Academic Physician Specialists' Approaches to Counseling Patients Interested in Unproven Stem Cell and Regenerative Therapies-A Qualitative Analysis

OBJECTIVE

To explore the experiences, approaches, and challenges of physicians consulting patients about experimental stem cell and regenerative medicine interventions (SCRIs).

PARTICIPANTS AND METHODS

From August 21, 2018, through July 30, 2019, semistructured interviews of 25 specialists in cardiology, ophthalmology, orthopedics, pulmonology, and neurology were conducted and qualitatively analyzed using modified grounded theory.

RESULTS

All specialists used informational approaches to counsel patients, especially orthopedists. Informational approaches included explaining stem cell science, sharing risks, and providing principles. Several specialists also used relational counseling approaches including emphasizing that physicians want what is best for patients, acknowledging suffering, reassuring continued care, empathizing with patients and families, and underscoring that patients have the final decision. Many specialists reported being comfortable with the conversation, although some were less comfortable and several noted challenges in the consultation including wanting to support a patient's decision but worrying about harms from unproven SCRIs, navigating family pressure, and addressing stem cell hype and unrealistic expectations. Specialists also desired that additional resources be available for them and patients.

CONCLUSION

Physicians relied more heavily on providing patients with information about SCRIs than using relational counseling approaches. Efforts should be directed at helping physicians address the informational and relational needs of patients, including providing tools and resources that inform physicians about the unproven SCRI industry, building skills in empathic communication, and the creation and dissemination of evidence-based resources to offer patients.

The Importance of Being Earnest

Attempting to effect change in modern medicine, particularly as trainees or junior faculty, is often an overwhelming undertaking. While early-career physicians are in close contact with patients, they often lack the credibility or access to resources that are necessary to implement new ideas at large institutions. Although there may be scientific evidence to support new models of care, existing cultural patterns of practice can foster resistance to these interventions. The authors describe their own experience as residents reforming the management of endocarditis patients at an academic medical center, emphasizing the important role that residents can play in changing medical practice. Starting with a devastating patient case, the authors share their story of creating a multidisciplinary endocarditis team while navigating the many obstacles, some unseen, that can derail innovative ideas. Ultimately, through a combination of new perspectives, data-driven analysis, determination, and-most importantly-hope, the authors were able to dramatically improve outcomes for patients. Moving forward, their experience can serve as a model for young physicians and inspire them to effect change in their own institutions.

Harnessing the Power of Residents as Change Agents in Quality Improvement

Residency training represents a unique period when learners begin to personally experience the patient safety and quality-of-care issues that affect health care systems and increasingly take responsibility to address them. Their integration into the clinical workflow in clinics, wards, and operating rooms positions them perfectly to observe and characterize the underlying processes that contribute to patient safety and health care quality problems. Residents' practices and perspectives are less entrenched than those of their faculty counterparts, which enables them to offer fresh ideas on the quality improvement (QI) process. Their creativity and ingenuity serve as assets when coming up with new and innovative changes to test using rapid change cycles. As such, they are ideally suited to serve as health systems change agents. Training programs and clinical institutions typically see residents as frontline care providers whose primary role is to treat the patient in front of them. Yet, by enabling residents to "treat the system" through QI work, they can take on the role of residents as change agents, which has the potential to have long-lasting effects on patient care on a much wider scale. However, training programs must do more than simply harness residents' enthusiasm and root them on from the sidelines. Instead, they must create an environment that is conducive to successfully implementing changes at the curricular, institutional, and health systems levels.

Ethical aspects in the care of a child with infantile spinal muscular atrophy (SMA)

The pediatrician has a privileged relationship with a child with infantile spinal muscular atrophy (SMA). At all times, he/she must be the child's mentor, promoting a comprehensive approach and support in order to ensure the best possible solution for the patient's autonomy. In all circumstances, an ethical stance is essential. After a reminder on the notions of ethics of care, we will address various ethical questions encountered through three critical situations during the care of a child with infantile spinal muscular atrophy: the announcement of the diagnosis, the transmission of information on innovative therapies, and palliative care and end-of-life support. © 2020 French Society of Pediatrics. Published by Elsevier Masson SAS. All rights reserved.

Charlie Gard and the weight of parental rights to seek experimental treatment

The case of Charlie Gard, an infant with a genetic illness whose parents sought experimental treatment in the USA, brought important debates about the moral status of parents and children to the public eye. After setting out the facts of the case, this article considers some of these debates through the lens of parental rights. Parental rights are most commonly based on the promotion of a child's welfare; however, in Charlie's case, promotion of Charlie's welfare cannot explain every fact of the case. Indeed, some seem most logically to extend from intrinsic parental rights, that is, parental rights that exist independent of welfare promotion. I observe that a strong claim for intrinsic parental rights can be built on arguments for genetic propriety and children's limited personhood. Critique of these arguments suggests the scope of parental rights remains limited: property rights entail proper use; non-personhood includes only a small cohort of very young or seriously intellectually disabled children and the uniqueness of parental genetic connection is limited. Moreover, there are cogent arguments about parents' competence to make judgements, and public interest arguments against allowing access to experimental treatment. Nevertheless, while arguments based on propriety may raise concerns about the attitude involved in envisioning children as property, I conclude that these arguments do appear to offer a prima facie case for a parental right to seek experimental treatment in certain limited circumstances.

[Colorectal cancer: ten years of illusion of progress but advances are on the horizon]

Recent years have basically been marked by a modest progress in digestive oncology. Biologic drugs such as anti-EGFR and antiangiogenic antibodies have improved the overall survival of patients with advanced colorectal cancer for a few months, but did not alter adjuvant treatment paradigms after curative resection of a locally advanced colon cancer or of liver metastases. With the exception of the RAS gene mutations, predictive of lack of effectiveness to anti-EGFR antibodies, our knowledge of colon cancer tumor biology has hardly evolved. Long-awaited novelties come rather from fundamental discoveries about the different genomic subtypes of colorectal cancer and new immunotherapy approaches which both announce hopefully real giant leaps in the near future.

Contemplating complications: living the experience, learning the lessons

Complications related to the use of new diagnostic and therapeutic techniques are inherent to innovation in medicine. Appropriate consent should be obtained before subjecting patients to these techniques. In spite of doing this, when a complication does occur, one can easily relate to its devastating impact on the patient and his/her relatives. The toll that such events take on the treating physician also needs to be considered. The burden of conscience when a patient consents to such a procedure with implicit faith in the physician is immense. A case of irreversible paraplegia due to non-target embolisation of the anterior spinal artery in a young lady undergoing bronchial artery embolisation for hemoptysis is discussed. A feeling of "sadness and guilt" and a scientific analysis of the cause for the adverse event result in changing the protocol of the procedure leading to increased safety for future patients. Wide consultation with colleagues and help from institutional review boards are useful in assuring the treating physician about the justification of performing such procedures and help in coping should complications occur. The manner in which these events are managed, especially by medical teachers in teaching hospitals, is an important learning point for medical students and doctors in training. The need for appropriate open forums in institutions is emphasised, where such events are shared by physicians, resulting in unburdening themselves and potentially in education for all present.

Expecting innovation: psychoactive drug primes and the generation of creative solutions

Many individuals expect that alcohol and drug consumption will enhance creativity. The present studies tested whether substance related primes would influence creative performance for individuals who possessed creativity-related substance expectancies. Participants (n = 566) were briefly exposed to stimuli related to psychoactive substances (alcohol, for Study 1, Sample 1, and Study 2; and marijuana, for Study 1, Sample 2) or neutral stimuli. Participants in Study 1 then completed a creative problem-solving task, while participants in Study 2 completed a divergent thinking task or a task unrelated to creative problem solving. The results of Study 1 revealed that exposure to the experimental stimuli enhanced performance on the creative problem-solving task for those who expected the corresponding substance would trigger creative functioning. In a conceptual replication, Study 2 showed that participants exposed to alcohol cues performed better on a divergent thinking task if they expected alcohol to enhance creativity. It is important to note that this same interaction did not influence performance on measures unrelated to creative problem solving, suggesting that the activation of creativity-related expectancies influenced creative performance, specifically. These findings highlight the importance of assessing expectancies when examining pharmacological effects of alcohol and marijuana. Future directions and implications for substance-related interventions are discussed.

From closed ranks to open doors: Elaine and John Cummings' mental health education experiment in 1950s Saskatchewan

During late 1951 and early 1952, married couple, social biologist Elaine Cumming and psychiatrist John Cumming, led a mental health education experiment in Indian Head, Saskatchewan. The study, which was intended to inform strategies toward deinstitutionalization, sought to determine if attitudes regarding mental illness could be changed through commonly used educational practices. It was shaped by the shared interests of powerful philanthropic, charitable, psychiatric, academic and governmental bodies to create healthier citizens and a stronger democratic nation through expert knowledge. However, in addition to the disappointing findings indicating that attitudes remained unchanged, the town appeared to close ranks against the research team. Nonetheless, the Cummings' later association with sociologists at Harvard University enabled them to interpret the results in a way that lent the study credibility and themselves legitimacy, thus opening the door to their careers as very successful researchers and policy-makers.

The role of the media in steering public opinion on healthcare issues

The media can play an important role in influencing both the demand and supply of medical treatments, regardless of evidence of effectiveness. This can be highlighted by recent experiences in Italy following publicity for a new unproven treatment in Italy, which it was claimed was highly successful in treating a wide range of cancers. The media role in influencing both health authorities to fund large scale trials of the intervention and patients awareness and expectations of therapy are discussed. The changes in Italian media over the last 20 years have seen a reduction in the numbers of specialist medical journals, with increased emphasis placed on sensationalism rather than accuracy. The media though has the potential to play in future an important strategic role in disseminating accurate information on issues pertaining to health.