The representation of risk in routine medical experience: what actions for contemporary health policy?

Philosophy leading the way: An interdisciplinary approach to study communication of severe diagnoses

This paper explores a brand-new interdisciplinary approach applied to an enduring problem: the communication of severe diagnoses. The moment when physicians explain the diagnosis to patients and their relatives is sensitive, particularly for a disease that is rarely diagnosed early. The first part of the article is dedicated to the context of this delicate doctor-patient interaction. With this framework in mind, the paper delves into the innovative interdisciplinary methodology developed in the pilot study Communi.CARE, conducted in a hospital in Northern Italy, which focuses on the diagnosis of pancreatic ductal adenocarcinoma (PDAC). SARS-CoV-2 impact on the study development is highlighted. The study aims to explore the topic by combining different areas of expertise, including medicine, philosophy, sociology, and psychology. The contribution of philosophy is here presented as essential: it has a leading role in the conception of the study, its development, and the elaboration of results. It is shown throughout the study, from methodology to the analysis of results. Strengths and weaknesses of the methodology are discussed. In conclusion, further philosophical considerations on effective and ethical communication in this delicate context are recommended.

Implicit understandings and trust in the doctor-patient relationship: a philosophy of language analysis of pre-operative evaluations

The aim of this paper is to enhance doctors' awareness of implicit understandings between doctors and patients in the context of pre-operative communication of risks. This paper draws on insights from the philosophy of language - in particular pragmatic analysis tools - that make explicit the implicit understandings of the interaction. Mastering not only what is said but also what is unsaid allows doctors to improve their communication with their patients. I suggest that being aware of the implications of the interactions is useful for improving both the doctor's and the patient's experience, further strengthening the therapeutic alliance. In this article I analyze actual cases involving pre-operative evaluation before cardiac surgery from a philosophy of language perspective. The paper is structured as follows: a description of the relevant philosophy of language tools that I will apply; an overview of the risk-communication context; an explanation of the link between "the implicit dimension" and trust, addressing whether the doctor needs to convey the whole truth; and the analysis of real cases. In conclusion, I re-emphasize the importance of implicit meanings during risk communication.

Choosing Wisely - An international and multimorbid perspective

Some medical diagnostic and therapeutic interventions are non-beneficial or even harmful. The Choosing Wisely campaign has encouraged the generation of "top five" lists of unnecessary low-value services in different specialist areas. In the USA alone, where the campaign was launched, these lists include a total of 450 evidence-based recommendations. Medical scientific societies in further countries such as Canada, Australia, New Zealand, England, Switzerland and Germany have since initiated Choosing Wisely campaigns. Besides implementing top five lists, these aim to change attitudes, expectations and practices in the culture of medicine. The field of internal medicine has initiated change in Switzerland (Swiss Society of General Internal Medicine: Smarter Medicine) and Germany (German Society of Internal Medicine: Klug entscheiden). Formulating Choosing Wisely principles in managing complex patients with multiple concurrent acute or chronic diseases, i. e., multimorbidity (MM), will present a particular challenge. Research is needed to determine the primary sources of overuse in specific combinations of diseases (i. e., MM clusters) and spearhead corresponding recommendations. National Choosing Widely campaigns may serve as a forerunner to a more global initiative.

Value as the key concept in the health care system: how it has influenced medical practice and clinical decision-making processes

In the last 10 years, value has played a key role in the health care system. In this concept, innovations in medical practice and the increasing importance of patient centeredness have contributed to draw the attention of the medical community. Nonetheless, a large consensus on the meaning of "value" is still lacking: patients, physicians, policy makers, and other health care professionals have different ideas on which component of value may play a prominent role. Yet, shared clinical decision-making and patient empowerment have been recognized as fundamental features of the concept of value. Different paradigms of health care system embrace different meanings of value, and the absence of common and widely accepted definition does not help to identify a unique model of care in health care system. Our aim is to provide an overview of those paradigms that have considered value as a key theoretical concept and to investigate how the presence of value can influence the medical practice. This article may contribute to draw attention toward patients and propose a possible link between health care system based on "value" and new paradigms such as patient-centered system (PCS), patient empowerment, and P5 medicine, in order to create a predictive, personalized, preventive, participatory, and psycho-cognitive model to treat patients. Indeed, patient empowerment, value-based system, and P5 medicine seem to shed light on different aspects of a PCS, and this allows a better understanding of people under care.

Health Orientation, Knowledge, and Attitudes toward Genetic Testing and Personalized Genomic Services: Preliminary Data from an Italian Sample

Objective. The study aims at assessing personality tendencies and orientations that could be closely correlated with knowledge, awareness, and interest toward undergoing genetic testing. Methods. A sample of 145 subjects in Italy completed an online survey, investigating demographic data, health orientation, level of perceived knowledge about genetic risk, genetic screening, and personal attitudes toward direct to consumer genetic testing (DTCGT). Results. Results showed that respondents considered genetic assessment to be helpful for disease prevention, but they were concerned that results could affect their life planning with little clinical utility. Furthermore, a very high percentage of respondents (67%) had never heard about genetic testing directly available to the public. Data showed that personality tendencies, such as personal health consciousness, health internal control, health esteem, and confidence, motivation to avoid unhealthiness and motivation for healthiness affected the uptake of genetic information and the interest in undergoing genetic testing. Conclusions. Public knowledge and attitudes toward genetic risk and genetic testing among European countries, along with individual personality and psychological tendencies that could affect these attitudes, remain unexplored. The present study constitutes one of the first attempts to investigate how such personality tendencies could motivation to undergo genetic testing and engagement in lifestyle changes.

Optimistic bias in young adults for cancer, cardiovascular and respiratory diseases: A pilot study on smokers and drinkers

Optimistic bias defines the tendency for human beings to underrate risk when it pertains to themselves compared with their view of risk pertaining to other people in the same conditions. The aim of this work is to investigate the optimistic bias in risk perception and health-related behaviours for three specific conditions in a young adult sample: cancer, respiratory disorders and cardiovascular diseases. Young adults showed an optimistic bias related to cancer, and to cardiovascular diseases. Our findings suggest that optimistic bias is linked to specific behavioural patterns, largely widespread in young adults, such as tobacco cigarette smoking and alcohol consumption.

A Rejoinder

Three commentaries on the Nesselroade and Molenaar target article in this issue are responded to in the interest of elaborating and defending the points of view expressed in our article. The commentaries feature philosophy of science, general structural modeling, and broad behavioral research perspectives. Responding to the commentaries afforded us the opportunity to clarify further matters that we deem critical to the fundamental matter of measurement in behavioral science, especially as it emphasizes (properly, we believe) the individual as the primary unit of analysis.

The choice dilemma in chronic hematological conditions: Why choosing is not only a medical issue? A psycho-cognitive perspective

Research in cognitive psychology focused on risk perception and decision making was shown to facilitate treatment choice and patient's satisfaction with decision in a number of medical conditions, increasing perceived alliance between patient and physician, and adherence to treatment. However, this aspect has been mostly neglected in the literature investigating choice of treatment for chronic hematological conditions. In this paper, a patient centered model and a shared decision making (SDM) approach to treatment switch in chronic hematological conditions, in particular chronic myeloid leukemia, atrial fibrillation, and β-thalassemia is proposed. These pathologies have a series of implications requiring important decisions about new available treatments. Although new generation treatments may provide a significant improvement in patient's health and health-related quality of life (HrQoL), a significant percentage of them is uncertain about or refuse treatment switch, even when strongly suggested by healthcare guidelines. Possible cognitive and emotional factors which may influence decision making in this field and may prevent appropriate risk-and-benefits evaluation of new treatment approaches are reviewed. Possible adaptive strategies to improve quality of care, patient participation, adherence to treatment and final satisfaction are proposed, and implications relatively to new treatment options available are discussed.

What are judgment skills in health literacy? A psycho-cognitive perspective of judgment and decision-making research

OBJECTIVE

The aim of this review is to summarize current research relating to psychological processes involved in judgment and decision-making (JDM) and identify which processes can be incorporated and used in the construct of health literacy (HL) in order to enrich its conceptualization and to provide more information about people's preferences.

METHODS

The literature review was aimed at identifying comprehensive research in the field; therefore appropriate databases were searched for English language articles dated from 1998 to 2015.

RESULTS

Several psychological processes have been found to be constituents of JDM and potentially incorporated in the definition of HL: cognition, self-regulation, emotion, reasoning-thinking, and social perception.

CONCLUSION

HL research can benefit from this JDM literature overview, first, by elaborating on the idea that judgment is multidimensional and constituted by several specific processes, and second, by using the results to implement the definition of "judgment skills". Moreover, this review can favor the development of new instruments that can measure HL.

PRACTICAL IMPLICATIONS

Future researchers in HL should work together with researchers in psychological sciences not only to investigate the processes behind JDM in-depth but also to create effective opportunities to improve HL in all patients, to promote good decisions, and orient patients' preferences in all health contexts.

Translation, cross-cultural adaptation, and reliability, of the Italian version of the Passive Risk Taking (PRT) Scale

The concept of “passive risk taking”, which refers to the risk brought on or magnified by inaction, has recently appeared in the literature on risk taking. Keinan and Bereby-Meyer (2012) have developed a scale to measure the personal tendency for passive risk taking (PRT); the scale has criterion validity and high test-retest reliability; it correlates with reported passive risk taking in everyday life and with the DOSPERT scale. Furthermore, it presents divergent validity from classic risk-taking constructs such as sensation seeking, and convergent validity with procrastination and avoidance. In this paper we propose a validation of the PRT scale in Italian. We performed the linguistic adaptation to Italian via the five steps suggested by Guillemin and colleagues (1993) and Beaton and colleagues (2000); we then submitted the derived questionnaire to a 297-adult sample. Results show that two out of three factors from the original scale were confirmed. However the third factor, originally composed of 6 items, was not consistent. We present the scale derived from such results, and discuss the differences with the original scale.

What Do Physicians Believe About the Way Decisions Are Made? A Pilot Study on Metacognitive Knowledge in the Medical Context

Metacognition relative to medical decision making has been poorly investigated to date. However, beliefs about methods of decision making (metacognition) play a fundamental role in determining the efficiency of the decision itself. In the present study, we investigated a set of beliefs that physicians develop in relation to the modes of making decisions in a professional environment. The Solomon Questionnaire, designed to assess metacognitive knowledge about behaviors and mental processes involved in decision making, was administered to a sample of 18 emergency physicians, 18 surgeons, and 18 internists. Significant differences in metacognitive knowledge emerged among these three medical areas. Physicians' self-reports about the decision process mirrored the peculiarities of the context in which they operate. Their metacognitive knowledge demonstrated a reflective attitude that is an effective tool during the decision making process.

What Do Physicians Believe About the Way Decisions Are Made? A Pilot Study on Metacognitive Knowledge in the Medical Context

Metacognition relative to medical decision making has been poorly investigated to date. However, beliefs about methods of decision making (metacognition) play a fundamental role in determining the efficiency of the decision itself. In the present study, we investigated a set of beliefs that physicians develop in relation to the modes of making decisions in a professional environment. The Solomon Questionnaire, designed to assess metacognitive knowledge about behaviors and mental processes involved in decision making, was administered to a sample of 18 emergency physicians, 18 surgeons, and 18 internists. Significant differences in metacognitive knowledge emerged among these three medical areas. Physicians' self-reports about the decision process mirrored the peculiarities of the context in which they operate. Their metacognitive knowledge demonstrated a reflective attitude that is an effective tool during the decision making process.

Computational Psychometrics in Communication and Implications in Decision Making

Recent investigations emphasized the role of communication features on behavioral trust and reciprocity in economic decision making but no studies have been focused on the effect of communication on affective states in such a context. Thanks to advanced methods of computational psychometrics, in this study, affective states were deeply examined using simultaneous and synchronized recordings of gazes and psychophysiological signals in 28 female students during an investment game. Results showed that participants experienced different affective states according to the type of communication (personal versus impersonal). In particular, participants involved in personal communication felt more relaxed than participants involved in impersonal communication. Moreover, personal communication influenced reciprocity and participants' perceptions about trust and reciprocity. Findings were interpreted in the light of the Arousal/Valence Model and self-disclosure process.

Cognitive and psychological profiles in treatment compliance: a study in an elderly population with hemophilia

Elderly patients with hemophilia have to face new challenges linked to concomitant pathologies and concurrent use of different treatments. In order to promote optimal care in the elderly hemophilia population, this study is aimed to analyze treatment compliance in relation to the presence of comorbidities and the role of potential determinants that can affect compliance (positively or negatively), including health-related quality of life, cognitive decline, and sociodemographic parameters (eg, living situation, partnership, presence of caregivers). This will be an observational study of elderly patients with hemophilia (aged >60 years). Patients will be interviewed during their routine medical visits. The data interview will pertaining to several dimension of treatment management. This study will detect more vulnerable patients with special care needs and will highlight psychological factors that should be considered for future psychosocial interventions.

A Cohort Pilot Study on HIV-Associated Neuropsychological Impairments in Hemophilia Patients

Despite advances in the management of HIV infection with the introduction of combination antiretroviral therapy, it is well known that HIV can directly infect the central nervous system and, as a result of such infection, neuropsychological impairments can be manifested. In this study, we tried to determine whether seropositivity was associated with a poor neuropsychological performance in patients with hemophilia and HIV. Such a cohort of patients is very often underrepresented and understudied in the HIV literature. To amend such a gap, we carried out an extensive neuropsychological evaluation on these patients, and compared their performance with that of a group of seronegative hemophilia patients. The results revealed that HIV infection in HIV-seropositive (HIV+) hemophilia patients was associated with deficits in attention, short-term memory, abstraction, and visual recognition. Such results are still preliminary and explorative due to the small cohort of patients enrolled. However, the results do seem to have some important implications for day-to-day functioning, as the level of impairment detected may cause difficulties in completing common everyday tasks such as maintaining adherence to complex medication regimens or maintaining social life activities. Continued research into the mechanisms related to HIV and neurocognitive dysfunction may provide targets for interventions that could have meaningful consequences in the real world for HIV hemophilia patients.

Interactive sections of an Internet-based intervention increase empowerment of chronic back pain patients: randomized controlled trial

Background

Chronic back pain (CBP) represents a significant public health problem. As one of the most common causes of disability and sick leave, there is a need to develop cost-effective ways, such as Internet-based interventions, to help empower patients to manage their disease. Research has provided evidence for the effectiveness of Internet-based interventions in many fields, but it has paid little attention to the reasons why they are effective.

Objective

This study aims to assess the impact of interactive sections of an Internet-based self-management intervention on patient empowerment, their management of the disease, and, ultimately, health outcomes.

Methods

A total of 51 patients were recruited through their health care providers and randomly assigned to either an experimental group with full access to the Internet-based intervention or a control group that was denied access to the interactive sections and knew nothing thereof. The intervention took 8 weeks. A baseline, a mid-term after 4 weeks, and a final assessment after 8 weeks measured patient empowerment, physical exercise, medication misuse, and pain burden.

Results

All patients completed the study. Overall, the intervention had a moderate effect (F_1.52=2.83, P=.03, η²=0.30, d=0.55). Compared to the control group, the availability of interactive sections significantly increased patient empowerment (midterm assessment: mean difference=+1.2, P=.03, d=0.63; final assessment: mean difference=+0.8, P=.09, d=0.44) and reduced medication misuse (midterm assessment: mean difference=−1.5, P=.04, d=0.28; final assessment: mean difference=−1.6, P=.03, d=−0.55) in the intervention group. Both the frequency of physical exercise and pain burden decreased, but to equal measures in both groups.

Conclusions

Results suggest that interactive sections as part of Internet-based interventions can positively alter patients’ feelings of empowerment and help prevent medication misuse. Detrimental effects were not observed.

Trial Registration

ClinicalTrials.gov: NCT02114788; http://www.clinicaltrials.gov/ct2/show/NCT02114788 (Archived by WebCite at http://www.webcitation.org/6ROXYVoPR).

A preliminary mixed-method investigation of trust and hidden signals in medical consultations

Background

Several factors influence patients' trust, and trust influences the doctor-patient relationship. Recent literature has investigated the quality of the personal relationship and its dynamics by considering the role of communication and the elements that influence trust giving in the frame of general practitioner (GP) consultations.

Objective

We analysed certain aspects of the interaction between patients and GPs to understand trust formation and maintenance by focusing on communication channels. The impact of socio-demographic variables in trust relationships was also evaluated.

Method

A cross-sectional design using concurrent mixed qualitative and quantitative research methods was employed. One hundred adults were involved in a semi-structured interview composed of both qualitative and quantitative items for descriptive and exploratory purposes. The study was conducted in six community-based departments adjacent to primary care clinics in Trento, Italy.

Results

The findings revealed that patients trusted their GP to a high extent by relying on simple signals that were based on the quality of the one-to-one communication and on behavioural and relational patterns. Patients inferred the ability of their GP by adopting simple heuristics based mainly on the so-called social “honest signals” rather than on content-dependent features. Furthermore, socio-demographic variables affected trust: less literate and elderly people tended to trust more.

Conclusions

This study is unique in attempting to explore the role of simple signals in trust relationships within medical consultation: people shape trust and give meaning to their relationships through a powerful channel of communication that orbits not around words but around social relations. The findings have implications for both clinicians and researchers. For doctors, these results suggest a way of thinking about encounters with patients. For researchers, the findings underline the importance of analysing some new key factors around trust for future investigations in medical practice and education.