work drivers and mode traps followed by repairing and releasing the same drivers and traps. Reincentivizing aims at explaining what is going on when work absence is dealt with and the theory may add to social psychological research on work and work absence, and possibly inform sick leave policies.