Does Shared Decision Making Actually Occur in the Emergency Department? Looking at It from the Patients' Perspective

OBJECTIVE

We sought to assess the frequency, content, and quality of shared decision making (SDM) in the emergency department (ED), from patients' perspectives.

METHODS

Utilizing a cross-sectional, multisite approach, we administered an instrument, consisting of two validated SDM assessment tools-the CollaboRATE and the SDM-Q-9-and one newly developed tool to a sample of ED patients. Our primary outcome was the occurrence of SDM in the clinical encounter, as defined by participants giving "top-box" scores on the CollaboRATE measure, and the ability of patients to identify the topic of their SDM conversation. Secondary outcomes included the content of the SDM conversations, as judged by patients, and whether patients were able to complete each of the two validated scales included in the instrument.

RESULTS

After exclusions, 285 participants from two sites completed the composite instrument. Just under half identified as female (47%) or as white (47%). Roughly half gave top-box scores (i.e., indicating optimal SDM) on the CollaboRATE scale (49%). Less than half of the participants were able to indicate a decision they were involved in (44%), although those who did gave high scores for such conversations (73/100 via the SDM-Q-9 tool). The most frequently identified decisions discussed were admission versus discharge (19%), medication options (17%), and options for follow-up care (15%).

CONCLUSIONS

Fewer than half of ED patients surveyed reported they were involved in SDM. The most common decision for which SDM was used was around ED disposition (admission vs. discharge). When SDM was employed, patients generally rated the discussion highly.

Patient Preferences Regarding Shared Decision Making in the Emergency Department: Findings From a Multisite Survey

OBJECTIVES

As shared decision making (SDM) has received increased attention as a method to improve the patient-centeredness of emergency department (ED) care, we sought to determine patients' desired level of involvement in medical decisions and their perceptions of potential barriers and facilitators to SDM in the ED.

METHODS

We surveyed a cross-sectional sample of adult ED patients at three academic medical centers across the United States. The survey included 32 items regarding patient involvement in medical decisions including a modified Control Preference Scale and questions about barriers and facilitators to SDM in the ED. Items were developed and refined based on prior literature and qualitative interviews with ED patients. Research assistants administered the survey in person.

RESULTS

Of 797 patients approached, 661 (83%) agreed to participate. Participants were 52% female, 45% white, and 30% Hispanic. The majority of respondents (85%-92%, depending on decision type) expressed a desire for some degree of involvement in decision making in the ED, while 8% to 15% preferred to leave decision making to their physician alone. Ninety-eight percent wanted to be involved with decisions when "something serious is going on." The majority of patients (94%) indicated that self-efficacy was not a barrier to SDM in the ED. However, most patients (55%) reported a tendency to defer to the physician's decision making during an ED visit, with about half reporting they would wait for a physician to ask them to be involved.

CONCLUSION

We found that the majority of ED patients in our large, diverse sample wanted to be involved in medical decisions, especially in the case of a "serious" medical problem, and felt that they had the ability to do so. Nevertheless, many patients were unlikely to actively seek involvement and defaulted to allowing the physician to make decisions during the ED visit. After fully explaining the consequences of a decision, clinicians should make an effort to explicitly ascertain patients' desired level of involvement in decision making.

Association of Mindfulness With Residency Preference and Curriculum Selection in Preclinical Osteopathic Medical Students

Context

Recent studies suggest the shortage of US primary care physicians will be more than 50,000 by the year 2025. Mindful osteopathic medical students may be more inclined to pursue a career in primary care practice than those demonstrating lower levels of mindfulness. If so, assessing mindfulness before and after admission to medical school may reduce this shortage.

Objective

In this cross-sectional survey-based study, the authors assessed whether mindfulness among preclinical osteopathic medical students was associated with (a) their current preference for primary care practice as a residency, and (b) their choice between 2 alternative curricula.

Method

Participants were first- and second-year osteopathic medical students enrolled at the New York Institute of Technology College of Osteopathic Medicine (NYITCOM). They completed a 7-factor questionnaire of demographic variables and the online Five Facet Mindfulness Questionnaire (FFMQ) to determine their mindfulness score. They also identified their current preference for a residency. Data were then presented using various descriptive statistics and analyzed using independent t tests, χ2 tests, and multiple logistic regression.

Results

Among the 208 respondents, authors found that osteopathic medical students who expressed a preference for primary care practice showed no significant differences in mindfulness compared with those interested in specialist fields, as indicated by mean (SD) mindfulness scores of 3.34 (0.44) vs 3.33 (0.41), respectively (P=.88). However, among demographic variables, female students expressed a preference for primary care practice fields at significantly higher rates than male students (OR, 4.4; 95% CI, 2.2-8.5; P<.001). Also, students who matriculated less than 6 months after completing their undergraduate education were drawn to primary care practice at higher rates than those who delayed enrollment (OR, 2.3; 95% CI, 1.2-4.5; P=.016). None of the remaining demographic variables were associated with students’ residency preference.

Conclusion

Being female and matriculating immediately after undergraduate education was associated with a preference for primary care residency. However, no significant association was found between mindfulness and either residency preference or choice of alternative curricula.

Pontibacter ummariensis sp. nov., isolated from a hexachlorocyclohexane-contaminated soil

A Gram-stain-negative, pinkish-red, rod-shaped bacterium designated strain NKM1^T was isolated from soil samples contaminated with hexachlorocyclohexane isomers, collected from Ummari village, Lucknow, Uttar Pradesh, India. The strain was characterized by a polyphasic taxonomic approach. 16S rRNA gene sequence analysis showed that strain NKM1^T clustered exclusively with members of the genus Pontibacter of the family Cytophagaceae, phylum Bacteroidetes. The 16S rRNA gene sequence similarity to type strains of the genus Pontibacter ranged from 96.7 to 93.8 %, with the highest sequence similarity found with Pontibacter odishensis JC130^T (96.7 %). Cells of strain NKM1^T were aerobic, non-flagellated and non-motile. Strain NKM1^T was catalase- and oxidase-positive but negative for nitrate reduction and hydrolysis of gelatin. The major fatty acids in strain NKM1^T were anteiso-C_15 : 0, iso-C_15 : 0, C_16 : 0, C_18 : 1ω9c and summed feature 3 (C_16 : 1ω7c and/or C_16 : 1ω6c). The polar lipid profile of strain NKM1^T showed the presence of phosphatidylethanolamine and unknown glycolipids as well as aminolipids. sym-Homospermidine was found to be the major polyamine and menaquinone 7 (MK-7) was the major respiratory quinone. The DNA G+C content of strain NKM1^T was determined to be 58.6 mol%. Based on phenotypic, chemotaxonomic, physiological and biochemical evidence, it is proposed that isolate NKM1^T represents a novel species that belongs to the genus Pontibacter, for which the name Pontibacter ummariensis sp. nov. is proposed. The type strain is NKM1^T ( = DSM 100161^T = KCTC 42944^T = MCC 2777^T).