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Turbitt E, Bourne M, McEwen A, Amor DJ. Parents' preferences for receiving and discussing prognostic genetic information regarding their children's neurodevelopmental condition: A qualitative study. Dev Med Child Neurol 2024; 66:872-881. [PMID: 38111102 DOI: 10.1111/dmcn.15830] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 11/16/2023] [Accepted: 11/20/2023] [Indexed: 12/20/2023]
Abstract
AIM To investigate parents' preferences and motivations for receiving and discussing prognostic genetic test results. METHOD We used a cross-sectional, interpretive description qualitative study design. We collected data through semi-structured interviews with Australian parents, which we analysed using reflexive thematic analysis. RESULTS Parents (n = 32) had a child or children with a genetic neurodevelopmental condition, such as fragile X syndrome, DiGeorge (22q11.2 deletion) syndrome, or Angelman syndrome. Parents of mildly impacted or older children were tolerant to prognostic uncertainty. Parents found conversations about their child's prognosis emotional and preferred to discuss their child's potential strengths and challenges. While most were enthusiastic about prognostic tests and described many motivations for testing, the potential for prognostic information to contribute to a loss of hope and stigmatizing societal views were also discussed. INTERPRETATION Parents had mixed preferences and motivations for acquiring prognostic genetic information about their child, contrasting evidence in other contexts such as cancer where parents typically have minimal tolerance of uncertainty. Health professionals should consider strength-based framing of prognostic information gained from current and emerging technologies when returning results to families. WHAT THIS PAPER ADDS Parents had varied views about receiving prognostic information on their children's neurodevelopmental condition. Some parents preferred prognostic uncertainty about their children's genetic neurodevelopmental condition.
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Affiliation(s)
- Erin Turbitt
- Discipline of Genetic Counselling, University of Technology Sydney, Ultimo, NSW, Australia
| | - Meg Bourne
- Discipline of Genetic Counselling, University of Technology Sydney, Ultimo, NSW, Australia
| | - Alison McEwen
- Discipline of Genetic Counselling, University of Technology Sydney, Ultimo, NSW, Australia
| | - David J Amor
- Murdoch Children's Research Institute, Parkville, VIC, Australia
- Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia
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Rodenbach RA, Thordardottir T, Brauer M, Hall AC, Ward E, Smith CB, Campbell TC. Balancing risks and rewards: How hematologists discuss uncertainty in allogeneic hematopoietic cell transplantation outcomes. PATIENT EDUCATION AND COUNSELING 2024; 123:108177. [PMID: 38341898 PMCID: PMC10997451 DOI: 10.1016/j.pec.2024.108177] [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: 09/22/2023] [Revised: 01/11/2024] [Accepted: 01/26/2024] [Indexed: 02/13/2024]
Abstract
OBJECTIVE Allogeneic hematopoietic cell transplant (alloHCT) offers many patients with blood cancers a chance of cure but carries risks. We characterized how hematologists discuss the high-risk, high-reward concept of alloHCT. METHODS Qualitative analysis of video-recorded virtual encounters of hematologists who routinely perform alloHCT with actors portraying an older man recently diagnosed with high-risk myelodysplastic syndrome. RESULTS Hematologists (n = 37) were a median age of 44 years, 65% male, and 68% white. They frequently used "teeter-totter" language that juxtaposed alloHCT's risks and rewards in a dynamic, quickly alternating fashion and communicated uncertainty in transplant outcomes. This dialogue oscillated between encouragement about alloHCT's potential for cure and caution about its risks and occurred within single speech turns and in exchanges between hematologist and patient. Fewer hematologists outlined their big-picture stance on transplant's risks and benefits early in the conversation. Meanwhile, hematologists varied in how they counseled patients to manage transplant-related uncertainty and consider treatment decision making. CONCLUSION Hematologists use "teeter-totter" language to express hope and concern, confidence and uncertainty, and encouragement and caution about the high-risk, high-reward nature of alloHCT. PRACTICE IMPLICATIONS Teeter-totter language may help frame big-picture content about alloHCT's risks and benefits that is essential for patient education and decision making.
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Affiliation(s)
| | | | - Markus Brauer
- University of Wisconsin Department of Psychology, Madison, WI, USA
| | - Aric C Hall
- University of Wisconsin Carbone Cancer Center, Madison, WI, USA
| | - Earlise Ward
- University of Wisconsin Carbone Cancer Center, Madison, WI, USA; University of Wisconsin School of Medicine and Public Health, Department of Family Medicine and Community Health, Madison, WI, USA
| | | | - Toby C Campbell
- University of Wisconsin Carbone Cancer Center, Madison, WI, USA
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Thompson CM, Pulido MD, Gangidi S, Arnold P. How Chronic Pain Patients' and Physicians' Communication Influences Patients' Uncertainty: A Pre- and Post-Consultation Study. JOURNAL OF HEALTH COMMUNICATION 2024; 29:357-370. [PMID: 38742771 DOI: 10.1080/10810730.2024.2352556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
Chronic pain is a health problem that is difficult to diagnose, treat, and manage, partly owing to uncertainty surrounding ambiguous causes, few treatment options, and frequent misunderstandings in clinical encounters. Pairing uncertainty management theory with medical communication competence, we predicted that both physicians and patients are influential to patients' uncertainty appraisals and uncertainty management. We collected pre- and post-consultation data from 200 patients with chronic neck and spine/back pain and their physicians. Patients' reports of their physician's communication were a consistent predictor of their post-consultation uncertainty outcomes. Physicians' reports of both their own and patients' communication competence were associated with patients' positive uncertainty appraisals. Physicians' reports of patients' communication competence were also associated with reductions in patients' uncertainty. Findings illustrate how both interactants' perceptions of communication competence-how they view their own (for physicians) and the other's-are associated with patients' post-consultation outcomes.
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Affiliation(s)
- Charee M Thompson
- Department of Communication, University of Illinois Urbana-Champaign, Champaign, Illinois, USA
| | - Manuel D Pulido
- Department of Communication Studies, California State University, Long Beach, California, USA
| | - Suma Gangidi
- Carle Illinois College of Medicine, University of Illinois Urbana-Champaign, Champaign, Illinois, USA
| | - Paul Arnold
- Carle Illinois College of Medicine, University of Illinois Urbana-Champaign, Champaign, Illinois, USA
- Department of Neurosurgery, Carle Foundation Hospital, Urbana, Illinois, USA
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Singh S, Degeling C, Drury P, Montgomery A, Caputi P, Deane FP. Nurses' Anxiety Mediates the Relationship between Clinical Tolerance to Uncertainty and Antibiotic Initiation Decisions in Residential Aged-Care Facilities. Med Decis Making 2024; 44:415-425. [PMID: 38532728 PMCID: PMC11102643 DOI: 10.1177/0272989x241239871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 02/06/2024] [Indexed: 03/28/2024]
Abstract
HIGHLIGHTS The impact of non-clinical factors (e.g., resident and family preferences) on prescribing is well-established. There is a gap in the literature regarding the mechanisms through which these preferences are experienced as pressure by prescribers within the unique context of residential aged-care facilities (RACFs).A significant relationship was found between nurses' anxiety, clinical tolerance of uncertainty, and the perceived need for antibiotics and assessment.As such, there is a need to expand stewardship beyond education alone to include interventions that help nurses manage uncertainty and anxiety and include other stakeholders (e.g., family members) when making clinical decisions in the RACF setting.
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Affiliation(s)
- Saniya Singh
- School of Psychology, University of Wollongong, Wollongong, NSW, Australia
- Australian Centre for Health Engagement, Evidence and Values, School of Health and Society, University of Wollongong, Wollongong NSW, Australia
| | - Chris Degeling
- Australian Centre for Health Engagement, Evidence and Values, School of Health and Society, University of Wollongong, Wollongong NSW, Australia
| | - Peta Drury
- School of Nursing, University of Wollongong, Wollongong NSW, Australia
| | - Amy Montgomery
- School of Nursing, University of Wollongong, Wollongong NSW, Australia
| | - Peter Caputi
- School of Psychology, University of Wollongong, Wollongong, NSW, Australia
| | - Frank P. Deane
- School of Psychology, University of Wollongong, Wollongong, NSW, Australia
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Singh S, Degeling C, Drury P, Montgomery A, Caputi P, Deane FP. What influences antibiotic initiation? Developing a scale to measure nursing behaviour in residential aged-care facilities. Nurs Open 2024; 11:e2184. [PMID: 38804158 PMCID: PMC11130760 DOI: 10.1002/nop2.2184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 03/29/2024] [Accepted: 04/25/2024] [Indexed: 05/29/2024] Open
Abstract
AIM The purpose of the current study was to develop and assess the psychometric properties of a measure that captures nursing behaviours that have the potential to influence the initiation of antibiotics in residential aged-care facilities. DESIGN Cross-sectional online survey. METHOD One hundred and fifty-seven nurses completed an online survey. The survey consisted of two clinical vignettes and measures of tolerance of uncertainty and anxiety. The vignettes consisted of the most common presentations (urinary tract infections and upper respiratory tract infections) of two hypothetical residents in aged-care facilities. The vignettes provided participants with incremental information with varying levels of symptoms, input from other people and availability of test results. Both vignettes were subjected to exploratory factor analysis. RESULTS The results focus on the 16 items in the second vignette which resulted in the extraction of three factors. The derived factors were labelled as follows: (i) Noting and Calling GP, (ii) Consult a Colleague and (iii) Immediate Assessment and Antibiotics. Reliability analysis revealed excellent to satisfactory reliability. All three scales were significantly correlated with measures of clinical tolerance of uncertainty, and the 'noting and calling GP' scale was also negatively correlated with measures of anxiety and general tolerance of uncertainty. The measure showed satisfactory reliability and validity for capturing nursing behaviours that have the potential to influence decisions regarding antibiotics. As such, the current study provides a first step towards addressing the lack of ecologically valid measures that capture the complex and nuanced context of nurses' behaviours in RACF that have the potential to inform future stewardship interventions.
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Affiliation(s)
- Saniya Singh
- School of PsychologyUniversity of WollongongWollongongNew South WalesAustralia
- Australian Centre for Health Engagement, Evidence and Values, School of Health and SocietyUniversity of WollongongWollongongNew South WalesAustralia
| | - Chris Degeling
- Australian Centre for Health Engagement, Evidence and Values, School of Health and SocietyUniversity of WollongongWollongongNew South WalesAustralia
| | - Peta Drury
- School of NursingUniversity of WollongongWollongongNew South WalesAustralia
| | - Amy Montgomery
- School of NursingUniversity of WollongongWollongongNew South WalesAustralia
| | - Peter Caputi
- School of PsychologyUniversity of WollongongWollongongNew South WalesAustralia
| | - Frank P. Deane
- School of PsychologyUniversity of WollongongWollongongNew South WalesAustralia
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Gardner NP, Gormley GJ, Kearney GP. Learning to navigate uncertainty in primary care: a scoping literature review. BJGP Open 2024:BJGPO.2023.0191. [PMID: 38097267 DOI: 10.3399/bjgpo.2023.0191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 11/28/2023] [Accepted: 12/12/2023] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Clinical practice occurs in the context of uncertainty. Primary care is a clinical environment that accepts and works with uncertainty differently from secondary care. Recent literature reviews have contributed to understanding how clinical uncertainty is taught in educational settings and navigated in secondary care, and, to a lesser extent, by experienced GPs. We do not know how medical students and doctors in training learn to navigate uncertainty in primary care. AIM To explore what is known about primary care as an opportunity for learning to navigate uncertainty. DESIGN & SETTING Scoping review of articles written in English. METHOD Using a scoping review methodology, Embase, MEDLINE, and Web of Science databases were searched, with additional articles obtained through citation searching. Studies were included in this review if they: (a) were based within populations of medical students and/or doctors in training; and (b) considered clinical uncertainty or ambiguity in primary care or a simulated primary care setting. Study findings were analysed thematically. RESULTS Thirty-six studies were included from which the following three major themes were developed: uncertainty contributes to professional identity formation (PIF); adaptive responses; and maladaptive behaviours. Relational and social factors that influence PIF were identified. Adaptive responses included adjusting epistemic expectations and shared decision making (SDM). CONCLUSION Educators can play a key role in helping learners navigate uncertainty through socialisation, discussing primary care epistemology, recognising maladaptive behaviours, and fostering a culture of constructive responses to uncertainty.
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Affiliation(s)
- Nick P Gardner
- Centre for Medical Education, Queen's University Belfast, Whitla Medical Building, Belfast, Northern Ireland
| | - Gerard J Gormley
- Centre for Medical Education, Queen's University Belfast, Whitla Medical Building, Belfast, Northern Ireland
| | - Grainne P Kearney
- Centre for Medical Education, Queen's University Belfast, Whitla Medical Building, Belfast, Northern Ireland
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Etkind SN, Barclay S, Spathis A, Hopkins SA, Bowers B, Koffman J. Uncertainty in serious illness: A national interdisciplinary consensus exercise to identify clinical research priorities. PLoS One 2024; 19:e0289522. [PMID: 38422036 PMCID: PMC10903860 DOI: 10.1371/journal.pone.0289522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 01/16/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND Serious illness is characterised by uncertainty, particularly in older age groups. Uncertainty may be experienced by patients, family carers, and health professionals about a broad variety of issues. There are many evidence gaps regarding the experience and management of uncertainty. AIM We aimed to identify priority research areas concerning uncertainty in serious illness, to ensure that future research better meets the needs of those affected by uncertainty and reduce research inefficiencies. METHODS Rapid prioritisation workshop comprising five focus groups to identify research areas, followed by a ranking exercise to prioritise them. Participants were healthcare professionals caring for those with serious illnesses including geriatrics, palliative care, intensive care; researchers; patient/carer representatives, and policymakers. Descriptive analysis of ranking data and qualitative framework analysis of focus group transcripts was undertaken. RESULTS Thirty-four participants took part; 67% female, mean age 47 (range 33-67). The highest priority was communication of uncertainty, ranked first by 15 participants (overall ranking score 1.59/3). Subsequent priorities were: 2) How to cope with uncertainty; 3) healthcare professional education/training; 4) Optimising clinical approaches to uncertainty; and 5) exploring in-depth experiences of uncertainty. Research questions regarding optimal management of uncertainty were given higher priority than questions about experiences of uncertainty and its impact. CONCLUSIONS These co-produced, clinically-focused research priorities map out key evidence gaps concerning uncertainty in serious illness. Managing uncertainty is the most pressing issue, and researchers should prioritise how to optimally manage uncertainty in order to reduce distress, unlock decision paralysis and improve illness and care experience.
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Affiliation(s)
- Simon N. Etkind
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Stephen Barclay
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Anna Spathis
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Sarah A. Hopkins
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Ben Bowers
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Jonathan Koffman
- Hull York Medical School, University of Hull, Hull, United Kingdom
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Cox C, Hatfield T, Fritz Z. How and why do doctors communicate diagnostic uncertainty: An experimental vignette study. Health Expect 2024; 27:e13957. [PMID: 38828702 DOI: 10.1111/hex.13957] [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] [Received: 09/20/2023] [Revised: 12/14/2023] [Accepted: 12/16/2023] [Indexed: 06/05/2024] Open
Abstract
BACKGROUND Diagnostic uncertainty is common, but its communication to patients is under-explored. This study aimed to (1) characterise variation in doctors' communication of diagnostic uncertainty and (2) explore why variation occurred. METHODS Four written vignettes of clinical scenarios involving diagnostic uncertainty were developed. Doctors were recruited from five hospitals until theoretical saturation was reached (n = 36). Participants read vignettes in a randomised order, and were asked to discuss the diagnosis/plan with an online interviewer, as they would with a 'typical patient'. Semi-structured interviews explored reasons for communication choices. Interview transcripts were coded; quantitative and qualitative (thematic) analyses were undertaken. RESULTS There was marked variation in doctors' communication: in their discussion about differential diagnoses, their reference to the level of uncertainty in diagnoses/investigations and their acknowledgement of diagnostic uncertainty when safety-netting. Implicit expressions of uncertainty were more common than explicit. Participants expressed both different communication goals (including reducing patient anxiety, building trust, empowering patients and protecting against diagnostic errors) and different perspectives on how to achieve these goals. Training in diagnostic uncertainty communication is rare, but many felt it would be useful. CONCLUSIONS Significant variation in diagnostic uncertainty communication exists, even in a controlled setting. Differing communication goals-often grounded in conflicting ethical principles, for example, respect for autonomy versus nonmaleficence-and differing ideas on how to prioritise and achieve them may underlie this. The variation in communication behaviours observed has important implications for patient safety and health inequalities. Patient-focused research is required to guide practice. PATIENT OR PUBLIC CONTRIBUTION In the design stage of the study, two patient and public involvement groups (consisting of members of the public of a range of ages and backgrounds) were consulted to gain an understanding of patient perspectives on the concept of communicating diagnostic uncertainty. Their feedback informed the formulations of the research questions and the choice of vignettes used.
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Affiliation(s)
- Caitríona Cox
- The Healthcare Improvement Studies (THIS) Institute, University of Cambridge, Cambridge, UK
| | - Thea Hatfield
- The Healthcare Improvement Studies (THIS) Institute, University of Cambridge, Cambridge, UK
| | - Zoë Fritz
- The Healthcare Improvement Studies (THIS) Institute, University of Cambridge, Cambridge, UK
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Poço PCE, Collares CF, Haydar A, de Oliveira VB, de Arruda Martins M, Tempski PZ. Measurement of uncertainty tolerance revisited. CLINICAL TEACHER 2023; 20:e13619. [PMID: 37608765 DOI: 10.1111/tct.13619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 07/10/2023] [Indexed: 08/24/2023]
Abstract
INTRODUCTION Uncertainty tolerance (UT) is attracting increasing attention in medical education due to the numerous challenges associated with uncertainty in professional life. Inconsistencies in analysing the relationship between UT and moderators may arise from inadequate measurement methods. Most instruments were formulated before the most widely accepted framework was published. Our aim was to investigate the validity of an UT scale using an actual framework to corroborate with better and accurate instruments. METHODS A total of 1052 students were invited. Various psychometric methods were used to explore validity of the TAMSAD scale in light of actual framework. Classic exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were performed. Secondly, content item classification was triangulated with exploratory graph analysis (EGA), and the new EFA, CFA, and cognitive diagnostic modelling (CDM) analysis were conducted. The reliability was calculated using Cronbach's alpha and McDonald's omega. RESULTS A total of 694 students (65.9%) responded to the questionnaire. The reliability of the TAMSAD scale was 0.782. The initial EFA revealed no clear interpretable dimensions. The TAMSAD scale items can be classified into sources of uncertainty. The EGA has three dimensions, and the new EFA led to a 17-item TAMSAD scale with the following three dimensions: ambiguity, complexity, and probability. These dimensions lead to better adjustment fit indices in the new CFA and CDM analyses. CONCLUSION We found evidence that the TAMSAD scale can be considered a multidimensional scale, organised in terms of sources of uncertainty.
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Affiliation(s)
- Paula Cristina Eiras Poço
- Faculdade São Leopoldo Mandic, Campinas, Brazil
- Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | - Ahmed Haydar
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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Ingram S, Stenner R, May S. The experiences of uncertainty amongst musculoskeletal physiotherapists in first contact practitioner roles within primary care. Musculoskeletal Care 2023; 21:644-654. [PMID: 36683250 DOI: 10.1002/msc.1735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 01/09/2023] [Accepted: 01/10/2023] [Indexed: 01/24/2023]
Abstract
AIM The aim of this research was to explore the experiences of uncertainty amongst Musculoskeletal First Contact Practitioners working in primary care. BACKGROUND The Musculoskeletal First Contact Practitioner role involves advanced physiotherapists providing an alternative to the GP by acting as first point of contact for people presenting to primary care with musculoskeletal conditions. Limited research into the role exists but the first-contact aspect, clinical complexity and time pressures are deemed to contribute to uncertainty within the role. METHOD A qualitative research design was undertaken using a hermeneutic interpretative phenomenological approach. Data was collected using semi-structured interviews with subsequent thematic analysis of the data. FINDINGS Eight participants working as Musculoskeletal First Contact Practitioners across England were recruited using purposive sampling. Five themes were identified: (1) Role clarity within primary care, (2) Burden of responsibility, (3) Preparedness for the primary care environment, (4) 'I'm not really sure how long I am going to stay in this role', (5) Mitigating uncertainty. CONCLUSION This study demonstrates the multifaceted phenomenon of uncertainty amongst Musculoskeletal First Contact Practitioners. Uncertainty appeared to be influenced by the primary care environment, preparedness for the role and perceived burden of responsibility. Diagnostic uncertainty was prevalent with concerns of missing serious pathology evident. The impact of uncertainty on wellbeing was linked to possible burnout and retention issues. Consultation approaches, access to support networks and a cultural shift in tolerating uncertainty were reported to mitigate uncertainty. Further research into possible differences in experiences related to employment models appears warranted.
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Affiliation(s)
- Simon Ingram
- Somerset NHS Foundation Trust, Musgrove Park Hospital, Taunton, Somerset, UK
| | - Rob Stenner
- Somerset NHS Foundation Trust, Musgrove Park Hospital, Taunton, Somerset, UK
| | - Sue May
- School of Health Professions, Peninsula Allied Health Centre, University of Plymouth, Plymouth, Devon, UK
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Orstad S, Fløtten Ø, Madebo T, Gulbrandsen P, Strand R, Lindemark F, Fluge S, Tilseth RH, Schaufel MA. "The challenge is the complexity" - A qualitative study about decision-making in advanced lung cancer treatment. Lung Cancer 2023; 183:107312. [PMID: 37481888 DOI: 10.1016/j.lungcan.2023.107312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 07/15/2023] [Accepted: 07/18/2023] [Indexed: 07/25/2023]
Abstract
INTRODUCTION The value of shared decision-making and decision aids (DA) has been well documented yet remain difficult to integrate into clinical practice. We wanted to investigate needs and challenges regarding decision-making about advanced lung cancer treatment after first-line therapy, focusing on DA applicability. METHODS Qualitative data from separate, semi-structured focus groups with patients/relatives and healthcare professionals were analysed using systematic text condensation. 12 patients with incurable lung cancer, seven relatives, 12 nurses and 18 doctors were recruited from four different hospitals in Norway. RESULTS The participants described the following needs and challenges affecting treatment decisions: 1) Continuity of clinician-patient-relationships as a basic framework for decision-making; 2) barriers to information exchange; 3) negotiation of autonomy; and 4) assessment of uncertainty and how to deal with it. Some clinicians feared DA would steal valuable time and disrupt consultations, arguing that such tools could not incorporate the complexity and uncertainty of decision-making. Patients and relatives reported a need for more information and the possibility both to decline or continue burdensome therapy. Participants welcomed interventions supporting information exchange, like communicative techniques and organizational changes ensuring continuity and more time for dialogue. Doctors called for tools decreasing uncertainty about treatment tolerance and futile therapy. CONCLUSION Our study suggests it is difficult to develop an applicable DA for advanced lung cancer after first-line therapy that meets the composite requirements of stakeholders. Comprehensive decision support interventions are needed to address organizational structures, communication training including scientific and existential uncertainty, and assessment of frailty and treatment toxicity.
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Affiliation(s)
- Silje Orstad
- Department of Thoracic Medicine, Haukeland University Hospital, Bergen, Norway
| | - Øystein Fløtten
- Department of Thoracic Medicine, Haukeland University Hospital, Bergen, Norway; Department of Clinical Science, University of Bergen, Norway
| | - Tesfaye Madebo
- Department of Pulmonary Medicine, Stavanger University Hospital, Stavanger, Norway
| | - Pål Gulbrandsen
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway; Health Services Research Unit HØKH, Akershus University Hospital, Norway
| | - Roger Strand
- Centre for the Study of the Sciences and the Humanities, University of Bergen, Norway
| | - Frode Lindemark
- Department of Thoracic Medicine, Haukeland University Hospital, Bergen, Norway
| | - Sverre Fluge
- Department of Pulmonary Medicine, Haugesund Hospital, Haugesund, Norway
| | | | - Margrethe Aase Schaufel
- Department of Thoracic Medicine, Haukeland University Hospital, Bergen, Norway; Department of Clinical Science, University of Bergen, Norway; Bergen Centre for Ethics and Priority Setting, University of Bergen, Norway.
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Lee C, Hall KH, Anakin M. Finding Themselves, Their Place, Their Way: Uncertainties Identified by Medical Students. TEACHING AND LEARNING IN MEDICINE 2023:1-11. [PMID: 37435723 DOI: 10.1080/10401334.2023.2233003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 05/19/2023] [Accepted: 06/16/2023] [Indexed: 07/13/2023]
Abstract
Phenomenon: Navigating uncertainty is a core skill when practicing medicine. Increasingly, the need to better prepare medical students for uncertainty has been recognized. Our current understanding of medical students' perspectives on uncertainty is primarily based on quantitative studies with limited qualitative research having been performed to date. We need to know from where and how sources of uncertainty can arise so that educators can better support medical students learning to respond to uncertainty. This research's aim was to describe the sources of uncertainty that medical students identify in their education. Approach: Informed by our previously published framework of clinical uncertainty, we designed and distributed a survey to second, fourth-, and sixth-year medical students at the University of Otago, Aotearoa New Zealand. Between February and May 2019, 716 medical students were invited to identify sources of uncertainty encountered in their education to date. We used reflexive thematic analysis to analyze responses. Findings: Four-hundred-sixty-five participants completed the survey (65% response rate). We identified three major sources of uncertainty: insecurities, role confusion, and navigating learning environments. Insecurities related to students' doubts about knowledge and capabilities, which were magnified by comparing themselves to peers. Role confusion impacted upon students' ability to learn, meet the expectations of others, and contribute to patient care. Navigating the educational, social, and cultural features of clinical and non-clinical learning environments resulted in uncertainty as students faced new environments, hierarchies, and identified challenges with speaking up. Insights: This study provides an in-depth understanding of the wide range of sources of medical students' uncertainties, encompassing how they see themselves, their roles, and their interactions with their learning environments. These results enhance our theoretical understanding of the complexity of uncertainty in medical education. Insights from this research can be applied by educators to better support students develop the skills to respond to a core element of medical practice.
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Affiliation(s)
- Ciara Lee
- Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Katherine Helen Hall
- Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Megan Anakin
- Education Unit, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
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Schrager S. How Does Your Garden Grow? Fam Med 2023; 55:424-425. [PMID: 37450844 PMCID: PMC10622063 DOI: 10.22454/fammed.2023.755296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Affiliation(s)
- Sarina Schrager
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI
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Härgestam M, Jacobsson M, Bååthe F, Brulin E. Challenges in preserving the "good doctor" norm: physicians' discourses on changes to the medical logic during the initial wave of the COVID-19 pandemic. Front Psychol 2023; 14:1083047. [PMID: 37359864 PMCID: PMC10285475 DOI: 10.3389/fpsyg.2023.1083047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 05/15/2023] [Indexed: 06/28/2023] Open
Abstract
Introduction The COVID-19 pandemic was a tremendous challenge to the practice of modern medicine. In this study, we use neo-institutional theory to gain an in-depth understanding of how physicians in Sweden narrate how they position themselves as physicians when practicing modern medicine during the first wave of the pandemic. At focus is medical logic, which integrates rules and routines based on medical evidence, practical experience, and patient perspectives in clinical decision-making. Methods To understand how physicians construct their versions of the pandemic and how it impacted the medical logic in which they practice, we analyzed the interviews from 28 physicians in Sweden by discursive psychology. Results The interpretative repertoires showed how COVID-19 created an experience of knowledge vacuum in medical logic and how physicians dealt with clinical patient dilemmas. They had to find unorthodox ways to rebuild a sense of medical evidence while still being responsible for clinical decision-making for patients with critical care needs. Discussion In the knowledge vacuum occurring during the first wave of COVID-19, physicians could not use their common medical knowledge nor rely on published evidence or their clinical judgment. They were thus challenged in their norm of being the "good doctor". One practical implication of this research is that it provides a rich empirical account where physicians are allowed to mirror, make sense, and normalize their own individual and sometimes painful struggle to uphold the professional role and related medical responsibility in the early phases of the COVID-19 pandemic. It will be important to follow how the tremendous challenge of COVID-19 to medical logic plays out over time in the community of physicians. There are many dimensions to study, with sick leave, burnout, and attrition being some interesting areas.
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Affiliation(s)
| | | | - Fredrik Bååthe
- Institute of Stress Medicine, Gothenburg, Sweden
- Institute of Health and Care Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
- Institute for Studies of the Medical Profession, Oslo, Norway
| | - Emma Brulin
- Unit of Occupational Medicine, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
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15
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Kerr AM, Rubinsky V, Duty K. Pediatricians' Communication about Medical Uncertainty: Goal-Oriented Communication and Uncertainty Management. HEALTH COMMUNICATION 2023; 38:1454-1466. [PMID: 34894911 DOI: 10.1080/10410236.2021.2012896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Despite the prevalence of uncertainty in medicine, many physicians experience anxiety as a result of medical uncertainty and are reluctant to discuss uncertainty with others. When pediatricians do disclose uncertainty to parents, they are managing both the parents' and their own feelings of uncertainty. The current study applies uncertainty management theory and multiple goals theory to explore pediatricians' communication about uncertainty. We collected data using in-depth semi-structured interviews with 18 pediatricians. The results suggest that pediatricians prioritize task and relational goals with parents and task and identity goals with fellow physicians. Though, their appraisal of uncertainty influences their goal-oriented communication. The results highlight the relationship between uncertainty management theory and a multiple goals framework. These frameworks provide a valuable approach for gaining a more thorough understanding of pediatrician communication in the context of uncertainty.
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Affiliation(s)
- Anna M Kerr
- Department of Primary Care, Heritage College of Osteopathic Medicine, Ohio University
| | | | - Kayla Duty
- School of Communication Studies, Ohio University
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16
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Pieterse AH, Gulbrandsen P, Ofstad EH, Menichetti J. What does shared decision making ask from doctors? Uncovering suppressed qualities that could improve person-centered care. PATIENT EDUCATION AND COUNSELING 2023; 114:107801. [PMID: 37230040 DOI: 10.1016/j.pec.2023.107801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 05/12/2023] [Accepted: 05/17/2023] [Indexed: 05/27/2023]
Abstract
OBJECTIVE Shared decision making (SDM) is infrequently seen in clinical practice despite four decades of efforts. We propose a need to explore what SDM asks from doctors in terms of enabling competencies and necessary, underlying qualities, and how these can be nurtured or suppressed in medical training. DISCUSSION Key SDM tasks call for doctors to understand communication and decision mechanisms to carry them out well, including reflecting on what they know and do not know, considering what to say and how, and listening unprejudiced to patients. Different doctor qualities can support accomplishing these tasks; humility, flexibility, honesty, fairness, self-regulation, curiosity, compassion, judgment, creativity, and courage, all relevant to deliberation and decision making. Patient deference to doctors, lack of supervised training opportunities with professional feedback, and high demands in the work environment may all inflate the risk of only superficially involving patients. CONCLUSIONS We have identified ten professional qualities and related competencies required for SDM, with each to be selected based on the specific situation. The competencies and qualities need to be preserved and nurtured during doctor identity building, to bridge the gap between knowledge, technical skills, and authentic efforts to achieve SDM.
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Affiliation(s)
- Arwen H Pieterse
- Department of Biomedical Data Sciences, Leiden University Medical Center, 2333 ZA Leiden, the Netherlands.
| | - Pål Gulbrandsen
- Institute of Clinical Medicine, University of Oslo, 0316 Oslo, Norway; Health Services Research Unit (HØKH), Akershus University Hospital, 1478 Lørenskog, Norway
| | - Eirik H Ofstad
- The Medical Clinic, Nordland Hospital Trust, 8005 Bodø, Norway
| | - Julia Menichetti
- Health Services Research Unit (HØKH), Akershus University Hospital, 1478 Lørenskog, Norway
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17
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Kerr AM, Thompson CM, Stewart CA, Rakowsky A. "I Want Them to Still Trust Me with Their Child's Care": A Longitudinal Study of Pediatric Residents' Reactions to and Communication with Parents about Medical Uncertainty across Residency. HEALTH COMMUNICATION 2023; 38:1054-1064. [PMID: 34702092 DOI: 10.1080/10410236.2021.1991637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Physicians in residency training experience high levels of medical uncertainty, yet they are often hesitant to discuss uncertainty with parents. Guided by the theory of motivated information management and a multiple goals perspective, this mixed-methods longitudinal study examines associations among residents' tolerance of and reactions to uncertainty, efficacy communicating about uncertainty, and perceptions of parents' trust in them as physicians. To contextualize these associations, we also examined residents' task, identity, and relational goals when communicating about uncertainty with parents. We surveyed 47 pediatric residents at the beginning of each year of their residency program. As they progressed through their training, residents' uncertainty-related anxiety and reluctance to communicate uncertainty to parents decreased, and their efficacy communicating uncertainty with parents increased. Residents' concerns about bad outcomes remained unchanged. Residents pursued multiple, often conflicting, conversational goals when communicating uncertainty with parents. Results reveal important considerations for addressing how residents can manage their uncertainty in productive ways.
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Affiliation(s)
| | - Charee M Thompson
- Department of Communication, University of Illinois, Urbana-Champaign
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18
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Miller LE, Woo D. "We Aren't Here to Win; We are Here Not to Lose": Emergency Physicians' Communicative Management of Uncertainty. HEALTH COMMUNICATION 2023; 38:1255-1265. [PMID: 34802338 DOI: 10.1080/10410236.2021.2001916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Healthcare providers in hospital emergency departments (EDs) work under high uncertainty and pressure to manage a variety of patients efficiently. Whereas much existing research has examined communicative implications of uncertainty from patients' perspectives, we explored ED physicians' experiences of uncertainty in their everyday work environment. Through an ethnographic fieldwork in an ED, we identified three main sources of uncertainty routinely faced by physicians: (a) patients' incorrect expectation about the role of ED; (b); patient variability and ED physicians' breadth of expertise; and (c) emerging and unexpected changes in patient cases after handoffs. We also found how ED physicians managed these uncertainties, including: (1) direct admission of scientific uncertainty to patients; (2) lowering epistemic uncertainty through swift Internet searches; and (3) maintenance of situational uncertainty. We discuss implications of these findings for researchers, providers, and hospital organizations.
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Affiliation(s)
- Laura E Miller
- School of Communication Studies, University of Tennessee
| | - Dajung Woo
- Department of Communication, Rutgers University
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19
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Meljes I, Slootweg I, Nierkens V, van den Bogaard M, Kramer A. Learning in a real-life escape room: an explorative study on the supervisory relationship in GP residency during the COVID-19 pandemic. BMC PRIMARY CARE 2023; 24:87. [PMID: 37005566 PMCID: PMC10066972 DOI: 10.1186/s12875-023-02031-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 03/09/2023] [Indexed: 04/04/2023]
Abstract
BACKGROUND The relationship between supervisors and residents plays a prominent role in the professional development of general practice (GP) residents. When disruptions occur in the normal course of healthcare, due to effects of e.g. war or emerging epidemics, we need to consider how this may affect the training of the next generation of general practitioners. As both supervisors and residents face new and unprecedented challenges that impact overall quality of the training. In this study, we examined the characteristics of the supervisory relationship in GP training during the disruptions early on during COVID-19. Our aim was to understand better how resident learning is affected in these circumstances, which is a first step in enabling supervisors, residents and faculty to anticipate disruptive situations better in the future. METHODS We conducted a qualitative case study with a constructivist approach. Seven GP residents at the start of their second placement, and their 10 supervisors participated in this study. Participants came from a University Medical Centre in the Netherlands. Semi-structured interviews were held between September 2020 and February 2021. The subjects were (1) interviewed individually about what they had learned regarding COVID-19, and (2) they were interviewed in supervisory pairs about how they had learned. Data were iteratively analysed; thematic analysis for (1) and template analysis in (2). RESULTS We identified notable changes in the supervisor-resident relationship attributable to COVID-19. Supervisors and residents were confronted with an all-encompassing uncertainty in the workplace, and disruptive changes in patient care and learning opportunities for residents. Supervisors and residents addressed these emerging workplace challenges through three types of collaboration, (1) getting the job done; (2) residents' learning; and (3) collective learning. Each type had a different focus and distinctive characteristics of the supervisory relationship. CONCLUSION With the outbreak of COVID-19, supervisors and residents were faced with disruptive uncertainty. In these circumstances, learning occurred not only between residents and their supervisors, but also with non-supervising GPs and assistants in collective learning. We propose to complement collective learning in the workplace with reflection between residents and supervisors at the training institution.
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Affiliation(s)
- Iris Meljes
- Department of Public Health and Primary Care, Leiden University Medical Center, Hippocratespad 21, Zone V0-P, 2300 RC, PO Box 9600, Leiden, The Netherlands.
| | - Irene Slootweg
- Department of Public Health and Primary Care, Leiden University Medical Center, Hippocratespad 21, Zone V0-P, 2300 RC, PO Box 9600, Leiden, The Netherlands
| | - Vera Nierkens
- Department of Public Health and Primary Care, Leiden University Medical Center, Hippocratespad 21, Zone V0-P, 2300 RC, PO Box 9600, Leiden, The Netherlands
| | - Maartje van den Bogaard
- Department of Plant Pathology and Microbiology, Iowa State University, 1344 Advanced Teaching & Research Bldg, 2213 Pammel Drive, 50011, Ames, IA, USA
| | - Anneke Kramer
- Department of Public Health and Primary Care, Leiden University Medical Center, Hippocratespad 21, Zone V0-P, 2300 RC, PO Box 9600, Leiden, The Netherlands
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20
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Bylund CL, Mullis MD, Alpert J, Markham MJ, Onega T, Fisher CL, Johnson SB. Clinician Communication With Patients About Cancer Misinformation: A Qualitative Study. JCO Oncol Pract 2023; 19:e389-e396. [PMID: 36626708 DOI: 10.1200/op.22.00526] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
PURPOSE Clinicians regularly face conversations about information that patients have found online. Given the prevalence of misinformation, these conversations can include cancer-related misinformation, which is often harmful. Clinicians are in a key position as trusted sources of information to educate patients. However, there is no research on clinician-patient conversations about cancer-related misinformation. As a first step, the objective of this study was to describe how cancer clinicians report communicating with patients about online cancer misinformation. METHODS We used convenience and snowball sampling to contact 59 cancer clinicians by e-mail. Contacted clinicians predominately worked at academic centers across the United States. Clinicians who agreed participated in semistructured interviews about communication in health care. For this study, we focused specifically on clinicians' experiences discussing online cancer-related misinformation with patients. We conducted a thematic analysis using a constant comparative approach to identify how clinicians address misinformation during clinical visits. RESULTS Twenty-one cancer clinicians participated in the study. Nineteen were physicians, one was a physician assistant, and one was a nurse practitioner. The majority (62%) were female. We identified four themes that describe how cancer clinicians address misinformation: (1) work to understand the misinformation; (2) correct misinformation through education; (3) advise about future online searches, and (4) preserve the clinician-patient relationship. CONCLUSION Our study identified four strategies that clinicians use to address online cancer-related misinformation with their patients. These findings provide a foundation for future research, allowing us to test these strategies in larger samples to examine their effectiveness.
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Affiliation(s)
- Carma L Bylund
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL
| | - Michaela D Mullis
- College of Journalism and Communications, University of Florida, Gainesville, FL
| | - Jordan Alpert
- College of Journalism and Communications, University of Florida, Gainesville, FL
| | - Merry Jennifer Markham
- Division of Hematology and Oncology, Department of Medicine, University of Florida, Gainesville, FL
| | - Tracy Onega
- Department of Population Health Sciences, School of Medicine, University of Utah, Salt Lake City, UT
| | - Carla L Fisher
- College of Journalism and Communications, University of Florida, Gainesville, FL
| | - Skyler B Johnson
- Department of Radiation Oncology, School of Medicine, University of Utah, Salt Lake City, UT
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21
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Jagannath AD, Dreicer JJ, Penner JC, Dhaliwal G. The cognitive apprenticeship: advancing reasoning education by thinking aloud. Diagnosis (Berl) 2023; 10:9-12. [PMID: 36450097 DOI: 10.1515/dx-2022-0043] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 10/25/2022] [Indexed: 12/03/2022]
Abstract
Teaching clinical reasoning has long challenged educators because it requires familiarity with reasoning concepts, experience with describing thinking, and comfort with exposing uncertainty and error. We propose that teachers adopt the cognitive apprenticeship model and a method of disclosing uncertainty known as intellectual streaking. These approaches reflect a shift in the educator's mindset from transmitting medical knowledge to broadcasting cognition. We provide several examples to guide the adoption of these strategies and make recommendations for teachers and training programs to improve the teaching of clinical reasoning.
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Affiliation(s)
- Anand D Jagannath
- Division of Hospital Medicine, VA Portland Healthcare System, Portland, OR, USA.,Department of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Jessica J Dreicer
- Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - John C Penner
- Medical Service, VA San Francisco Healthcare System, San Francisco, CA, USA.,Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Gurpreet Dhaliwal
- Medical Service, VA San Francisco Healthcare System, San Francisco, CA, USA.,Department of Medicine, University of California San Francisco, San Francisco, CA, USA
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22
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Politi MC, Housten AJ, Forcino RC, Jansen J, Elwyn G. Discussing Cost and Value in Patient Decision Aids and Shared Decision Making: A Call to Action. MDM Policy Pract 2023; 8:23814683221148651. [PMID: 36643615 PMCID: PMC9834940 DOI: 10.1177/23814683221148651] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 12/05/2022] [Indexed: 01/12/2023] Open
Abstract
Direct and indirect costs of care influence patients' health choices and the ability to implement those choices. Despite the significant impact of care costs on patients' health and daily lives, patient decision aid (PtDA) and shared decision-making (SDM) guidelines almost never mention a discussion of costs of treatment options as part of minimum standards or quality criteria. Given the growing study of the impact of costs in health decisions and the rising costs of care more broadly, in fall 2021 we organized a symposium at the Society for Medical Decision Making's annual meeting. The focus was on the role of cost information in PtDAs and SDM. Panelists gave an overview of work in this space at this virtual meeting, and attendees engaged in rich discussion with the panelists about the state of the problem as well as ideas and challenges in incorporating cost-related issues into routine care. This article summarizes and extends our discussion based on the literature in this area and calls for action. We recommend that PtDA and SDM guidelines routinely include a discussion of direct and indirect care costs and that researchers measure the frequency, quality, and response to this information.
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Affiliation(s)
- Mary C. Politi
- Division of Public Health Sciences, Department
of Surgery, Washington University in St Louis, St Louis, MO, USA
| | - Ashley J. Housten
- Division of Public Health Sciences, Department
of Surgery, Washington University in St Louis, St Louis, MO, USA
| | - Rachel C. Forcino
- The Dartmouth Institute for Health Policy and
Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon,
NH, USA
| | - Jesse Jansen
- School for Public Health and Primary Care
CAPHRI, Maastricht University, Maastricht, the Netherlands
| | - Glyn Elwyn
- The Dartmouth Institute for Health Policy and
Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon,
NH, USA
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23
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Simonovic N, Taber JM, Scherr CL, Dean M, Hua J, Howell JL, Chaudhry BM, Wain KE, Politi MC. Uncertainty in healthcare and health decision making: Five methodological and conceptual research recommendations from an interdisciplinary team. J Behav Med 2022. [DOI: 10.1007/s10865-022-00384-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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24
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Russell D, Spence NJ, Chase JAD, Schwartz T, Tumminello CM, Bouldin E. Support amid uncertainty: Long COVID illness experiences and the role of online communities. SSM. QUALITATIVE RESEARCH IN HEALTH 2022; 2:100177. [PMID: 36212783 PMCID: PMC9531408 DOI: 10.1016/j.ssmqr.2022.100177] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 10/02/2022] [Accepted: 10/03/2022] [Indexed: 01/12/2023]
Abstract
Long COVID is characterized by persistent and debilitating long-term symptoms from COVID-19. Many persons with Long COVID began gathering in online communities during the early phases of the pandemic to share their illness experiences. This qualitative interview study explored the subjective experiences of 20 persons with Long COVID recruited from five online communities. Their understandings of illness and associated implications for social relationships with family and friends, healthcare professionals, and online community members were explored. Three themes were identified from our analysis, including (1) complex and unpredictable illness experienced amid an evolving understanding of the pandemic; (2) frustration, dismissal, and gaslighting in healthcare interactions; and (3) validation and support from online communities. These findings highlight the significant uncertainty that persons with Long COVID navigated, the features of their often dismaying healthcare experiences, and the ways in which online communities aided them in understanding their illness.
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Affiliation(s)
| | - Naomi J Spence
- Lehman College, City University of New York, United States
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25
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Reber N, De Clercq E. Enduring uncertainties. Medical accounts on caring for young people with variations of sex characteristics. DIALOGUES IN HEALTH 2022; 1:100014. [PMID: 38515880 PMCID: PMC10953950 DOI: 10.1016/j.dialog.2022.100014] [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: 01/11/2022] [Revised: 05/05/2022] [Accepted: 05/10/2022] [Indexed: 03/23/2024]
Abstract
Objectives The diagnosis of intersex or variations of sex characteristics (VSC) often has a big impact on families who fear social stigmatization. Research has shown that intersex populations often experience important health disparities and that poor mental health and daily function are common among youth with VSC. The present study aimed to explore what healthcare professionals of adolescents and young adults (AYA) with VSC find important in terms of care to this group of patients. Methods Semi-structured interviews were conducted with Swiss healthcare providers involved in the care of youth born with an intersex variation. The qualitative data were analyzed using reflexive thematic analysis. Results Analysis resulted in six major themes: (1) With regard to patients' and families lived experiences, interviewees reported that fertility was as a major issue for parents but not for intersex youth as they were said to live in the moment. (2) Respondents considered various forms of psycho-social care (professional support, peer support and informal support from family and friends) to be of fundamental importance for their patients, but many of them seemed critical about support from advocacy groups and activists. All healthcare providers reported significant gaps in (3) the transition process and (4) the establishment of multidisciplinary care teams due to structural, provider- and patient-related barriers. (5) Participants were in favor of a more holistic and patient-centred care approach and (6) were critical about the medicalized use of DSD (disorder of sex development) with patients and families. Conclusion These findings suggest that although clinicians work hard to implement a holistic approach to care, their intentions are often undercut by a desire to hold a position of medical control. Healthcare professionals need to come to see medical uncertainty not only as a threat but also as an opportunity.
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Affiliation(s)
- Nina Reber
- University of Basel, Institute for Biomedical Ethics, Bernoullistrasse 28, 4056 Basel, Switzerland (CH)
| | - Eva De Clercq
- University of Basel, Institute for Biomedical Ethics, Bernoullistrasse 28, 4056 Basel, Switzerland (CH)
- University of Zürich, Institute of Biomedical Ethics and History of Medicine, Winterthurerstrasse 30, 8006 Zürich, Switzerland (CH)
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26
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The Role of the Infectious Disease Consultation in Lyme Disease. Infect Dis Clin North Am 2022; 36:703-718. [PMID: 36116844 DOI: 10.1016/j.idc.2022.04.003] [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: 11/22/2022]
Abstract
A consultation regarding Lyme disease can be challenging for the infectious disease physician when the referral question centers on the use of prolonged or empirical antibiotic treatment of Lyme disease and associated tick-borne infections. Patients who have been infected with Borrelia burgdorferi, and many who have been misdiagnosed, are confronted with a seemingly endless array of misinformation that is not in keeping with the current understanding of the clinical spectrum of Lyme disease and its response to evidence-based treatment. Preparing for these conversations with a good grasp of the public beliefs regarding Lyme disease and its treatment can be beneficial.
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27
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Kim K. Exploring factors influencing coping with uncertainties in medical practice: insights from residents' experience. KOREAN JOURNAL OF MEDICAL EDUCATION 2022; 34:213-222. [PMID: 36070991 PMCID: PMC9452374 DOI: 10.3946/kjme.2022.231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 07/21/2022] [Accepted: 07/21/2022] [Indexed: 06/15/2023]
Abstract
PURPOSE Despite attempts to teach medical students and trainees about uncertainty in medical practice and how to tolerate it, studies on how to promote tolerance to uncertainty remain scarce. this study aims to investigate factors that could foster residents' tolerance to uncertainty. METHODS The authors used data sources, including semi-structured individual in-depth interviews with 20 medical residents working in two tertiary university hospitals. Inductive analysis of interview records determined key themes, identified categories, and performed a theoretical-type analysis of the participants' coping behaviors according to the attributes of uncertainty tolerance. RESULTS Two characteristics of residents which could lead to constructive coping with uncertainty were discovered: (1) communicative/collaborative behavior with their colleagues, superiors, and patients and (2) self-reflective/self-directed attitude in their medical practice. Both were used to classify four types of uncertainty coping behaviors: adaptive, self-contained, submissive, and isolated. CONCLUSION Fostering communicative/collaborative behaviors and self-reflective/self-directed attitude throughout the training period may result in residents being more tolerant of uncertainties in medical practice.
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Affiliation(s)
- Kangmoon Kim
- Department of Medical Education, Konkuk University School of Medicine, Chungju, Korea
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28
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Fan Z, Chen H, Wu H, Zhang X. Patient Toward Physician Occupational Stigma Scale: Development of the Chinese Version. Psychol Res Behav Manag 2022; 15:2117-2127. [PMID: 35983020 PMCID: PMC9379113 DOI: 10.2147/prbm.s375032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 07/31/2022] [Indexed: 01/17/2023] Open
Abstract
Background/Objective Physicians’ occupational stigma could eradicate physician-patient trust, threatening physicians’ social status and occupational reputation. Hitherto, there has been no scale obtaining good psychometric properties to assess patients’ stigma toward physicians. The present study aimed to develop the Patient toward Physician Occupational Stigma Scale (PPOSS) and examine its reliability and validity. Methods The questionnaire comprising sociodemographic information and the PPOSS were employed to survey 645 Chinese patients in two phases. In Sample 2, the Wake Forest Physician Trust Scale (WFOTS), the Intolerance of Uncertainty Scale-12 (IUS-12), and the Brief Illness Perception Questionnaire (BIPQ) were tested. Results The PPOSS includes 19 items subsumed into three dimensions of stereotype, discrimination, and prejudice. According to the results of confirmatory factor analysis (CFA), the three-factor model fitted well (χ2/df=2.065, RMSEA=0.057, SRMR=0.045, RFI=0.904, CFI=0.956, IFI=0.956, PNFI=0.779, PCFI=0.811). The PPOSS was significantly negatively correlated with the WFOTS, and significantly positively correlated with the IUS-12 and the BIPQ. The Cronbach’s alpha coefficients for the total scale and each dimension were between 0.87 and 0.94, and the split-half reliability coefficients were between 0.84 and 0.93. Besides, the PPOSS had the measurement invariance across gender. Conclusion With its satisfactory psychometric properties, the PPOSS can be used as an effective instrument to assess patients’ stigma toward physicians.
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Affiliation(s)
- Zhiguang Fan
- Department of Education, Jilin International Studies University, Changchun City, Jilin Province, People's Republic of China.,Department of Marxism, Changchun University of Chinese Medicine, Changchun City, Jilin Province, People's Republic of China
| | - Hongyan Chen
- Department of Chinese Medicine, Changchun University of Chinese Medicine, Changchun City, Jilin Province, People's Republic of China
| | - Hanwei Wu
- Department of English, Jilin International Studies University, Changchun City, Jilin Province, People's Republic of China
| | - Xinghai Zhang
- Department of Marxism, Changchun University of Chinese Medicine, Changchun City, Jilin Province, People's Republic of China
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29
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Harris E, Conway D, Jimenez-Aranda A, Butts J, Hedley-Takhar P, Thomson R, Astin F. Development and user-testing of a digital patient decision aid to facilitate shared decision-making for people with stable angina. BMC Med Inform Decis Mak 2022; 22:143. [PMID: 35624456 PMCID: PMC9137092 DOI: 10.1186/s12911-022-01882-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 04/22/2022] [Indexed: 11/10/2022] Open
Abstract
Background Research shows that people with stable angina need decision support when considering elective treatments. Initial treatment is with medicines but patients may gain further benefit with invasive percutaneous coronary intervention (PCI). Choosing between these treatments can be challenging for patients because both confer similar benefits but have different risks. Patient decision aids (PtDAs) are evidence-based interventions that support shared decision-making (SDM) when making healthcare decisions. This study aimed to develop and user-test a digital patient decision aid (CONNECT) to facilitate SDM for people with stable angina considering invasive treatment with elective PCI. Methods A multi-phase study was conducted to develop and test CONNECT (COroNary aNgioplasty dECision Tool) using approaches recommended by the International Patient Decision Aid Standards Collaboration: (i) Steering Group assembled, (ii) review of clinical guidance, (iii) co-design workshops with patients and cardiology health professionals, (iv) first prototype developed and ‘alpha’ tested (semi-structured cognitive interviews and 12-item acceptability questionnaire) with patients, cardiologists and cardiac nurses, recruited from two hospitals in Northern England, and (v) final PtDA refined following iterative user-feedback. Quantitative data were analysed descriptively and qualitative data from the interviews analysed using deductive content analysis. Results CONNECT was developed and user-tested with 34 patients and 29 cardiology health professionals. Findings showed that CONNECT was generally acceptable, usable, comprehensible, and desirable. Participants suggested that CONNECT had the potential to improve care quality by personalising consultations and facilitating SDM and informed consent. Patient safety may be improved as CONNECT includes questions about symptom burden which can identify asymptomatic patients unlikely to benefit from PCI, as well as those who may need to be fast tracked because of worsening symptoms. Conclusions CONNECT is the first digital PtDA for people with stable angina considering elective PCI, developed in the UK using recommended processes and fulfilling international quality criteria. CONNECT shows promise as an approach to facilitate SDM and should be evaluated in a clinical trial. Further work is required to standardise the provision of probabilistic risk information for people considering elective PCI and to understand how CONNECT can be accessible to underserved communities. Supplementary Information The online version contains supplementary material available at 10.1186/s12911-022-01882-x.
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Affiliation(s)
- Emma Harris
- Centre for Applied Research in Health, School of Human and Health Sciences, University of Huddersfield, Queensgate, Huddersfield, HD1 3DH, UK
| | - Dwayne Conway
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Angel Jimenez-Aranda
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.,NIHR Devices for Dignity MedTech Co-Operative, Sheffield, UK
| | - Jeremy Butts
- Calderdale and Huddersfield NHS Foundation Trust, Huddersfield, UK
| | - Philippa Hedley-Takhar
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.,NIHR Devices for Dignity MedTech Co-Operative, Sheffield, UK
| | - Richard Thomson
- Population Health Sciences Institute, Newcastle University, Newcastle, UK
| | - Felicity Astin
- Centre for Applied Research in Health, School of Human and Health Sciences, University of Huddersfield, Queensgate, Huddersfield, HD1 3DH, UK. .,Calderdale and Huddersfield NHS Foundation Trust, Huddersfield, UK.
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30
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Han PKJ, Scharnetzki E, Anderson E, DiPalazzo J, Strout TD, Gutheil C, Lucas FL, Edelman E, Rueter J. Epistemic Beliefs: Relationship to Future Expectancies and Quality of Life in Cancer Patients. J Pain Symptom Manage 2022; 63:512-521. [PMID: 34952170 PMCID: PMC8930513 DOI: 10.1016/j.jpainsymman.2021.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 12/08/2021] [Accepted: 12/11/2021] [Indexed: 11/28/2022]
Abstract
CONTEXT Expectations about the future (future expectancies) are important determinants of psychological well-being among cancer patients, but the strategies patients use to maintain positive and cope with negative expectancies are incompletely understood. OBJECTIVES To obtain preliminary evidence on the potential role of one strategy for managing future expectancies: the adoption of "epistemic beliefs" in fundamental limits to medical knowledge. METHODS A sample of 1307 primarily advanced-stage cancer patients participating in a genomic tumor testing study in community oncology practices completed measures of epistemic beliefs, positive future expectancies, and mental and physical health-related quality of life (HRQOL). Descriptive and linear regression analyses were conducted to assess the relationships between these factors and test two hypotheses: 1) epistemic beliefs affirming fundamental limits to medical knowledge ("fallibilistic epistemic beliefs") are associated with positive future expectancies and mental HRQOL, and 2) positive future expectancies mediate this association. RESULTS Participants reported relatively high beliefs in limits to medical knowledge (M = 2.94, s.d.=.67) and positive future expectancies (M = 3.01, s.d.=.62) (range 0-4), and relatively low mental and physical HRQOL. Consistent with hypotheses, fallibilistic epistemic beliefs were associated with positive future expectancies (b = 0.11, SE=.03, P< 0.001) and greater mental HRQOL (b = 0.99, SE=.34, P = 0.004); positive expectancies also mediated the association between epistemic beliefs and mental HRQOL (Sobel Z=4.27, P<0.001). CONCLUSIONS Epistemic beliefs in limits to medical knowledge are associated with positive future expectancies and greater mental HRQOL; positive expectancies mediate the association between epistemic beliefs and HRQOL. More research is needed to confirm these relationships and elucidate their causal mechanisms.
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Affiliation(s)
- Paul K J Han
- Center for Outcomes Research and Evaluation, Maine Medical Center (P.K.J.H., E.S., E.A., J.D., C.G., F.L.L.), Portland, Maine; Tufts University School of Medicine (P.K.J.H., E.A., T.D.S., F.L.L.), Boston, Massachusetts.
| | - Elizabeth Scharnetzki
- Center for Outcomes Research and Evaluation, Maine Medical Center (P.K.J.H., E.S., E.A., J.D., C.G., F.L.L.), Portland, Maine
| | - Eric Anderson
- Center for Outcomes Research and Evaluation, Maine Medical Center (P.K.J.H., E.S., E.A., J.D., C.G., F.L.L.), Portland, Maine; Tufts University School of Medicine (P.K.J.H., E.A., T.D.S., F.L.L.), Boston, Massachusetts
| | - John DiPalazzo
- Center for Outcomes Research and Evaluation, Maine Medical Center (P.K.J.H., E.S., E.A., J.D., C.G., F.L.L.), Portland, Maine
| | - Tania D Strout
- Tufts University School of Medicine (P.K.J.H., E.A., T.D.S., F.L.L.), Boston, Massachusetts; Department of Emergency Medicine, Maine Medical Center (T.D.S.), Portland, Maine
| | - Caitlin Gutheil
- Center for Outcomes Research and Evaluation, Maine Medical Center (P.K.J.H., E.S., E.A., J.D., C.G., F.L.L.), Portland, Maine
| | - F Lee Lucas
- Center for Outcomes Research and Evaluation, Maine Medical Center (P.K.J.H., E.S., E.A., J.D., C.G., F.L.L.), Portland, Maine; Tufts University School of Medicine (P.K.J.H., E.A., T.D.S., F.L.L.), Boston, Massachusetts
| | - Emily Edelman
- The Jackson Laboratory (E.E., J.R.), Bar Harbor, Maine
| | - Jens Rueter
- The Jackson Laboratory (E.E., J.R.), Bar Harbor, Maine
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Psychological impact of the COVID-19 pandemic on primary care workers: a cross-sectional study. Br J Gen Pract 2022; 72:e501-e510. [PMID: 35440468 PMCID: PMC9037185 DOI: 10.3399/bjgp.2021.0691] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 02/28/2022] [Indexed: 11/24/2022] Open
Abstract
Background The COVID-19 pandemic has had a major impact on the mental health of healthcare workers, yet studies in primary care workers are scarce. Aim To investigate the prevalence of and associated factors for psychological distress in primary care workers during the first COVID-19 outbreak. Design and setting This was a multicentre, cross-sectional, web-based survey conducted in primary healthcare workers in Spain, between May and September 2020. Method Healthcare workers were invited to complete a survey to evaluate sociodemographic and work-related characteristics, COVID-19 infection status, exposure to patients with COVID-19, and resilience (using the Connor–Davidson Resilience Scale), in addition to being screened for common mental disorders (depression, anxiety disorders, post-traumatic stress disorder, panic attacks, and substance use disorder). Positive screening for any of these disorders was analysed globally using the term ‘any current mental disorder’. Results A total of 2928 primary care professionals participated in the survey. Of them, 43.7% (95% confidence interval [CI] = 41.9 to 45.4) tested positive for a current mental disorder. Female sex (odds ratio [OR] 1.61, 95% CI = 1.25 to 2.06), having previous mental disorders (OR 2.58, 95% CI = 2.15 to 3.10), greater occupational exposure to patients with COVID-19 (OR 2.63, 95% CI = 1.98 to 3.51), having children or dependents (OR 1.35, 95% CI = 1.04 to 1.76 and OR 1.59, 95% CI = 1.20 to 2.11, respectively), or having an administrative job (OR 2.24, 95% CI = 1.66 to 3.03) were associated with a higher risk of any current mental disorder. Personal resilience was shown to be a protective factor. Conclusion Almost half of primary care workers showed significant psychological distress. Strategies to support the mental health of primary care workers are necessary, including designing psychological support and resilience-building interventions based on risk factors identified.
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Moffett J, Armitage-Chan E, Hammond J, Kelly S, Pawlikowska T. "It's okay to not know …" a qualitative exploration of faculty approaches to working with uncertainty. BMC MEDICAL EDUCATION 2022; 22:135. [PMID: 35232453 PMCID: PMC8887020 DOI: 10.1186/s12909-022-03180-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 02/11/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Whilst it is recognised that a capacity to manage uncertainty is an essential aspect of working as a healthcare professional, there is little clear guidance on how to facilitate student learning in this domain. A lack of faculty development opportunities also suggests that health professions' educators may feel ill-equipped to assist students in developing effective approaches to uncertainty. The purpose of this study was to explore a faculty development intervention designed to help educators unpack students' experiences of uncertainty, and identify attributes which may help students to manage uncertain situations. METHODS This qualitative study was informed by a constructivist methodological approach, where participants were encouraged to share meaning around the nature of uncertainty in health professions' education. Two 90-min faculty development sessions were held. These sessions invited participants to apply Han et al.'s taxonomy of uncertainty to role-played scenarios of student uncertainty within a focus group setting. Focus group data were collected, and examined using a two-stage, hybrid approach of deductive and inductive thematic analysis. RESULTS Han et al.'s taxonomy helped participants to identify multiple sources and issues of uncertainty in the role played scenarios, thus unveiling the extent of uncertainties encountered by health professions' learners. Data analysis revealed four themes overall: "Sources of uncertainty", "Issues of uncertainty", "Uncertainty attributes", and "Learning environment." Participants also contributed to a list of attributes which they considered helpful to undergraduate health professions' students in managing uncertain situations. These included an awareness of the nature of uncertainty within healthcare practice, an ability to recognise uncertainty, and adopting attitudes of adaptability, positivity, and resilience. CONCLUSIONS This study highlights the successful use of Han et al.'s taxonomy of uncertainty within a faculty development setting. Our findings suggest that the taxonomy is a practical and versatile tool that health professions' educators can use in shared reflections and conversations around uncertainty with students or colleagues.
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Affiliation(s)
- Jenny Moffett
- Health Professions’ Education Centre, RCSI University of Medicine and Health Sciences, 123 St. Stephen’s Green, Dublin 2, D02 YN77 Ireland
| | | | - Jennifer Hammond
- University of Glasgow, Garscube Estate, 464 Bearsden Road, Glasgow, G61 1QH Scotland
| | - Síle Kelly
- RCSI, Smurfit Building, Beaumont Hospital, Beaumont Road, Dublin 9, D09 YD60 Ireland
| | - Teresa Pawlikowska
- Health Professions’ Education Centre, RCSI University of Medicine and Health Sciences, 123 St. Stephen’s Green, Dublin 2, D02 YN77 Ireland
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Patel SJ, Ipsaro A, Brady PW. Conversations on Diagnostic Uncertainty and Its Management Among Pediatric Acute Care Physicians. Hosp Pediatr 2022:e2021006076. [PMID: 35224634 DOI: 10.1542/hpeds.2021-006076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Diagnosis is a complex, iterative, and nonlinear process, often occurring over time. When presenting signs, symptoms, and diagnostic testing cannot be integrated into a diagnosis, clinicians are confronted with diagnostic uncertainty. Our aim was to study the self-reported cognitive, communication, and management behaviors of pediatric emergency medicine (PEM) and pediatric hospital medicine (PHM) physicians regarding diagnostic uncertainty. METHODS A qualitative study was conducted through focus groups with PEM and PHM physicians in a large academic pediatric medical center. Four focus groups were conducted. Interviews were recorded, deidentified, and transcribed by a team member. Thematic analysis was used to review the transcripts, highlight ideas, and organize ideas into themes. RESULTS Themes were categorized using the model of the diagnostic process from the National Academy of Sciences. "Red flags" and "gut feelings" were prominent during the information, integration, and interpretation phases. To combat diagnostic uncertainty, physicians employed strategies such as "the diagnostic pause" and having a set of "fresh eyes" to review the data. It was important to all clinicians to rule out any "cannot miss" diagnoses. Interphysician communication was direct; communication with patient and families about uncertainty was less direct because of physician concern of being thought of as untrustworthy. Contingency planning, "disposition over diagnosis" by ensuring patient safety, the "test of time," and availability of resources were techniques used by physicians to manage diagnostic uncertainty. CONCLUSIONS Physicians shared common mitigation strategies, which included consulting colleagues and targeting cannot miss diagnoses, but gaps remain regarding communicating diagnostic uncertainty to families.
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Affiliation(s)
- Shivani J Patel
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Anna Ipsaro
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio
| | - Patrick W Brady
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Meid AD, Wirbka L, Groll A, Haefeli WE. Can Machine Learning from Real-World Data Support Drug Treatment Decisions? A Prediction Modeling Case for Direct Oral Anticoagulants. Med Decis Making 2021; 42:587-598. [PMID: 34911402 PMCID: PMC9189725 DOI: 10.1177/0272989x211064604] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Decision making for the "best" treatment is particularly challenging in situations in which individual patient response to drugs can largely differ from average treatment effects. By estimating individual treatment effects (ITEs), we aimed to demonstrate how strokes, major bleeding events, and a composite of both could be reduced by model-assisted recommendations for a particular direct oral anticoagulant (DOAC). METHODS In German claims data for the calendar years 2014-2018, we selected 29 901 new users of the DOACs rivaroxaban and apixaban. Random forests considered binary events within 1 y to estimate ITEs under each DOAC according to the X-learner algorithm with 29 potential effect modifiers; treatment recommendations were based on these estimated ITEs. Model performance was evaluated by the c-for-benefit statistics, absolute risk reduction (ARR), and absolute risk difference (ARD) by trial emulation. RESULTS A significant proportion of patients would be recommended a different treatment option than they actually received. The stroke model significantly discriminated patients for higher benefit and thus indicated improved decisions by reduced outcomes (c-for-benefit: 0.56; 95% confidence interval [0.52; 0.60]). In the group with apixaban recommendation, the model also improved the composite endpoint (ARR: 1.69 % [0.39; 2.97]). In trial emulations, model-assisted recommendations significantly reduced the composite event rate (ARD: -0.78 % [-1.40; -0.03]). CONCLUSIONS If prescribers are undecided about the potential benefits of different treatment options, ITEs can support decision making, especially if evidence is inconclusive, risk-benefit profiles of therapeutic alternatives differ significantly, and the patients' complexity deviates from "typical" study populations. In the exemplary case for DOACs and potentially in other situations, the significant impact could also become practically relevant if recommendations were available in an automated way as part of decision making.HighlightsIt was possible to calculate individual treatment effects (ITEs) from routine claims data for rivaroxaban and apixaban, and the characteristics between the groups with recommendation for one or the other option differed significantly.ITEs resulted in recommendations that were significantly superior to usual (observed) treatment allocations in terms of absolute risk reduction, both separately for stroke and in the composite endpoint of stroke and major bleeding.When similar patients from routine data were selected (precision cohorts) for patients with a strong recommendation for one option or the other, those similar patients under the respective recommendation showed a significantly better prognosis compared with the alternative option.Many steps may still be needed on the way to clinical practice, but the principle of decision support developed from routine data may point the way toward future decision-making processes.
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Affiliation(s)
- Andreas D Meid
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Lucas Wirbka
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | | | - Andreas Groll
- Department of Statistics, TU Dortmund University, Dortmund, Germany
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
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