Development and validation of a musculoskeletal physical examination decision-making test for medical students.

PubMed

Bishop, Julie Y; Awan, Hisham M; Rowley, David M; Nagel, Rollin W

2013-01-01

Despite a renewed emphasis among educators, musculoskeletal education is still lacking in medical school and residency training programs. We created a musculoskeletal multiple-choice physical examination decision-making test to assess competency and physical examination knowledge of our trainees. We developed a 20-question test in musculoskeletal physical examination decision-making test with content that most medical students and orthopedic residents should know. All questions were reviewed by ratings of US orthopedic chairmen. It was administered to postgraduate year 2 to 5 orthopedic residents and 2 groups of medical students: 1 group immediately after their 3-week musculoskeletal course and the other 1 year after the musculoskeletal course completion. We hypothesized that residents would score highest, medical students 1 year post-musculoskeletal training lowest, and students immediately post-musculoskeletal training midrange. We administered an established cognitive knowledge test to compare student knowledge base as we expected the scores to correlate. Academic medical center in the Midwestern United States. Orthopedic residents, chairmen, and medical students. Fifty-four orthopedic chairmen (54 of 110 or 49%) responded to our survey, rating a mean overall question importance of 7.12 (0 = Not Important; 5 = Important; 10 = Very Important). Mean physical examination decision-making scores were 89% for residents, 77% for immediate post-musculoskeletal trained medical students, and 59% 1 year post-musculoskeletal trained medical students (F = 42.07, p<0.001). The physical examination decision-making test was found to be internally consistent (Kuder-Richardson Formula 20 = 0.69). The musculoskeletal cognitive knowledge test was 78% for immediate post-musculoskeletal trained students and 71% for the 1 year post-musculoskeletal trained students. The student physical examination and cognitive knowledge scores were correlated (r = 0.54, p<0.001), but were not

Acceptable regret in medical decision making.

PubMed

Djulbegovic, B; Hozo, I; Schwartz, A; McMasters, K M

1999-09-01

When faced with medical decisions involving uncertain outcomes, the principles of decision theory hold that we should select the option with the highest expected utility to maximize health over time. Whether a decision proves right or wrong can be learned only in retrospect, when it may become apparent that another course of action would have been preferable. This realization may bring a sense of loss, or regret. When anticipated regret is compelling, a decision maker may choose to violate expected utility theory to avoid regret. We formulate a concept of acceptable regret in medical decision making that explicitly introduces the patient's attitude toward loss of health due to a mistaken decision into decision making. In most cases, minimizing expected regret results in the same decision as maximizing expected utility. However, when acceptable regret is taken into consideration, the threshold probability below which we can comfortably withhold treatment is a function only of the net benefit of the treatment, and the threshold probability above which we can comfortably administer the treatment depends only on the magnitude of the risks associated with the therapy. By considering acceptable regret, we develop new conceptual relations that can help decide whether treatment should be withheld or administered, especially when the diagnosis is uncertain. This may be particularly beneficial in deciding what constitutes futile medical care.

Patient decision-making: medical ethics and mediation.

PubMed Central

Craig, Y J

1996-01-01

A review of medical ethics literature relating to the importance of the participation of patients in decision-making introduces the role of rights-based mediation as a voluntary process now being developed innovatively in America. This is discussed in relation to the theory of communicative ethics and moral personhood. References are then made to the work of medical ethics committees and the role of mediation within these. Finally it is suggested that mediation is part of an eirenic ethic already being used informally in good patient care, and that there is a case for developing it further. PMID:8798939

Family interests and medical decisions for children

PubMed Central

2017-01-01

Abstract Medical decisions for children are usually justified by the claim that they are in a child's best interests. More recently, following criticisms of the best interests standard, some advocate that the family's interests should influence medical decisions for children, although what is meant by family interests is often not made clear. I argue that at least two senses of family interests may be discerned. There is a ‘weak’ sense (as the amalgamated interests of family members) of family interests and a ‘strong’ sense (that the family itself has interests over and above the interests of individuals). I contend that there are problems with both approaches in making medical decisions for children but that the weak sense is more plausible. Despite this, I argue that claims for family interests are not helpful in making medical decisions for children. PMID:28901601

Family interests and medical decisions for children.

PubMed

Baines, Paul

2017-10-01

Medical decisions for children are usually justified by the claim that they are in a child's best interests. More recently, following criticisms of the best interests standard, some advocate that the family's interests should influence medical decisions for children, although what is meant by family interests is often not made clear. I argue that at least two senses of family interests may be discerned. There is a 'weak' sense (as the amalgamated interests of family members) of family interests and a 'strong' sense (that the family itself has interests over and above the interests of individuals). I contend that there are problems with both approaches in making medical decisions for children but that the weak sense is more plausible. Despite this, I argue that claims for family interests are not helpful in making medical decisions for children. © 2017 John Wiley & Sons Ltd.

Navigating the Decision Space: Shared Medical Decision Making as Distributed Cognition.

PubMed

Lippa, Katherine D; Feufel, Markus A; Robinson, F Eric; Shalin, Valerie L

2017-06-01

Despite increasing prominence, little is known about the cognitive processes underlying shared decision making. To investigate these processes, we conceptualize shared decision making as a form of distributed cognition. We introduce a Decision Space Model to identify physical and social influences on decision making. Using field observations and interviews, we demonstrate that patients and physicians in both acute and chronic care consider these influences when identifying the need for a decision, searching for decision parameters, making actionable decisions Based on the distribution of access to information and actions, we then identify four related patterns: physician dominated; physician-defined, patient-made; patient-defined, physician-made; and patient-dominated decisions. Results suggests that (a) decision making is necessarily distributed between physicians and patients, (b) differential access to information and action over time requires participants to transform a distributed task into a shared decision, and (c) adverse outcomes may result from failures to integrate physician and patient reasoning. Our analysis unifies disparate findings in the medical decision-making literature and has implications for improving care and medical training.

Shared decision making for psychiatric medication management: beyond the micro-social.

PubMed

Morant, Nicola; Kaminskiy, Emma; Ramon, Shulamit

2016-10-01

Mental health care has lagged behind other health-care domains in developing and applying shared decision making (SDM) for treatment decisions. This is despite compatibilities with ideals of modern mental health care such as self-management and recovery-oriented practice, and growing policy-level interest. Psychiatric medication is a mainstay of mental health treatment, but there are known problems with prescribing practices, and service users report feeling uninvolved in medication decisions and concerned about adverse effects. SDM has potential to produce better tailoring of psychiatric medication to individuals' needs. This conceptual review argues that several aspects of mental health care that differ from other health-care contexts (e.g. forms of coercion, questions about service users' insight and disempowerment) may impact on processes and possibilities for SDM. It is therefore problematic to uncritically import models of SDM developed in other health-care contexts. We argue that decision making for psychiatric medication is better understood in a broader way that moves beyond the micro-social focus of a medical consultation. Contextualizing specific medication-related consultations within longer term relationships, and broader service systems enables recognition of the multiple processes, actors and agendas that shape how psychiatric medication is prescribed, managed and used, and which may facilitate or impede SDM. A broad conceptualization of decision making for psychiatric medication that moves beyond the micro-social can account for why SDM in this domain remains a rarity. It has both conceptual and practical utility for evaluating research evidence, identifying future research priorities and highlighting fruitful ways of developing and implementing SDM in mental health care. © 2015 The Authors Health Expectations Published by John Wiley & Sons Ltd.

Use of a computerized medication shared decision making tool in community mental health settings: impact on psychotropic medication adherence.

PubMed

Stein, Bradley D; Kogan, Jane N; Mihalyo, Mark J; Schuster, James; Deegan, Patricia E; Sorbero, Mark J; Drake, Robert E

2013-04-01

Healthcare reform emphasizes patient-centered care and shared decision-making. This study examined the impact on psychotropic adherence of a decision support center and computerized tool designed to empower and activate consumers prior to an outpatient medication management visit. Administrative data were used to identify 1,122 Medicaid-enrolled adults receiving psychotropic medication from community mental health centers over a two-year period from community mental health centers. Multivariate linear regression models were used to examine if tool users had higher rates of 180-day medication adherence than non-users. Older clients, Caucasian clients, those without recent hospitalizations, and those who were Medicaid-eligible due to disability had higher rates of 180-day medication adherence. After controlling for sociodemographics, clinical characteristics, baseline adherence, and secular changes over time, using the computerized tool did not affect adherence to psychotropic medications. The computerized decision tool did not affect medication adherence among clients in outpatient mental health clinics. Additional research should clarify the impact of decision-making tools on other important outcomes such as engagement, patient-prescriber communication, quality of care, self-management, and long-term clinical and functional outcomes.

The emergency patient's participation in medical decision-making.

PubMed

Wang, Li-Hsiang; Goopy, Suzanne; Lin, Chun-Chih; Barnard, Alan; Han, Chin-Yen; Liu, Hsueh-Erh

2016-09-01

The purpose of this research was to explore the medical decision-making processes of patients in emergency departments. Studies indicate that patients should be given enough time to acquire relevant information and receive adequate support when they need to make medical decisions. It is difficult to satisfy these requirements in emergency situations. Limited research has addressed the topic of decision-making among emergency patients. This qualitative study used a broadly defined grounded theory approach to explore decision-making in an emergency department in Taiwan. Thirty emergency patients were recruited between June and December 2011 for semi-structured interviews that were audio-taped and transcribed verbatim. The study identified three stages in medical decision-making by emergency patients: predecision (interpreting the problem); decision (a balancing act) and postdecision (reclaiming the self). Transference was identified as the core category and pattern of behaviour through which patients resolved their main concerns. This transference around decision-making represents a type of bricolage. The findings fill a gap in knowledge about the decision-making process among emergency patients. The results inform emergency professionals seeking to support patients faced with complex medical decision-making and suggest an emphasis on informed patient decision-making, advocacy, patient-centred care and in-service education of health staff. © 2016 John Wiley & Sons Ltd.

Medical decision and patient's preference: 'much ethics' and more trust always needed.

PubMed

Anyfantakis, Dimitrios; Symvoulakis, Emmanouil K

2011-01-01

There is much discussion on medical ethics literature regarding the importance of the patients' right for self-determination. We discuss some of the limitations of patient's autonomy with the aim to draw attention to the ethical complexity of medical decision making in the everyday clinical practice.

Which medical and social decision topics are important after early diagnosis of Alzheimer's Disease from the perspectives of people with Alzheimer's Disease, spouses and professionals?

PubMed

Bronner, Katharina; Perneczky, Robert; McCabe, Rose; Kurz, Alexander; Hamann, Johannes

2016-03-08

The relevance of early decision making will rise with increasing availability of early detection of Alzheimer's disease (AD) using brain imaging or biomarkers. Five people with mild AD, six relatives and 13 healthcare professionals with experience in the management of AD were interviewed in a qualitative study regarding medical and social decision topics that emerge after early diagnosis of Alzheimer's disease. Medical treatment, assistance in everyday life and legal issues emerged as the main decision topics after an early diagnosis of AD. People with AD mostly got in contact with the health and social care system through the initiative of their spouses. They were usually aware of their illness and most received antidementia drugs and/or behavioural interventions. Following diagnosis people with AD received support by their spouses. Healthcare professionals were aware of the risk of excessive demand on relatives due to supporting their family member with AD. In the opinion of healthcare professionals legal issues should be arranged in time before patients lose their decisional capacity. In addition, people with AD and spouses reported various coping strategies, in particular "carry on as normal" after diagnosis but mostly are reluctant to actively plan for future stages of the disease. Due to the common desire to "carry on as usual" after a diagnosis of AD, many people with AD and spouses may miss the opportunity to discuss and decide on important medical and social topics. A structured approach e.g. a decision aid might support people with AD and spouses in their decision making process and thereby preserve persons' with AD autonomy before they lose the capacity in decision-making.

Shared decision making in mental health: the importance for current clinical practice.

PubMed

Alguera-Lara, Victoria; Dowsey, Michelle M; Ride, Jemimah; Kinder, Skye; Castle, David

2017-12-01

We reviewed the literature on shared decision making (regarding treatments in psychiatry), with a view to informing our understanding of the decision making process and the barriers that exist in clinical practice. Narrative review of published English-language articles. After culling, 18 relevant articles were included. Themes identified included models of psychiatric care, benefits for patients, and barriers. There is a paucity of published studies specifically related to antipsychotic medications. Shared decision making is a central part of the recovery paradigm and is of increasing importance in mental health service delivery. The field needs to better understand the basis on which decisions are reached regarding psychiatric treatments. Discrete choice experiments might be useful to inform the development of tools to assist shared decision making in psychiatry.

Medical Decision and Patient's Preference: 'Much Ethics' and More Trust Always Needed

PubMed Central

Anyfantakis, Dimitrios; Symvoulakis, Emmanouil K

2011-01-01

There is much discussion on medical ethics literature regarding the importance of the patients' right for self-determination. We discuss some of the limitations of patient's autonomy with the aim to draw attention to the ethical complexity of medical decision making in the everyday clinical practice. PMID:21647328

Decision making in acquiring medical technologies in Israeli medical centers: a preliminary study.

PubMed

Greenberg, Dan; Pliskin, Joseph S; Peterburg, Yitzhak

2003-01-01

This preliminary study had two objectives: a) charting the considerations relevant to decisions about acquisition of new medical technology at the hospital level; and b) creating a basis for the development of a research tool that will examine the function of the Israeli health system in assessment of new medical technologies. A comprehensive literature review and in-depth interviews with decision makers at different levels allowed formulation of criteria considered by decision makers when they decide to purchase and use (or disallow the use) of new medical technology. The resulting questionnaire was sent to medical center directors, along with a letter explaining the goals of the study. The questionnaire included 31 possible considerations for decision making concerning the acquisition of new medical technology by medical centers. The interviewees were asked to indicate the relevance of each consideration in the decision-making process. The most relevant criteria for the adoption of new technologies related to the need for a large capital investment, clinical efficacy of the technology as well as its influence on side effects and complication rates, and a formal approval by the Ministry of Health. Most interviewees stated that pressures exerted by the industry, by patients, or by senior physicians in the hospital are less relevant to decision making. Very small and usually not statistically significant differences in the ranking of hospital directors were found according to the hospitals' ownership, size, or location. The present study is a basis for a future study that will map and describe the function of hospital decision makers within the area of new technology assessment and the decision-making process in the adoption of new healthcare technologies.

The Attitude-Behavior Discrepancy in Medical Decision Making

PubMed Central

He, Fei; Li, Dongdong; Cao, Rong; Zeng, Juli; Guan, Hao

2014-01-01

Background: In medical practice, the dissatisfaction of patients about medical decisions made by doctors is often regarded as the fuse of doctor-patient conflict. However, a few studies have looked at why there are such dissatisfactions. Objectives: This experimental study aimed to explore the discrepancy between attitude and behavior within medical situations and its interaction with framing description. Patients and Methods: A total of 450 clinical undergraduates were randomly assigned to six groups and investigated using the classic medical decision making problem, which was described either in a positive or a negative frame (2) × decision making behavior\\attitude to risky plan\\attitude to conservative plan (3). Results: A discrepancy between attitude and behavior did exist in medical situations. Regarding medical dilemmas, if the mortality rate was described, subjects had a significant tendency to choose a conservative plan (t = 3.55, P < 0.01) yet if the survival rate was described, there was no such preference (t = -1.48, P > 0.05). However, regardless of the plan chosen by the doctor, the subjects had a significant opposing attitude (P < .05). Framing description had a significant impact on both decision making behavior and attitude (t behavior = -3.24, P < 0.01；t attitude to surgery = 4.08，P < 0.01；t attitude to radiation = -2.15，P < 0.05). Conclusions: A discrepancy of attitude-behavior does exist in medical situations. The framing of a description has an impact on medical decision-making. PMID:25763230

The attitude-behavior discrepancy in medical decision making.

PubMed

He, Fei; Li, Dongdong; Cao, Rong; Zeng, Juli; Guan, Hao

2014-12-01

In medical practice, the dissatisfaction of patients about medical decisions made by doctors is often regarded as the fuse of doctor-patient conflict. However, a few studies have looked at why there are such dissatisfactions. This experimental study aimed to explore the discrepancy between attitude and behavior within medical situations and its interaction with framing description. A total of 450 clinical undergraduates were randomly assigned to six groups and investigated using the classic medical decision making problem, which was described either in a positive or a negative frame (2) × decision making behavior\\attitude to risky plan\\attitude to conservative plan (3). A discrepancy between attitude and behavior did exist in medical situations. Regarding medical dilemmas, if the mortality rate was described, subjects had a significant tendency to choose a conservative plan (t = 3.55, P < 0.01) yet if the survival rate was described, there was no such preference (t = -1.48, P > 0.05). However, regardless of the plan chosen by the doctor, the subjects had a significant opposing attitude (P < .05). Framing description had a significant impact on both decision making behavior and attitude (t behavior = -3.24, P < 0.01；t attitude to surgery = 4.08，P < 0.01；t attitude to radiation = -2.15，P < 0.05). A discrepancy of attitude-behavior does exist in medical situations. The framing of a description has an impact on medical decision-making.

Influence of framing on medical decision making.

PubMed

Gong, Jingjing; Zhang, Yan; Feng, Jun; Huang, Yonghua; Wei, Yazhou; Zhang, Weiwei

2013-01-01

Numerous studies have demonstrated the robustness of the framing effect in a variety of contexts, especially in medical decision making. Unfortunately, research is still inconsistent as to how so many variables impact framing effects in medical decision making. Additionally, much attention should be paid to the framing effect not only in hypothetical scenarios but also in clinical experience.

Medical Decision-Making by Psychiatry Residents

ERIC Educational Resources Information Center

El-Mallakh, Rif; Zinner, Jill; Mackey, Amanda; Tamas, Rebecca L.; Martin, Chanley M.; Dalton, Jerad; Dhaliwal, Nitu; Luddington, Nicole; Numan, Farhad U.; Nunes, Ross; Taylor, Stephen; Ye, Lu

2007-01-01

Objective: Several conspiring factors have resulted in an increase in the level of medical burden in psychiatric patients. Psychiatry residents require increasing levels of medical sophistication. To assess the medical decision-making of psychiatry residents, the authors examined the outcome in subjects initially seen in the emergency psychiatric…

Dual processing model of medical decision-making.

PubMed

Djulbegovic, Benjamin; Hozo, Iztok; Beckstead, Jason; Tsalatsanis, Athanasios; Pauker, Stephen G

2012-09-03

Dual processing theory of human cognition postulates that reasoning and decision-making can be described as a function of both an intuitive, experiential, affective system (system I) and/or an analytical, deliberative (system II) processing system. To date no formal descriptive model of medical decision-making based on dual processing theory has been developed. Here we postulate such a model and apply it to a common clinical situation: whether treatment should be administered to the patient who may or may not have a disease. We developed a mathematical model in which we linked a recently proposed descriptive psychological model of cognition with the threshold model of medical decision-making and show how this approach can be used to better understand decision-making at the bedside and explain the widespread variation in treatments observed in clinical practice. We show that physician's beliefs about whether to treat at higher (lower) probability levels compared to the prescriptive therapeutic thresholds obtained via system II processing is moderated by system I and the ratio of benefit and harms as evaluated by both system I and II. Under some conditions, the system I decision maker's threshold may dramatically drop below the expected utility threshold derived by system II. This can explain the overtreatment often seen in the contemporary practice. The opposite can also occur as in the situations where empirical evidence is considered unreliable, or when cognitive processes of decision-makers are biased through recent experience: the threshold will increase relative to the normative threshold value derived via system II using expected utility threshold. This inclination for the higher diagnostic certainty may, in turn, explain undertreatment that is also documented in the current medical practice. We have developed the first dual processing model of medical decision-making that has potential to enrich the current medical decision-making field, which is still to the

Dual processing model of medical decision-making

PubMed Central

2012-01-01

Background Dual processing theory of human cognition postulates that reasoning and decision-making can be described as a function of both an intuitive, experiential, affective system (system I) and/or an analytical, deliberative (system II) processing system. To date no formal descriptive model of medical decision-making based on dual processing theory has been developed. Here we postulate such a model and apply it to a common clinical situation: whether treatment should be administered to the patient who may or may not have a disease. Methods We developed a mathematical model in which we linked a recently proposed descriptive psychological model of cognition with the threshold model of medical decision-making and show how this approach can be used to better understand decision-making at the bedside and explain the widespread variation in treatments observed in clinical practice. Results We show that physician’s beliefs about whether to treat at higher (lower) probability levels compared to the prescriptive therapeutic thresholds obtained via system II processing is moderated by system I and the ratio of benefit and harms as evaluated by both system I and II. Under some conditions, the system I decision maker’s threshold may dramatically drop below the expected utility threshold derived by system II. This can explain the overtreatment often seen in the contemporary practice. The opposite can also occur as in the situations where empirical evidence is considered unreliable, or when cognitive processes of decision-makers are biased through recent experience: the threshold will increase relative to the normative threshold value derived via system II using expected utility threshold. This inclination for the higher diagnostic certainty may, in turn, explain undertreatment that is also documented in the current medical practice. Conclusions We have developed the first dual processing model of medical decision-making that has potential to enrich the current medical

Predictors of hospitalised patients' preferences for physician-directed medical decision-making.

PubMed

Chung, Grace S; Lawrence, Ryan E; Curlin, Farr A; Arora, Vineet; Meltzer, David O

2012-02-01

Although medical ethicists and educators emphasise patient-centred decision-making, previous studies suggest that patients often prefer their doctors to make the clinical decisions. To examine the associations between a preference for physician-directed decision-making and patient health status and sociodemographic characteristics. Sociodemographic and clinical information from all consenting general internal medicine patients at the University of Chicago Medical Center were examined. The primary objectives were to (1) assess the extent to which patients prefer an active role in clinical decision-making, and (2) determine whether religious service attendance, the importance of religion, self-rated spirituality, Charlson Comorbidity Index, self-reported health, Vulnerable Elder Score and several demographic characteristics were associated with these preferences. Data were collected from 8308 of 11,620 possible participants. Ninety-seven per cent of respondents wanted doctors to offer them choices and to consider their opinions. However, two out of three (67%) preferred to leave medical decisions to the doctor. In multiple regression analyses, preferring to leave decisions to the doctor was associated with older age (per year, OR=1.019, 95% CI 1.003 to 1.036) and frequently attending religious services (OR=1.5, 95% CI 1.1 to 2.1, compared with never), and it was inversely associated with female sex (OR=0.6, 95% CI 0.5 to 0.8), university education (OR=0.6, 95% CI 0.4 to 0.9, compared with no high school diploma) and poor health (OR=0.6, 95% CI 0.3 to 0.9). Almost all patients want doctors to offer them choices and to consider their opinions, but most prefer to leave medical decisions to the doctor. Patients who are male, less educated, more religious and healthier are more likely to want to leave decisions to their doctors, but effects are small.

Influence of framing on medical decision making

PubMed Central

Gong, Jingjing; Zhang, Yan; Feng, Jun; Huang, Yonghua; Wei, Yazhou; Zhang, Weiwei

2013-01-01

Numerous studies have demonstrated the robustness of the framing effect in a variety of contexts, especially in medical decision making. Unfortunately, research is still inconsistent as to how so many variables impact framing effects in medical decision making. Additionally, much attention should be paid to the framing effect not only in hypothetical scenarios but also in clinical experience. PMID:27034630

The framing effect in medical decision-making: a review of the literature.

PubMed

Gong, Jingjing; Zhang, Yan; Yang, Zheng; Huang, Yonghua; Feng, Jun; Zhang, Weiwei

2013-01-01

The framing effect, identified by Tversky and Kahneman, is one of the most striking cognitive biases, in which people react differently to a particular choice depending whether it is presented as a loss or as a gain. Numerous studies have subsequently demonstrated the robustness of the framing effect in a variety of contexts, especially in medical decision-making. Compared to daily decisions, medical decisions are of low frequency but of paramount importance. The framing effect is a well-documented bias in a variety of studies, but research is inconsistent regarding whether and how variables influence framing effects in medical decision-making. To clarify the discrepancy in the previous literature, published literature in the English language concerning the framing effect was retrieved using electronic and bibliographic searches. Two reviewers examined each article for inclusion and evaluated the articles' methodological quality. The framing effect in medical decision-making was reviewed in these papers. No studies identified an influence of framing information upon compliance with health recommendations, and different studies demonstrate different orientations of the framing effect. Because so many variables influence the presence or absence of the framing effect, the unexplained heterogeneity between studies suggests the possibility of a framing effect under specific conditions. Further research is needed to determine why the framing effect is induced and how it can be precluded.

Managing Complexity: Exploring Decision Making on Medication by Young Adults with ADHD.

PubMed

Druedahl, Louise C; Kälvemark Sporrong, Sofia

2018-04-19

Attention-deficit hyperactivity disorder (ADHD) causes difficulties with hyperactivity, impulsivity and inattention. Treatment of ADHD includes both medication and non-pharmacological options. Knowledge of treatment preferences by young adults with ADHD is sparse. The objective of this study was to explore the beliefs and experiences of young adults with ADHD related to their medication treatment decisions. Data were collected in Denmark in 2016 through a focus group and individual in-depth interviews. Conventional content analysis was used. Ten young adults with ADHD (22-to 29-year-old) participated. Three major themes were identified: (1) the patient’s right to choose concerning ADHD medicine; (2) the patient’s decision of whether or not to treat ADHD with medication; and (3) factors affecting the patient’s decision on whether to take ADHD medication or not. The latter theme contained 15 factors, which were distributed across three levels: individual, between-individuals, and societal. The dominant factors were increasing quality of life and improving oneself e.g., improving social skills. For counselling at the pharmacy and by prescribers, it is important to be aware of the different factors that affect young adult patients’ decisions on whether to take ADHD medication or not. This knowledge will aid to understand reasons for non-adherence and to determine appropriate treatment for the individual patient.

The effects of consultation on over-the-counter medication purchasing decisions.

PubMed

Nichol, M B; McCombs, J S; Johnson, K A; Spacapan, S; Sclar, D A

1992-11-01

This article examines factors that predict changes in consumer purchasing decisions of nonprescription medications. Variables corresponding to factors in Andersen's behavioral model are measured, in addition to data regarding characteristics of the 17 pharmacy consultants who provided counseling services. One thousand seven hundred and thirteen consumers in five stores in southern California were provided consultation during a 6-month period, resulting in 25.4% of the patients purchasing a different drug than intended when entering the pharmacy, 1.3% being referred to a physician, and 13.4% not purchasing any over-the-counter medication at all. Logistic regression techniques demonstrated that one enabling variable (availability of generic medications), and four need factors (the discussion of clinical issues, short encounters, cough and cold products, and vitamin products) were significant predictors of the consumer's decision to purchase a different product than intended. Consultant characteristics (introversion, external locus of control) were also important predictors, but opposite the expected direction. Consumers who received information from female consultants were more likely to change their purchasing decisions.

Minors' rights in medical decision making.

PubMed

Hickey, Kathryn

2007-01-01

In the past, minors were not considered legally capable of making medical decisions and were viewed as incompetent because of their age. The authority to consent or refuse treatment for a minor remained with a parent or guardian. This parental authority was derived from the constitutional right to privacy regarding family matters, common law rule, and a general presumption that parents or guardians will act in the best interest of their incompetent child. However, over the years, the courts have gradually recognized that children younger than 18 years who show maturity and competence deserve a voice in determining their course of medical treatment. This article will explore the rights and interests of minors, parents, and the state in medical decision making and will address implications for nursing administrators and leaders.

What role does health literacy play in patients' involvement in medical decision-making?

PubMed

Brabers, Anne E M; Rademakers, Jany J D J M; Groenewegen, Peter P; van Dijk, Liset; de Jong, Judith D

2017-01-01

Patients vary in their preferences towards involvement in medical decision-making. Previous research, however, gives no clear explanation for this observed variation in their involvement. One possible explanation might be health literacy. Health literacy refers to personal characteristics and social resources needed for people to access, understand and use information to make decisions about their health. This study aimed to examine the relationship between health literacy and self-reported patient involvement. With respect to health literacy, we focused on those competences relevant for medical decision-making. We hypothesized that people with higher health literacy report that they are more involved in medical decision-making. A structured questionnaire was sent to members of the Dutch Health Care Consumer Panel in May 2015 (response 46%, N = 974). Health literacy was measured using five scales of the Health Literacy Questionnaire. A regression model was used to estimate the relationship between health literacy and self-reported involvement. In general, our results did not show a relationship between health literacy and self-reported involvement. We did find a positive significant association between the health literacy scale appraisal of health information and self-reported involvement. Our hypothesis was partly confirmed. The results from this study suggest that higher order competences, that is to say critical health literacy, in particular, are important in reporting involvement in medical decision-making. Future research is recommended to unravel further the relationship between health literacy and patient involvement in order to gain insight into whether health literacy might be an asset to enhance patient participation in medical decision-making.

What role does health literacy play in patients' involvement in medical decision-making?

PubMed Central

Brabers, Anne E. M.; Rademakers, Jany J. D. J. M.; Groenewegen, Peter P.; van Dijk, Liset; de Jong, Judith D.

2017-01-01

Patients vary in their preferences towards involvement in medical decision-making. Previous research, however, gives no clear explanation for this observed variation in their involvement. One possible explanation might be health literacy. Health literacy refers to personal characteristics and social resources needed for people to access, understand and use information to make decisions about their health. This study aimed to examine the relationship between health literacy and self-reported patient involvement. With respect to health literacy, we focused on those competences relevant for medical decision-making. We hypothesized that people with higher health literacy report that they are more involved in medical decision-making. A structured questionnaire was sent to members of the Dutch Health Care Consumer Panel in May 2015 (response 46%, N = 974). Health literacy was measured using five scales of the Health Literacy Questionnaire. A regression model was used to estimate the relationship between health literacy and self-reported involvement. In general, our results did not show a relationship between health literacy and self-reported involvement. We did find a positive significant association between the health literacy scale appraisal of health information and self-reported involvement. Our hypothesis was partly confirmed. The results from this study suggest that higher order competences, that is to say critical health literacy, in particular, are important in reporting involvement in medical decision-making. Future research is recommended to unravel further the relationship between health literacy and patient involvement in order to gain insight into whether health literacy might be an asset to enhance patient participation in medical decision-making. PMID:28257472

The limits of parental responsibility regarding medical treatment decisions.

PubMed

Woolley, Sarah L

2011-11-01

Parental responsibility (PR) was a concept introduced by the Children Act (CA) 1989 which aimed to replace the outdated notion of parental rights and duties which regarded children as parental possessions. Section 3(1) CA 1989 defines PR as 'all the rights, duties, powers, responsibilities and authority which by law a parent of a child has in relation to the child'. In exercising PR, individuals may make medical treatment decisions on children's behalf. Medical decision-making is one area of law where both children and the state can intercede and limit parental decision-making. Competent children can consent to treatment and the state can interfere if parental decisions are not seemingly in the child's 'best interests'. This article examines the concept, and limitations, of PR in relation to medical treatment decision-making.

Decision Making Based on Fuzzy Aggregation Operators for Medical Diagnosis from Dental X-ray images.

PubMed

Ngan, Tran Thi; Tuan, Tran Manh; Son, Le Hoang; Minh, Nguyen Hai; Dey, Nilanjan

2016-12-01

Medical diagnosis is considered as an important step in dentistry treatment which assists clinicians to give their decision about diseases of a patient. It has been affirmed that the accuracy of medical diagnosis, which is much influenced by the clinicians' experience and knowledge, plays an important role to effective treatment therapies. In this paper, we propose a novel decision making method based on fuzzy aggregation operators for medical diagnosis from dental X-Ray images. It firstly divides a dental X-Ray image into some segments and identified equivalent diseases by a classification method called Affinity Propagation Clustering (APC+). Lastly, the most potential disease is found using fuzzy aggregation operators. The experimental validation on real dental datasets of Hanoi Medical University Hospital, Vietnam showed the superiority of the proposed method against the relevant ones in terms of accuracy.

The Importance Of Integrating Narrative Into Health Care Decision Making.

PubMed

Dohan, Daniel; Garrett, Sarah B; Rendle, Katharine A; Halley, Meghan; Abramson, Corey

2016-04-01

When making health care decisions, patients and consumers use data but also gather stories from family and friends. When advising patients, clinicians consult the medical evidence but also use professional judgment. These stories and judgments, as well as other forms of narrative, shape decision making but remain poorly understood. Furthermore, qualitative research methods to examine narrative are rarely included in health science research. We illustrate how narratives shape decision making and explain why it is difficult but necessary to integrate qualitative research on narrative into the health sciences. We draw on social-scientific insights on rigorous qualitative research and our ongoing studies of decision making by patients with cancer, and we describe new tools and approaches that link qualitative research findings with the predominantly quantitative health science scholarship. Finally, we highlight the benefits of more fully integrating qualitative research and narrative analysis into the medical evidence base and into evidence-based medical practice. Project HOPE—The People-to-People Health Foundation, Inc.

Collective intelligence meets medical decision-making: the collective outperforms the best radiologist.

PubMed

Wolf, Max; Krause, Jens; Carney, Patricia A; Bogart, Andy; Kurvers, Ralf H J M

2015-01-01

While collective intelligence (CI) is a powerful approach to increase decision accuracy, few attempts have been made to unlock its potential in medical decision-making. Here we investigated the performance of three well-known collective intelligence rules ("majority", "quorum", and "weighted quorum") when applied to mammography screening. For any particular mammogram, these rules aggregate the independent assessments of multiple radiologists into a single decision (recall the patient for additional workup or not). We found that, compared to single radiologists, any of these CI-rules both increases true positives (i.e., recalls of patients with cancer) and decreases false positives (i.e., recalls of patients without cancer), thereby overcoming one of the fundamental limitations to decision accuracy that individual radiologists face. Importantly, we find that all CI-rules systematically outperform even the best-performing individual radiologist in the respective group. Our findings demonstrate that CI can be employed to improve mammography screening; similarly, CI may have the potential to improve medical decision-making in a much wider range of contexts, including many areas of diagnostic imaging and, more generally, diagnostic decisions that are based on the subjective interpretation of evidence.

Patients' Non-Medical Characteristics Contribute to Collective Medical Decision-Making at Multidisciplinary Oncological Team Meetings.

PubMed

Restivo, Léa; Apostolidis, Thémis; Bouhnik, Anne-Déborah; Garciaz, Sylvain; Aurran, Thérèse; Julian-Reynier, Claire

2016-01-01

The contribution of patients' non-medical characteristics to individual physicians' decision-making has attracted considerable attention, but little information is available on this topic in the context of collective decision-making. Medical decision-making at cancer centres is currently carried out using a collective approach, at MultiDisciplinary Team (MDT) meetings. The aim of this study was to determine how patients' non-medical characteristics are presented at MDT meetings and how this information may affect the team's final medical decisions. Observations were conducted at a French Cancer Centre during MDT meetings at which non-standard cases involving some uncertainty were discussed from March to May 2014. Physicians' verbal statements and predefined contextual parameters were collected with a non-participant observational approach. Non numerical data collected in the form of open notes were then coded for quantitative analysis. Univariate and multivariate statistical analyses were performed. In the final sample of patients' records included and discussed (N = 290), non-medical characteristics were mentioned in 32.8% (n = 95) of the cases. These characteristics corresponded to demographics in 22.8% (n = 66) of the cases, psychological data in 11.7% (n = 34), and relational data in 6.2% (n = 18). The patient's age and his/her "likeability" were the most frequently mentioned characteristics. In 17.9% of the cases discussed, the final decision was deferred: this outcome was positively associated with the patients' non-medical characteristics and with uncertainty about the outcome of the therapeutic options available. The design of the study made it difficult to draw definite cause-and-effect conclusions. The Social Representations approach suggests that patients' non-medical characteristics constitute a kind of tacit professional knowledge that may be frequently mobilised in physicians' everyday professional practice. The links observed between patients

Patients’ Non-Medical Characteristics Contribute to Collective Medical Decision-Making at Multidisciplinary Oncological Team Meetings

PubMed Central

Restivo, Léa; Apostolidis, Thémis; Bouhnik, Anne-Déborah; Garciaz, Sylvain; Aurran, Thérèse; Julian-Reynier, Claire

2016-01-01

Background The contribution of patients’ non-medical characteristics to individual physicians’ decision-making has attracted considerable attention, but little information is available on this topic in the context of collective decision-making. Medical decision-making at cancer centres is currently carried out using a collective approach, at MultiDisciplinary Team (MDT) meetings. The aim of this study was to determine how patients’ non-medical characteristics are presented at MDT meetings and how this information may affect the team’s final medical decisions. Design Observations were conducted at a French Cancer Centre during MDT meetings at which non-standard cases involving some uncertainty were discussed from March to May 2014. Physicians’ verbal statements and predefined contextual parameters were collected with a non-participant observational approach. Non numerical data collected in the form of open notes were then coded for quantitative analysis. Univariate and multivariate statistical analyses were performed. Results In the final sample of patients’ records included and discussed (N = 290), non-medical characteristics were mentioned in 32.8% (n = 95) of the cases. These characteristics corresponded to demographics in 22.8% (n = 66) of the cases, psychological data in 11.7% (n = 34), and relational data in 6.2% (n = 18). The patient’s age and his/her “likeability” were the most frequently mentioned characteristics. In 17.9% of the cases discussed, the final decision was deferred: this outcome was positively associated with the patients’ non-medical characteristics and with uncertainty about the outcome of the therapeutic options available. Limitations The design of the study made it difficult to draw definite cause-and-effect conclusions. Conclusion The Social Representations approach suggests that patients’ non-medical characteristics constitute a kind of tacit professional knowledge that may be frequently mobilised in physicians�

Braving difficult choices alone: children's and adolescents' medical decision making.

PubMed

Ruggeri, Azzurra; Gummerum, Michaela; Hanoch, Yaniv

2014-01-01

What role should minors play in making medical decisions? The authors examined children's and adolescents' desire to be involved in serious medical decisions and the emotional consequences associated with them. Sixty-three children and 76 adolescents were presented with a cover story about a difficult medical choice. Participants were tested in one of four conditions: (1) own informed choice; (2) informed parents' choice to amputate; (3) informed parents' choice to continue a treatment; and (4) uninformed parents' choice to amputate. In a questionnaire, participants were asked about their choices, preference for autonomy, confidence, and emotional reactions when faced with a difficult hypothetical medical choice. Children and adolescents made different choices and participants, especially adolescents, preferred to make the difficult choice themselves, rather than having a parent make it. Children expressed fewer negative emotions than adolescents. Providing information about the alternatives did not affect participants' responses. Minors, especially adolescents, want to be responsible for their own medical decisions, even when the choice is a difficult one. For the adolescents, results suggest that the decision to be made, instead of the agent making the decision, is the main element influencing their emotional responses and decision confidence. For children, results suggest that they might be less able than adolescents to project how they would feel. The results, overall, draw attention to the need to further investigate how we can better involve minors in the medical decision-making process.

Braving Difficult Choices Alone: Children's and Adolescents' Medical Decision Making

PubMed Central

Ruggeri, Azzurra; Gummerum, Michaela; Hanoch, Yaniv

2014-01-01

Objective What role should minors play in making medical decisions? The authors examined children's and adolescents' desire to be involved in serious medical decisions and the emotional consequences associated with them. Methods Sixty-three children and 76 adolescents were presented with a cover story about a difficult medical choice. Participants were tested in one of four conditions: (1) own informed choice; (2) informed parents' choice to amputate; (3) informed parents' choice to continue a treatment; and (4) uninformed parents' choice to amputate. In a questionnaire, participants were asked about their choices, preference for autonomy, confidence, and emotional reactions when faced with a difficult hypothetical medical choice. Results Children and adolescents made different choices and participants, especially adolescents, preferred to make the difficult choice themselves, rather than having a parent make it. Children expressed fewer negative emotions than adolescents. Providing information about the alternatives did not affect participants' responses. Conclusions Minors, especially adolescents, want to be responsible for their own medical decisions, even when the choice is a difficult one. For the adolescents, results suggest that the decision to be made, instead of the agent making the decision, is the main element influencing their emotional responses and decision confidence. For children, results suggest that they might be less able than adolescents to project how they would feel. The results, overall, draw attention to the need to further investigate how we can better involve minors in the medical decision-making process. PMID:25084274

Not a Humbug: the evolution of patient-centred medical decision-making.

PubMed

Trump, Benjamin D; Linkov, Faina; Edwards, Robert P; Linkov, Igor

2015-12-01

This 'Christmas Issue'-type paper uses the framework of 'A Christmas Carol' to tell about the evolution of decision-making in evidence-based medicine (EBM). The Ghost of the Past represents paternalistic medicine, the Ghost of the Present symbolises EBM, while the Ghost of the Future serves as a patient-centred system where research data and tools of decision science are jointly used to make optimal medical decisions for individual patients. We argue that this shift towards a patient-centred approach to EBM and medical care is the next step in the evolution of medical decision-making, which would help to empower patients with the capability to make educated decisions throughout the course of their medical treatment.

Heuristics: foundations for a novel approach to medical decision making.

PubMed

Bodemer, Nicolai; Hanoch, Yaniv; Katsikopoulos, Konstantinos V

2015-03-01

Medical decision-making is a complex process that often takes place during uncertainty, that is, when knowledge, time, and resources are limited. How can we ensure good decisions? We present research on heuristics-simple rules of thumb-and discuss how medical decision-making can benefit from these tools. We challenge the common view that heuristics are only second-best solutions by showing that they can be more accurate, faster, and easier to apply in comparison to more complex strategies. Using the example of fast-and-frugal decision trees, we illustrate how heuristics can be studied and implemented in the medical context. Finally, we suggest how a heuristic-friendly culture supports the study and application of heuristics as complementary strategies to existing decision rules.

[The Intentions Affecting the Medical Decision-Making Behavior of Surrogate Decision Makers of Critically Ill Patients and Related Factors].

PubMed

Su, Szu-Huei; Wu, Li-Min

2018-04-01

The severity of diseases and high mortality rates that typify the intensive care unit often make it difficult for surrogate decision makers to make decisions for critically ill patients regarding whether to continue medical treatments or to accept palliative care. To explore the behavioral intentions that underlie the medical decisions of surrogate decision makers of critically ill patients and the related factors. A cross-sectional, correlation study design was used. A total of 193 surrogate decision makers from six ICUs in a medical center in southern Taiwan were enrolled as participants. Three structured questionnaires were used, including a demographic datasheet, the Family Relationship Scale, and the Behavioral Intention of Medical Decisions Scale. Significantly positive correlations were found between the behavioral intentions underlying medical decisions and the following variables: the relationship of the participant to the patient (Eta = .343, p = .020), the age of the patient (r = .295, p < .01), and whether the patient had signed a currently valid advance healthcare directive (Eta = .223, p = .002). Furthermore, a significantly negative correlation was found between these intentions and length of stay in the ICU (r = -.263, p < .01). Patient age, whether the patient had signed a currently valid advance healthcare directive, and length of stay in the ICU were all predictive factors for the behavioral intentions underlying the medical decisions of the surrogate decision makers, explaining 13.9% of the total variance. In assessing the behavioral intentions underlying the medical decisions of surrogate decision makers, health providers should consider the relationship between critical patients and their surrogate decision makers, patient age, the length of ICU stay, and whether the patient has a pre-signed advance healthcare directive in order to maximize the effectiveness of medical care provided to critically ill patients.

Medical Decision-Making for Adults Who Lack Decision-Making Capacity and a Surrogate: State of the Science.

PubMed

Kim, Hyejin; Song, Mi-Kyung

2018-01-01

Adults who lack decision-making capacity and a surrogate ("unbefriended" adults) are a vulnerable, voiceless population in health care. But little is known about this population, including how medical decisions are made for these individuals. This integrative review was to examine what is known about unbefriended adults and identify gaps in the literature. Six electronic databases were searched using 4 keywords: "unbefriended," "unrepresented patients," "adult orphans," and "incapacitated patients without surrogates." After screening, the final sample included 10 data-based articles for synthesis. Main findings include the following: (1) various terms were used to refer to adults who lack decision-making capacity and a surrogate; (2) the number of unbefriended adults was sizable and likely to grow; (3) approaches to medical decision-making for this population in health-care settings varied; and (4) professional guidelines and laws to address the issues related to this population were inconsistent. There have been no studies regarding the quality of medical decision-making and its outcomes for this population or societal impact. Extremely limited empirical data exist on unbefriended adults to develop strategies to improve how medical decisions are made for this population. There is an urgent need for research to examine the quality of medical decision-making and its outcomes for this vulnerable population.

Adolescent and parental perceptions of medical decision-making in Hong Kong.

PubMed

Hui, Edwin

2011-11-01

To investigate whether Chinese adolescents in Hong Kong share similar perceptions with their Western counterparts regarding their capacity for autonomous decision-making, and secondarily whether Chinese parents underestimate their adolescent children's desire and capacity for autonomous decision-making. 'Healthy Adolescents' and their parents were recruited from four local secondary schools, and 'Sick Adolescents' and their parents from the pediatric wards and outpatient clinics. Their perceptions of adolescents' understanding of illnesses and treatments, maturity in judgment, risk-taking, openness to divergent opinions, pressure from parents and doctors, submission to parental authority and preference for autonomy in medical decision-making are surveyed by a 50-item questionnaire on a five-point Likert scale. Findings indicate that Chinese adolescents aged 14-16 perceive themselves to possess the necessary cognitive abilities and maturity in judgment to be autonomous decision-makers like their Western counterparts. Paradoxically, although they hesitate to assert their autonomy, they are also unwilling to surrender that autonomy to their parents even under coercion or intimidation. Parents tend to underestimate their adolescents' preferences for making autonomous decisions and overestimate the importance of parental authority in decision-making. '14-and-above' Chinese adolescents in Hong Kong perceive themselves as capable of autonomous decision-making in medically-related matters, but hesitate to assert their autonomy, probably because of the Confucian values of parental authority and filial piety that are deeply embedded in the local culture. © 2010 Blackwell Publishing Ltd.

Applying STOPP Guidelines in Primary Care Through Electronic Medical Record Decision Support: Randomized Control Trial Highlighting the Importance of Data Quality.

PubMed

Price, Morgan; Davies, Iryna; Rusk, Raymond; Lesperance, Mary; Weber, Jens

2017-06-15

prescribing workflows. Many of the STOPP criteria can be implemented in EMRs using simple logic. However, data quality in EMRs continues to be a challenge and was a limiting step in the effectiveness of the decision support in this study. This is important as decision makers continue to fund implementation and adoption of EMRs with the expectation of the use of advanced tools (such as decision support) without ongoing review of data quality and improvement. Clinicaltrials.gov NCT02130895; https://clinicaltrials.gov/ct2/show/NCT02130895 (Archived by WebCite at http://www.webcitation.org/6qyFigSYT). ©Morgan Price, Iryna Davies, Raymond Rusk, Mary Lesperance, Jens Weber. Originally published in JMIR Medical Informatics (http://medinform.jmir.org), 15.06.2017.

Critical factors in career decision making for women medical graduates.

PubMed

Lawrence, Joanna; Poole, Phillippa; Diener, Scott

2003-04-01

Within the next 30 years there will be equal numbers of women and men in the medical workforce. Indications are that women are increasing their participation in specialties other than general practice, although at a slower rate than their participation in the workforce as a whole. To inform those involved in training and employment of medical women, this study investigated the influencing factors in career decision making for female medical graduates. A total of 305 women medical graduates from the University of Auckland responded to a mail survey (73% response rate) which examined influences on decision making, in both qualitative and quantitative ways, as part of a larger survey. Most women were satisfied with their careers. The principal component analysis of the influencing factors identified four distinct factors important in career choice - interest, flexibility, women friendliness and job security, although the first two of these were rated more highly than the others. Barriers to full participation by medical women in training and employment need to be systematically examined and removed. This is not only to allow women themselves to reach their full potential, but for workforce and socio-economic reasons. Initiatives that allow and value more flexible training and work practices, particularly through the years of child raising, are necessary for women and the health care workforce at large.

Medical decision-making during the guardianship process for incapacitated, hospitalized adults: a descriptive cohort study.

PubMed

Bandy, Robin J; Helft, Paul R; Bandy, Robert W; Torke, Alexia M

2010-10-01

It is sometimes necessary for courts to appoint guardians for adult, incapacitated patients. There are few data describing how medical decisions are made for such patients before and during the guardianship process. To describe the process of medical decision-making for incapacitated, hospitalized adults for whom court-appointed guardians are requested. Retrospective, descriptive cohort study. Patients were identified from the legal files of a public, urban hospital. Medical and legal records were reviewed for demographic data, code status, diagnoses, code status orders and invasive procedures and person authorizing the order or procedure, dates of incapacitation and appointment of temporary guardian, reason for guardianship, and documentation of communication with a guardian. A total of 79 patients met inclusion criteria; 68.4% were male and 56.2% African-American. The median age was 65 years. Of the 71 patients with medical records available 89% of patients had a temporary guardianship petitioned because of the need for placement only. Seventeen patients had a new DNR order written during hospitalization, eight of which were ordered by physicians without consultation with a surrogate decision maker. Overall, 32 patients underwent a total of 81 documented invasive procedures, 16 of which were authorized by the patient, 15 by family or friend, and 11 by a guardian; consent was not required for 39 of the procedures because of emergency conditions or because a procedure was medically necessary and no surrogate decision maker was available. Although most of the guardianships were requested for placement purposes, important medical decisions were made while patients were awaiting appointment of a guardian. Hospitalized, incapacitated adults awaiting guardianship may lack a surrogate decision maker when serious decisions must be made about their medical care.

The medical decision model and decision maker tools for management of radiological and nuclear incidents.

PubMed

Koerner, John F; Coleman, C Norman; Murrain-Hill, Paula; FitzGerald, Denis J; Sullivan, Julie M

2014-06-01

Effective decision making during a rapidly evolving emergency such as a radiological or nuclear incident requires timely interim decisions and communications from onsite decision makers while further data processing, consultation, and review are ongoing by reachback experts. The authors have recently proposed a medical decision model for use during a radiological or nuclear disaster, which is similar in concept to that used in medical care, especially when delay in action can have disastrous effects. For decision makers to function most effectively during a complex response, they require access to onsite subject matter experts who can provide information, recommendations, and participate in public communication efforts. However, in the time before this expertise is available or during the planning phase, just-in-time tools are essential that provide critical overview of the subject matter written specifically for the decision makers. Recognizing the complexity of the science, risk assessment, and multitude of potential response assets that will be required after a nuclear incident, the Office of the Assistant Secretary for Preparedness and Response, in collaboration with other government and non-government experts, has prepared a practical guide for decision makers. This paper illustrates how the medical decision model process could facilitate onsite decision making that includes using the deliberative reachback process from science and policy experts and describes the tools now available to facilitate timely and effective incident management.

Human-Computer Interaction with Medical Decisions Support Systems

NASA Technical Reports Server (NTRS)

Adolf, Jurine A.; Holden, Kritina L.

1994-01-01

Decision Support Systems (DSSs) have been available to medical diagnosticians for some time, yet their acceptance and use have not increased with advances in technology and availability of DSS tools. Medical DSSs will be necessary on future long duration space missions, because access to medical resources and personnel will be limited. Human-Computer Interaction (HCI) experts at NASA's Human Factors and Ergonomics Laboratory (HFEL) have been working toward understanding how humans use DSSs, with the goal of being able to identify and solve the problems associated with these systems. Work to date consists of identification of HCI research areas, development of a decision making model, and completion of two experiments dealing with 'anchoring'. Anchoring is a phenomenon in which the decision maker latches on to a starting point and does not make sufficient adjustments when new data are presented. HFEL personnel have replicated a well-known anchoring experiment and have investigated the effects of user level of knowledge. Future work includes further experimentation on level of knowledge, confidence in the source of information and sequential decision making.

Uncertainties in real-world decisions on medical technologies.

PubMed

Lu, C Y

2014-08-01

Patients, clinicians, payers and policy makers face substantial uncertainties in their respective healthcare decisions as they attempt to achieve maximum value, or the greatest level of benefit possible at a given cost. Uncertainties largely come from incomplete information at the time that decisions must be made. This is true in all areas of medicine because evidence from clinical trials is often incongruent with real-world patient care. This article highlights key uncertainties around the (comparative) benefits and harms of medical technologies. Initiatives and strategies such as comparative effectiveness research and coverage with evidence development may help to generate reliable and relevant evidence for decisions on coverage and treatment. These efforts could result in better decisions that improve patient outcomes and better use of scarce medical resources. © 2014 John Wiley & Sons Ltd.

Participation of Children in Medical Decision-Making: Challenges and Potential Solutions.

PubMed

Jeremic, Vida; Sénécal, Karine; Borry, Pascal; Chokoshvili, Davit; Vears, Danya F

2016-12-01

Participation in healthcare decision-making is considered to be an important right of minors, and is highlighted in both international legislation and public policies. However, despite the legal recognition of children's rights to participation, and also the benefits that children experience by their involvement, there is evidence that legislation is not always translated into healthcare practice. There are a number of factors that may impact on the ability of the child to be involved in decisions regarding their medical care. Some of these factors relate to the child, including their capacity to be actively involved in these decisions. Others relate to the family situation, sociocultural context, or the underlying beliefs and practices of the healthcare provider involved. In spite of these challenges to including children in decisions regarding their clinical care, we argue that it is an important factor in their treatment. The extent to which children should participate in this process should be determined on a case-by-case basis, taking all of the potential barriers into account.

"It Was the Best Decision of My Life": a thematic content analysis of former medical tourists' patient testimonials.

PubMed

Hohm, Carly; Snyder, Jeremy

2015-01-22

Medical tourism is international travel with the intention of receiving medical care. Medical tourists travel for many reasons, including cost savings, limited domestic access to specific treatments, and interest in accessing unproven interventions. Medical tourism poses new health and safety risks to patients, including dangers associated with travel following surgery, difficulty assessing the quality of care abroad, and complications in continuity of care. Online resources are important to the decision-making of potential medical tourists and the websites of medical tourism facilitation companies (companies that may or may not be affiliated with a clinic abroad and help patients plan their travel) are an important source of online information for these individuals. These websites fail to address the risks associated with medical tourism, which can undermine the informed decision-making of potential medical tourists. Less is known about patient testimonials on these websites, which can be a particularly powerful influence on decision-making. A thematic content analysis was conducted of patient testimonials hosted on the YouTube channels of four medical tourism facilitation companies. Five videos per company were viewed. The content of these videos was analyzed and themes identified and counted for each video. Ten main themes were identified. These themes were then grouped into three main categories: facilitator characteristics (e.g., mentions of the facilitator by name, reference to the price of the treatment or to cost savings); service characteristics (e.g., the quality and availability of the surgeon, the quality and friendliness of the support staff); and referrals (e.g., referrals to other potential medical tourists). These testimonials were found either not to mention risks associated with medical tourism or to claim that these risks can be effectively managed through the use of the facilitation company. The failure fully to address the risks of medical

How the elderly and young adults differ in the decision making process of nonprescription medication purchases.

PubMed

Sansgiry, S S; Cady, P S

1996-01-01

The study compared elderly and young adults in their behavior and involvement in the decision making process of over-the-counter (OTC) medication purchases. Elderly subjects were more involved in the decision making process to purchase OTC medications compared to young adults. The elderly not only purchase and spend more money on medications but also read OTC labels completely. They requested help from the pharmacist more frequently than young adults. Needs of the elderly in making an OTC medication purchase were different compared to young adults. The two age groups differed on importance rating for several attributes regarding OTC medications, such as; ease of opening the package, child resistant package, side effects of medicine, manufacturer of medicine, print size on package labels, and greater choice of medicine.

Framing effect debiasing in medical decision making.

PubMed

Almashat, Sammy; Ayotte, Brian; Edelstein, Barry; Margrett, Jennifer

2008-04-01

Numerous studies have demonstrated the robustness of the framing effect in a variety of contexts. The present study investigated the effects of a debiasing procedure designed to prevent the framing effect for young adults who made decisions based on hypothetical medical decision-making vignettes. The debiasing technique involved participants listing advantages and disadvantages of each treatment prior to making a choice. One hundred and two undergraduate students read a set of three medical treatment vignettes that presented information in terms of different outcome probabilities under either debiasing or control conditions. The framing effect was demonstrated by the control group in two of the three vignettes. The debiasing group successfully avoided the framing effect for both of these vignettes. These results further support previous findings of the framing effect as well as an effective debiasing technique. This study improved upon previous framing debiasing studies by including a control group and personal medical scenarios, as well as demonstrating debiasing in a framing condition in which the framing effect was demonstrated without a debiasing procedure. The findings suggest a relatively simple manipulation may circumvent the use of decision-making heuristics in patients.

Ethnic bias and clinical decision-making among New Zealand medical students: an observational study.

PubMed

Harris, Ricci; Cormack, Donna; Stanley, James; Curtis, Elana; Jones, Rhys; Lacey, Cameron

2018-01-23

overall this was not associated with clinical decision-making. This study both adds to the small body of literature internationally on racial/ethnic bias among medical students and provides relevant and important information for medical education on indigenous health and ethnic health inequities in New Zealand.

Justice and care: decision making by medical school student Promotions Committees

PubMed Central

Green, Emily P.; Gruppuso, Philip A.

2017-01-01

CONTEXT The function of medical school entities that determine student advancement or dismissal has gone largely unexplored. Decision making of “academic progress” or student promotions committees is examined using a theoretical framework contrasting ethics of justice and care, with roots in the moral development work of theorists Kohlberg and Gilligan. OBJECTIVES To ascertain promotions committee members’ conceptualization of the role of their committee, ethical orientations used in member decision making, and student characteristics most influential to that decision making. METHODS An electronic survey was distributed to voting members of promotions committees at 143 accredited allopathic medical schools in the U.S. Descriptive statistics were calculated and data were analyzed by gender, role, institution type and class size. RESULTS Respondents included 241 voting members of promotions committees at 55 medical schools. Respondents endorsed various promotions committee roles, including acting in the best interest of learners’ future patients and graduating highly qualified learners. Implementing policy was assigned lower importance. The overall pattern of responses did not indicate a predominant orientation toward an ethic of justice or care. Respondents indicated that committees have discretion to take individual student characteristics into consideration during deliberations, and that they do so in practice. Among the student characteristics with the greatest influence on decision making, professionalism and academic performance were paramount. Eighty-five percent of participants indicated that they received no training. CONCLUSIONS Promotions committee members do not regard orientations of justice and care as being mutually exclusive, and endorse an array of statements regarding committee purpose that may conflict with one another. The considerable variance in the influence of student characteristics, and the general absence of committee member

What are the Essential Elements to Enable Patient Participation in Medical Decision Making?

PubMed Central

McGraw, Sarah

2007-01-01

BACKGROUND Patient participation in shared decision making (SDM) results in increased patient knowledge, adherence, and improved outcomes. Despite the benefits of the SDM model, many patients do not attain the level of participation they desire. OBJECTIVE To gain a more complete understanding of the essential elements, or the prerequisites, critical to active patient participation in medical decision making from the patient’s perspective. DESIGN Qualitative study. SETTING Individual, in-depth patient interviews were conducted until thematic saturation was reached. Two analysts independently read the transcripts and jointly developed a list of codes. PATIENTS Twenty-six consecutive subjects drawn from community dwelling subjects undergoing bone density measurements. MEASUREMENTS Respondents’ experiences and beliefs related to patient participation in SDM. RESULTS Five elements were repeatedly described by respondents as being essential to enable patient participation in medical decision making: (1) patient knowledge, (2) explicit encouragement of patient participation by physicians, (3) appreciation of the patient’s responsibility/rights to play an active role in decision making, (4) awareness of choice, and (5) time. LIMITATIONS The generalizability of the results is limited by the homogeneity of the study sample. CONCLUSIONS Our findings have important clinical implications and suggest that several needs must be met before patients can become active participants in decisions related to their health care. These needs include ensuring that patients (1) appreciate that there is uncertainty in medicine and “buy in” to the importance of active patient participation in decisions related to their health care, (2) understand the trade-offs related to available options, and (3) have the opportunity to discuss these options with their physician to arrive at a decision concordant with their values. PMID:17443368

Attitudes to infant feeding decision-making--a mixed-methods study of Australian medical students and GP registrars.

PubMed

Brodribb, Wendy; Fallon, Tony; Jackson, Claire; Hegney, Desley

2010-03-01

Breastfeeding is an important public health issue. While medical practitioners can have a significant impact on breastfeeding initiation and duration, there are few studies investigating their views regarding women's infant feeding decisions. This mixed-methods study employed qualitative (focus groups and interviews) and quantitative (questionnaire) data collection techniques to investigate the attitudes and views of Australian medical students and GP registrars about infant feeding decision-making. Three approaches to infant feeding decisions were evident: 'the moral choice' (women were expected to breastfeed); 'the free choice' (doctors should not influence a woman's decision); and 'the equal choice' (the outcome of the decision was unimportant). Participants were uncertain about differences between artificial-feeding and breastfeeding outcomes, and there was some concern that advising a mother to breastfeed may lead to maternal feelings of guilt and failure. These findings, the first in an Australian setting, provide a foundation on which to base further educational interventions for medical practitioners.

Factors influencing US medical students' decision to pursue surgery.

PubMed

Schmidt, Lauren E; Cooper, Clairice A; Guo, Weidun Alan

2016-06-01

Interest and applications to surgery have steadily decreased over recent years in the United States. The goal of this review is to collect the current literature regarding US medical students' experience in surgery and factors influencing their intention to pursue surgery as a career. We hypothesize that multiple factors influence US medical students' career choice in surgery. Six electronic databases (PubMed, SCOPUS, Web of Science, Education Resources Information Center, Embase, and PsycINFO) were searched. The inclusion criteria were studies published after the new century related to factors influencing surgical career choice among US medical students. Factors influencing US medical student surgical career decision-making were recorded. A quality index score was given to each article selected to minimize risk of bias. We identified 38 relevant articles of more than 1000 nonduplicated titles. The factors influencing medical student decision for a surgical career were categorized into five domains: mentorship and role model (n = 12), experience (clerkship n = 9, stereotype n = 4), timing of exposure (n = 9), personal (lifestyle n = 8, gender n = 6, finance n = 3), and others (n = 2). This comprehensive systemic review identifies mentorship, experience in surgery, stereotypes, timing of exposure, and personal factors to be major determinants in medical students' decisions to pursue surgery. These represent areas that can be improved to attract applicants to general surgery residencies. Surgical faculty and residents can have a positive influence on medical students' decisions to pursue surgery as a career. Early introduction to the field of surgery, as well as recruitment strategies during the preclinical and clinical years of medical school can increase students' interest in a surgical career. Copyright © 2016 Elsevier Inc. All rights reserved.

Justice and care: decision making by medical school student promotions committees.

PubMed

Green, Emily P; Gruppuso, Philip A

2017-06-01

The function of medical school entities that determine student advancement or dismissal has gone largely unexplored. The decision making of 'academic progress' or student promotions committees is examined using a theoretical framework contrasting ethics of justice and care, with roots in the moral development work of theorists Kohlberg and Gilligan. To ascertain promotions committee members' conceptualisation of the role of their committee, ethical orientations used in member decision making, and student characteristics most influential in that decision making. An electronic survey was distributed to voting members of promotions committees at 143 accredited allopathic medical schools in the USA. Descriptive statistics were calculated and data were analysed by gender, role, institution type and class size. Respondents included 241 voting members of promotions committees at 55 medical schools. Respondents endorsed various promotions committee roles, including acting in the best interest of learners' future patients and graduating highly qualified learners. Implementing policy was assigned lower importance. The overall pattern of responses did not indicate a predominant orientation toward an ethic of justice or care. Respondents indicated that committees have discretion to take individual student characteristics into consideration during deliberations, and that they do so in practice. Among the student characteristics with the greatest influence on decision making, professionalism and academic performance were paramount. Eighty-five per cent of participants indicated that they received no training. Promotions committee members do not regard orientations of justice and care as being mutually exclusive and endorse an array of statements regarding the committee's purpose that may conflict with one another. The considerable variance in the influence of student characteristics and the general absence of committee member training indicate a need for clear delineation of the

Measurement Decision Risk - The Importance of Definitions

NASA Technical Reports Server (NTRS)

Mimbs, Scott M.

2008-01-01

One of the more misunderstood areas of metrology is the Test Uncertainty Ratio (TUR) and the Test Accuracy Ratio (TAR). There have been many definitions over the years, but why are these definitions important to a discussion on measurement decision risk? The importance lies in the clarity of communication. Problems can immediately arise in the application (or misapplication) of the definition of these terms. In other words, while it is important to understand the definitions, it is more important to understand concepts behind the definitions and to be precise in how they are applied. The objective of any measurement is a decision. Measurement Decision Risk is a way to look at the quality of a measurement, and although it is not a new concept, it has generated a lot of attention since its addition as a requirement in the new U.S. National Standard, ANSIINCSL Z540.3-2006. In addition to Measurement Decision Risk as the prime method of managing measurement risk, Z540.3 has added, as a fall-back, an explicit definition for TUR. The impact these new requirements may have on calibration service providers has become the topic of much discussion and in some cases concern. This paper will look at the concepts behind the definitions and how they relate to Measurement Decision Risk. Using common examples, this paper will also provide a comparison of various elements of risk related to measurement science using the concepts of TAR, TUR, accuracy ratios, and Consumer Risk (False Accept Risk). The goal of this paper is to provide a better understanding of their relevance to the measurement decision process.

Measurement Decision Risk - The Importance of Definitions

NASA Technical Reports Server (NTRS)

Mimbs, Scott M.

2007-01-01

One of the more misunderstood areas of metrology is the Test Uncertainty Ratio (TUR) and its cousin, the Test Accuracy Ratio (TAR). There have been many definitions over the years, but why are these definitions important to a discussion on measurement decision risk? The importance lies in the clarity of communication. Problems can immediately arise in the application (or misapplication) of the definition of these terms. In other words, while it is important to understand the definitions, it is more important to understand concepts behind the definitions and to be precise in how they are applied. The objective of any measurement is a decision. Measurement Decision Risk is a way to look at the quality of a measurement and although it is not a new concept, it has generated a lot of attention since its addition as a requirement in the new U.S. National Standard, ANSI/NCSL Z540.3-2006. In addition to Measurement Decision Risk as the prime method of managing measurement risk, Z540.3 has also added, as a fall-back, an explicit definition for TUR. The impact these changes might have on calibration service providers if these requirements are levied on them has become the topic of much discussion and in some cases concern. This paper looks at the concepts behind the definitions and how they relate to Measurement Decision Risk. Using common examples, this paper will also provide a comparison of various elements of risk related to measurement science using the concepts of TAR, TUR, accuracy ratios, and Consumer Risk (False Accept Risk). The goal is to provide a better understanding of their relevance to the measurement decision process.

Reasoning in the Capacity to Make Medical Decisions: The Consideration of Values

PubMed Central

Karel, Michele J.; Gurrera, Ronald J.; Hicken, Bret; Moye, Jennifer

2010-01-01

Purpose To examine the contribution of “values-based reasoning” in evaluating older adults’ capacity to make medical decisions. Design and Methods Older men with schizophrenia (n=20) or dementia (n=20), and a primary care comparison group (n=19), completed cognitive and psychiatric screening and an interview to determine their capacity to make medical decisions, which included a component on values. All of the participants were receiving treatment at Veterans Administration (VA) outpatient clinics. Results Participants varied widely in the activities and relationships they most valued, the extent to which religious beliefs would influence healthcare decisions, and in ratings of the importance of preserving quality versus length of life. Most participants preferred shared decision making with doctor, family, or both. Individuals with schizophrenia or dementia performed worse than a primary care comparison group in reasoning measured by the ability to list risks and benefits and compare choices. Individuals with dementia performed comparably to the primary care group in reasoning measured by the ability to justify choices in terms of valued abilities or activities, whereas individuals with schizophrenia performed relatively worse compared to the other two groups. Compared to primary care patients, participants with schizophrenia and with dementia were impaired on the ability to explain treatment choices in terms of valued relationships. Conclusion Medical decision making may be influenced by strongly held values and beliefs, emotions, and long life experience. To date, these issues have not been explicitly included in structured evaluations of medical decision-making capacity. This study demonstrated that it is possible to inquire of and elicit a range of healthcare related values and preferences from older adults with dementia or schizophrenia, and individuals with mild to moderate dementia may be able to discuss healthcare options in relation to their values

Combining multi-criteria decision analysis and mini-health technology assessment: A funding decision-support tool for medical devices in a university hospital setting.

PubMed

Martelli, Nicolas; Hansen, Paul; van den Brink, Hélène; Boudard, Aurélie; Cordonnier, Anne-Laure; Devaux, Capucine; Pineau, Judith; Prognon, Patrice; Borget, Isabelle

2016-02-01

At the hospital level, decisions about purchasing new and oftentimes expensive medical devices must take into account multiple criteria simultaneously. Multi-criteria decision analysis (MCDA) is increasingly used for health technology assessment (HTA). One of the most successful hospital-based HTA approaches is mini-HTA, of which a notable example is the Matrix4value model. To develop a funding decision-support tool combining MCDA and mini-HTA, based on Matrix4value, suitable for medical devices for individual patient use in French university hospitals - known as the IDA tool, short for 'innovative device assessment'. Criteria for assessing medical devices were identified from a literature review and a survey of 18 French university hospitals. Weights for the criteria, representing their relative importance, were derived from a survey of 25 members of a medical devices committee using an elicitation technique involving pairwise comparisons. As a test of its usefulness, the IDA tool was applied to two new drug-eluting beads (DEBs) for transcatheter arterial chemoembolization. The IDA tool comprises five criteria and weights for each of two over-arching categories: risk and value. The tool revealed that the two new DEBs conferred no additional value relative to DEBs currently available. Feedback from participating decision-makers about the IDA tool was very positive. The tool could help to promote a more structured and transparent approach to HTA decision-making in French university hospitals. Copyright © 2015 Elsevier Inc. All rights reserved.

Minorities with lupus nephritis and medications: a study of facilitators to medication decision-making.

PubMed

Singh, Jasvinder A; Qu, Haiyan; Yazdany, Jinoos; Chatham, Winn; Shewchuk, Richard

2015-12-17

Medication decision-making poses a challenge for a significant proportion of patients. This is an even more challenging for patients who have complex, rare, immune conditions that affect them at a young age and are associated with the use of life-long treatment, perceived by some as having significant risk of side effects and toxicity. The aim of our study was to examine the perspectives of women with lupus nephritis on facilitators to medication decision-making. We used the nominal group technique (NGT), a structured formative process to elicit patient perspectives. An NGT expert moderated eight patient group meetings. Participants (n = 52) responded to the question "What sorts of things make it easier for people to decide to take the medicines that doctors prescribe for treating their lupus kidney disease?" Patients nominated, discussed, and prioritized facilitators to medication decisional processes. Fifty-two women with lupus nephritis participated in eight NGT meetings (27 African-American, 13 Hispanic, and 12 Caucasian). Average age was 40.6 years (standard deviation (SD) = 13.3), and disease duration was 11.8 years (SD = 8.3); 36.5 % obtained at least a college education, and 55.8 % had difficulty in reading health materials. Patients generated 280 decision-making facilitators (range of 26 to 42 per panel). Of these, 102 (36 %) facilitators were perceived by patients as having relatively more influence in decision-making processes than others. Prioritized facilitators included effective patient-physician communication regarding benefits/harms, patient desire to live a normal life and improve quality of life, concern for their dependents, experiencing benefits and few/infrequent/no harms with lupus medications, and their affordability. Relative to African-Americans, Caucasian and Hispanic patients endorsed a smaller percentage of facilitators as influential. Level of agreement with which patients within panels independently agreed in their

Modeling paradigms for medical diagnostic decision support: a survey and future directions.

PubMed

Wagholikar, Kavishwar B; Sundararajan, Vijayraghavan; Deshpande, Ashok W

2012-10-01

Use of computer based decision tools to aid clinical decision making, has been a primary goal of research in biomedical informatics. Research in the last five decades has led to the development of Medical Decision Support (MDS) applications using a variety of modeling techniques, for a diverse range of medical decision problems. This paper surveys literature on modeling techniques for diagnostic decision support, with a focus on decision accuracy. Trends and shortcomings of research in this area are discussed and future directions are provided. The authors suggest that-(i) Improvement in the accuracy of MDS application may be possible by modeling of vague and temporal data, research on inference algorithms, integration of patient information from diverse sources and improvement in gene profiling algorithms; (ii) MDS research would be facilitated by public release of de-identified medical datasets, and development of opensource data-mining tool kits; (iii) Comparative evaluations of different modeling techniques are required to understand characteristics of the techniques, which can guide developers in choice of technique for a particular medical decision problem; and (iv) Evaluations of MDS applications in clinical setting are necessary to foster physicians' utilization of these decision aids.

Medical decision-making in children and adolescents: developmental and neuroscientific aspects.

PubMed

Grootens-Wiegers, Petronella; Hein, Irma M; van den Broek, Jos M; de Vries, Martine C

2017-05-08

Various international laws and guidelines stress the importance of respecting the developing autonomy of children and involving minors in decision-making regarding treatment and research participation. However, no universal agreement exists as to at what age minors should be deemed decision-making competent. Minors of the same age may show different levels of maturity. In addition, patients deemed rational conversation-partners as a child can suddenly become noncompliant as an adolescent. Age, context and development all play a role in decision-making competence. In this article we adopt a perspective on competence that specifically focuses on the impact of brain development on the child's decision-making process. We believe that the discussion on decision-making competence of minors can greatly benefit from a multidisciplinary approach. We adopted such an approach in order to contribute to the understanding on how to deal with children in decision-making situations. Evidence emerging from neuroscience research concerning the developing brain structures in minors is combined with insights from various other fields, such as psychology, decision-making science and ethics. Four capacities have been described that are required for (medical) decision-making: (1) communicating a choice; (2) understanding; (3) reasoning; and (4) appreciation. Each capacity is related to a number of specific skills and abilities that need to be sufficiently developed to support the capacity. Based on this approach it can be concluded that at the age of 12 children can have the capacity to be decision-making competent. However, this age coincides with the onset of adolescence. Early development of the brain's reward system combined with late development of the control system diminishes decision-making competence in adolescents in specific contexts. We conclude that even adolescents possessing capacities required for decision-making, may need support of facilitating environmental factors

Does electronic clinical microbiology results reporting influence medical decision making: a pre- and post-interview study of medical specialists.

PubMed

Bruins, Marjan J; Ruijs, Gijs J H M; Wolfhagen, Maurice J H M; Bloembergen, Peter; Aarts, Jos E C M

2011-03-30

Clinicians view the accuracy of test results and the turnaround time as the two most important service aspects of the clinical microbiology laboratory. Because of the time needed for the culturing of infectious agents, final hardcopy culture results will often be available too late to have a significant impact on early antimicrobial therapy decisions, vital in infectious disease management. The clinical microbiologist therefore reports to the clinician clinically relevant preliminary results at any moment during the diagnostic process, mostly by telephone. Telephone reporting is error prone, however. Electronic reporting of culture results instead of reporting on paper may shorten the turnaround time and may ensure correct communication of results. The purpose of this study was to assess the impact of the implementation of electronic reporting of final microbiology results on medical decision making. In a pre- and post-interview study using a semi-structured design we asked medical specialists in our hospital about their use and appreciation of clinical microbiology results reporting before and after the implementation of an electronic reporting system. Electronic reporting was highly appreciated by all interviewed clinicians. Major advantages were reduction of hardcopy handling and the possibility to review results in relation to other patient data. Use and meaning of microbiology reports differ significantly between medical specialties. Most clinicians need preliminary results for therapy decisions quickly. Therefore, after the implementation of electronic reporting, telephone consultation between clinician and microbiologist remained the key means of communication. Overall, electronic reporting increased the workflow efficiency of the medical specialists, but did not have an impact on their decision-making. © 2011 Bruins et al; licensee BioMed Central Ltd.

Analysis of metallic medical devices after cremation: The importance in identification.

PubMed

De Angelis, Danilo; Collini, Federica; Muccino, Enrico; Cappella, Annalisa; Sguazza, Emanuela; Mazzucchi, Alessandra; Cattaneo, Cristina

2017-03-01

The recovery of a charred cadaver raises many issues concerning personal identification; the presence of prosthetic materials may provide very important and decisive information. Who is involved in the recovery of a charred body or of burnt human fragments, should therefore be able to recognize medical devices even if modified by fire effects. Metallic residues (585kg) that came from 2785 cremations were studied. Medical devices were then divided by type and material in order to esteem the representativeness of each typology. The study illustrates the great presence of metal medical devices that could be of great help in identifying bodies and underlines that metallic medical devices types and morphology should be known by forensic practitioner involved in identification cases and that this kind of material can still be identified by physician and dentists, even if exposed to very high temperatures. Copyright © 2016 The Chartered Society of Forensic Sciences. Published by Elsevier B.V. All rights reserved.

Registered nurses' experiences of their decision-making at an Emergency Medical Dispatch Centre.

PubMed

Ek, Bosse; Svedlund, Marianne

2015-04-01

To describe registered nurses' experiences at an Emergency Medical Dispatch Centre. It is important that ambulances are urgently directed to patients who are in need of immediate help and of quick transportation to a hospital. Because resources are limited, Emergency Medical Dispatch centres cannot send ambulances with high priority to all callers. The efficiency of the system is therefore dependent on triage. Nurses worldwide are involved in patient triage, both before the patient's arrival to the hospital and in the subsequent emergency care. Ambulance dispatching is traditionally a duty for operators at Emergency Medical Dispatch centres, and in Sweden this duty has become increasingly performed by registered nurses. A qualitative design was used for this study. Fifteen registered nurses with experience at Emergency Medical Dispatch centres were interviewed. The participants were asked to describe the content of their work and their experiences. They also described the most challenging and difficult situations according to the critical incidence technique. Content analysis was used. Two themes emerged during the analysis: 'Having a profession with opportunities and obstacles' and 'Meeting serious and difficult situations', with eight sub-themes. The results showed that the decisions to dispatch ambulances were both challenging and difficult. Difficulties included conveying medical advice without seeing the patient, teaching cardio-pulmonary resuscitation via telephone and dealing with intoxicated and aggressive callers. Conflicts with colleagues and ambulance crews as well as fear of making wrong decisions were also mentioned. Work at Emergency Medical Dispatch centres is a demanding but stimulating duty for registered nurses. Great benefits can be achieved using experienced triage nurses, including increased patient safety and better use of medical resources. Improved internal support systems at Emergency Medical Dispatch centres and striving for a blame

Medication-related clinical decision support in computerized provider order entry systems: a review.

PubMed

Kuperman, Gilad J; Bobb, Anne; Payne, Thomas H; Avery, Anthony J; Gandhi, Tejal K; Burns, Gerard; Classen, David C; Bates, David W

2007-01-01

While medications can improve patients' health, the process of prescribing them is complex and error prone, and medication errors cause many preventable injuries. Computer provider order entry (CPOE) with clinical decision support (CDS), can improve patient safety and lower medication-related costs. To realize the medication-related benefits of CDS within CPOE, one must overcome significant challenges. Healthcare organizations implementing CPOE must understand what classes of CDS their CPOE systems can support, assure that clinical knowledge underlying their CDS systems is reasonable, and appropriately represent electronic patient data. These issues often influence to what extent an institution will succeed with its CPOE implementation and achieve its desired goals. Medication-related decision support is probably best introduced into healthcare organizations in two stages, basic and advanced. Basic decision support includes drug-allergy checking, basic dosing guidance, formulary decision support, duplicate therapy checking, and drug-drug interaction checking. Advanced decision support includes dosing support for renal insufficiency and geriatric patients, guidance for medication-related laboratory testing, drug-pregnancy checking, and drug-disease contraindication checking. In this paper, the authors outline some of the challenges associated with both basic and advanced decision support and discuss how those challenges might be addressed. The authors conclude with summary recommendations for delivering effective medication-related clinical decision support addressed to healthcare organizations, application and knowledge base vendors, policy makers, and researchers.

Microrisks for medical decision analysis.

PubMed

Howard, R A

1989-01-01

Many would agree on the need to inform patients about the risks of medical conditions or treatments and to consider those risks in making medical decisions. The question is how to describe the risks and how to balance them with other factors in arriving at a decision. In this article, we present the thesis that part of the answer lies in defining an appropriate scale for risks that are often quite small. We propose that a convenient unit in which to measure most medical risks is the microprobability, a probability of 1 in 1 million. When the risk consequence is death, we can define a micromort as one microprobability of death. Medical risks can be placed in perspective by noting that we live in a society where people face about 270 micromorts per year from interactions with motor vehicles. Continuing risks or hazards, such as are posed by following unhealthful practices or by the side-effects of drugs, can be described in the same micromort framework. If the consequence is not death, but some other serious consequence like blindness or amputation, the microrisk structure can be used to characterize the probability of disability. Once the risks are described in the microrisk form, they can be evaluated in terms of the patient's willingness-to-pay to avoid them. The suggested procedure is illustrated in the case of a woman facing a cranial arteriogram of a suspected arterio-venous malformation. Generic curves allow such analyses to be performed approximately in terms of the patient's sex, age, and economic situation. More detailed analyses can be performed if desired. Microrisk analysis is based on the proposition that precision in language permits the soundness of thought that produces clarity of action and peace of mind.

Shared decision making in senior medical students: results from a national survey.

PubMed

Zeballos-Palacios, Claudia; Quispe, Renato; Mongilardi, Nicole; Diaz-Arocutipa, Carlos; Mendez-Davalos, Carlos; Lizarraga, Natalia; Paz, Aldo; Montori, Victor M; Malaga, German

2015-05-01

To explore perceptions and experiences of Peruvian medical students about observed, preferred, and feasible decision-making approaches. We surveyed senior medical students from 19 teaching hospitals in 4 major cities in Peru. The self-administered questionnaire collected demographic information, current approach, exposure to role models for and training in shared decision making, and perceptions of the pertinence and feasibility of the different decision-making approaches in general as well as in challenging scenarios. A total of 327 senior medical students (51% female) were included. The mean age was 25 years. Among all respondents, 2% reported receiving both theoretical and practical training in shared decision making. While 46% of students identified their current decision-making approach as clinician-as-perfect-agent, 50% of students identified their teachers with the paternalistic approach. Remarkably, 53% of students thought shared decision making should be the preferred approach and 50% considered it feasible in Peru. Among the 10 challenging scenarios, shared decision making reached a plurality (40%) in only one scenario (terminally ill patients). Despite limited exposure and training, Peruvian medical students aspire to practice shared decision making but their current attitude reflects the less participatory approaches they see role modeled by their teachers. © The Author(s) 2015.

The professional medical ethics model of decision making under conditions of clinical uncertainty.

PubMed

McCullough, Laurence B

2013-02-01

The professional medical ethics model of decision making may be applied to decisions clinicians and patients make under the conditions of clinical uncertainty that exist when evidence is low or very low. This model uses the ethical concepts of medicine as a profession, the professional virtues of integrity and candor and the patient's virtue of prudence, the moral management of medical uncertainty, and trial of intervention. These features combine to justifiably constrain clinicians' and patients' autonomy with the goal of preventing nondeliberative decisions of patients and clinicians. To prevent biased recommendations by the clinician that promote such nondeliberative decisions, medically reasonable alternatives supported by low or very low evidence should be offered but not recommended. The professional medical ethics model of decision making aims to improve the quality of decisions by reducing the unacceptable variation that can result from nondeliberative decision making by patients and clinicians when evidence is low or very low.

Culture and medical decision making: Healthcare consumer perspectives in Japan and the United States.

PubMed

Alden, Dana L; Friend, John M; Lee, Angela Y; de Vries, Marieke; Osawa, Ryosuke; Chen, Qimei

2015-12-01

Two studies identified core value influences on medical decision-making processes across and within cultures. In Study 1, Japanese and American adults reported desired levels of medical decision-making influence across conditions that varied in seriousness. Cultural antecedents (interdependence, independence, and power distance) were also measured. In Study 2, American adults reviewed a colorectal cancer screening decision aid. Decision preparedness was measured along with interdependence, independence, and desire for medical information. In Study 1, higher interdependence predicted stronger desire for decision-making information in both countries, but was significantly stronger in Japan. The path from information desire to decision-making influence desire was significant only in Japan. The independence path to desire for decision-making influence was significant only in the United States. Power distance effects negatively predicted desire for decision-making influence only in the United States. For Study 2, high (low) interdependents and women (men) in the United States felt that a colorectal cancer screening decision aid helped prepare them more (less) for a medical consultation. Low interdependent men were at significantly higher risk for low decision preparedness. Study 1 suggests that Japanese participants may tend to view medical decision-making influence as an interdependent, information sharing exchange, whereas American respondents may be more interested in power sharing that emphasizes greater independence. Study 2 demonstrates the need to assess value influences on medical decision-making processes within and across cultures and suggests that individually tailored versions of decision aids may optimize decision preparedness. (c) 2015 APA, all rights reserved).

Performance evaluation of the machine learning algorithms used in inference mechanism of a medical decision support system.

PubMed

Bal, Mert; Amasyali, M Fatih; Sever, Hayri; Kose, Guven; Demirhan, Ayse

2014-01-01

The importance of the decision support systems is increasingly supporting the decision making process in cases of uncertainty and the lack of information and they are widely used in various fields like engineering, finance, medicine, and so forth, Medical decision support systems help the healthcare personnel to select optimal method during the treatment of the patients. Decision support systems are intelligent software systems that support decision makers on their decisions. The design of decision support systems consists of four main subjects called inference mechanism, knowledge-base, explanation module, and active memory. Inference mechanism constitutes the basis of decision support systems. There are various methods that can be used in these mechanisms approaches. Some of these methods are decision trees, artificial neural networks, statistical methods, rule-based methods, and so forth. In decision support systems, those methods can be used separately or a hybrid system, and also combination of those methods. In this study, synthetic data with 10, 100, 1000, and 2000 records have been produced to reflect the probabilities on the ALARM network. The accuracy of 11 machine learning methods for the inference mechanism of medical decision support system is compared on various data sets.

Medical futility in children's nursing: making end-of-life decisions.

PubMed

Brien, Irene O; Duffy, Anita; Shea, Ellen O

Caring for infants at end of life is challenging and distressing for parents and healthcare professionals, especially in relation to making decisions regarding withholding or withdrawal of treatment. The concept of medical futility must be considered under these circumstances. Parents and healthcare professionals should be involved together in making these difficult decisions. However, for some parents, emotions and guilt often are unbearable and, understandably, parents can be reluctant to make a decision. Despite the recognition of parental autonomy, if parents disagree with a decision made by medical staff, the case will be referred to and solved by the courts. The courts' decisions are often based on the best interest of the child. In this article, the authors discuss the concepts of 'parental autonomy' and 'the child's best interests' when determining medical futility for infants or neonates. The role of the nurse when caring for the dying child and their family is multifaceted. While nurses do not have a legitimate role in decision making at the end of life, it is often nurses who, through their advocacy role, inform doctors about parents' wishes and it is often nurses who support parents during this difficult time. Furthermore, nurses caring for dying children should be familiar to the family, experienced in end-of-life care and comfortable talking to parents about death and dying and treatment choices. Children's nurses therefore require advanced communication skills and an essential understanding of the ethical and legal knowledge relating to medical futility in end-of-life children's nursing.

Use of the Analytic Hierarchy Process for Medication Decision-Making in Type 2 Diabetes

PubMed Central

Maruthur, Nisa M.; Joy, Susan M.; Dolan, James G.; Shihab, Hasan M.; Singh, Sonal

2015-01-01

Aim To investigate the feasibility and utility of the Analytic Hierarchy Process (AHP) for medication decision-making in type 2 diabetes. Methods We conducted an AHP with nine diabetes experts using structured interviews to rank add-on therapies (to metformin) for type 2 diabetes. During the AHP, participants compared treatment alternatives relative to eight outcomes (hemoglobin A1c-lowering and seven potential harms) and the relative importance of the different outcomes. The AHP model and instrument were pre-tested and pilot-tested prior to use. Results were discussed and an evaluation of the AHP was conducted during a group session. We conducted the quantitative analysis using Expert Choice software with the ideal mode to determine the priority of treatment alternatives. Results Participants judged exenatide to be the best add-on therapy followed by sitagliptin, sulfonylureas, and then pioglitazone. Maximizing benefit was judged 21% more important than minimizing harm. Minimizing severe hypoglycemia was judged to be the most important harm to avoid. Exenatide was the best overall alternative if the importance of minimizing harms was prioritized completely over maximizing benefits. Participants reported that the AHP improved transparency, consistency, and an understanding of others’ perspectives and agreed that the results reflected the views of the group. Conclusions The AHP is feasible and useful to make decisions about diabetes medications. Future studies which incorporate stakeholder preferences should evaluate other decision contexts, objectives, and treatments. PMID:26000636

Lessons learned by (from?) an economist working in medical decision making.

PubMed

Wakker, Peter P

2008-01-01

This article is a personal account of the author's experiences as an economist working in medical decision making. He discusses the differences between economic decision theory and medical decision making and gives examples of the mutual benefits resulting from interactions. In particular, he discusses the pros and cons of different methods for measuring quality of life (or, as economists would call it, utility), including the standard gamble, the time tradeoff, and the healthy-years equivalent methods.

How Numeracy Influences Risk Comprehension and Medical Decision Making

PubMed Central

Reyna, Valerie F.; Nelson, Wendy L.; Han, Paul K.; Dieckmann, Nathan F.

2009-01-01

We review the growing literature on health numeracy, the ability to understand and use numerical information, and its relation to cognition, health behaviors, and medical outcomes. Despite the surfeit of health information from commercial and noncommercial sources, national and international surveys show that many people lack basic numerical skills that are essential to maintain their health and make informed medical decisions. Low numeracy distorts perceptions of risks and benefits of screening, reduces medication compliance, impedes access to treatments, impairs risk communication (limiting prevention efforts among the most vulnerable), and, based on the scant research conducted on outcomes, appears to adversely affect medical outcomes. Low numeracy is also associated with greater susceptibility to extraneous factors (i.e., factors that do not change the objective numerical information). That is, low numeracy increases susceptibility to effects of mood or how information is presented (e.g., as frequencies vs. percentages) and to biases in judgment and decision making (e.g., framing and ratio bias effects). Much of this research is not grounded in empirically supported theories of numeracy or mathematical cognition, which are crucial for designing evidence-based policies and interventions that are effective in reducing risk and improving medical decision making. To address this gap, we outline four theoretical approaches (psychophysical, computational, standard dual-process, and fuzzy trace theory), review their implications for numeracy, and point to avenues for future research. PMID:19883143

Preferences of acutely ill patients for participation in medical decision-making.

PubMed

Wilkinson, C; Khanji, M; Cotter, P E; Dunne, O; O'Keeffe, S T

2008-04-01

To determine patient preferences for information and for participation in decision-making, and the determinants of these preferences in patients recently admitted to an acute hospital. Prospective questionnaire-based study. Medical wards of an acute teaching hospital. One hundred and fifty-two consecutive acute medical inpatients, median age 74 years. Standardised assessment included abbreviated mental test and subjective measure of severity of illness. Patients' desire for information was assessed using a 5-point Likert scale, and their desire for a role in medical decision-making using the Degner Control of Preferences Scale. Of the 152 patients, 93 (61%) favoured a passive approach to decision-making (either "leave all decisions to the doctor" or "doctor makes final decision but seriously considers my opinion." In contrast, 101 (66%) patients sought "very extensive" or "a lot" of information about their condition. No significant effects of age, sex, socio-economic group or severity of acute illness on desire for information or the Degner scale result were found. There was no agreement between patients' preferences on the Degner scale and their doctors' predictions of those preferences. Acute medical inpatients want to receive a lot of information about their illness, but most prefer a relatively passive role in decision-making. The only way to determine individual patient preferences is to ask them; preferences cannot be predicted from clinical or sociodemographic data.

Dementia, Decision Making, and Capacity.

PubMed

Darby, R Ryan; Dickerson, Bradford C

After participating in this activity, learners should be better able to:• Assess the neuropsychological literature on decision making and the medical and legal assessment of capacity in patients with dementia• Identify the limitations of integrating findings from decision-making research into capacity assessments for patients with dementia ABSTRACT: Medical and legal professionals face the challenge of assessing capacity and competency to make medical, legal, and financial decisions in dementia patients with impaired decision making. While such assessments have classically focused on the capacity for complex reasoning and executive functions, research in decision making has revealed that motivational and metacognitive processes are also important. We first briefly review the neuropsychological literature on decision making and on the medical and legal assessment of capacity. Next, we discuss the limitations of integrating findings from decision-making research into capacity assessments, including the group-to-individual inference problem, the unclear role of neuroimaging in capacity assessments, and the lack of capacity measures that integrate important facets of decision making. Finally, we present several case examples where we attempt to demonstrate the potential benefits and important limitations of using decision-making research to aid in capacity determinations.

Family involvement in medical decision-making: Perceptions of nursing and psychology students.

PubMed

Itzhaki, Michal; Hildesheimer, Galya; Barnoy, Sivia; Katz, Michael

2016-05-01

Family members often rely on health care professionals to guide and support them through the decision-making process. Although family involvement in medical decisions should be included in the preservice curriculum for the health care professions, perceptions of students in caring professions on family involvement in medical decision-making have not yet been examined. To examine the perceptions of nursing and psychology students on family involvement in medical decision-making for seriously ill patients. A descriptive cross-sectional design was used. First year undergraduate nursing and psychology students studying for their Bachelor of Arts degree were recruited. Perceptions were assessed with a questionnaire constructed based on the Multi-Attribute Utility Theory (MAUT), which examines decision-maker preferences. The questionnaire consisted of two parts referring to the respondent once as the patient and then as the family caregiver. Questionnaires were completed by 116 nursing students and 156 psychology students. Most were of the opinion that family involvement in decision-making is appropriate, especially when the patient is incapable of making decisions. Nursing students were more inclined than psychology students to think that financial, emotional, and value-based considerations should be part of the family's involvement in decision-making. Both groups of students perceived the emotional consideration as most acceptable, whereas the financial consideration was considered the least acceptable. Nursing and psychology students perceive family involvement in medical decision-making as appropriate. In order to train students to support families in the process of decision-making, further research should examine Shared Decision-Making (SDM) programs, which involve patient and clinician collaboration in health care decisions. Copyright © 2016 Elsevier Ltd. All rights reserved.

A focus group study investigating medical decision making in octogenarians of high socioeconomic status with successful outcomes following cardiac surgery.

PubMed

Oldroyd, John C; Levinson, Michele R; Stephenson, Gemma; Rouse, Alice; Leeuwrik, Tina

2014-09-01

To explore medical decision making in octogenarians having cardiac surgery. Five focus groups conducted in a private hospital setting with octogenarians of high socioeconomic status who had successful cardiac surgery in the previous 3-13 months. Octogenarian's motivations for having cardiac surgery include survival, relief of symptoms, convenience and improving quality of life. The decision to have surgery involved clinical advice by doctors that the time had come to take up a surgical option. Patient's decisions did not take into account alternative treatment options either because these had not been presented by doctors or because medical management had failed. The final decision was made by patients. Decisions to have cardiac surgery in octogenarians are made by patients after discussions with family based on their risks as communicated by their doctors. This underlines the importance of effective risk communication by doctors to help patients make appropriate medical decisions. © 2013 The Authors. Australasian Journal on Ageing © 2013 ACOTA.

A study to enhance medical students' professional decision-making, using teaching interventions on common medications.

PubMed

Wilcock, Jane; Strivens, Janet

2015-01-01

Aim To create sustained improvements in medical students' critical thinking skills through short teaching interventions in pharmacology. Method The ability to make professional decisions was assessed by providing year-4 medical students at a UK medical school with a novel medical scenario (antenatal pertussis vaccination). Forty-seven students in the 2012 cohort acted as a pretest group, answering a questionnaire on this novel scenario. To improve professional decision-making skills, 48 students from the 2013 cohort were introduced to three commonly used medications, through tutor-led 40-min teaching interventions, among six small groups using a structured presentation of evidence-based medicine and ethical considerations. Student members then volunteered to peer-teach on a further three medications. After a gap of 8 weeks, this cohort (post-test group) was assessed for professional decision-making skills using the pretest questionnaire, and differences in the 2-year groups analysed. Results Students enjoyed presenting on medications to their peers but had difficulty interpreting studies and discussing ethical dimensions; this was improved by contextualising information via patient scenarios. After 8 weeks, most students did not show enhanced clinical curiosity, a desire to understand evidence, or ethical questioning when presented with a novel medical scenario compared to the previous year group who had not had the intervention. Students expressed a high degree of trust in guidelines and expert tutors and felt that responsibility for their own actions lay with these bodies. Conclusion Short teaching interventions in pharmacology did not lead to sustained improvements in their critical thinking skills in enhancing professional practice. It appears that students require earlier and more frequent exposure to these skills in their medical training.

A study to enhance medical students’ professional decision-making, using teaching interventions on common medications

PubMed Central

Wilcock, Jane; Strivens, Janet

2015-01-01

Aim To create sustained improvements in medical students’ critical thinking skills through short teaching interventions in pharmacology. Method The ability to make professional decisions was assessed by providing year-4 medical students at a UK medical school with a novel medical scenario (antenatal pertussis vaccination). Forty-seven students in the 2012 cohort acted as a pretest group, answering a questionnaire on this novel scenario. To improve professional decision-making skills, 48 students from the 2013 cohort were introduced to three commonly used medications, through tutor-led 40-min teaching interventions, among six small groups using a structured presentation of evidence-based medicine and ethical considerations. Student members then volunteered to peer-teach on a further three medications. After a gap of 8 weeks, this cohort (post-test group) was assessed for professional decision-making skills using the pretest questionnaire, and differences in the 2-year groups analysed. Results Students enjoyed presenting on medications to their peers but had difficulty interpreting studies and discussing ethical dimensions; this was improved by contextualising information via patient scenarios. After 8 weeks, most students did not show enhanced clinical curiosity, a desire to understand evidence, or ethical questioning when presented with a novel medical scenario compared to the previous year group who had not had the intervention. Students expressed a high degree of trust in guidelines and expert tutors and felt that responsibility for their own actions lay with these bodies. Conclusion Short teaching interventions in pharmacology did not lead to sustained improvements in their critical thinking skills in enhancing professional practice. It appears that students require earlier and more frequent exposure to these skills in their medical training. PMID:26051556

A study to enhance medical students' professional decision-making, using teaching interventions on common medications.

PubMed

Wilcock, Jane; Strivens, Janet

2015-01-01

To create sustained improvements in medical students' critical thinking skills through short teaching interventions in pharmacology. The ability to make professional decisions was assessed by providing year-4 medical students at a UK medical school with a novel medical scenario (antenatal pertussis vaccination). Forty-seven students in the 2012 cohort acted as a pretest group, answering a questionnaire on this novel scenario. To improve professional decision-making skills, 48 students from the 2013 cohort were introduced to three commonly used medications, through tutor-led 40-min teaching interventions, among six small groups using a structured presentation of evidence-based medicine and ethical considerations. Student members then volunteered to peer-teach on a further three medications. After a gap of 8 weeks, this cohort (post-test group) was assessed for professional decision-making skills using the pretest questionnaire, and differences in the 2-year groups analysed. Students enjoyed presenting on medications to their peers but had difficulty interpreting studies and discussing ethical dimensions; this was improved by contextualising information via patient scenarios. After 8 weeks, most students did not show enhanced clinical curiosity, a desire to understand evidence, or ethical questioning when presented with a novel medical scenario compared to the previous year group who had not had the intervention. Students expressed a high degree of trust in guidelines and expert tutors and felt that responsibility for their own actions lay with these bodies. Short teaching interventions in pharmacology did not lead to sustained improvements in their critical thinking skills in enhancing professional practice. It appears that students require earlier and more frequent exposure to these skills in their medical training.

Differences in Simulated Doctor and Patient Medical Decision Making: A Construal Level Perspective

PubMed Central

Zhang, Yan; Liu, Quanhui; Miao, Danmin; Xiao, Wei

2013-01-01

Background Patients are often confronted with diverse medical decisions. Often lacking relevant medical knowledge, patients fail to independently make medical decisions and instead generally rely on the advice of doctors. Objective This study investigated the characteristics of and differences in doctor–patient medical decision making on the basis of construal level theory. Methods A total of 420 undergraduates majoring in clinical medicine were randomly assigned to six groups. Their decisions to opt for radiotherapy and surgery were investigated, with the choices described in a positive/neutral/negative frame × decision making for self/others. Results Compared with participants giving medical advice to patients, participants deciding for themselves were more likely to select radiotherapy (F1, 404 = 13.92, p = 011). Participants from positive or neutral frames exhibited a higher tendency to choose surgery than did those from negative frames (F2, 404 = 22.53, p<.001). The effect of framing on independent decision making was nonsignificant (F2, 404 = 1.07, p = 35); however the effect of framing on the provision of advice to patients was significant (F2, 404 = 12.95, p<.001). The effect of construal level was significant in the positive frame (F1, 404 = 8.06, p = 005) and marginally significant in the neutral frame (F2, 404 = 3.31, p = 07) but nonsignificant in the negative frame (F2, 404 = .29, p = 59). Conclusion Both social distance and framing depiction significantly affected medical decision making and exhibited a significant interaction. Differences in medical decision making between doctors and patients need further investigation. PMID:24244445

Do social norms play a role in explaining involvement in medical decision-making?

PubMed

Brabers, Anne E M; van Dijk, Liset; Groenewegen, Peter P; de Jong, Judith D

2016-12-01

Patients' involvement in medical decision-making is crucial to provide good quality of care that is respectful of, and responsive to, patients' preferences, needs and values. Whether people want to be involved in medical decision-making is associated with individual patient characteristics, and health status. However, the observation of differences in whether people want to be involved does not in itself provide an explanation. Insight is necessary into mechanisms that explain people's involvement. This study aims to examine one mechanism, namely social norms. We make a distinction between subjective norms, that is doing what others think one ought to do, and descriptive norms, doing what others do. We focus on self-reported involvement in medical decision-making. A questionnaire was sent to members of the Dutch Health Care Consumer Panel in May 2015 (response 46%; N = 974). A regression model was used to estimate the relationship between socio-demographics, social norms and involvement in medical decision-making. In line with our hypotheses, we observed that the more conservative social norms are, the less people are involved in medical decision-making. The effects for both types of norms were comparable. This study indicates that social norms play a role as a mechanism to explain involvement in medical decision-making. Our study offers a first insight into the possibility that the decision to be involved in medical decision-making is not as individual as it at first seems; someone's social context also plays a role. Strategies aimed at emphasizing patient involvement have to address this social context. © The Author 2016. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.

Differences in simulated doctor and patient medical decision making: a construal level perspective.

PubMed

Peng, Jiaxi; He, Fei; Zhang, Yan; Liu, Quanhui; Miao, Danmin; Xiao, Wei

2013-01-01

Patients are often confronted with diverse medical decisions. Often lacking relevant medical knowledge, patients fail to independently make medical decisions and instead generally rely on the advice of doctors. This study investigated the characteristics of and differences in doctor-patient medical decision making on the basis of construal level theory. A total of 420 undergraduates majoring in clinical medicine were randomly assigned to six groups. Their decisions to opt for radiotherapy and surgery were investigated, with the choices described in a positive/neutral/negative frame × decision making for self/others. Compared with participants giving medical advice to patients, participants deciding for themselves were more likely to select radiotherapy (F1, 404 = 13.92, p = 011). Participants from positive or neutral frames exhibited a higher tendency to choose surgery than did those from negative frames (F2, 404 = 22.53, p<.001). The effect of framing on independent decision making was nonsignificant (F2, 404 = 1.07, p = 35); however the effect of framing on the provision of advice to patients was significant (F2, 404 = 12.95, p<.001). The effect of construal level was significant in the positive frame (F1, 404 = 8.06, p = 005) and marginally significant in the neutral frame (F2, 404 = 3.31, p = 07) but nonsignificant in the negative frame (F2, 404 = .29, p = 59). Both social distance and framing depiction significantly affected medical decision making and exhibited a significant interaction. Differences in medical decision making between doctors and patients need further investigation.

A mobile decision support system for red eye diseases diagnosis: experience with medical students.

PubMed

López, Marta Manovel; López, Miguel Maldonado; de la Torre Díez, Isabel; Jimeno, José Carlos Pastor; López-Coronado, Miguel

2016-06-01

A good primary health care is the base for a better healthcare system. Taking a good decision on time by the primary health care physician could have a huge repercussion. In order to ease the diagnosis task arise the Decision Support Systems (DSS), which offer counselling instead of refresh the medical knowledge, in a profession where it is still learning every day. The implementation of these systems in diseases which are a frequent cause of visit to the doctor like ophthalmologic pathologies are, which affect directly to our quality of life, takes more importance. This paper aims to develop OphthalDSS, a totally new mobile DSS for red eye diseases diagnosis. The main utilities that OphthalDSS offers will be a study guide for medical students and a clinical decision support system for primary care professionals. Other important goal of this paper is to show the user experience results after OphthalDSS being used by medical students of the University of Valladolid. For achieving the main purpose of this research work, a decision algorithm will be developed and implemented by an Android mobile application. Moreover, the Quality of Experience (QoE) has been evaluated by the students through the questions of a short inquiry. The app developed which implements the algorithm OphthalDSS is capable of diagnose more than 30 eye's anterior segment diseases. A total of 67 medical students have evaluated the QoE. The students find the diseases' information presented very valuable, the appearance is adequate, it is always available and they have ever found what they were looking for. Furthermore, the students think that their quality of life has not been improved using the app and they can do the same without using the OphthalDSS app. OphthalDSS is easy to use, which is capable of diagnose more than 30 ocular diseases in addition to be used as a DSS tool as an educational tool at the same time.

What is a good medical decision? A research agenda guided by perspectives from multiple stakeholders.

PubMed

Hamilton, Jada G; Lillie, Sarah E; Alden, Dana L; Scherer, Laura; Oser, Megan; Rini, Christine; Tanaka, Miho; Baleix, John; Brewster, Mikki; Craddock Lee, Simon; Goldstein, Mary K; Jacobson, Robert M; Myers, Ronald E; Zikmund-Fisher, Brian J; Waters, Erika A

2017-02-01

Informed and shared decision making are critical aspects of patient-centered care, which has contributed to an emphasis on decision support interventions to promote good medical decision making. However, researchers and healthcare providers have not reached a consensus on what defines a good decision, nor how to evaluate it. This position paper, informed by conference sessions featuring diverse stakeholders held at the 2015 Society of Behavioral Medicine and Society for Medical Decision Making annual meetings, describes key concepts that influence the decision making process itself and that may change what it means to make a good decision: interpersonal factors, structural constraints, affective influences, and values clarification methods. This paper also proposes specific research questions within each of these priority areas, with the goal of moving medical decision making research to a more comprehensive definition of a good medical decision, and enhancing the ability to measure and improve the decision making process.

The Re-contextualization of the Patient: What Home Health Care Can Teach Us About Medical Decision-Making.

PubMed

Salter, Erica K

2015-06-01

This article examines the role of context in the development and deployment of standards of medical decision-making. First, it demonstrates that bioethics, and our dominant standards of medical decision-making, developed out of a specific historical and philosophical environment that prioritized technology over the person, standardization over particularity, individuality over relationship and rationality over other forms of knowing. These forces de-contextualize the patient and encourage decision-making that conforms to the unnatural and contrived environment of the hospital. The article then explores several important differences between the home health care and acute care settings. Finally, it argues that the personalized, embedded, relational and idiosyncratic nature of the home is actually a much more accurate reflection of the context in which real people make real decisions. Thus, we should work to "re-contextualize" patients, in order that they might be better equipped to make decisions that harmonize with their real lives.

Research on Radar Importance with Decision Matrix

NASA Astrophysics Data System (ADS)

Meng, Lingjie; Du, Yu; Wang, Liuheng

2017-12-01

Considering the characteristic of radar, constructed the evaluation index system of radar importance, established the comprehensive evaluation model based on decision matrix. Finally, by means of an example, the methods of this evaluation on radar importance was right and feasibility.

Medical practice and legal background of decisions for severely ill newborn infants: viewpoints from seven European countries.

PubMed

Sauer, P J J; Dorscheidt, J H H M; Verhagen, A A E; Hubben, J H

2013-02-01

To comparing attitudes towards end-of-life (EOL) decisions in newborn infants between seven European countries. One paediatrician and one lawyer from seven European countries were invited to attend a conference to discuss the practice of EOL decisions in newborn infants and the legal aspects involved. All paediatricians/neonatologists indicated that the best interest of the child should be the leading principle in all decisions. However, especially when discussing cases, important differences in attitude became apparent, although there are no significant differences between the involved countries with regard to national legal frameworks. Important differences in attitude towards neonatal EOL decisions between European countries exist, but they cannot be explained solely by medical or legal reasons. ©2012 The Author(s)/Acta Paediatrica ©2012 Foundation Acta Paediatrica.

What is a good medical decision? A research agenda guided by perspectives from multiple stakeholders

PubMed Central

Hamilton, Jada G.; Lillie, Sarah E.; Alden, Dana L.; Scherer, Laura; Oser, Megan; Rini, Christine; Tanaka, Miho; Baleix, John; Brewster, Mikki; Lee, Simon Craddock; Goldstein, Mary K.; Jacobson, Robert M.; Myers, Ronald E.; Zikmund-Fisher, Brian J.; Waters, Erika A.

2016-01-01

Informed and shared decision making are critical aspects of patient-centered care, which has contributed to an emphasis on decision support interventions to promote good medical decision making. However, researchers and healthcare providers have not reached a consensus on what defines a good decision, nor how to evaluate it. This position paper, informed by conference sessions featuring diverse stakeholders held at the 2015 Society of Behavioral Medicine and Society for Medical Decision Making annual meetings, describes key concepts that influence the decision making process itself and that may change what it means to make a good decision: interpersonal factors, structural constraints, affective influences, and values clarification methods. This paper also proposes specific research questions within each of these priority areas, with the goal of moving medical decision making research to a more comprehensive definition of a good medical decision, and enhancing the ability to measure and improve the decision making process. PMID:27566316

[Passive euthanasia in clinical practice--the medical decision reflected in the legal position].

PubMed

Möller, T; Grabensee, B; Frister, H

2008-05-01

Doctors are often confronted with end-of-life decisions. When deciding on the withdrawal of medical treatment physicians have to consider the legal position. This study was done to evaluated how far doctors at the university medical center in Düsseldorf had acted in conformity with the established case law in Germany. Between April and August 2006 doctors at the university medical center in Düsseldorf filled in a standardized questionnaire about the decisions they had taken to withdraw life-support treatment. 128 of a total of 512 doctors questioned replied (25 %; 32,8 % females and 67,2 % males) . The survey showed that the judicial decision (that it is not necessary to provide treatment if life-support measures are not indicated) is largely determined by non-medical criteria. The clinical decision by doctors depended mainly on his personal opinion. Furthermore the survey showed that only a few doctors made use of the - lawful - option to withdraw medical treatment when this was not indicated. Finally the survey revealed that, in case of conflict between indication and perceived patients' wishes, the vast majority of doctors behaved in contravention of the decisions established by case law. There is the need to discuss what non-medical issues should be taken into account when determining the indication of withdrawal of life-support measures. The results also highlighted the uncertainties that exist regarding a doctor's decisions about it. Not only should legislation clarify whether "passive euthanasia" is allowed, but it would also be useful to delegate end-of-life decisions to a review board.

An experimental comparison of fuzzy logic and analytic hierarchy process for medical decision support systems.

PubMed

Uzoka, Faith-Michael Emeka; Obot, Okure; Barker, Ken; Osuji, J

2011-07-01

The task of medical diagnosis is a complex one, considering the level vagueness and uncertainty management, especially when the disease has multiple symptoms. A number of researchers have utilized the fuzzy-analytic hierarchy process (fuzzy-AHP) methodology in handling imprecise data in medical diagnosis and therapy. The fuzzy logic is able to handle vagueness and unstructuredness in decision making, while the AHP has the ability to carry out pairwise comparison of decision elements in order to determine their importance in the decision process. This study attempts to do a case comparison of the fuzzy and AHP methods in the development of medical diagnosis system, which involves basic symptoms elicitation and analysis. The results of the study indicate a non-statistically significant relative superiority of the fuzzy technology over the AHP technology. Data collected from 30 malaria patients were used to diagnose using AHP and fuzzy logic independent of one another. The results were compared and found to covary strongly. It was also discovered from the results of fuzzy logic diagnosis covary a little bit more strongly to the conventional diagnosis results than that of AHP. Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.

Understanding medical decision making in hand surgery.

PubMed

Myers, John; McCabe, Steven J

2005-10-01

The practice of medicine takes place in an environment of uncertainty. Expected value decision making, prospect theory, and regret theory are three theories of decision making under uncertainty that may be used to help us learn how patients and physicians make decisions. These theories form the underpinnings of decision analysis and provide the opportunity to introduce the broad discipline of decision science. Because decision analysis and economic analysis are underrepresented in upper extremity surgery, the authors believe these are important areas for future research.

Towards meaningful medication-related clinical decision support: recommendations for an initial implementation.

PubMed

Phansalkar, S; Wright, A; Kuperman, G J; Vaida, A J; Bobb, A M; Jenders, R A; Payne, T H; Halamka, J; Bloomrosen, M; Bates, D W

2011-01-01

Clinical decision support (CDS) can improve safety, quality, and cost-effectiveness of patient care, especially when implemented in computerized provider order entry (CPOE) applications. Medication-related decision support logic forms a large component of the CDS logic in any CPOE system. However, organizations wishing to implement CDS must either purchase the computable clinical content or develop it themselves. Content provided by vendors does not always meet local expectations. Most organizations lack the resources to customize the clinical content and the expertise to implement it effectively. In this paper, we describe the recommendations of a national expert panel on two basic medication-related CDS areas, specifically, drug-drug interaction (DDI) checking and duplicate therapy checking. The goals of this study were to define a starter set of medication-related alerts that healthcare organizations can implement in their clinical information systems. We also draw on the experiences of diverse institutions to highlight the realities of implementing medication decision support. These findings represent the experiences of institutions with a long history in the domain of medication decision support, and the hope is that this guidance may improve the feasibility and efficiency CDS adoption across healthcare settings.

The importance of decision onset

PubMed Central

Grinband, Jack; Ferrera, Vincent

2015-01-01

The neural mechanisms of decision making are thought to require the integration of evidence over time until a response threshold is reached. Much work suggests that response threshold can be adjusted via top-down control as a function of speed or accuracy requirements. In contrast, the time of integration onset has received less attention and is believed to be determined mostly by afferent or preprocessing delays. However, a number of influential studies over the past decade challenge this assumption and begin to paint a multifaceted view of the phenomenology of decision onset. This review highlights the challenges involved in initiating the integration of evidence at the optimal time and the potential benefits of adjusting integration onset to task demands. The review outlines behavioral and electrophysiolgical studies suggesting that the onset of the integration process may depend on properties of the stimulus, the task, attention, and response strategy. Most importantly, the aggregate findings in the literature suggest that integration onset may be amenable to top-down regulation, and may be adjusted much like response threshold to exert cognitive control and strategically optimize the decision process to fit immediate behavioral requirements. PMID:26609111

Surviving Surrogate Decision-Making: What Helps and Hampers the Experience of Making Medical Decisions for Others

PubMed Central

Starks, Helene; Taylor, Janelle S.; Hopley, Elizabeth K.; Fryer-Edwards, Kelly

2007-01-01

BACKGROUND A majority of end-of-life medical decisions are made by surrogate decision-makers who have varying degrees of preparation and comfort with their role. Having a seriously ill family member is stressful for surrogates. Moreover, most clinicians have had little training in working effectively with surrogates. OBJECTIVES To better understand the challenges of decision-making from the surrogate’s perspective. DESIGN Semistructured telephone interview study of the experience of surrogate decision-making. PARTICIPANTS Fifty designated surrogates with previous decision-making experience. APPROACH We asked surrogates to describe and reflect on their experience of making medical decisions for others. After coding transcripts, we conducted a content analysis to identify and categorize factors that made decision-making more or less difficult for surrogates. RESULTS Surrogates identified four types of factors: (1) surrogate characteristics and life circumstances (such as coping strategies and competing responsibilities), (2) surrogates’ social networks (such as intrafamily discord about the “right” decision), (3) surrogate–patient relationships and communication (such as difficulties with honoring known preferences), and (4) surrogate–clinician communication and relationship (such as interacting with a single physician whom the surrogate recognizes as the clinical spokesperson vs. many clinicians). CONCLUSIONS These data provide insights into the challenges that surrogates encounter when making decisions for loved ones and indicate areas where clinicians could intervene to facilitate the process of surrogate decision-making. Clinicians may want to include surrogates in advance care planning prior to decision-making, identify and address surrogate stressors during decision-making, and designate one person to communicate information about the patient’s condition, prognosis, and treatment options. PMID:17619223

Are United States Medical Licensing Exam Step 1 and 2 scores valid measures for postgraduate medical residency selection decisions?

PubMed

McGaghie, William C; Cohen, Elaine R; Wayne, Diane B

2011-01-01

United States Medical Licensing Examination (USMLE) scores are frequently used by residency program directors when evaluating applicants. The objectives of this report are to study the chain of reasoning and evidence that underlies the use of USMLE Step 1 and 2 scores for postgraduate medical resident selection decisions and to evaluate the validity argument about the utility of USMLE scores for this purpose. This is a research synthesis using the critical review approach. The study first describes the chain of reasoning that underlies a validity argument about using test scores for a specific purpose. It continues by summarizing correlations of USMLE Step 1 and 2 scores and reliable measures of clinical skill acquisition drawn from nine studies involving 393 medical learners from 2005 to 2010. The integrity of the validity argument about using USMLE Step 1 and 2 scores for postgraduate residency selection decisions is tested. The research synthesis shows that USMLE Step 1 and 2 scores are not correlated with reliable measures of medical students', residents', and fellows' clinical skill acquisition. The validity argument about using USMLE Step 1 and 2 scores for postgraduate residency selection decisions is neither structured, coherent, nor evidence based. The USMLE score validity argument breaks down on grounds of extrapolation and decision/interpretation because the scores are not associated with measures of clinical skill acquisition among advanced medical students, residents, and subspecialty fellows. Continued use of USMLE Step 1 and 2 scores for postgraduate medical residency selection decisions is discouraged.

General practitioners' decisions about discontinuation of medication: an explorative study.

PubMed

Nixon, Michael Simon; Vendelø, Morten Thanning

2016-06-20

Purpose - The purpose of this paper is to investigate how general practitioners' (GPs) decisions about discontinuation of medication are influenced by their institutional context. Design/methodology/approach - In total, 24 GPs were interviewed, three practices were observed and documents were collected. The Gioia methodology was used to analyse data, drawing on a theoretical framework that integrate the sensemaking perspective and institutional theory. Findings - Most GPs, who actively consider discontinuation, are reluctant to discontinue medication, because the safest course of action for GPs is to continue prescriptions, rather than discontinue them. The authors conclude that this is in part due to the ambiguity about the appropriateness of discontinuing medication, experienced by the GPs, and in part because the clinical guidelines do not encourage discontinuation of medication, as they offer GPs a weak frame for discontinuation. Three reasons for this are identified: the guidelines provide dominating triggers for prescribing, they provide weak priming for discontinuation as an option, and they underscore a cognitive constraint against discontinuation. Originality/value - The analysis offers new insights about decision making when discontinuing medication. It also offers one of the first examinations of how the institutional context embedding GPs influences their decisions about discontinuation. For policymakers interested in the discontinuation of medication, the findings suggest that de-stigmatising discontinuation on an institutional level may be beneficial, allowing GPs to better justify discontinuation in light of the ambiguity they experience.

Shared decision-making in medication management: development of a training intervention

PubMed Central

Stead, Ute; Morant, Nicola; Ramon, Shulamit

2017-01-01

Shared decision-making is a collaborative process in which clinicians and patients make treatment decisions together. Although it is considered essential to patient-centred care, the adoption of shared decision-making into routine clinical practice has been slow, and there is a need to increase implementation. This paper describes the development and delivery of a training intervention to promote shared decision-making in medication management in mental health as part of the Shared Involvement in Medication Management Education (ShIMME) project. Three stakeholder groups (service users, care coordinators and psychiatrists) received training in shared decision-making, and their feedback was evaluated. The programme was mostly well received, with all groups rating interaction with peers as the best aspect of the training. This small-scale pilot shows that it is feasible to deliver training in shared decision-making to several key stakeholders. Larger studies will be required to assess the effectiveness of such training. PMID:28811918

Shared decision-making in medication management: development of a training intervention.

PubMed

Stead, Ute; Morant, Nicola; Ramon, Shulamit

2017-08-01

Shared decision-making is a collaborative process in which clinicians and patients make treatment decisions together. Although it is considered essential to patient-centred care, the adoption of shared decision-making into routine clinical practice has been slow, and there is a need to increase implementation. This paper describes the development and delivery of a training intervention to promote shared decision-making in medication management in mental health as part of the Shared Involvement in Medication Management Education (ShIMME) project. Three stakeholder groups (service users, care coordinators and psychiatrists) received training in shared decision-making, and their feedback was evaluated. The programme was mostly well received, with all groups rating interaction with peers as the best aspect of the training. This small-scale pilot shows that it is feasible to deliver training in shared decision-making to several key stakeholders. Larger studies will be required to assess the effectiveness of such training.

Teaching Advance Care Planning to Medical Students with a Computer-Based Decision Aid

PubMed Central

Levi, Benjamin H.

2013-01-01

Discussing end-of-life decisions with cancer patients is a crucial skill for physicians. This article reports findings from a pilot study evaluating the effectiveness of a computer-based decision aid for teaching medical students about advance care planning. Second-year medical students at a single medical school were randomized to use a standard advance directive or a computer-based decision aid to help patients with advance care planning. Students' knowledge, skills, and satisfaction were measured by self-report; their performance was rated by patients. 121/133 (91%) of students participated. The Decision-Aid Group (n=60) outperformed the Standard Group (n=61) in terms of students´ knowledge (p<0.01), confidence in helping patients with advance care planning (p<0.01), knowledge of what matters to patients (p=0.05), and satisfaction with their learning experience (p<0.01). Likewise, patients in the Decision Aid Group were more satisfied with the advance care planning method (p<0.01) and with several aspects of student performance. Use of a computer-based decision aid may be an effective way to teach medical students how to discuss advance care planning with cancer patients. PMID:20632222

Is race medically relevant? A qualitative study of physicians' attitudes about the role of race in treatment decision-making

PubMed Central

2011-01-01

Background The role of patient race in medical decision-making is heavily debated. While some evidence suggests that patient race can be used by physicians to predict disease risk and determine drug therapy, other studies document bias and stereotyping by physicians based on patient race. It is critical, then, to explore physicians' attitudes regarding the medical relevance of patient race. Methods We conducted a qualitative study in the United States using ten focus groups of physicians stratified by self-identified race (black or white) and led by race-concordant moderators. Physicians were presented with a medical vignette about a patient (whose race was unknown) with Type 2 diabetes and untreated hypertension, who was also a current smoker. Participants were first asked to discuss what medical information they would need to treat the patient. Then physicians were asked to explicitly discuss the importance of race to the hypothetical patient's treatment. To identify common themes, codes, key words and physician demographics were compiled into a comprehensive table that allowed for examination of similarities and differences by physician race. Common themes were identified using the software package NVivo (QSR International, v7). Results Forty self-identified black and 50 self-identified white physicians participated in the study. All physicians - regardless of their own race - believed that medical history, family history, and weight were important for making treatment decisions for the patient. However, black and white physicians reported differences in their views about the relevance of race. Several black physicians indicated that patient race is a central factor for choosing treatment options such as aggressive therapies, patient medication and understanding disease risk. Moreover, many black physicians considered patient race important to understand the patient's views, such as alternative medicine preferences and cultural beliefs about illness. However

[Judicial framework for medical decision-making concerning minors].

PubMed

Sirvent, N; Bérard, E

2010-02-01

One aim of the law promulgated in France on March 4, 2002 concerning patients' rights and the quality of the health care system was to reconsider the bases of the physician-patient relationship. The new legal framework recommends establishment of a true dialogue between the two protagonists, and it assigns decisional priority to the patient rather than to the physician or third parties. In the case of minors, the principle of parental authority requires that the physician consults the holders of this authority before making any medical decision. However, the law of March 4, 2002 also reinforced the participation of minors in medical decisions concerning them. The lawmaker explicitly envisaged the possibility of overruling the principle of parental authority. This new "balance of power" obliges the physician to inform the minor of his or her medical condition in a manner appropriate to the child's degree of maturity. The minor may even put forward the principle of medical secrecy to prevent the sharing of information with his or her parents. This new "autonomy" of minors gives rise to at least two reservations: i) the difficulty involved in assessment of a minor's degree of discernment; ii) the minor's vulnerability with respect to his or her entourage. Copyright (c) 2010 Elsevier Masson SAS. All rights reserved.

The Integrated Medical Model: A Risk Assessment and Decision Support Tool for Space Flight Medical Systems

NASA Technical Reports Server (NTRS)

Kerstman, Eric; Minard, Charles; Saile, Lynn; deCarvalho, Mary Freire; Myers, Jerry; Walton, Marlei; Butler, Douglas; Iyengar, Sriram; Johnson-Throop, Kathy; Baumann, David

2009-01-01

The Integrated Medical Model (IMM) is a decision support tool that is useful to mission planners and medical system designers in assessing risks and designing medical systems for space flight missions. The IMM provides an evidence based approach for optimizing medical resources and minimizing risks within space flight operational constraints. The mathematical relationships among mission and crew profiles, medical condition incidence data, in-flight medical resources, potential crew functional impairments, and clinical end-states are established to determine probable mission outcomes. Stochastic computational methods are used to forecast probability distributions of crew health and medical resource utilization, as well as estimates of medical evacuation and loss of crew life. The IMM has been used in support of the International Space Station (ISS) medical kit redesign, the medical component of the ISS Probabilistic Risk Assessment, and the development of the Constellation Medical Conditions List. The IMM also will be used to refine medical requirements for the Constellation program. The IMM outputs for ISS and Constellation design reference missions will be presented to demonstrate the potential of the IMM in assessing risks, planning missions, and designing medical systems. The implementation of the IMM verification and validation plan will be reviewed. Additional planned capabilities of the IMM, including optimization techniques and the inclusion of a mission timeline, will be discussed. Given the space flight constraints of mass, volume, and crew medical training, the IMM is a valuable risk assessment and decision support tool for medical system design and mission planning.

IMPRESS: medical location-aware decision making during emergencies

NASA Astrophysics Data System (ADS)

Gkotsis, I.; Eftychidis, G.; Leventakis, G.; Mountzouris, M.; Diagourtas, D.; Kostaridis, A.; Hedel, R.; Olunczek, A.; Hahmann, S.

2017-09-01

Emergency situations and mass casualties involve several agencies and public authorities, which need to gather data from the incident scene and exchange geo-referenced information to provide fast and accurate first aid to the people in need. Tracking patients on their way to the hospitals can prove critical in taking lifesaving decisions. Increased and continuous flow of information combined by vital signs and geographic location of emergency victims can greatly reduce the response time of the medical emergency chain and improve the efficiency of disaster medicine activity. Recent advances in mobile positioning systems and telecommunications are providing the technology needed for the development of location-aware medical applications. IMPRESS is an advanced ICT platform based on adequate technologies for developing location-aware medical response during emergencies. The system incorporates mobile and fixed components that collect field data from diverse sources, support medical location and situation-based services and share information on the patient's transport from the field to the hospitals. In IMPRESS platform tracking of victims, ambulances and emergency services vehicles is integrated with medical, traffic and crisis management information into a common operational picture. The Incident Management component of the system manages operational resources together with patient tracking data that contain vital sign values and patient's status evolution. Thus, it can prioritize emergency transport decisions, based on medical and location-aware information. The solution combines positioning and information gathered and owned by various public services involved in MCIs or large-scale disasters. IMPRESS solution, were validated in field and table top exercises in cooperation with emergency services and hospitals.

Legal perceptions and medical decision making.

PubMed

Kapp, Marshall B; Lo, Bernard

1986-01-01

Medicine and law are more closely intertwined than ever before, particularly regarding issues of life-sustaining treatment for the elderly. The legal system's potential as a positive force in medical decision making has been limited by pervasive misperceptions by physicians of its processes and role. Identifying these myths and misperceptions is a first step toward a more effective partnership of medicine and law on behalf of the dying or demented patient.

Medication-related clinical decision support alert overrides in inpatients.

PubMed

Nanji, Karen C; Seger, Diane L; Slight, Sarah P; Amato, Mary G; Beeler, Patrick E; Her, Qoua L; Dalleur, Olivia; Eguale, Tewodros; Wong, Adrian; Silvers, Elizabeth R; Swerdloff, Michael; Hussain, Salman T; Maniam, Nivethietha; Fiskio, Julie M; Dykes, Patricia C; Bates, David W

2018-05-01

To define the types and numbers of inpatient clinical decision support alerts, measure the frequency with which they are overridden, and describe providers' reasons for overriding them and the appropriateness of those reasons. We conducted a cross-sectional study of medication-related clinical decision support alerts over a 3-year period at a 793-bed tertiary-care teaching institution. We measured the rate of alert overrides, the rate of overrides by alert type, the reasons cited for overrides, and the appropriateness of those reasons. Overall, 73.3% of patient allergy, drug-drug interaction, and duplicate drug alerts were overridden, though the rate of overrides varied by alert type (P < .0001). About 60% of overrides were appropriate, and that proportion also varied by alert type (P < .0001). Few overrides of renal- (2.2%) or age-based (26.4%) medication substitutions were appropriate, while most duplicate drug (98%), patient allergy (96.5%), and formulary substitution (82.5%) alerts were appropriate. Despite warnings of potential significant harm, certain categories of alert overrides were inappropriate >75% of the time. The vast majority of duplicate drug, patient allergy, and formulary substitution alerts were appropriate, suggesting that these categories of alerts might be good targets for refinement to reduce alert fatigue. Almost three-quarters of alerts were overridden, and 40% of the overrides were not appropriate. Future research should optimize alert types and frequencies to increase their clinical relevance, reducing alert fatigue so that important alerts are not inappropriately overridden.

Hospital Contracts: Important Issues for Medical Groups.

PubMed

Rosolio, Charles E

2016-01-01

Relationships with hospitals and outpatient medical facilities have always been an important part of the business model for private medical practices. As healthcare delivery to patients has evolved in the United States (much of it driven by the new government mandates, regulations, and the Affordable Care Act), the delivery of such services is becoming more and more centered on the hospital or institutional setting, thus making contractual relationships with hospitals even more important for medical practices. As a natural outgrowth of this relationship, attention to hospital contracts is becoming more important.

Exploring medical student decisions regarding attending live lectures and using recorded lectures.

PubMed

Gupta, Anmol; Saks, Norma Susswein

2013-09-01

Student decisions about lecture attendance are based on anticipated effect on learning. Factors involved in decision-making, the use of recorded lectures and their effect on lecture attendance, all warrant investigation. This study was designed to identify factors in student decisions to attend live lectures, ways in which students use recorded lectures, and if their use affects live lecture attendance. A total of 213 first (M1) and second year (M2) medical students completed a survey about lecture attendance, and rated factors related to decisions to attend live lectures and to utilize recorded lectures. Responses were analyzed overall and by class year and gender. M1 attended a higher percentage of live lectures than M2, while both classes used the same percentage of recorded lectures. Females attended more live lectures, and used a smaller percentage of recorded lectures. The lecturer was a key in attendance decisions. Also considered were the subject and availability of other learning materials. Students use recorded lectures as replacement for live lectures and as supplement to them. Lectures, both live and recorded, are important for student learning. Decisions about lecture placement in the curriculum need to be based on course content and lecturer quality.

Effect of electronic prescribing with formulary decision support on medication tier, copayments, and adherence

PubMed Central

2014-01-01

Background Medication non-adherence is prevalent. We assessed the effect of electronic prescribing (e-prescribing) with formulary decision support on preferred formulary tier usage, copayment, and concomitant adherence. Methods We retrospectively analyzed 14,682 initial pharmaceutical claims for angiotensin receptor blocker and inhaled steroid medications among 14,410 patients of 2189 primary care physicians (PCPs) who were offered e-prescribing with formulary decision support, including 297 PCPs who adopted it. Formulary decision support was initially non-interruptive, such that formulary tier symbols were displayed adjacent to medication names. Subsequently, interruptive formulary decision support alerts also interrupted e-prescribing when preferred-tier alternatives were available. A difference in differences design was used to compare the pre-post differences in medication tier for each new prescription attributed to non-adopters, low user (<30% usage rate), and high user PCPs (>30% usage rate). Second, we modeled the effect of formulary tier on prescription copayment. Last, we modeled the effect of copayment on adherence (proportion of days covered) to each new medication. Results Compared with non-adopters, high users of e-prescribing were more likely to prescribe preferred-tier medications (vs. non-preferred tier) when both non-interruptive and interruptive formulary decision support were in place (OR 1.9 [95% CI 1.0-3.4], p = 0.04), but no more likely to prescribe preferred-tier when only non-interruptive formulary decision support was in place (p = 0.90). Preferred-tier claims had only slightly lower mean monthly copayments than non-preferred tier claims (angiotensin receptor blocker: $10.60 versus $11.81, inhaled steroid: $14.86 versus $16.42, p < 0.0001). Medication possession ratio was 8% lower for each $1.00 increase in monthly copayment to the one quarter power (p < 0.0001). However, we detected no significant direct association

Effect of electronic prescribing with formulary decision support on medication tier, copayments, and adherence.

PubMed

Pevnick, Joshua M; Li, Ning; Asch, Steven M; Jackevicius, Cynthia A; Bell, Douglas S

2014-08-28

Medication non-adherence is prevalent. We assessed the effect of electronic prescribing (e-prescribing) with formulary decision support on preferred formulary tier usage, copayment, and concomitant adherence. We retrospectively analyzed 14,682 initial pharmaceutical claims for angiotensin receptor blocker and inhaled steroid medications among 14,410 patients of 2189 primary care physicians (PCPs) who were offered e-prescribing with formulary decision support, including 297 PCPs who adopted it. Formulary decision support was initially non-interruptive, such that formulary tier symbols were displayed adjacent to medication names. Subsequently, interruptive formulary decision support alerts also interrupted e-prescribing when preferred-tier alternatives were available. A difference in differences design was used to compare the pre-post differences in medication tier for each new prescription attributed to non-adopters, low user (<30% usage rate), and high user PCPs (>30% usage rate). Second, we modeled the effect of formulary tier on prescription copayment. Last, we modeled the effect of copayment on adherence (proportion of days covered) to each new medication. Compared with non-adopters, high users of e-prescribing were more likely to prescribe preferred-tier medications (vs. non-preferred tier) when both non-interruptive and interruptive formulary decision support were in place (OR 1.9 [95% CI 1.0-3.4], p = 0.04), but no more likely to prescribe preferred-tier when only non-interruptive formulary decision support was in place (p = 0.90). Preferred-tier claims had only slightly lower mean monthly copayments than non-preferred tier claims (angiotensin receptor blocker: $10.60 versus $11.81, inhaled steroid: $14.86 versus $16.42, p < 0.0001). Medication possession ratio was 8% lower for each $1.00 increase in monthly copayment to the one quarter power (p < 0.0001). However, we detected no significant direct association between formulary decision

Medical decision-making capacity in patients with malignant glioma.

PubMed

Triebel, Kristen L; Martin, Roy C; Nabors, Louis B; Marson, Daniel C

2009-12-15

Patients with malignant glioma (MG) must make ongoing medical treatment decisions concerning a progressive disease that erodes cognition. We prospectively assessed medical decision-making capacity (MDC) in patients with MG using a standardized psychometric instrument. Participants were 22 healthy controls and 26 patients with histologically verified MG. Group performance was compared on the Capacity to Consent to Treatment Instrument (CCTI), a psychometric measure of MDC incorporating 4 standards (choice, understanding, reasoning, and appreciation), and on neuropsychological and demographic variables. Capacity outcomes (capable, marginally capable, or incapable) on the CCTI standards were identified for the MG group. Within the MG group, scores on demographic, clinical, and neuropsychological variables were correlated with scores on each CCTI standard, and significant bivariate correlates were subsequently entered into exploratory stepwise regression analyses to identify multivariate cognitive predictors of the CCTI standards. Patients with MG performed significantly below controls on consent standards of understanding and reasoning, and showed a trend on appreciation. Relative to controls, more than 50% of the patients with MG demonstrated capacity compromise (marginally capable or incapable outcomes) in MDC. In the MG group, cognitive measures of verbal acquisition/recall and, to a lesser extent, semantic fluency predicted performance on the appreciation, reasoning, and understanding standards. Karnofsky score was also associated with CCTI performance. Soon after diagnosis, patients with malignant glioma (MG) have impaired capacity to make treatment decisions relative to controls. Medical decision-making capacity (MDC) impairment in MG seems to be primarily related to the effects of short-term verbal memory deficits. Ongoing assessment of MDC in patients with MG is strongly recommended.

[End-of-life care and end-of-life medical decisions: the ITAELD study].

PubMed

Miccinesi, Guido; Puliti, Donella; Paci, Eugenio

2011-01-01

To describe the attitudes towards end of life care and the practice of end-of-life medical decisions with possible life-shortening effect among Italian physicians. Cross sectional study (last death among the assisted patients in the last 12 months was considered). In the year 2007, 5,710 GPs and 8,950 hospital physicians were invited all over Italy to participate in the ITAELDstudy through anonymous mail questionnaire. Proportion of agreement with statements on end-of-life care issues. Proportion of deaths with an end-of-life medical decision. The response rate was 19.2%. The 65% of respondents agreed with the duty to respect any non-treatment request of the competent patient, the 55% agreed with the same duty in case of advanced directives, the 39% in case of proxy's request. The 53% of respondents agreed with the ethical acceptability of active euthanasia in selected cases. Among 1,850 deaths the 57.7% did not receive any end-of-life medical decision. For a further 21.0% no decision was possible, being sudden and unexpected deaths. In the remaining 21.3% at least one end-of-life medical decision was reported: 0.8% was classified as physician assisted death, 20.5% as non-treatment decision. Among all deceased the 19.6% were reported to have been deeply sedated. Being favourable to the use of opioids in terminal patients was associated to non-treatment decisions with possible but non-intentional life shortening effect; agreeing with the duty to fully respect any actual non-treatment request of the competent patient was associated to end-of life medical decisions with intentional life-shortening effect (adjusted OR>10 in both cases). The life stance and ethical beliefs of physicians determine their behaviour at the end of life wherever specific statements of law are lacking. Therefore education and debate are needed on these issues.

Who Decides: Me or We? Family Involvement in Medical Decision Making in Eastern and Western Countries.

PubMed

Alden, Dana L; Friend, John; Lee, Ping Yein; Lee, Yew Kong; Trevena, Lyndal; Ng, Chirk Jenn; Kiatpongsan, Sorapop; Lim Abdullah, Khatijah; Tanaka, Miho; Limpongsanurak, Supanida

2018-01-01

Research suggests that desired family involvement (FI) in medical decision making may depend on cultural values. Unfortunately, the field lacks cross-cultural studies that test this assumption. As a result, providers may be guided by incomplete information or cultural biases rather than patient preferences. Researchers developed 6 culturally relevant disease scenarios varying from low to high medical seriousness. Quota samples of approximately 290 middle-aged urban residents in Australia, China, Malaysia, India, South Korea, Thailand, and the USA completed an online survey that examined desired levels of FI and identified individual difference predictors in each country. All reliability coefficients were acceptable. Regression models met standard assumptions. The strongest finding across all 7 countries was that those who desired higher self-involvement (SI) in medical decision making also wanted lower FI. On the other hand, respondents who valued relational-interdependence tended to want their families involved - a key finding in 5 of 7 countries. In addition, in 4 of 7 countries, respondents who valued social hierarchy desired higher FI. Other antecedents were less consistent. These results suggest that it is important for health providers to avoid East-West cultural stereotypes. There are meaningful numbers of patients in all 7 countries who want to be individually involved and those individuals tend to prefer lower FI. On the other hand, more interdependent patients are likely to want families involved in many of the countries studied. Thus, individual differences within culture appear to be important in predicting whether a patient desires FI. For this reason, avoiding culture-based assumptions about desired FI during medical decision making is central to providing more effective patient centered care.

In search of tools to aid logical thinking and communicating about medical decision making.

PubMed

Hunink, M G

2001-01-01

To have real-time impact on medical decision making, decision analysts need a wide variety of tools to aid logical thinking and communication. Decision models provide a formal framework to integrate evidence and values, but they are commonly perceived as complex and difficult to understand by those unfamiliar with the methods, especially in the context of clinical decision making. The theory of constraints, introduced by Eliyahu Goldratt in the business world, provides a set of tools for logical thinking and communication that could potentially be useful in medical decision making. The author used the concept of a conflict resolution diagram to analyze the decision to perform carotid endarterectomy prior to coronary artery bypass grafting in a patient with both symptomatic coronary and asymptomatic carotid artery disease. The method enabled clinicians to visualize and analyze the issues, identify and discuss the underlying assumptions, search for the best available evidence, and use the evidence to make a well-founded decision. The method also facilitated communication among those involved in the care of the patient. Techniques from fields other than decision analysis can potentially expand the repertoire of tools available to support medical decision making and to facilitate communication in decision consults.

What’s Important to the Patient?: Informational Needs of Patients Making Decisions about Hepatitis C Treatment

PubMed Central

Evon, Donna M.; Golin, Carol E.; Stoica, Teodora; Jones, Rachel; Willis, Sarah; Galanko, Joseph; Fried, Michael W.

2017-01-01

Background & Objectives Multiple treatment options with direct-acting antivirals (DAAs) are now available for hepatitis C virus (HCV). Study aims were to understand (1) The informational topics patients want to have to make informed treatment decisions; (2) The importance patients place on each topic; and (3) The topics patients prioritize as most important. Methods Mixed methods study utilizing two samples recruited from an academic liver center. Participants were not currently on treatment. Sample I (n=45) free-listed all informational topics deemed important to decision-making. Raw responses were coded into several broad and subcategories. Sample II (n=38) rated the importance of the subcategories from Sample I and ranked their highest priorities on two surveys, one containing topics for which sufficient research existed to inform patients (“static”), and the other containing topics that would require additional research. Results The topics listed by Sample I fell into 6 broad categories with 17 total subcategories. The most oft-cited informational topics were harms of treatment (100%), treatment benefits (62%) and treatment regimen details (84%). Sample II rated 16 of 17 subcategories as “pretty important’ or “extremely important.” Sample II prioritized (1) viral cure, (2) long-term survival, and (3) side effects on the survey of topics requiring additional research, and (1) liver disease, (2) lifestyle changes, and (3) medication details on the second survey of the most important static topics patients needed. Conclusions Patients weighed several informational topics to make an informed decision about HCV treatment. These findings lay the groundwork for future patient-centered outcomes research in HCV and patient-provider communication to enhance patients’ informed decision-making regarding DAA treatment options. PMID:27882509

Medication adherence decision-making among adolescents and young adults with cancer.

PubMed

McGrady, Meghan E; Brown, Gabriella A; Pai, Ahna L H

2016-02-01

Nearly half of all adolescents and young adults (AYAs) with cancer struggle to adhere to oral chemotherapy or antibiotic prophylactic medication included in treatment protocols. The mechanisms that drive non-adherence remain unknown, leaving health care providers with few strategies to improve adherence among their patients. The purpose of this study was to use qualitative methods to investigate the mechanisms that drive the daily adherence decision-making process among AYAs with cancer. Twelve AYAs (ages 15-31) with cancer who had a current medication regimen that included oral chemotherapy or antibiotic prophylactic medication participated in this study. Adolescents and young adults completed a semi-structured interview and a card sorting task to elucidate the themes that impact adherence decision-making. Interviews were transcribed verbatim and coded twice by two independent raters to identify key themes and develop an overarching theoretical framework. Adolescents and young adults with cancer described adherence decision-making as a complex, multi-dimensional process influenced by personal goals and values, knowledge, skills, and environmental and social factors. Themes were generally consistent across medication regimens but differed with age, with older AYAs discussing long-term impacts and receiving physical support from their caregivers more than younger AYAs. The mechanisms that drive daily adherence decision-making among AYAs with cancer are consistent with those described in empirically-supported models of adherence among adults with other chronic medical conditions. These mechanisms offer several modifiable targets for health care providers striving to improve adherence among this vulnerable population. Copyright © 2015 Elsevier Ltd. All rights reserved.

Medication Adherence Decision-Making Among Adolescents and Young Adults with Cancer

PubMed Central

McGrady, Meghan E.; Brown, Gabriella A.; Pai, Ahna L. H.

2015-01-01

Purpose Nearly half of all adolescents and young adults (AYAs) with cancer struggle to adhere to oral chemotherapy or antibiotic prophylactic medication included in treatment protocols. The mechanisms that drive non-adherence remain unknown, leaving health care providers with few strategies to improve adherence among their patients. The purpose of this study was to use qualitative methods to investigate the mechanisms that drive the daily adherence decision-making process among AYAs with cancer. Methods Twelve AYAs (ages 15–31) with cancer who had a current medication regimen that included oral chemotherapy or antibiotic prophylactic medication participated in this study. Adolescents and young adults completed a semi-structured interview and a card sorting task to elucidate the themes that impact adherence decision-making. Interviews were transcribed verbatim and coded twice by two independent raters to identify key themes and develop an overarching theoretical framework. Results Adolescents and young adults with cancer described adherence decision-making as a complex, multi-dimensional process influenced by personal goals and values, knowledge, skills, and environmental and social factors. Themes were generally consistent across medication regimens but differed with age, with older AYAs discussing long-term impacts and receiving physical support from their caregivers more than younger AYAs. Conclusions The mechanisms that drive daily adherence decision-making among AYAs with cancer are consistent with those described in empirically-supported models of adherence among adults with other chronic medical conditions. These mechanisms offer several modifiable targets for health care providers striving to improve adherence among this vulnerable population. PMID:26372619

Medical Decision-Making Processes and Online Behaviors Among Cannabis Dispensary Staff

PubMed Central

Peiper, Nicholas C; Gourdet, Camille; Meinhofer, Angélica; Reiman, Amanda; Reggente, Nicco

2017-01-01

Background: Most cannabis patients engage with dispensary staff, like budtenders, for medical advice on cannabis. Yet, little is known about these interactions and how the characteristics of budtenders affect these interactions. This study investigated demographics, workplace characteristics, medical decision-making, and online behaviors among a sample of budtenders. Methods: Between June and September 2016, a cross-sectional Internet survey was administered to budtenders in the San Francisco Bay Area and Greater Los Angeles. A total of 158 budtenders fully responded to the survey. A series of comparisons were conducted to determine differences between trained and untrained budtenders. Results: Among the 158 budtenders, 56% had received formal training to become a budtender. Several demographic differences were found between trained and untrained budtenders. For workplace characteristics, trained budtenders were more likely to report budtender as their primary job (74% vs 53%), practice more than 5 years (34% vs 11%), and receive sales commission (57% vs 16%). Trained budtenders were significantly less likely to perceive medical decision-making as very important (47% vs 68%) and have a patient-centered philosophy (77% vs 89%). Although trained budtenders had significantly lower Internet usage, they were significantly more likely to exchange information with patients through e-mail (58% vs 39%), text message (46% vs 30%), mobile app (33% vs 11%), video call (26% vs 3%), and social media (51% vs 23%). Conclusions: Budtenders who are formally trained exhibit significantly different patterns of interaction with medical cannabis patients. Future studies will use multivariate methods to better determine which factors independently influence interactions and how budtenders operate after the introduction of regulations under the newly passed Proposition 64 that permits recreational cannabis use in California. PMID:28855796

The effect of how outcomes are framed on decisions about whether to take antihypertensive medication: a randomized trial.

PubMed

Carling, Cheryl L L; Kristoffersen, Doris Tove; Oxman, Andrew D; Flottorp, Signe; Fretheim, Atle; Schünemann, Holger J; Akl, Elie A; Herrin, Jeph; MacKenzie, Thomas D; Montori, Victor M

2010-03-01

We conducted an Internet-based randomized trial comparing three valence framing presentations of the benefits of antihypertensive medication in preventing cardiovascular disease (CVD) for people with newly diagnosed hypertension to determine which framing presentation resulted in choices most consistent with participants' values. In this second in a series of televised trials in cooperation with the Norwegian Broadcasting Company, adult volunteers rated the relative importance of the consequences of taking antihypertensive medication using visual analogue scales (VAS). Participants viewed information (or no information) to which they were randomized and decided whether or not to take medication. We compared positive framing over 10 years (the number escaping CVD per 1000); negative framing over 10 years (the number that will have CVD) and negative framing per year over 10 years of the effects of antihypertensive medication on the 10-year risk for CVD for a 40 year-old man with newly diagnosed hypertension without other risk factors. Finally, all participants were shown all presentations and detailed patient information about hypertension and were asked to decide again. We calculated a relative importance score (RIS) by subtracting the VAS-scores for the undesirable consequences of antihypertensive medication from the VAS-score for the benefit of CVD risk reduction. We used logistic regression to determine the association between participants' RIS and their choice. 1,528 participants completed the study. The statistically significant differences between the groups in the likelihood of choosing to take antihypertensive medication in relation to different values (RIS) increased as the RIS increased. Positively framed information lead to decisions most consistent with those made by everyone for the second, more fully informed decision. There was a statistically significant decrease in deciding to take antihypertensives on the second decision, both within groups and

Do patients want to participate in medical decision making?

PubMed

Strull, W M; Lo, B; Charles, G

1984-12-07

Although shared decision making by patients and clinicians has been advocated, little is known about the degree of participation in decision making that patients actually prefer or about clinicians' appreciation of these preferences. We administered questionnaires about three aspects of decision making to 210 hypertensive outpatients and to their 50 clinicians, who represented three types of medical practices. We found that 41% of patients preferred more information about hypertension; clinicians underestimated patient preferences for discussion about therapy in 29% of cases and overestimated 11% (k = .22); and 53% of patients preferred to participate in making decisions, while clinicians believed that their patients desired to participate in 78% of cases. Many patients who preferred not to make initial therapeutic decisions did want to participate in ongoing evaluation of therapy. Thus, clinicians underestimate patients' desire for information and discussion but overestimate patients' desire to make decisions. Awareness of this discrepancy may facilitate communication and decision making.

Shared decision-making in medical encounters regarding breast cancer treatment: the contribution of methodological triangulation.

PubMed

Durif-Bruckert, C; Roux, P; Morelle, M; Mignotte, H; Faure, C; Moumjid-Ferdjaoui, N

2015-07-01

The aim of this study on shared decision-making in the doctor-patient encounter about surgical treatment for early-stage breast cancer, conducted in a regional cancer centre in France, was to further the understanding of patient perceptions on shared decision-making. The study used methodological triangulation to collect data (both quantitative and qualitative) about patient preferences in the context of a clinical consultation in which surgeons followed a shared decision-making protocol. Data were analysed from a multi-disciplinary research perspective (social psychology and health economics). The triangulated data collection methods were questionnaires (n = 132), longitudinal interviews (n = 47) and observations of consultations (n = 26). Methodological triangulation revealed levels of divergence and complementarity between qualitative and quantitative results that suggest new perspectives on the three inter-related notions of decision-making, participation and information. Patients' responses revealed important differences between shared decision-making and participation per se. The authors note that subjecting patients to a normative behavioural model of shared decision-making in an era when paradigms of medical authority are shifting may undermine the patient's quest for what he or she believes is a more important right: a guarantee of the best care available. © 2014 John Wiley & Sons Ltd.

Classifying clinical decision making: interpreting nursing intuition, heuristics and medical diagnosis.

PubMed

Buckingham, C D; Adams, A

2000-10-01

This is the second of two linked papers exploring decision making in nursing. The first paper, 'Classifying clinical decision making: a unifying approach' investigated difficulties with applying a range of decision-making theories to nursing practice. This is due to the diversity of terminology and theoretical concepts used, which militate against nurses being able to compare the outcomes of decisions analysed within different frameworks. It is therefore problematic for nurses to assess how good their decisions are, and where improvements can be made. However, despite the range of nomenclature, it was argued that there are underlying similarities between all theories of decision processes and that these should be exposed through integration within a single explanatory framework. A proposed solution was to use a general model of psychological classification to clarify and compare terms, concepts and processes identified across the different theories. The unifying framework of classification was described and this paper operationalizes it to demonstrate how different approaches to clinical decision making can be re-interpreted as classification behaviour. Particular attention is focused on classification in nursing, and on re-evaluating heuristic reasoning, which has been particularly prone to theoretical and terminological confusion. Demonstrating similarities in how different disciplines make decisions should promote improved multidisciplinary collaboration and a weakening of clinical elitism, thereby enhancing organizational effectiveness in health care and nurses' professional status. This is particularly important as nurses' roles continue to expand to embrace elements of managerial, medical and therapeutic work. Analysing nurses' decisions as classification behaviour will also enhance clinical effectiveness, and assist in making nurses' expertise more visible. In addition, the classification framework explodes the myth that intuition, traditionally associated

Affective Forecasting and Medication Decision Making in Breast Cancer Prevention

PubMed Central

Hoerger, Michael; Scherer, Laura D.; Fagerlin, Angela

2016-01-01

Objectives Over two million American women at elevated risk of breast cancer are eligible to take chemoprevention medications such as Tamoxifen and Raloxifene, which can cut in half the risk of developing breast cancer but also have a number of side effects. Historically, very few at-risk women have opted to use chemoprevention medications. Affective forecasting theory suggests that people may avoid these medications if they expect taking them to increase their health-related stress. Methods After receiving an individually tailored decision aid that provided personalized information about the risks and benefits of these medications, 661 women at elevated risk of breast cancer were asked to make three affective forecasts, predicting what their level of health-related stress would be if taking Tamoxifen, Raloxifene, or neither medication. They also completed measures of decisional preferences and intentions, and at a three-month follow-up reported on whether or not they had decided to use either medication. Results On the affective forecasting items, very few women (< 10%) expected the medications to reduce their health-related stress, relative to no medication at all. Participants with more negative affective forecasts about taking a chemoprevention medication expressed lower preferences and intentions for using the medications (Cohen’s ds from 0.74 to 0.79) and were more likely to have opted against using medication at follow-up (odds ratios from 1.34 to 2.66). Conclusions These findings suggest that affective forecasting may explain avoidance of breast cancer chemoprevention medications. They also highlight the need for more research aimed at integrating emotional content into decision aids. PMID:26867042

Barriers to Medication Decision Making in Women with Lupus Nephritis: A Formative Study using Nominal Group Technique.

PubMed

Singh, Jasvinder A; Qu, Haiyan; Yazdany, Jinoos; Chatham, Winn; Dall'era, Maria; Shewchuk, Richard M

2015-09-01

To assess the perspectives of women with lupus nephritis on barriers to medication decision making. We used the nominal group technique (NGT), a structured process to elicit ideas from participants, for a formative assessment. Eight NGT meetings were conducted in English and moderated by an expert NGT researcher at 2 medical centers. Participants responded to the question: "What sorts of things make it hard for people to decide to take the medicines that doctors prescribe for treating their lupus kidney disease?" Patients nominated, discussed, and prioritized barriers to decisional processes involving medications for treating lupus nephritis. Fifty-one women with lupus nephritis with a mean age of 40.6 ± 13.3 years and disease duration of 11.8 ± 8.3 years participated in 8 NGT meetings: 26 African Americans (4 panels), 13 Hispanics (2 panels), and 12 whites (2 panels). Of the participants, 36.5% had obtained at least a college degree and 55.8% needed some help in reading health materials. Of the 248 responses generated (range 19-37 responses/panel), 100 responses (40%) were perceived by patients as having relatively greater importance than other barriers in their own decision-making processes. The most salient perceived barriers, as indicated by percent-weighted votes assigned, were known/anticipated side effects (15.6%), medication expense/ability to afford medications (8.2%), and the fear that the medication could cause other diseases (7.8%). Women with lupus nephritis identified specific barriers to decisions related to medications. Information relevant to known/anticipated medication side effects and medication cost will form the basis of a patient guide for women with systemic lupus erythematosus, currently under development.

Computerized decision support for medication dosing in renal insufficiency: a randomized, controlled trial.

PubMed

Terrell, Kevin M; Perkins, Anthony J; Hui, Siu L; Callahan, Christopher M; Dexter, Paul R; Miller, Douglas K

2010-12-01

Emergency physicians prescribe several discharge medications that require dosage adjustment for patients with renal disease. The hypothesis for this research was that decision support in a computerized physician order entry system would reduce the rate of excessive medication dosing for patients with renal impairment. This was a randomized, controlled trial in an academic emergency department (ED), in which computerized physician order entry was used to write all prescriptions for patients being discharged from the ED. The sample included 42 physicians who were randomized to the intervention (21 physicians) or control (21 physicians) group. The intervention was decision support that provided dosing recommendations for targeted medications for patients aged 18 years and older when the patient's estimated creatinine clearance level was below the threshold for dosage adjustment. The primary outcome was the proportion of targeted medications that were excessively dosed. For 2,783 (46%) of the 6,015 patient visits, the decision support had sufficient information to estimate the patient's creatinine clearance level. The average age of these patients was 46 years, 1,768 (64%) were women, and 1,523 (55%) were black. Decision support was provided 73 times to physicians in the intervention group, who excessively dosed 31 (43%) prescriptions. In comparison, control physicians excessively dosed a significantly larger proportion of medications: 34 of 46, 74% (effect size=31%; 95% confidence interval 14% to 49%; P=.001). Emergency physicians often prescribed excessive doses of medications that require dosage adjustment for renal impairment. Computerized physician order entry with decision support significantly reduced excessive dosing of targeted medications. Copyright © 2010 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.

Design of decision support interventions for medication prescribing.

PubMed

Horsky, Jan; Phansalkar, Shobha; Desai, Amrita; Bell, Douglas; Middleton, Blackford

2013-06-01

Describe optimal design attributes of clinical decision support (CDS) interventions for medication prescribing, emphasizing perceptual, cognitive and functional characteristics that improve human-computer interaction (HCI) and patient safety. Findings from published reports on success, failures and lessons learned during implementation of CDS systems were reviewed and interpreted with regard to HCI and software usability principles. We then formulated design recommendations for CDS alerts that would reduce unnecessary workflow interruptions and allow clinicians to make informed decisions quickly, accurately and without extraneous cognitive and interactive effort. Excessive alerting that tends to distract clinicians rather than provide effective CDS can be reduced by designing only high severity alerts as interruptive dialog boxes and less severe warnings without explicit response requirement, by curating system knowledge bases to suppress warnings with low clinical utility and by integrating contextual patient data into the decision logic. Recommended design principles include parsimonious and consistent use of color and language, minimalist approach to the layout of information and controls, the use of font attributes to convey hierarchy and visual prominence of important data over supporting information, the inclusion of relevant patient data in the context of the alert and allowing clinicians to respond with one or two clicks. Although HCI and usability principles are well established and robust, CDS and EHR system interfaces rarely conform to the best known design conventions and are seldom conceived and designed well enough to be truly versatile and dependable tools. These relatively novel interventions still require careful monitoring, research and analysis of its track record to mature. Clarity and specificity of alert content and optimal perceptual and cognitive attributes, for example, are essential for providing effective decision support to clinicians

Shared decision making and medication management in the recovery process.

PubMed

Deegan, Patricia E; Drake, Robert E

2006-11-01

Mental health professionals commonly conceptualize medication management for people with severe mental illness in terms of strategies to increase compliance or adherence. The authors argue that compliance is an inadequate construct because it fails to capture the dynamic complexity of autonomous clients who must navigate decisional conflicts in learning to manage disorders over the course of years or decades. Compliance is rooted in medical paternalism and is at odds with principles of person-centered care and evidence-based medicine. Using medication is an active process that involves complex decision making and a chance to work through decisional conflicts. It requires a partnership between two experts: the client and the practitioner. Shared decision making provides a model for them to assess a treatment's advantages and disadvantages within the context of recovering a life after a diagnosis of a major mental disorder.

The normalization heuristic: an untested hypothesis that may misguide medical decisions.

PubMed

Aberegg, Scott K; O'Brien, James M

2009-06-01

Medical practice is increasingly informed by the evidence from randomized controlled trials. When such evidence is not available, clinical hypotheses based on pathophysiological reasoning and common sense guide clinical decision making. One commonly utilized general clinical hypothesis is the assumption that normalizing abnormal laboratory values and physiological parameters will lead to improved patient outcomes. We refer to the general use of this clinical hypothesis to guide medical therapeutics as the "normalization heuristic". In this paper, we operationally define this heuristic and discuss its limitations as a rule of thumb for clinical decision making. We review historical and contemporaneous examples of normalization practices as empirical evidence for the normalization heuristic and to highlight its frailty as a guide for clinical decision making.

Professional Decisions and Ethical Values in Medical and Law Students.

ERIC Educational Resources Information Center

Rezler, Agnes G.; And Others

1990-01-01

This project evaluated and compared the values used by medical and law students when dealing with ethical dilemmas in the practice of law and medicine. The Professional Decisions and Values Test was given to 77 medical students and 92 law students. Differences were noted on beneficence, professional responsibility, and harm avoidance. (MLW)

Cognitive biases and heuristics in medical decision making: a critical review using a systematic search strategy.

PubMed

Blumenthal-Barby, J S; Krieger, Heather

2015-05-01

The role of cognitive biases and heuristics in medical decision making is of growing interest. The purpose of this study was to determine whether studies on cognitive biases and heuristics in medical decision making are based on actual or hypothetical decisions and are conducted with populations that are representative of those who typically make the medical decision; to categorize the types of cognitive biases and heuristics found and whether they are found in patients or in medical personnel; and to critically review the studies based on standard methodological quality criteria. Data sources were original, peer-reviewed, empirical studies on cognitive biases and heuristics in medical decision making found in Ovid Medline, PsycINFO, and the CINAHL databases published in 1980-2013. Predefined exclusion criteria were used to identify 213 studies. During data extraction, information was collected on type of bias or heuristic studied, respondent population, decision type, study type (actual or hypothetical), study method, and study conclusion. Of the 213 studies analyzed, 164 (77%) were based on hypothetical vignettes, and 175 (82%) were conducted with representative populations. Nineteen types of cognitive biases and heuristics were found. Only 34% of studies (n = 73) investigated medical personnel, and 68% (n = 145) confirmed the presence of a bias or heuristic. Each methodological quality criterion was satisfied by more than 50% of the studies, except for sample size and validated instruments/questions. Limitations are that existing terms were used to inform search terms, and study inclusion criteria focused strictly on decision making. Most of the studies on biases and heuristics in medical decision making are based on hypothetical vignettes, raising concerns about applicability of these findings to actual decision making. Biases and heuristics have been underinvestigated in medical personnel compared with patients. © The Author(s) 2014.

End-of-Life Care Decisions: Importance of Reviewing Systems and Limitations After 2 Recent North American Cases

PubMed Central

Burkle, Christopher M.; Benson, Jeffre J.

2012-01-01

Two recent and unfortunate North American cases involving end-of-life treatment highlight the difficulties surrounding medical futility conflicts. As countries have explored the greater influence that patients and their representatives may play on end-of-life treatment decisions, the benefits and struggles involved with such a movement must be appreciated. These 2 cases are used to examine the present systems existing in the United States and Canada for resolving end-of-life decisions, including the difficulty in defining medical futility, the role of medical ethics committees, and controversies involving surrogate decision making. PMID:23127734

Primary care specialty career choice among Canadian medical students: Understanding the factors that influence their decisions.

PubMed

Osborn, Heather Ann; Glicksman, Jordan T; Brandt, Michael G; Doyle, Philip C; Fung, Kevin

2017-02-01

To identify which factors influence medical students' decision to choose a career in family medicine and pediatrics, and which factors influence their decision to choose careers in non-front-line specialties. Survey that was created based on a comprehensive literature review to determine which factors are considered important when choosing practice specialty. Ontario medical school. An open cohort of medical students in the graduating classes of 2008 to 2011 (inclusive). The main factors that influenced participants' decision to choose a career in primary care or pediatrics, and the main factors that influenced participants' decision to choose a career in a non-front-line specialty. A total of 323 participants were included in this study. Factors that significantly influenced participants' career choice in family medicine or pediatrics involved work-life balance (acceptable hours of practice [ P = .005], acceptable on-call demands [ P = .012], and lifestyle flexibility [ P = .006]); a robust physician-patient relationship (ability to promote individual health promotion [ P = .014] and the opportunity to form long-term relationships [ P  < .001], provide comprehensive care [ P = .001], and treat patients and their families [ P = .006]); and duration of residency program ( P = .001). The career-related factors that significantly influenced participants' decision to choose a non-front-line specialty were as follows: becoming an expert ( P  < .001), maintaining a focused scope of practice ( P  < .001), having a procedure-focused practice ( P = .001), seeing immediate results from one's actions ( P  < .001), potentially earning a high income ( P  < .001), and having a perceived status among colleagues ( P  < .001). In this study, 8 factors were found to positively influence medical students' career choice in family medicine and pediatrics, and 6 factors influenced the decision to choose a career in a non-front-line specialty. Medical students can be

Considering Research Outcomes as Essential Tools for Medical Education Decision Making.

PubMed

Miller, Karen Hughes; Miller, Bonnie M; Karani, Reena

2015-11-01

As medical educators face the challenge of incorporating new content, learning methods, and assessment techniques into the curriculum, the need for rigorous medical education research to guide efficient and effective instructional planning increases. When done properly, well-designed education research can provide guidance for complex education decision making. In this Commentary, the authors consider the 2015 Research in Medical Education (RIME) research and review articles in terms of the critical areas in teaching and learning that they address. The broad categories include (1) assessment (the largest collection of RIME articles, including both feedback from learners and instructors and the reliability of learner assessment), (2) the institution's impact on the learning environment, (3) what can be learned from program evaluation, and (4) emerging issues in faculty development. While the articles in this issue are broad in scope and potential impact, the RIME committee noted few studies of sufficient rigor focusing on areas of diversity and diverse learners. Although challenging to investigate, the authors encourage continuing innovation in research focused on these important areas.

Medical students, clinical preventive services, and shared decision-making.

PubMed

Keefe, Carole W; Thompson, Margaret E; Noel, Mary Margaret

2002-11-01

Improving access to preventive care requires addressing patient, provider, and systems barriers. Patients often lack knowledge or are skeptical about the importance of prevention. Physicians feel that they have too little time, are not trained to deliver preventive services, and are concerned about the effectiveness of prevention. We have implemented an educational module in the required family practice clerkship (1) to enhance medical student learning about common clinical preventive services and (2) to teach students how to inform and involve patients in shared decision making about those services. Students are asked to examine available evidence-based information for preventive screening services. They are encouraged to look at the recommendations of various organizations and use such resources as reports from the U.S. Preventive Services Task Force to determine recommendations they want to be knowledgeable about in talking with their patients. For learning shared decision making, students are trained to use a model adapted from Braddock and colleagues(1) to discuss specific screening services and to engage patients in the process of making informed decisions about what is best for their own health. The shared decision making is presented and modeled by faculty, discussed in small groups, and students practice using Web-based cases and simulations. The students are evaluated using formative and summative performance-based assessments as they interact with simulated patients about (1) screening for high blood cholesterol and other lipid abnormalities, (2) screening for colorectal cancer, (3) screening for prostate cancer, and (4) screening for breast cancer. The final student evaluation is a ten-minute, videotaped discussion with a simulated patient about screening for colorectal cancer that is graded against a checklist that focuses primarily on the elements of shared decision making. Our medical students appear quite willing to accept shared decision making as

[Medical decision making in symptoms of type 2 diabetes mellitus in general practice].

PubMed

de Cruppé, W; von dem Knesebeck, O; Gerstenberger, E; Link, C; Marceau, L; Siegrist, J; Geraedts, M; McKinlay, J

2011-02-01

Patient and physician attributes influence medical decisions as non-medical factors. The current study examines the influence of patient age and gender and physicians' gender and years of clinical experience on medical decision making in patients with undiagnosed diabetes type 2. A factorial experiment was conducted to estimate the influence of patient and physician attributes. An identical physician patient encounter with a patient presenting with diabetes symptoms was videotaped with varying patient attributes. Professional actors played the "patients". A sample of 64 randomly chosen and stratified (gender and years of experience) primary care physicians was interviewed about the presented videos. Results show few significant differences in diagnostic decisions: Younger patients were asked more frequently about psychosocial problems while with older patients a cancer diagnosis was more often taken into consideration. Female physicians made an earlier second appointment date compared to male physicians. Physicians with more years of professional experience considered more often diabetes as the diagnosis than physicians with less experience. Medical decision making in patients with diabetes type 2 is only marginally influenced by patients' and physicians' characteristics under study. © Georg Thieme Verlag KG Stuttgart · New York.

Effect of Health Literacy on Decision-Making Preferences among Medically Underserved Patients.

PubMed

Seo, Joann; Goodman, Melody S; Politi, Mary; Blanchard, Melvin; Kaphingst, Kimberly A

2016-05-01

Participation in the decision-making process and health literacy may both affect health outcomes; data on how these factors are related among diverse groups are limited. This study examined the relationship between health literacy and decision-making preferences in a medically underserved population. We analyzed a sample of 576 primary care patients. Multivariable logistic regression was used to examine the independent association of health literacy (measured by the Rapid Estimate of Adult Literacy in Medicine-Revised) and patients' decision-making preferences (physician directed or patient involved), controlling for age, race/ethnicity, and gender. We tested whether having a regular doctor modified this association. Adequate health literacy (odds ratio [OR] = 1.7;P= 0.009) was significantly associated with preferring patient-involved decision making, controlling for age, race/ethnicity, and gender. Having a regular doctor did not modify this relationship. Males were significantly less likely to prefer patient-involved decision making (OR = 0.65;P= 0.024). Findings suggest health literacy affects decision-making preferences in medically underserved patients. More research is needed on how factors, such as patient knowledge or confidence, may influence decision-making preferences, particularly for those with limited health literacy. © The Author(s) 2016.

Making reasonable decisions: a qualitative study of medical decision making in the care of patients with a clinically significant haemoglobin disorder.

PubMed

Crowther, Helen J; Kerridge, Ian

2015-10-01

Therapies utilized in patients with clinically significant haemoglobin disorders appear to vary between clinicians and units. This study aimed to investigate the processes of evidence implementation and medical decision making in the care of such patients in NSW, Australia. Using semi-structured interviews, 11 haematologists discussed their medical decision-making processes with particular attention paid to the use of published evidence. Transcripts were thematically analysed by a single investigator on a line-by-line basis. Decision making surrounding the care of patients with significant haemoglobin disorders varied and was deeply contextual. Three main determinants of clinical decision making were identified - factors relating to the patient and to their illness, factors specific to the clinician and the institution in which they were practising and factors related to the notion of evidence and to utility and role of evidence-based medicine in clinical practice. Clinicians pay considerable attention to medical decision making and evidence incorporation and attempt to tailor these to particular patient contexts. However, the patient context is often inferred and when discordant with the clinician's own contexture can lead to discomfort with decision recommendations. Clinicians strive to improve comfort through the use of experience and trustworthy evidence. © 2015 John Wiley & Sons, Ltd.

Clinical-decision support based on medical literature: A complex network approach

NASA Astrophysics Data System (ADS)

Jiang, Jingchi; Zheng, Jichuan; Zhao, Chao; Su, Jia; Guan, Yi; Yu, Qiubin

2016-10-01

In making clinical decisions, clinicians often review medical literature to ensure the reliability of diagnosis, test, and treatment because the medical literature can answer clinical questions and assist clinicians making clinical decisions. Therefore, finding the appropriate literature is a critical problem for clinical-decision support (CDS). First, the present study employs search engines to retrieve relevant literature about patient records. However, the result of the traditional method is usually unsatisfactory. To improve the relevance of the retrieval result, a medical literature network (MLN) based on these retrieved papers is constructed. Then, we show that this MLN has small-world and scale-free properties of a complex network. According to the structural characteristics of the MLN, we adopt two methods to further identify the potential relevant literature in addition to the retrieved literature. By integrating these potential papers into the MLN, a more comprehensive MLN is built to answer the question of actual patient records. Furthermore, we propose a re-ranking model to sort all papers by relevance. We experimentally find that the re-ranking model can improve the normalized discounted cumulative gain of the results. As participants of the Text Retrieval Conference 2015, our clinical-decision method based on the MLN also yields higher scores than the medians in most topics and achieves the best scores for topics: #11 and #12. These research results indicate that our study can be used to effectively assist clinicians in making clinical decisions, and the MLN can facilitate the investigation of CDS.

The Importance of Professional Activity to Personnel Decisions for Medical Technologists in Academia.

ERIC Educational Resources Information Center

Miller, Sharon; Kimball, Olive M.

Criteria related to merit evaluations of medical technology faculty were evaluated, based on a survey of members of the American Society for Medical Technology's scientific section on education. Questionnaire responses were obtained from 27 academic institutions. Criteria included publications, institutional committee activity, research, clinical…

Field trials of medical decision-aids: potential problems and solutions.

PubMed Central

Wyatt, J.; Spiegelhalter, D.

1991-01-01

Only clinical trials can assess the impact of prototype medical decision-aids, but they are seldom performed before dissemination. Many problems are encountered when designing such studies, including ensuring generality, deciding what to measure, feasible study designs, correcting for biases caused by the trial itself and by the decision-aid, resolving the "Evaluation Paradox", and potential legal and ethical doubts. These are discussed in this paper. PMID:1807610

Decision conflict and regret among surrogate decision makers in the medical intensive care unit.

PubMed

Miller, Jesse J; Morris, Peter; Files, D Clark; Gower, Emily; Young, Michael

2016-04-01

Family members of critically ill patients in the intensive care unit face significant morbidity. It may be the decision-making process that plays a significant role in the psychological morbidity associated with being a surrogate in the ICU. We hypothesize that family members facing end-of-life decisions will have more decisional conflict and decisional regret than those facing non-end-of-life decisions. We enrolled a sample of adult patients and their surrogates in a tertiary care, academic medical intensive care unit. We queried the surrogates regarding decisions they had made on behalf of the patient and assessed decision conflict. We then contacted the family member again to assess decision regret. Forty (95%) of 42 surrogates were able to identify at least 1 decision they had made on behalf of the patient. End-of-life decisions (defined as do not resuscitate [DNR]/do not intubate [DNI] or continuation of life support) accounted for 19 of 40 decisions (47.5%). Overall, the average Decision Conflict Scale (DCS) score was 21.9 of 100 (range 0-100, with 0 being little decisional conflict and 100 being great decisional conflict). The average DCS score for families facing end-of-life decisions was 25.5 compared with 18.7 for all other decisions. Those facing end-of-life decisions scored higher on the uncertainty subscale (subset of DCS questions that indicates level of certainty regarding decision) with a mean score of 43.4 compared with all other decisions with a mean score of 27.0. Overall, very few surrogates experienced decisional regret with an average DRS score of 13.4 of 100. Nearly all surrogates enrolled were faced with decision-making responsibilities on behalf of his or her critically ill family member. In our small pilot study, we found more decisional conflict in those surrogates facing end-of-life decisions, specifically on the subset of questions dealing with uncertainty. Surrogates report low levels of decisional regret. Copyright © 2015 Elsevier

Targeting Continuing Medical Education on Decision Makers: Who Decides to Transfuse Blood?

ERIC Educational Resources Information Center

Goodnough, Lawrence T.; And Others

1992-01-01

Staff communication patterns were observed during 13 open-heart surgeries to identify the transfusion decision makers. It was determined that targeting decision makers for continuing medical education would improve the quality of transfusion practice and increase the efficiency of continuing education. (SK)

Feminist ethics and menopause: autonomy and decision-making in primary medical care.

PubMed

Murtagh, Madeleine J; Hepworth, Julie

2003-04-01

The construction of menopause as a long-term risk to health and the adoption of discourses of prevention has made necessary a decision by women about medical treatment; specifically regarding the use of hormone replacement therapy. In a study of general practitioners' accounts of menopause and treatment in Australia, women's 'choice', 'informed decision-making' and 'empowerment' were key themes through which primary medical care for women at menopause was presented. These accounts create a position for women defined by the concept of individual choice and an ethic of autonomy. These data are a basis for theorising more generally in this paper. We critically examine the construct of 'informed decision-making' in relation to several approaches to ethics including bioethics and a range of feminist ethics. We identify the intensification of power relations produced by an ethic of autonomy and discuss the ways these considerations inform a feminist ethics of decision-making by women. We argue that an 'ethic of autonomy' and an 'offer of choice' in relation to health care for women at menopause, far from being emancipatory, serves to intensify power relations. The dichotomy of choice, to take or not to take hormone replacement therapy, is required to be a choice and is embedded in relations of power and bioethical discourse that construct meanings about what constitutes decision-making at menopause. The deployment of the principle of autonomy in medical practice limits decision-making by women precisely because it is detached from the construction of meaning and the self and makes invisible the relations of power of which it is a part.

Exploring differences in the use of the statin choice decision aid and diabetes medication choice decision aid in primary care.

PubMed

Ballard, Aimee Yu; Kessler, Maya; Scheitel, Marianne; Montori, Victor M; Chaudhry, Rajeev

2017-08-10

Shared decision making is essential to patient centered care, but can be difficult for busy clinicians to implement into practice. Tools have been developed to aid in shared decision making and embedded in electronic medical records (EMRs) to facilitate use. This study was undertaken to explore the patterns of use and barriers and facilitators to use of two decision aids, the Statin Choice Decision Aid (SCDA) and the Diabetes Medication Choice Decision Aid (DMCDA), in primary care practices where the decision aids are embedded in the EMR. A survey exploring factors that influenced use of each decision aid was sent to eligible primary care clinicians affiliated with the Mayo Clinic in Rochester, MN. Survey data was collected and clinician use of each decision aid via links from the EMR was tracked. The survey response rate was 40% (105/262). Log file data indicated 51% of clinicians used the SCDA and 9% of clinicians used the DMCDA. Reasons for lack of use included lack of knowledge of the EMR link, not finding the decision aids helpful, and time constraints. Survey responses indicated that use of the tool as intended was low, with many clinicians only discussing decision aid topics that they found relevant. Although guidelines for both the treatment of blood cholesterol with a statin and for the treatment of hyperglycemia in type 2 diabetes recommend shared decision making, tools that facilitate shared decision making are not routinely used even when embedded in the EMR. Even when decision aids are used, their use may not reflect patient centered care.

Evaluation of RxNorm for Medication Clinical Decision Support.

PubMed

Freimuth, Robert R; Wix, Kelly; Zhu, Qian; Siska, Mark; Chute, Christopher G

2014-01-01

We evaluated the potential use of RxNorm to provide standardized representations of generic drug name and route of administration to facilitate management of drug lists for clinical decision support (CDS) rules. We found a clear representation of generic drug name but not route of administration. We identified several issues related to data quality, including erroneous or missing defined relationships, and the use of different concept hierarchies to represent the same drug. More importantly, we found extensive semantic precoordination of orthogonal concepts related to route and dose form, which would complicate the use of RxNorm for drug-based CDS. This study demonstrated that while RxNorm is a valuable resource for the standardization of medications used in clinical practice, additional work is required to enhance the terminology so that it can support expanded use cases, such as managing drug lists for CDS.

Linking decision-making research and cancer prevention and control: important themes.

PubMed

McCaul, Kevin D; Peters, Ellen; Nelson, Wendy; Stefanek, Michael

2005-07-01

This article describes 6 themes underlying the multiple presentations from the Basic and Applied Decision Making in Cancer Control meeting, held February 19-20, 2004. The following themes have important implications for research and practice linking basic decision-making research to cancer prevention and control: (a) Traditional decision-making theories fail to capture real-world decision making, (b) decision makers are often unable to predict future preferences, (c) preferences are often constructed on the spot and thus are influenced by situational cues, (d) decision makers often rely on feelings rather than beliefs when making a decision, (e) the perspective of the decision maker is critical in determining preferences, and (f) informed decision making may--or may not--yield the best decisions.

Pediatric obstetrical ethics: Medical decision-making by, with, and for pregnant early adolescents.

PubMed

Mercurio, Mark R

2016-06-01

Pregnancy in an early adolescent carries with it specific ethical considerations, in some ways different from pregnancy in an adult and from medical care of a non-pregnant adolescent. Obstetrical ethics emphasizes the right of the patient to autonomy and bodily integrity, including the right to refuse medical intervention. Pediatric ethics recognizes the right of parents, within limits, to make medical decisions for their children, and the right of a child to receive medical or surgical interventions likely to be of benefit to her, sometimes over her own objections. As the child gets older, and particularly during the years of adolescence, there is also a recognition of the right to an increasingly prominent role in decisions about her own healthcare. Pediatric obstetrical ethics, referring to ethical decisions made by, with, and for pregnant early adolescents, represents the intersection of these different cultures. Principles and approaches from both obstetrical and pediatric ethics, as well as a unified understanding of rights, obligations, and practical considerations, will be needed. Copyright © 2016. Published by Elsevier Inc.

Racial-ethnic biases, time pressure, and medical decisions.

PubMed

Stepanikova, Irena

2012-09-01

This study examined two types of potential sources of racial-ethnic disparities in medical care: implicit biases and time pressure. Eighty-one family physicians and general internists responded to a case vignette describing a patient with chest pain. Time pressure was manipulated experimentally. Under high time pressure, but not under low time pressure, implicit biases regarding blacks and Hispanics led to a less serious diagnosis. In addition, implicit biases regarding blacks led to a lower likelihood of a referral to specialist when physicians were under high time pressure. The results suggest that when physicians face stress, their implicit biases may shape medical decisions in ways that disadvantage minority patients.

Congruence between patients' preferred and perceived participation in medical decision-making: a review of the literature.

PubMed

Brom, Linda; Hopmans, Wendy; Pasman, H Roeline W; Timmermans, Danielle R M; Widdershoven, Guy A M; Onwuteaka-Philipsen, Bregje D

2014-04-03

Patients are increasingly expected and asked to be involved in health care decisions. In this decision-making process, preferences for participation are important. In this systematic review we aim to provide an overview the literature related to the congruence between patients' preferences and their perceived participation in medical decision-making. We also explore the direction of mismatched and outline factors associated with congruence. A systematic review was performed on patient participation in medical decision-making. Medline, PsycINFO, CINAHL, EMBASE and the Cochrane Library databases up to September 2012, were searched and all studies were rigorously critically appraised. In total 44 papers were included, they sampled contained 52 different patient samples. Mean of congruence between preference for and perceived participation in decision-making was 60% (49 and 70 representing 25th and 75th percentiles). If no congruence was found, of 36 patient samples most patients preferred more involvement and of 9 patient samples most patients preferred less involvement. Factors associated with preferences the most investigated were age and educational level. Younger patients preferred more often an active or shared role as did higher educated patients. This review suggests that a similar approach to all patients is not likely to meet patients' wishes, since preferences for participation vary among patients. Health care professionals should be sensitive to patients individual preferences and communicate about patients' participation wishes on a regular basis during their illness trajectory.

Congruence between patients’ preferred and perceived participation in medical decision-making: a review of the literature

PubMed Central

2014-01-01

Background Patients are increasingly expected and asked to be involved in health care decisions. In this decision-making process, preferences for participation are important. In this systematic review we aim to provide an overview the literature related to the congruence between patients’ preferences and their perceived participation in medical decision-making. We also explore the direction of mismatched and outline factors associated with congruence. Methods A systematic review was performed on patient participation in medical decision-making. Medline, PsycINFO, CINAHL, EMBASE and the Cochrane Library databases up to September 2012, were searched and all studies were rigorously critically appraised. In total 44 papers were included, they sampled contained 52 different patient samples. Results Mean of congruence between preference for and perceived participation in decision-making was 60% (49 and 70 representing 25th and 75th percentiles). If no congruence was found, of 36 patient samples most patients preferred more involvement and of 9 patient samples most patients preferred less involvement. Factors associated with preferences the most investigated were age and educational level. Younger patients preferred more often an active or shared role as did higher educated patients. Conclusion This review suggests that a similar approach to all patients is not likely to meet patients’ wishes, since preferences for participation vary among patients. Health care professionals should be sensitive to patients individual preferences and communicate about patients’ participation wishes on a regular basis during their illness trajectory. PMID:24708833

Court decisions on medical malpractice.

PubMed

Knaak, Jan-Paul; Parzeller, Markus

2014-11-01

Recent studies on court cases dealing with medical malpractice are few and far between. This retrospective study, therefore, undertakes an analysis of medical malpractice lawsuits brought before regional courts in two judicial districts of the federal state of Hesse. Over a 5-year period (2006-2010), 232 court decisions on medical malpractice taken by the regional courts (Landgericht) of Kassel and Marburg were evaluated according to medical discipline, diagnosis, therapy, relevant level of care, charge of neglect of duty by the claimant party, outcome of the lawsuit, and further criteria. With certain overlaps, the disciplines most frequently confronted with claims of medical malpractice were accident surgery and orthopedics (30.2%; n = 70), dentistry (16.4%; n = 38), surgery (12.1%; n = 28), and gynecology and obstetrics (7.8%; n = 18), followed by the remaining medical disciplines (38.8%; n = 90). Malpractice allegations were brought against the practice-based sector in 35.8 % (n = 83) of cases, the hospital-based sector in 63.3% (n = 147) of cases, and other sectors in 0.9% (n = 2) of cases. The allegation grounds included false administration of treatment (67.2%; n = 156), false indication of treatment (37.1%; n = 86), false diagnosis (31.5%; n = 73), and/or organizational negligence (13.8%; n = 32). A breach of duty to inform was given as grounds for the claim in 38.8% (n = 90) of cases. A significant majority of 65.6% (n = 152) of cases ended in a court settlement. Of the cases, 18.9% (n = 44) were concluded by claim withdrawal, 11.2% (n = 26) by claim dismissal and 2.6% (n = 6) by criminal sentence. Of the cases, 1.7% (n = 4) were for purposes of securing evidence. Although there was no conclusive evidence of malpractice, two thirds of the cases ended in a court settlement. On the one hand, this outcome reduces the burden on the courts, but on the other, it can in the long term give

Factors influencing a nurse's decision to question medication administration in a neonatal clinical care unit.

PubMed

Aydon, Laurene; Hauck, Yvonne; Zimmer, Margo; Murdoch, Jamee

2016-09-01

The aim of this study was to identify factors that influence nurse's decisions to question concerning aspects of medication administration within the context of a neonatal clinical care unit. Medication error in the neonatal setting can be high with this particularly vulnerable population. As the care giver responsible for medication administration, nurses are deemed accountable for most errors. However, they are recognised as the forefront of prevention. Minimal evidence is available around reasoning, decision making and questioning around medication administration. Therefore, this study focuses upon addressing the gap in knowledge around what nurses believe influences their decision to question. A critical incident design was employed where nurses were asked to describe clinical incidents around their decision to question a medication issue. Nurses were recruited from a neonatal clinical care unit and participated in an individual digitally recorded interview. One hundred and three nurses participated between December 2013-August 2014. Use of the constant comparative method revealed commonalities within transcripts. Thirty-six categories were grouped into three major themes: 'Working environment', 'Doing the right thing' and 'Knowledge about medications'. Findings highlight factors that influence nurses' decision to question issues around medication administration. Nurses feel it is their responsibility to do the right thing and speak up for their vulnerable patients to enhance patient safety. Negative dimensions within the themes will inform planning of educational strategies to improve patient safety, whereas positive dimensions must be reinforced within the multidisciplinary team. The working environment must support nurses to question and ultimately provide safe patient care. Clear and up to date policies, formal and informal education, role modelling by senior nurses, effective use of communication skills and a team approach can facilitate nurses to

Attitudes towards informed consent, confidentiality, and substitute treatment decisions in southern African medical students: a case study from Zimbabwe.

PubMed

Hipshman, L

1999-08-01

This study explored the attitudes of biomedical science students (medical students) in a non-Western setting towards three medical ethics concepts that are based on fundamental Western culture ethical principles. A dichotomous (agree/disagree) response questionnaire was constructed using Western ethnocentric culture (WEC) based perspectives of informed consent, confidentiality, and substitute decision-making. Hypothesized WEC-Biased responses were assigned to the questionnaire's questions or propositions. A number of useful responses (169) were obtained from a large, cross-sectional, convenience sample of the MBChB students at the University of Zimbabwe Medical School. Statistical analysis described the differences in response patterns between the student's responses compared to the hypothesized WEC-Biased response. The effect of the nine independent variables on selected dependent variables (responses to certain questionnaire questions) was analyzed by stepwise logistic regression. Students concurred with the hypothesized WEC-Biased responses for two-thirds of the questionnaire items. This agreement included support for the role of legal advocacy in the substitute decision-making process. The students disagreed with the hypothesized WEC-Biased responses in several important medical ethics aspects. Most notably, the students indicated that persons with mental dysfunctions, as a class, were properly considered incompetent to make treatment decisions. None of the studied independent variables was often associated with students' responses, but training year was more frequently implicated than either ethnicity or gender. In order to develop internationally and culturally relevant medical ethics standards, non-Western perspectives ought to be acknowledged and incorporated. Two main areas for further efforts include: curriculum development in ethics reasoning and related clinical (medico-legal) decision-making processes that would be relevant to medical students from

Using a Context-aware Medical Application to Address Information Needs for Extubation Decisions

PubMed Central

Zhu, Xinxin; Lord, William

2005-01-01

Information overload has been one of the causes of preventable medical errors [1] and escalating costs [2]. A context-aware application with embedded clinical knowledge is proposed to provide practitioners with the appropriate amount of information and content. We developed a prototype of a context-aware medical application to address clinicians’ information needs that arise in a data-intensive unit, the Cardio-Thoracic Intensive Care Unit (CTICU). A major clinical decision supported by the prototype, the extubation decision, is illustrated. PMID:16779455

The Context of Medical Decision-Making: An Analysis of Practitioner/Patient Communication.

ERIC Educational Resources Information Center

Fisher, Sue

This paper examines how the exchange of information in medical interviews is organized, and how that organization produces and constrains the negotiation of treatment decisions. The analysis is drawn from the verbatim transcripts of audio-taped practitioner/patient communications, information gathered from medical files, and other ethnographic…

Medical decision making: guide to improved CPT coding.

PubMed

Holt, Jim; Warsy, Ambreen; Wright, Paula

2010-04-01

The Current Procedural Terminology (CPT) coding system for office visits, which has been in use since 1995, has not been well studied, but it is generally agreed that the system contains much room for error. In fact, the available literature suggests that only slightly more than half of physicians will agree on the same CPT code for a given visit, and only 60% of professional coders will agree on the same code for a particular visit. In addition, the criteria used to assign a code are often related to the amount of written documentation. The goal of this study was to evaluate two novel methods to assess if the most appropriate CPT code is used: the level of medical decision making, or the sum of all problems mentioned by the patient during the visit. The authors-a professional coder, a residency faculty member, and a PGY-3 family medicine resident-reviewed 351 randomly selected visit notes from two residency programs in the Northeast Tennessee region for the level of documentation, the level of medical decision making, and the total number of problems addressed. The authors assigned appropriate CPT codes at each of those three levels. Substantial undercoding occurred at each of the three levels. Approximately 33% of visits were undercoded based on the written documentation. Approximately 50% of the visits were undercoded based on the level of documented medical decision making. Approximately 80% of the visits were undercoded based on the total number of problems which the patient presented during the visit. Interrater agreement was fair, and similar to that noted in other coding studies. Undercoding is not only common in a family medicine residency program but it also occurs at levels that would not be evident from a simple audit of the documentation on the visit note. Undercoding also occurs from not exploring problems mentioned by the patient and not documenting additional work that was performed. Family physicians may benefit from minor alterations in their

Evaluation of RxNorm for Medication Clinical Decision Support

PubMed Central

Freimuth, Robert R.; Wix, Kelly; Zhu, Qian; Siska, Mark; Chute, Christopher G.

2014-01-01

We evaluated the potential use of RxNorm to provide standardized representations of generic drug name and route of administration to facilitate management of drug lists for clinical decision support (CDS) rules. We found a clear representation of generic drug name but not route of administration. We identified several issues related to data quality, including erroneous or missing defined relationships, and the use of different concept hierarchies to represent the same drug. More importantly, we found extensive semantic precoordination of orthogonal concepts related to route and dose form, which would complicate the use of RxNorm for drug-based CDS. This study demonstrated that while RxNorm is a valuable resource for the standardization of medications used in clinical practice, additional work is required to enhance the terminology so that it can support expanded use cases, such as managing drug lists for CDS. PMID:25954360

Guided medication dosing for elderly emergency patients using real-time, computerized decision support.

PubMed

Griffey, Richard T; Lo, Helen G; Burdick, Elisabeth; Keohane, Carol; Bates, David W

2012-01-01

To evaluate the impact of a real-time computerized decision support tool in the emergency department that guides medication dosing for the elderly on physician ordering behavior and on adverse drug events (ADEs). A prospective controlled trial was conducted over 26 weeks. The status of the decision support tool alternated OFF (7/17/06-8/29/06), ON (8/29/06-10/10/06), OFF (10/10/06-11/28/06), and ON (11/28/06-1/16/07) in consecutive blocks during the study period. In patients ≥65 who were ordered certain benzodiazepines, opiates, non-steroidals, or sedative-hypnotics, the computer application either adjusted the dosing or suggested a different medication. Physicians could accept or reject recommendations. The primary outcome compared medication ordering consistent with recommendations during ON versus OFF periods. Secondary outcomes included the admission rate, emergency department length of stay for discharged patients, 10-fold dosing orders, use of a second drug to reverse the original medication, and rate of ADEs using previously validated explicit chart review. 2398 orders were placed for 1407 patients over 1548 visits. The majority (49/53; 92.5%) of recommendations for alternate medications were declined. More orders were consistent with dosing recommendations during ON (403/1283; 31.4%) than OFF (256/1115; 23%) periods (p≤0.0001). 673 (43%) visits were reviewed for ADEs. The rate of ADEs was lower during ON (8/237; 3.4%) compared with OFF (31/436; 7.1%) periods (p=0.02). The remaining secondary outcomes showed no difference. Single institution study, retrospective chart review for ADEs. Though overall agreement with recommendations was low, real-time computerized decision support resulted in greater acceptance of medication recommendations. Fewer ADEs were observed when computerized decision support was active.

[What medical students want - evaluation of medical recruitment ads by future physicians].

PubMed

Renkawitz, T; Schuster, T; Benditz, A; Craiovan, B; Grifka, J; Lechler, P

2013-10-01

Three-quarters of all hospitals in Germany are now struggling to fill open positions for doctors. The medical job ad is a vital tool for human resources marketing and an important image factor. The present study examines the importance of information and offers in medical recruitment ads on application decisions by medical students. A total of 184 future physicians from clinical semesters participated voluntarily in an anonymous cross-sectional survey. Using a standardised questionnaire, the importance of 49 -individual items extracted from medical recruitment ads were rated with the help of a 4-point Likert Scale. Finally, the study participants prioritised their reasons for an application as a physician. Primary influence on the application decision on medical recruitment ads by medical students had offers/information in relation to education and training aspects and work-life balance. Payment rates for physicians and work load played an important role for the application motivation. Additional earnings for, e. g., emergency calls, providing of medical expertise and assistance with housing, relocation and reimbursement of interview expenses were less crucial. In prioritising key reasons for selecting a prospective employer "regular working hours," an "individual training concept" and an "attractive work-life balance" scored the highest priority. The "opportunity for scientific work" was assigned only a small significance. High importance for the application decision by future physicians on medical recruitment ads is placed on jobs with an opportunity for personal development and aspects that contribute to work-life balance. © Georg Thieme Verlag KG Stuttgart · New York.

The Medication Recommendation Tracking Form: a novel tool for tracking changes in prescribed medication, clinical decision making, and use in comparative effectiveness research.

PubMed

Reilly-Harrington, Noreen A; Sylvia, Louisa G; Leon, Andrew C; Shesler, Leah W; Ketter, Terence A; Bowden, Charles L; Calabrese, Joseph R; Friedman, Edward S; Ostacher, Michael J; Iosifescu, Dan V; Rabideau, Dustin J; Thase, Michael E; Nierenberg, Andrew A

2013-11-01

This paper describes the development and use of the Medication Recommendation Tracking Form (MRTF), a novel method for capturing physician prescribing behavior and clinical decision making. The Bipolar Trials Network developed and implemented the MRTF in a comparative effectiveness study for bipolar disorder (LiTMUS). The MRTF was used to assess the frequency, types, and reasons for medication adjustments. Changes in treatment were operationalized by the metric Necessary Clinical Adjustments (NCA), defined as medication adjustments to reduce symptoms, optimize treatment response and functioning, or to address intolerable side effects. Randomized treatment groups did not differ in rates of NCAs, however, responders had significantly fewer NCAs than non-responders. Patients who had more NCAs during their previous visit had significantly lower odds of responding at the current visit. For each one-unit increase in previous CGI-BP depression score and CGI-BP overall severity score, patients had an increased NCA rate of 13% and 15%, respectively at the present visit. Ten-unit increases in previous Montgomery Asberg Depression Rating Scale (MADRS) and Young Mania Rating Scale (YMRS) scores resulted in an 18% and 14% increase in rates of NCAs, respectively. Patients with fewer NCAs had increased quality of life and decreased functional impairment. The MRTF standardizes the reporting and rationale for medication adjustments and provides an innovative metric for clinical effectiveness. As the first tool in psychiatry to track the types and reasons for medication changes, it has important implications for training new clinicians and examining clinical decision making. (ClinicalTrials.gov number NCT00667745). Copyright © 2013. Published by Elsevier Ltd.

The Ethics of Ambiguity: Rethinking the Role and Importance of Uncertainty in Medical Education and Practice.

PubMed

Domen, Ronald E

2016-01-01

Understanding and embracing uncertainty are critical for effective teacher-learner relationships as well as for shared decision-making in the physician-patient relationship. However, ambiguity has not been given serious consideration in either the undergraduate or graduate medical curricula or in the role it plays in patient-centered care. In this article, the author examines the ethics of ambiguity and argues for a pedagogy that includes education in the importance of, and tolerance of, ambiguity that is inherent in medical education and practice. Common threads running through the ethics of ambiguity are the virtue of respect, and the development of a culture of respect is required for the successful understanding and implementation of a pedagogy of ambiguity.

Physicians' anxiety due to uncertainty and use of race in medical decision making.

PubMed

Cunningham, Brooke A; Bonham, Vence L; Sellers, Sherrill L; Yeh, Hsin-Chieh; Cooper, Lisa A

2014-08-01

The explicit use of race in medical decision making is contested. Researchers have hypothesized that physicians use race in care when they are uncertain. The aim of this study was to investigate whether physician anxiety due to uncertainty (ADU) is associated with a higher propensity to use race in medical decision making. This study included a national cross-sectional survey of general internists. A national sample of 1738 clinically active general internists drawn from the SK&A physician database were included in the study. ADU is a 5-item measure of emotional reactions to clinical uncertainty. Bonham and Sellers Racial Attributes in Clinical Evaluation (RACE) scale includes 7 items that measure self-reported use of race in medical decision making. We used bivariate regression to test for associations between physician characteristics, ADU, and RACE. Multivariate linear regression was performed to test for associations between ADU and RACE while adjusting for potential confounders. The mean score on ADU was 19.9 (SD=5.6). Mean score on RACE was 13.5 (SD=5.6). After adjusting for physician demographics, physicians with higher levels of ADU scored higher on RACE (+β=0.08 in RACE, P=0.04, for each 1-point increase in ADU), as did physicians who understood "race" to mean biological or genetic ancestral, rather than sociocultural, group. Physicians who graduated from a US medical school, completed fellowship, and had more white patients scored lower on RACE. This study demonstrates positive associations between physicians' ADU, meanings attributed to race, and self-reported use of race in medical decision making. Future research should examine the potential impact of these associations on patient outcomes and health care disparities.

Physicians’ Anxiety Due to Uncertainty and Use of Race in Medical Decision-Making

PubMed Central

Cunningham, Brooke A.; Bonham, Vence L.; Sellers, Sherrill L.; Yeh, Hsin-Chieh; Cooper, Lisa A.

2014-01-01

Background The explicit use of race in medical decision-making is contested. Researchers have hypothesized that physicians use race in care when they are uncertain. Objectives To investigate whether physician anxiety due to uncertainty is associated with a higher propensity to use race in medical decision-making. Research Design A national cross-sectional survey of general internists Subjects A national sample of 1738 clinically active general internists drawn from the SK&A physician database Measures Anxiety Due to Uncertainty (ADU) is a 5-item measure of emotional reactions to clinical uncertainty. Bonham and Sellers Racial Attributes in Clinical Evaluation (RACE) scale includes 7 items that measure self-reported use of race in medical decision-making. We used bivariate regression to test for associations between physician characteristics, ADU and RACE. Multivariate linear regression was performed to test for associations between ADU and RACE while adjusting for potential confounders. Results The mean score on ADU was 19.9 (SD=5.6). Mean score on RACE was 13.5 (SD=5.6). After adjusting for physician demographics, physicians with higher levels of ADU scored higher on RACE (+β=0.08 in RACE, p=0.04, for each 1-point increase in ADU), as did physicians who understand “race” to mean biological or genetic ancestral, rather than sociocultural, group. Physicians who graduated from a US medical school, completed fellowship, and had more white patients, scored lower on RACE. Conclusions This study demonstrates positive associations between physicians’ anxiety due to uncertainty, meanings attributed to race, and self-reported use of race in medical decision-making. Future research should examine the potential impact of these associations on patient outcomes and healthcare disparities. PMID:25025871

Factors predicting desired autonomy in medical decisions: Risk-taking and gambling behaviors

PubMed Central

Fortune, Erica E; Shotwell, Jessica J; Buccellato, Kiara; Moran, Erin

2016-01-01

This study investigated factors that influence patients’ desired level of autonomy in medical decisions. Analyses included previously supported demographic variables in addition to risk-taking and gambling behaviors, which exhibit a strong relationship with overall health and decision-making, but have not been investigated in conjunction with medical autonomy. Participants (N = 203) completed measures on Amazon’s Mechanical Turk, including two measures of autonomy. Two hierarchical regressions revealed that the predictors explained a significant amount of variance for both measures, but the contribution of predictor variables was incongruent between models. Possible causes for this incongruence and implications for patient–physician interactions are discussed. PMID:28070406

Medical decision-making and the patient: understanding preference patterns for growth hormone therapy using conjoint analysis.

PubMed

Singh, J; Cuttler, L; Shin, M; Silvers, J B; Neuhauser, D

1998-08-01

This study examines two questions that relate to patients' role in medical decision making: (1) Do patients utilize multiple attributes in evaluating different treatment options?, and (2) Do patient treatment preferences evidence heterogeneity and disparate patterns? Although research has examined these questions by using either individual- or aggregate-level approaches, the authors demonstrate an intermediate level approach (ie, relating to patient subgroups). The authors utilize growth augmentation therapy (GAT) as a context for analyzing these questions because GAT reflects a class of nonemergency treatments that (1) are based on genetic technology, (2) aim to improve the quality (rather than quantity) of life, and (3) offer useful insights for the patient's role in medical decision making. Using conjoint analysis, a methodology especially suited for the study of patient-consumer preferences but largely unexplored in the medical field, data were obtained from 154 parents for their decision to pursue GAT for their child. In all, six attributes were utilized to study GAT, including risk of long-term side effects (1:10,000 or 1:100,000), certainty of effect (50% or 100% of cases), amount of effect (1-2 inches or 4-5 inches in adult height), out-of-pocket cost ($100, $2,000, or $10,000/year) and child's attitude (likes or not likes therapy). An experimental design using conjoint analysis procedures revealed five preference patterns that reflect clear disparities in the importance that parents attach to the different attributes of growth therapy. These preference patterns are (1) child-focused (23%), (2) risk-conscious (36%), (3) balanced (23%), (4) cost-conscious (14%), and (5) ease-of-use (4%) oriented. Additional tests provided evidence for the validity of these preference patterns. Finally, this preference heterogeneity related systematically to parental characteristics (eg, demographic, psychologic). The study results offer additional insights into medical

Importance of perspective in economic analyses of cancer screening decisions.

PubMed

Mansley, E C; McKenna, M T

2001-10-06

As the fifth, and final, report in this Lancet series on health economics, we discuss how economic analyses in public health, with cancer screening as the example, differ depending on the perspective taken. We identify nine different, but related, decision makers at various levels, from the individual patient to society as a whole, and discuss how their different viewpoints affect their ultimate decisions. Central to our discussion is the identification of seven distinct components of perspective, each potentially important in the screening decision. In many fields of healthcare, decisions about the use of resources, such as time, wealth, or energy, are made by weighing up the positive and negative consequences of the alternatives under consideration and are thus based on an economic analysis of the situation (although sometimes this process is subconscious). For simplicity, we restrict our report to the effect of perspective on cancer screening decisions and show how the costs (negative consequences) and benefits (positive consequences) vary depending on the decision maker.

Medical Decision-Making Among Elderly People in Long Term Care.

ERIC Educational Resources Information Center

Tymchuk, Alexander J.; And Others

1988-01-01

Presented informed consent information on high and low risk medical procedures to elderly persons in long term care facility in standard, simplified, or storybook format. Comprehension was significantly better for simplified and storybook formats. Ratings of decision-making ability approximated comprehension test results. Comprehension test…

Asthma Medications and Pregnancy

MedlinePlus

... Associated Conditions Asthma & Pregnancy Asthma & Pregnancy: Medications Asthma & Pregnancy: Medications Make an Appointment Refer a Patient Ask ... mother and child. Making Decisions about Medication During Pregnancy It is important that your asthma be controlled ...

Surveying End-of-Life Medical Decisions in France: Evaluation of an Innovative Mixed-Mode Data Collection Strategy

PubMed Central

Pennec, Sophie; Monnier, Alain; Stephan, Amandine; Brouard, Nicolas; Bilsen, Johan; Cohen, Joachim

2016-01-01

Background Monitoring medical decisions at the end of life has become an important issue in many societies. Built on previous European experiences, the survey and project Fin de Vie en France (“End of Life in France,” or EOLF) was conducted in 2010 to provide an overview of medical end-of-life decisions in France. Objective To describe the methodology of EOLF and evaluate the effects of design innovations on data quality. Methods EOLF used a mixed-mode data collection strategy (paper and Internet) along with follow-up campaigns that employed various contact modes (paper and telephone), all of which were gathered from various institutions (research team, hospital, and medical authorities at the regional level). A telephone nonresponse survey was also used. Through descriptive statistics and multivariate logistic regressions, these innovations were assessed in terms of their effects on the response rate, quality of the sample, and differences between Web-based and paper questionnaires. Results The participation rate was 40.0% (n=5217). The respondent sample was very close to the sampling frame. The Web-based questionnaires represented only 26.8% of the questionnaires, and the Web-based secured procedure led to limitations in data management. The follow-up campaigns had a strong effect on participation, especially for paper questionnaires. With higher participation rates (63.21% and 63.74%), the telephone follow-up and nonresponse surveys showed that only a very low proportion of physicians refused to participate because of the topic or the absence of financial incentive. A multivariate analysis showed that physicians who answered on the Internet reported less medication to hasten death, and that they more often took no medical decisions in the end-of-life process. Conclusions Varying contact modes is a useful strategy. Using a mixed-mode design is interesting, but selection and measurement effects must be studied further in this sensitive field. PMID:26892632

A Medical Decision Support System for the Space Station Health Maintenance Facility

PubMed Central

Ostler, David V.; Gardner, Reed M.; Logan, James S.

1988-01-01

NASA is developing a Health Maintenance Facility (HMF) to provide the equipment and supplies necessary to deliver medical care in the Space Station. An essential part of the Health Maintenance Facility is a computerized Medical Decision Support System (MDSS) that will enhance the ability of the medical officer (“paramedic” or “physician”) to maintain the crew's health, and to provide emergency medical care. The computer system has four major functions: 1) collect and integrate medical information into an electronic medical record from Space Station medical officers, HMF instrumentation, and exercise equipment; 2) provide an integrated medical record and medical reference information management system; 3) manage inventory for logistical support of supplies and secure pharmaceuticals; 4) supply audio and electronic mail communications between the medical officer and ground based flight surgeons. ImagesFigure 1

Justification of automated decision-making: medical explanations as medical arguments.

PubMed Central

Shankar, R. D.; Musen, M. A.

1999-01-01

People use arguments to justify their claims. Computer systems use explanations to justify their conclusions. We are developing WOZ, an explanation framework that justifies the conclusions of a clinical decision-support system. WOZ's central component is the explanation strategy that decides what information justifies a claim. The strategy uses Toulmin's argument structure to define pieces of information and to orchestrate their presentation. WOZ uses explicit models that abstract the core aspects of the framework such as the explanation strategy. In this paper, we present the use of arguments, the modeling of explanations, and the explanation process used in WOZ. WOZ exploits the wealth of naturally occurring arguments, and thus can generate convincing medical explanations. Images Figure 5 PMID:10566388

Paediatricians' decision making about prescribing stimulant medications for children with attention-deficit/hyperactivity disorder.

PubMed

Chow, S-J; Sciberras, E; Gillam, L H; Green, J; Efron, D

2014-05-01

Attention-deficit/hyperactivity disorder (ADHD) is now the most common reason for a child to present to a paediatrician in Australia. Stimulant medications are commonly prescribed for children with ADHD, to reduce symptoms and improve function. In this study we investigated the factors that influence paediatricians' decisions about prescribing stimulant medications. In-depth, semi-structured interviews were conducted with paediatricians (n = 13) who were purposively recruited so as to sample a broad demographic of paediatricians working in diverse clinical settings. Paediatricians were recruited from public outpatient and private paediatrician clinics in Victoria, Australia. The interviews were audio-recorded and transcribed verbatim for thematic analysis. Paediatricians also completed a questionnaire describing their demographic and practice characteristics. Our findings showed that the decision to prescribe is a dynamic process involving two key domains: (1) weighing up clinical factors; and (2) interacting with parents and the patient along the journey to prescribing. Five themes relating to this process emerged from data analysis: comprehensive assessments that include history, examination and information from others; influencing factors such as functional impairment and social inclusion; previous success; facilitating parental understanding including addressing myths and parental confusion; and decision-making model. Paediatricians' decisions to prescribe stimulant medications are influenced by multiple factors that operate concurrently and interdependently. Paediatricians do not make decisions about prescribing in isolation; rather, they actively involve parents, teachers and patients, to arrive at a collective, well-informed decision. © 2013 John Wiley & Sons Ltd.

Do continuing medical education articles foster shared decision making?

PubMed

Labrecque, Michel; Lafortune, Valérie; Lajeunesse, Judith; Lambert-Perrault, Anne-Marie; Manrique, Hermes; Blais, Johanne; Légaré, France

2010-01-01

Defined as reviews of clinical aspects of a specific health problem published in peer-reviewed and non-peer-reviewed medical journals, offered without charge, continuing medical education (CME) articles form a key strategy for translating knowledge into practice. This study assessed CME articles for mention of evidence-based information on benefits and harms of available treatment and/or preventive options that are deemed essential for shared decision making (SDM) to occur in clinical practice. Articles were selected from 5 medical journals that publish CME articles and are provided free of charge to primary-care physicians of the Province of Quebec, Canada. Two individuals independently scored each article with the use of a 10-item checklist based on the International Patient Decision Aid Standards. In case of discrepancy, the item score was established by team consensus. Scores were added to produce a total article score ranging from 0 (no item present) to 10 (all items present). Thirty articles (6 articles per journal) were selected. Total article scores ranged from 1 to 9, with a mean (+/- SD) of 3.1 +/- 2.0 (95% confidence interval 2.8-4.3). Health conditions and treatment options were the items most frequently discussed in the articles; next came treatment benefits. Possible harms, the use of the same denominators for benefits and harms, and methods to facilitate the communication of benefits and harms to patients were almost never described. No significant differences between journals were observed. The CME articles evaluated did not include the evidence-based information necessary to foster SDM in clinical practice. Peer-reviewed and non-peer-reviewed medical journals should require CME articles to include this type of information.

Predicting the preferences for involvement in medical decision making among patients with mental disorders

PubMed Central

Michaelis, Svea; Kriston, Levente; Härter, Martin; Watzke, Birgit; Schulz, Holger; Melchior, Hanne

2017-01-01

Background The involvement of patients in medical decision making has been investigated widely in somatic diseases. However, little is known about the preferences for involvement and variables that could predict these preferences in patients with mental disorders. Objective This study aims to determine what roles mentally ill patients actually want to assume when making medical decisions and to identify the variables that could predict this role, including patients’ self-efficacy. Method Demographic and clinical data of 798 patients with mental disorders from three psychotherapeutic units in Germany were elicited using self-report questionnaires. Control preference was measured using the Control Preferences Scale, and patients’ perceived self-efficacy was assessed using the Self-Efficacy Scale. Bivariate and multivariate regression analyses were conducted to investigate the associations between patient variables and control preference. Results Most patients preferred a collaborative role (57.5%), followed by a semi passive (21.2%), a partly autonomous (16.2%), an autonomous (2.8%) and a fully passive (2.3%) role when making medical decisions. Age, sex, diagnosis, employment status, medical pretreatment and perceived self-efficacy were associated with the preference for involvement in the multivariate logistic model. Conclusion Our results confirm the preferences for involvement in medical decisions of mentally ill patients. We reconfirmed previous findings that older patients prefer a shared role over an autonomous role and that subjects with a high qualification prefer a more autonomous role over a shared role. The knowledge about predictors may help strengthen treatment effectiveness because matching the preferred and actual role preferences has been shown to improve clinical outcome. PMID:28837621

Predicting the preferences for involvement in medical decision making among patients with mental disorders.

PubMed

Michaelis, Svea; Kriston, Levente; Härter, Martin; Watzke, Birgit; Schulz, Holger; Melchior, Hanne

2017-01-01

The involvement of patients in medical decision making has been investigated widely in somatic diseases. However, little is known about the preferences for involvement and variables that could predict these preferences in patients with mental disorders. This study aims to determine what roles mentally ill patients actually want to assume when making medical decisions and to identify the variables that could predict this role, including patients' self-efficacy. Demographic and clinical data of 798 patients with mental disorders from three psychotherapeutic units in Germany were elicited using self-report questionnaires. Control preference was measured using the Control Preferences Scale, and patients' perceived self-efficacy was assessed using the Self-Efficacy Scale. Bivariate and multivariate regression analyses were conducted to investigate the associations between patient variables and control preference. Most patients preferred a collaborative role (57.5%), followed by a semi passive (21.2%), a partly autonomous (16.2%), an autonomous (2.8%) and a fully passive (2.3%) role when making medical decisions. Age, sex, diagnosis, employment status, medical pretreatment and perceived self-efficacy were associated with the preference for involvement in the multivariate logistic model. Our results confirm the preferences for involvement in medical decisions of mentally ill patients. We reconfirmed previous findings that older patients prefer a shared role over an autonomous role and that subjects with a high qualification prefer a more autonomous role over a shared role. The knowledge about predictors may help strengthen treatment effectiveness because matching the preferred and actual role preferences has been shown to improve clinical outcome.

78 FR 74225 - Decision That Certain Nonconforming Motor Vehicles Are Eligible for Importation

Federal Register 2010, 2011, 2012, 2013, 2014

2013-12-10

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Medical Decision-Making and Minors: Issues of Consent and Assent.

ERIC Educational Resources Information Center

Kuther, Tara L.

2003-01-01

After a brief discussion of legal perspectives on informed consent, the present review examines the developmental literature on children and adolescents' capacities to make medical decisions that are informed, voluntary, and rational. The purposes and benefits of assent are identified. Remaining questions of how to evaluate capacity and balance…

Medical leadership: An important and required competency for medical students

PubMed Central

Chen, Tsung-Ying

2018-01-01

Good medical leadership is the key to building high-quality healthcare. However, in the development of medical careers, the teaching of leadership has traditionally not equaled that of technical and academic competencies. As a result of changes in personal standards, the quality of medical leadership has led to variations between different organizations, as well as occasional catastrophic failure in the standard of care provided for patients. Leaders in the medical profession have called for reform in healthcare in response to challenges in the system and improvements in public health. Furthermore, there has been an increased drive to see leadership education for doctors starting earlier, and continuing throughout their careers so that they can take on more important leadership roles throughout the healthcare system. Being a physician requires not only management and leadership but also the need to transfer competencies to communication and critical thinking. These attributes can be obtained through experience in teamwork under the supervision of teaching staff. Therefore, medical students are expected to develop skills to deal with and resolve conflicts, learn to share leadership, prepare others to help and replace them, take mutual responsibility and discuss their performance.

Social support plays a role in the attitude that people have towards taking an active role in medical decision-making.

PubMed

Brabers, Anne E M; de Jong, Judith D; Groenewegen, Peter P; van Dijk, Liset

2016-09-21

There is a growing emphasis towards including patients in medical decision-making. However, not all patients are actively involved in such decisions. Research has so far focused mainly on the influence of patient characteristics on preferences for active involvement. However, it can be argued that a patient's social context has to be taken into account as well, because social norms and resources affect behaviour. This study aims to examine the role of social resources, in the form of the availability of informational and emotional support, on the attitude towards taking an active role in medical decision-making. A questionnaire was sent to members of the Dutch Health Care Consumer Panel (response 70 %; n = 1300) in June 2013. A regression model was then used to estimate the relation between medical and lay informational support and emotional support and the attitude towards taking an active role in medical decision-making. Availability of emotional support is positively related to the attitude towards taking an active role in medical decision-making only in people with a low level of education, not in persons with a middle and high level of education. The latter have a more positive attitude towards taking an active role in medical decision-making, irrespective of the level of emotional support available. People with better access to medical informational support have a more positive attitude towards taking an active role in medical decision-making; but no significant association was found for lay informational support. This study shows that social resources are associated with the attitude towards taking an active role in medical decision-making. Strategies aimed at increasing patient involvement have to address this.

Memory Accessibility and Medical Decision-Making for Significant Others: The Role of Socially Shared Retrieval-Induced Forgetting

PubMed Central

Coman, Dora; Coman, Alin; Hirst, William

2013-01-01

Medical decisions will often entail a broad search for relevant information. No sources alone may offer a complete picture, and many may be selective in their presentation. This selectivity may induce forgetting for previously learned material, thereby adversely affecting medical decision-making. In the study phase of two experiments, participants learned information about a fictitious disease and advantages and disadvantages of four treatment options. In the subsequent practice phase, they read a pamphlet selectively presenting either relevant (Experiment 1) or irrelevant (Experiment 2) advantages or disadvantages. A final cued recall followed and, in Experiment 2, a decision as to the best treatment for a patient. Not only did reading the pamphlet induce forgetting for related and unmentioned information, the induced forgetting adversely affected decision-making. The research provides a cautionary note about the risks of searching through selectively presented information when making a medical decision. PMID:23785320

Decision support environment for medical product safety surveillance.

PubMed

Botsis, Taxiarchis; Jankosky, Christopher; Arya, Deepa; Kreimeyer, Kory; Foster, Matthew; Pandey, Abhishek; Wang, Wei; Zhang, Guangfan; Forshee, Richard; Goud, Ravi; Menschik, David; Walderhaug, Mark; Woo, Emily Jane; Scott, John

2016-12-01

We have developed a Decision Support Environment (DSE) for medical experts at the US Food and Drug Administration (FDA). The DSE contains two integrated systems: The Event-based Text-mining of Health Electronic Records (ETHER) and the Pattern-based and Advanced Network Analyzer for Clinical Evaluation and Assessment (PANACEA). These systems assist medical experts in reviewing reports submitted to the Vaccine Adverse Event Reporting System (VAERS) and the FDA Adverse Event Reporting System (FAERS). In this manuscript, we describe the DSE architecture and key functionalities, and examine its potential contributions to the signal management process by focusing on four use cases: the identification of missing cases from a case series, the identification of duplicate case reports, retrieving cases for a case series analysis, and community detection for signal identification and characterization. Published by Elsevier Inc.

Liberal rationalism and medical decision-making.

PubMed

Savulescu, Julian

1997-04-01

I contrast Robert Veatch's recent liberal vision of medical decision-making with a more rationalist liberal model. According to Veatch, physicians are biased in their determination of what is in their patient's overall interests in favour of their medical interests. Because of the extent of this bias, we should abandon the practice of physicians offering what they guess to be the best treatment option. Patients should buddy up with physicians who share the same values -- 'deep value pairing'. The goal of choice is maximal promotion of patient values. I argue that if subjectivism about value and valuing is true, this move is plausible. However, if objectivism about value is true -- that there really are states which are good for people regardless of whether they desire to be in them -- then we should accept a more rationalist liberal alternative. According to this alternative, what is required to decide which course is best is rational dialogue between physicians and patients, both about the patient's circumstances and her values, and not the seeking out of people, physicians or others, who share the same values. Rational discussion requires that physicians be reasonable and empathic. I describe one possible account of a reasonable physician.

Decision Support Alerts for Medication Ordering in a Computerized Provider Order Entry (CPOE) System

PubMed Central

Beccaro, M. A. Del; Villanueva, R.; Knudson, K. M.; Harvey, E. M.; Langle, J. M.; Paul, W.

2010-01-01

Objective We sought to determine the frequency and type of decision support alerts by location and ordering provider role during Computerized Provider Order Entry (CPOE) medication ordering. Using these data we adjusted the decision support tools to reduce the number of alerts. Design Retrospective analyses were performed of dose range checks (DRC), drug-drug interaction and drug-allergy alerts from our electronic medical record. During seven sampling periods (each two weeks long) between April 2006 and October 2008 all alerts in these categories were analyzed. Another audit was performed of all DRC alerts by ordering provider role from November 2008 through January 2009. Medication ordering error counts were obtained from a voluntary error reporting system. Measurement/Results Between April 2006 and October 2008 the percent of medication orders that triggered a dose range alert decreased from 23.9% to 7.4%. The relative risk (RR) for getting an alert was higher at the start of the interventions versus later (RR= 2.40, 95% CI 2.28-2.52; p< 0.0001). The percentage of medication orders that triggered alerts for drug-drug interactions also decreased from 13.5% to 4.8%. The RR for getting a drug interaction alert at the start was 1.63, 95% CI 1.60-1.66; p< 0.0001. Alerts decreased in all clinical areas without an increase in reported medication errors. Conclusion We reduced the quantity of decision support alerts in CPOE using a systematic approach without an increase in reported medication errors PMID:23616845

Probability or Reasoning: Current Thinking and Realistic Strategies for Improved Medical Decisions

PubMed Central

2017-01-01

A prescriptive model approach in decision making could help achieve better diagnostic accuracy in clinical practice through methods that are less reliant on probabilistic assessments. Various prescriptive measures aimed at regulating factors that influence heuristics and clinical reasoning could support clinical decision-making process. Clinicians could avoid time-consuming decision-making methods that require probabilistic calculations. Intuitively, they could rely on heuristics to obtain an accurate diagnosis in a given clinical setting. An extensive literature review of cognitive psychology and medical decision-making theory was performed to illustrate how heuristics could be effectively utilized in daily practice. Since physicians often rely on heuristics in realistic situations, probabilistic estimation might not be a useful tool in everyday clinical practice. Improvements in the descriptive model of decision making (heuristics) may allow for greater diagnostic accuracy. PMID:29209469

Probability or Reasoning: Current Thinking and Realistic Strategies for Improved Medical Decisions.

PubMed

Nantha, Yogarabindranath Swarna

2017-11-01

A prescriptive model approach in decision making could help achieve better diagnostic accuracy in clinical practice through methods that are less reliant on probabilistic assessments. Various prescriptive measures aimed at regulating factors that influence heuristics and clinical reasoning could support clinical decision-making process. Clinicians could avoid time-consuming decision-making methods that require probabilistic calculations. Intuitively, they could rely on heuristics to obtain an accurate diagnosis in a given clinical setting. An extensive literature review of cognitive psychology and medical decision-making theory was performed to illustrate how heuristics could be effectively utilized in daily practice. Since physicians often rely on heuristics in realistic situations, probabilistic estimation might not be a useful tool in everyday clinical practice. Improvements in the descriptive model of decision making (heuristics) may allow for greater diagnostic accuracy.

Effectively marketing prepaid medical care with decision support systems.

PubMed

Forgionne, G A

1991-01-01

The paper reports a decision support system (DSS) that enables health plan administrators to quickly and easily: (1) manage relevant medical care market (consumer preference and competitors' program) information and (2) convert the information into appropriate medical care delivery and/or payment policies. As the paper demonstrates, the DSS enables providers to design cost efficient and market effective medical care programs. The DSS provides knowledge about subscriber preferences, customer desires, and the program offerings of the competition. It then helps administrators structure a medical care plan in a way that best meets consumer needs in view of the competition. This market effective plan has the potential to generate substantial amounts of additional revenue for the program. Since the system's data base consists mainly of the provider's records, routine transactions, and other readily available documents, the DSS can be implemented at a nominal incremental cost. The paper also evaluates the impact of the information system on the general financial performance of existing dental and mental health plans. In addition, the paper examines how the system can help contain the cost of providing medical care while providing better services to more potential beneficiaries than current approaches.

Doc, What Would You Do If You Were Me? On Self-Other Discrepancies in Medical Decision Making

ERIC Educational Resources Information Center

Garcia-Retamero, Rocio; Galesic, Mirta

2012-01-01

Doctors often make decisions for their patients and predict their patients' preferences and decisions to customize advice to their particular situation. We investigated how doctors make decisions about medical treatments for their patients and themselves and how they predict their patients' decisions. We also studied whether these decisions and…

Medical equipment classification: method and decision-making support based on paraconsistent annotated logic.

PubMed

Oshiyama, Natália F; Bassani, Rosana A; D'Ottaviano, Itala M L; Bassani, José W M

2012-04-01

As technology evolves, the role of medical equipment in the healthcare system, as well as technology management, becomes more important. Although the existence of large databases containing management information is currently common, extracting useful information from them is still difficult. A useful tool for identification of frequently failing equipment, which increases maintenance cost and downtime, would be the classification according to the corrective maintenance data. Nevertheless, establishment of classes may create inconsistencies, since an item may be close to two classes by the same extent. Paraconsistent logic might help solve this problem, as it allows the existence of inconsistent (contradictory) information without trivialization. In this paper, a methodology for medical equipment classification based on the ABC analysis of corrective maintenance data is presented, and complemented with a paraconsistent annotated logic analysis, which may enable the decision maker to take into consideration alerts created by the identification of inconsistencies and indeterminacies in the classification.

Medical Device Integrated Vital Signs Monitoring Application with Real-Time Clinical Decision Support.

PubMed

Moqeem, Aasia; Baig, Mirza; Gholamhosseini, Hamid; Mirza, Farhaan; Lindén, Maria

2018-01-01

This research involves the design and development of a novel Android smartphone application for real-time vital signs monitoring and decision support. The proposed application integrates market available, wireless and Bluetooth connected medical devices for collecting vital signs. The medical device data collected by the app includes heart rate, oxygen saturation and electrocardiograph (ECG). The collated data is streamed/displayed on the smartphone in real-time. This application was designed by adopting six screens approach (6S) mobile development framework and focused on user-centered approach and considered clinicians-as-a-user. The clinical engagement, consultations, feedback and usability of the application in the everyday practices were considered critical from the initial phase of the design and development. Furthermore, the proposed application is capable to deliver rich clinical decision support in real-time using the integrated medical device data.

Medical Decision-Making Among Adolescents with Neonatal Brachial Plexus Palsy and their Families: A Qualitative Study

PubMed Central

Squitieri, Lee; Larson, Bradley P.; Chang, Kate W-C; Yang, Lynda J-S.; Chung, Kevin C.

2016-01-01

Background Elective surgical management of neonatal brachial plexus palsy is complex, variable, and often individualized. Little is known about the medical decision-making process among adolescents with NBPP and their families faced with making complex treatment decisions. The experiences of these patients and their parents were analyzed to identify key factors in the decision-making process. Patients and Methods Eighteen adolescents with residual NBPP deficits between the ages of 10 to 17 years along with their parents were included in the present study. A qualitative research design was employed involving the use of separate one hour, in person, semi-structured interviews, which were audio recorded and transcribed. Grounded theory was applied by two independent members of the research team to identify recurrent themes and ultimately create a codebook that was then applied to the data. Results Medical decision-making among adolescents with NBPP and their families is multifaceted and individualized, comprised of both patient and system dependent factors. Four codes pertaining to the medical decision-making process were identified: 1) knowledge acquisition, 2) multidisciplinary care, 3) adolescent autonomy, and 4) patient expectations and treatment desires. Overall, parental decision-making was heavily influenced by system dependent factors, while adolescents largely based their medical decision-making on individual treatment desires to improve function and/or aesthetics. Conclusions There are many areas for improving the delivery of information and health care organization among adolescents with NBPP and their families. We recommend the development of educational interdisciplinary programs and decision aids containing evidence-based management guidelines targeted toward primary care providers and patients. We believe that a computer-based learning module may provide the best avenue to achieve maximum penetrance and convenience of information sharing. PMID:23714810

What is a medical decision? A taxonomy based on physician statements in hospital encounters: a qualitative study

PubMed Central

Ofstad, Eirik H; Frich, Jan C; Schei, Edvin; Frankel, Richard M; Gulbrandsen, Pål

2016-01-01

Objective The medical literature lacks a comprehensive taxonomy of decisions made by physicians in medical encounters. Such a taxonomy might be useful in understanding the physician-centred, patient-centred and shared decision-making in clinical settings. We aimed to identify and classify all decisions emerging in conversations between patients and physicians. Design Qualitative study of video recorded patient–physician encounters. Participants and setting 380 patients in consultations with 59 physicians from 17 clinical specialties and three different settings (emergency room, ward round, outpatient clinic) in a Norwegian teaching hospital. A randomised sample of 30 encounters from internal medicine was used to identify and classify decisions, a maximum variation sample of 20 encounters was used for reliability assessments, and the remaining encounters were analysed to test for applicability across specialties. Results On the basis of physician statements in our material, we developed a taxonomy of clinical decisions—the Decision Identification and Classification Taxonomy for Use in Medicine (DICTUM). We categorised decisions into 10 mutually exclusive categories: gathering additional information, evaluating test results, defining problem, drug-related, therapeutic procedure-related, legal and insurance-related, contact-related, advice and precaution, treatment goal, and deferment. Four-coder inter-rater reliability using Krippendorff's α was 0.79. Conclusions DICTUM represents a precise, detailed and comprehensive taxonomy of medical decisions communicated within patient–physician encounters. Compared to previous normative frameworks, the taxonomy is descriptive, substantially broader and offers new categories to the variety of clinical decisions. The taxonomy could prove helpful in studies on the quality of medical work, use of time and resources, and understanding of why, when and how patients are or are not involved in decisions. PMID:26868946

A novel clinical decision support algorithm for constructing complete medication histories.

PubMed

Long, Ju; Yuan, Michael Juntao

2017-07-01

A patient's complete medication history is a crucial element for physicians to develop a full understanding of the patient's medical conditions and treatment options. However, due to the fragmented nature of medical data, this process can be very time-consuming and often impossible for physicians to construct a complete medication history for complex patients. In this paper, we describe an accurate, computationally efficient and scalable algorithm to construct a medication history timeline. The algorithm is developed and validated based on 1 million random prescription records from a large national prescription data aggregator. Our evaluation shows that the algorithm can be scaled horizontally on-demand, making it suitable for future delivery in a cloud-computing environment. We also propose that this cloud-based medication history computation algorithm could be integrated into Electronic Medical Records, enabling informed clinical decision-making at the point of care. Copyright © 2017 Elsevier B.V. All rights reserved.

[Rational choice, prediction, and medical decision. Contribution of severity scores].

PubMed

Bizouarn, P; Fiat, E; Folscheid, D

2001-11-01

The aim of this study was to determine what type of representation the medical doctor adopted concerning the uncertainty about the future in critically ill patients in the context of preoperative evaluation and intensive care medicine and to explore through the representation of the patient health status the different possibilities of choice he was able to make. The role played by the severity classification systems in the process of medical decision-making under probabilistic uncertainty was assessed according to the theories of rational behaviour. In this context, a medical rationality needed to be discovered, going beyond the instrumental status of the objective and/or subjective constructions of rational choice theories and reaching a dimension where means and expected ends could be included.

The judicial role in life-sustaining medical treatment decisions.

PubMed

Hafemeister, T L; Keilitz, I; Banks, S M

1991-01-01

Although there has been speculation regarding the pervasiveness and nature of judicial decisions regarding life-sustaining medical treatment (LSMT), no attempt has been made to empirically assess their prevalence or the issues they address. An exploratory study utilizing a mail survey of a nationwide random sample (N = 905) of state trial court judges was conducted to provide initial information regarding this decision-making process. Twenty-two percent of the responding judges had heard at least one LSMT case, and judicial review did not appear endemic to particular states. The number of judges hearing LSMT cases dropped from 1975 to 1981 but has increased since then. Three major issues predominate: patient competency, appointment of a surrogate decisionmaker, and resolution of the ultimate issue of forgoing LSMT. Relatively few cases either contested a prior directive's validity or involved imposing sanctions for instituting or forgoing LSMT. Although subject to different interpretations, the results suggest the courts are having a significant impact on certain aspects of the LSMT decision-making process. However, the infrequency with which any one judge is called upon to make an LSMT decision causes concern about the judiciary's ability to respond in a timely and appropriate manner. With their potential for a profound effect on the actions of health care providers, greater attention to this decision-making process is warranted.

What is a medical decision? A taxonomy based on physician statements in hospital encounters: a qualitative study.

PubMed

Ofstad, Eirik H; Frich, Jan C; Schei, Edvin; Frankel, Richard M; Gulbrandsen, Pål

2016-02-11

The medical literature lacks a comprehensive taxonomy of decisions made by physicians in medical encounters. Such a taxonomy might be useful in understanding the physician-centred, patient-centred and shared decision-making in clinical settings. We aimed to identify and classify all decisions emerging in conversations between patients and physicians. Qualitative study of video recorded patient-physician encounters. 380 patients in consultations with 59 physicians from 17 clinical specialties and three different settings (emergency room, ward round, outpatient clinic) in a Norwegian teaching hospital. A randomised sample of 30 encounters from internal medicine was used to identify and classify decisions, a maximum variation sample of 20 encounters was used for reliability assessments, and the remaining encounters were analysed to test for applicability across specialties. On the basis of physician statements in our material, we developed a taxonomy of clinical decisions--the Decision Identification and Classification Taxonomy for Use in Medicine (DICTUM). We categorised decisions into 10 mutually exclusive categories: gathering additional information, evaluating test results, defining problem, drug-related, therapeutic procedure-related, legal and insurance-related, contact-related, advice and precaution, treatment goal, and deferment. Four-coder inter-rater reliability using Krippendorff's α was 0.79. DICTUM represents a precise, detailed and comprehensive taxonomy of medical decisions communicated within patient-physician encounters. Compared to previous normative frameworks, the taxonomy is descriptive, substantially broader and offers new categories to the variety of clinical decisions. The taxonomy could prove helpful in studies on the quality of medical work, use of time and resources, and understanding of why, when and how patients are or are not involved in decisions. Published by the BMJ Publishing Group Limited. For permission to use (where not already

Is expected utility theory normative for medical decision making?

PubMed

Cohen, B J

1996-01-01

Expected utility theory is felt by its proponents to be a normative theory of decision making under uncertainty. The theory starts with some simple axioms that are held to be rules that any rational person would follow. It can be shown that if one adheres to these axioms, a numerical quantity, generally referred to as utility, can be assigned to each possible outcome, with the preferred course of action being that which has the highest expected utility. One of these axioms, the independence principle, is controversial, and is frequently violated in experimental situations. Proponents of the theory hold that these violations are irrational. The independence principle is simply an axiom dictating consistency among preferences, in that it dictates that a rational agent should hold a specified preference given another stated preference. When applied to preferences between lotteries, the independence principle can be demonstrated to be a rule that is followed only when preferences are formed in a particular way. The logic of expected utility theory is that this demonstration proves that preferences should be formed in this way. An alternative interpretation is that this demonstrates that the independence principle is not a valid general rule of consistency, but in particular, is a rule that must be followed if one is to consistently apply the decision rule "choose the lottery that has the highest expected utility." This decision rule must be justified on its own terms as a valid rule of rationality by demonstration that violation would lead to decisions that conflict with the decision maker's goals. This rule does not appear to be suitable for medical decisions because often these are one-time decisions in which expectation, a long-run property of a random variable, would not seem to be applicable. This is particularly true for those decisions involving a non-trivial risk of death.

Collection of Medical Original Data with Search Engine for Decision Support.

PubMed

Orthuber, Wolfgang

2016-01-01

Medicine is becoming more and more complex and humans can capture total medical knowledge only partially. For specific access a high resolution search engine is demonstrated, which allows besides conventional text search also search of precise quantitative data of medical findings, therapies and results. Users can define metric spaces ("Domain Spaces", DSs) with all searchable quantitative data ("Domain Vectors", DSs). An implementation of the search engine is online in http://numericsearch.com. In future medicine the doctor could make first a rough diagnosis and check which fine diagnostics (quantitative data) colleagues had collected in such a case. Then the doctor decides about fine diagnostics and results are sent (half automatically) to the search engine which filters a group of patients which best fits to these data. In this specific group variable therapies can be checked with associated therapeutic results, like in an individual scientific study for the current patient. The statistical (anonymous) results could be used for specific decision support. Reversely the therapeutic decision (in the best case with later results) could be used to enhance the collection of precise pseudonymous medical original data which is used for better and better statistical (anonymous) search results.

Recovery and Resilience After a Nuclear Power Plant Disaster: A Medical Decision model for Managing an Effective, Timely, and Balanced Response

DOE Office of Scientific and Technical Information (OSTI.GOV)

Coleman, C. Norman; Blumenthal, Daniel J.

2013-05-01

Based on experiences in Tokyo responding to the Fukushima Daiichi nuclear power plant crisis, a real-time, medical decision model is presented by which to make key health-related decisions given the central role of health and medical issues in such disasters. Focus is on response and recovery activities that are safe, timely, effective, and well-organized. This approach empowers on-site decision makers to make interim decisions without undue delay using readily available and high-level scientific, medical, communication, and policy expertise. Key features of this approach include ongoing assessment, consultation, information, and adaption to the changing conditions. This medical decision model presented ismore » compatible with the existing US National Response Framework structure.« less

Practical considerations to guide development of access controls and decision support for genetic information in electronic medical records.

PubMed

Darcy, Diana C; Lewis, Eleanor T; Ormond, Kelly E; Clark, David J; Trafton, Jodie A

2011-11-02

Genetic testing is increasingly used as a tool throughout the health care system. In 2011 the number of clinically available genetic tests is approaching 2,000, and wide variation exists between these tests in their sensitivity, specificity, and clinical implications, as well as the potential for discrimination based on the results. As health care systems increasingly implement electronic medical record systems (EMRs) they must carefully consider how to use information from this wide spectrum of genetic tests, with whom to share information, and how to provide decision support for clinicians to properly interpret the information. Although some characteristics of genetic tests overlap with other medical test results, there are reasons to make genetic test results widely available to health care providers and counterbalancing reasons to restrict access to these test results to honor patient preferences, and avoid distracting or confusing clinicians with irrelevant but complex information. Electronic medical records can facilitate and provide reasonable restrictions on access to genetic test results and deliver education and decision support tools to guide appropriate interpretation and use. This paper will serve to review some of the key characteristics of genetic tests as they relate to design of access control and decision support of genetic test information in the EMR, emphasizing the clear need for health information technology (HIT) to be part of optimal implementation of genetic medicine, and the importance of understanding key characteristics of genetic tests when designing HIT applications.

Development of a SNOMED CT based national medication decision support system.

PubMed

Greibe, Kell

2013-01-01

Physicians often lack the time to familiarize themselves with the details of particular allergies or other drug restrictions. Clinical Decision Support (CDS), based on a structured terminology as SNOMED CT (SCT), can help physicians get an overview, by automatically alerting allergy, interactions and other important information. The centralized CDS platform based on SCT, controls Allergy, Interactions, Risk Situation Drugs and Max Dose restrictions by the help of databases developed for these specific purposes. The CDS will respond to automatic web service requests from the hospital or GP electronic medication system (EMS) during prescription, and return alerts and information. The CDS also contains a Physicians Preference Database where the physicians individually can set which kind of alerts they want to see. The result is clinically useful information physicians can use as a base for a more effective and safer treatment, without developing alert fatigue.

ONE SIZE FITS ALL? ON PATIENT AUTONOMY, MEDICAL DECISION-MAKING, AND THE IMPACT OF CULTURE.

PubMed

Gilbar, Roy; Miola, José

2015-01-01

While both medical law and medical ethics have developed in a way that has sought to prioritise patient autonomy, it is less clear whether it has done so in a way that enhances the self-determination of patients from non-western backgrounds. In this article, we consider the desire of some patients from non-western backgrounds for family involvement in decision-making and argue that this desire is not catered for effectively in either medical law or medical ethics. We examine an alternative approach based on relational autonomy that might serve both to allow such patients to exercise their self-determination while still allowing them to include family members in the decision-making process. © The Author 2014. Published by Oxford University Press; all rights reserved. For Permissions, please email: journals.permissions@oup.com.

A novel medical information management and decision model for uncertain demand optimization.

PubMed

Bi, Ya

2015-01-01

Accurately planning the procurement volume is an effective measure for controlling the medicine inventory cost. Due to uncertain demand it is difficult to make accurate decision on procurement volume. As to the biomedicine sensitive to time and season demand, the uncertain demand fitted by the fuzzy mathematics method is obviously better than general random distribution functions. To establish a novel medical information management and decision model for uncertain demand optimization. A novel optimal management and decision model under uncertain demand has been presented based on fuzzy mathematics and a new comprehensive improved particle swarm algorithm. The optimal management and decision model can effectively reduce the medicine inventory cost. The proposed improved particle swarm optimization is a simple and effective algorithm to improve the Fuzzy interference and hence effectively reduce the calculation complexity of the optimal management and decision model. Therefore the new model can be used for accurate decision on procurement volume under uncertain demand.

Medical decision-making among Hispanics and non-Hispanic Whites with chronic back and knee pain: A qualitative study

PubMed Central

2011-01-01

Background Musculoskeletal disorders affect all racial and ethnic groups, including Hispanics. Because these disorders are not life-threatening, decision-making is generally preference-based. Little is known about whether Hispanics in the U.S. differ from non-Hispanic Whites with respect to key decision making preferences. Methods We assembled six focus groups of Hispanic and non-Hispanic White patients with chronic back or knee pain at an urban medical center to discuss management of their conditions and the roles they preferred in medical decision-making. Hispanic groups were further stratified by socioeconomic status, using neighborhood characteristics as proxy measures. Discussions were led by a moderator, taped, transcribed and analyzed using a grounded theory approach. Results The analysis revealed ethnic differences in several areas pertinent to medical decision-making. Specifically, Hispanic participants were more likely to permit their physician to take the predominant role in making health decisions. Also, Hispanics of lower socioeconomic status generally preferred to use non-internet sources of health information to make medical decisions and to rely on advice obtained by word of mouth. Hispanics emphasized the role of faith and religion in coping with musculoskeletal disability. The analysis also revealed broad areas of concordance across ethnic strata including the primary role that pain and achieving pain relief play in patients' experiences and decisions. Conclusions These findings suggest differences between Hispanics and non-Hispanic Whites in preferred information sources and decision-making roles. These findings are hypothesis-generating. If confirmed in further research, they may inform the development of interventions to enhance preference-based decision-making among Hispanics. PMID:21510880

Medical decision-making among Hispanics and non-Hispanic Whites with chronic back and knee pain: a qualitative study.

PubMed

Katz, Jeffrey N; Lyons, Nancy; Wolff, Lisa S; Silverman, Jodie; Emrani, Parastu; Holt, Holly L; Corbett, Kelly L; Escalante, Agustin; Losina, Elena

2011-04-21

Musculoskeletal disorders affect all racial and ethnic groups, including Hispanics. Because these disorders are not life-threatening, decision-making is generally preference-based. Little is known about whether Hispanics in the U.S. differ from non-Hispanic Whites with respect to key decision making preferences. We assembled six focus groups of Hispanic and non-Hispanic White patients with chronic back or knee pain at an urban medical center to discuss management of their conditions and the roles they preferred in medical decision-making. Hispanic groups were further stratified by socioeconomic status, using neighborhood characteristics as proxy measures. Discussions were led by a moderator, taped, transcribed and analyzed using a grounded theory approach. The analysis revealed ethnic differences in several areas pertinent to medical decision-making. Specifically, Hispanic participants were more likely to permit their physician to take the predominant role in making health decisions. Also, Hispanics of lower socioeconomic status generally preferred to use non-internet sources of health information to make medical decisions and to rely on advice obtained by word of mouth. Hispanics emphasized the role of faith and religion in coping with musculoskeletal disability. The analysis also revealed broad areas of concordance across ethnic strata including the primary role that pain and achieving pain relief play in patients' experiences and decisions. These findings suggest differences between Hispanics and non-Hispanic Whites in preferred information sources and decision-making roles. These findings are hypothesis-generating. If confirmed in further research, they may inform the development of interventions to enhance preference-based decision-making among Hispanics.

Why Is It Important to Know My Family Medical History?

MedlinePlus

... is it important to know my family medical history? A family medical history is a record of ... professional regularly. For more information about family medical history: Educational resources related to family health history are ...

Medical Decision Making: A Selective Review for Child Psychiatrists and Psychologists

ERIC Educational Resources Information Center

Galanter, Cathryn A.; Patel, Vimla L.

2005-01-01

Physicians, including child and adolescent psychiatrists, show variability and inaccuracies in diagnosis and treatment of their patients and do not routinely implement evidenced-based medical and psychiatric treatments in the community. We believe that it is necessary to characterize the decision-making processes of child and adolescent…

Adoption Decisions for Medical Devices in the Field of Cardiology: Results from a European Survey.

PubMed

Hatz, Maximilian H M; Schreyögg, Jonas; Torbica, Aleksandra; Boriani, Giuseppe; Blankart, Carl R B

2017-02-01

Decisions to adopt medical devices at the hospital level have consequences for health technology assessment (HTA) on system level and are therefore important to decision makers. Our aim was to investigate the characteristics of organizations and individuals that are more inclined to adopt and utilize cardiovascular devices based on a comprehensive analysis of environmental, organizational, individual, and technological factors and to identify corresponding implications for HTA. Seven random intercept hurdle models were estimated using the data obtained from 1249 surveys completed by members of the European Society of Cardiology. The major findings were that better manufacturer support increased the adoption probability of 'new' devices (i.e. in terms of CE mark approval dates), and that budget pressure increased the adoption probability of 'old' devices. Based on our findings, we suggest investigating the role of manufacturer support in more detail to identify diffusion patterns relevant to HTA on system level, to verify whether it functions as a substitute for medical evidence of new devices, and to receive new insights about its relationship with clinical effectiveness and cost-effectiveness. © 2017 The Authors. Health Economics published by John Wiley & Sons, Ltd. © 2017 The Authors. Health Economics published by John Wiley & Sons, Ltd.

Evaluation of an educational program on deciphering heterogeneity for medical coverage decisions.

PubMed

Warholak, Terri L; Hilgaertner, Jianhua W; Dean, Joni L; Taylor, Ann M; Hines, Lisa E; Hurwitz, Jason; Brown, Mary; Malone, Daniel C

2014-06-01

It is increasingly important for decision makers, such as medical and pharmacy managers (or pharmacy therapeutics committee members and staff), to understand the variation and diversity in treatment response as decisions shift from an individual patient perspective to optimizing care for populations of patients. To assess the effectiveness of an instructional program on heterogeneity designed for medical and pharmacy managers. A live educational program was offered to members of the Academy of Managed Care Pharmacy at the fall 2012 educational meeting and also to medical directors and managers attending a national payer roundtable meeting in October 2012. Participants completed a retrospective pretest-posttest assessment of their knowledge, attitudes, and self-efficacy immediately following the program. Participants were offered the opportunity to participate in a follow-up assessment 6 months later. Willing participants for the follow-up assessment were contacted via e-mail and telephone. Rasch rating scale models were used to compare pre- and postscores measuring participants' knowledge about and attitude towards heterogeneity. A total of 49 individuals completed the retrospective pretest-posttest assessment and agreed to be a part of the program evaluation. Fifty percent (n = 25) of participants had heard of the phrase "heterogeneity of treatment effect," and 36 (72%) were familiar with the phrase "individualized treatment effect" prior to the live program. Participants reported a significant improvement in knowledge of heterogeneity (P  less than  0.01) and attitudes about heterogeneity (P  less than  0.01) immediately after attending the program. At the time of the educational program, participants had either never considered heterogeneity (26%) or reported not knowing (28%) whether their organizations considered it when determining basic coverage. Participants were more likely to report "sometimes" considering heterogeneity for determining

Decision to take osteoporosis medication in patients who have had a fracture and are 'high' risk for future fracture: a qualitative study.

PubMed

Sale, Joanna E M; Gignac, Monique A; Hawker, Gillian; Frankel, Lucy; Beaton, Dorcas; Bogoch, Earl; Elliot-Gibson, Victoria

2011-05-09

Patients' values and preferences are fundamental tenets of evidence-based practice, yet current osteoporosis (OP) clinical guidelines pay little attention to these issues in therapeutic decision making. This may be in part due to the fact that few studies have examined the factors that influence the initial decision to take OP medication. The purpose of our study was to examine patients' experiences with the decision to take OP medication after they sustained a fracture. A phenomenological qualitative study was conducted with outpatients identified in a university teaching hospital fracture clinic OP program. Individuals aged 65+ who had sustained a fragility fracture within 5 years, were 'high risk' for future fracture, and were prescribed OP medication were eligible. Analysis of interview data was guided by Giorgi's methodology. 21 patients (6 males, 15 females) aged 65-88 years participated. All participants had low bone mass; 9 had OP. Fourteen patients were taking a bisphosphonate while 7 patients were taking no OP medications. For 12 participants, the decision to take OP medication occurred at the time of prescription and involved minimal contemplation (10/12 were on medication). These patients made their decision because they liked/trusted their health care provider. However, 4/10 participants in this group indicated their OP medication-taking status might change. For the remaining 9 patients, the decision was more difficult (4/9 were on medication). These patients were unconvinced by their health care provider, engaged in risk-benefit analyses using other information sources, and were concerned about side effects; 7/9 patients indicated that their OP medication-taking status might change at a later date. Almost half of our older patients who had sustained a fracture found the decision to take OP medication a difficult one. In general, the decision was not considered permanent. Health care providers should be aware of their potential role in patients

Relational autonomy or undue pressure? Family's role in medical decision-making.

PubMed

Ho, Anita

2008-03-01

The intertwining ideas of self-determination and well-being have received tremendous support in western bioethics. They have been used to reject medical paternalism and to justify patients' rights to give informed consent (or refusal) and execute advanced directives. It is frequently argued that everyone is thoroughly unique, and as patients are most knowledgeable of and invested in their own interests, they should be the ones to make voluntary decisions regarding their care. Two results of the strong focus on autonomy are the rejection of the image of patients as passive care recipients and the suspicion against paternalistic influence anyone may have on patients' decision-making process. Although the initial focus in western bioethics was on minimizing professional coercion, there has been a steady concern of family's involvement in adult patients' medical decision-making. Many worry that family members may have divergent values and priorities from those of the patients, such that their involvement could counter patients' autonomy. Those who are heavily involved in competent patients' decision-making are often met with suspicion. Patients who defer to their families are sometimes presumed to be acting out of undue pressure. This essay argues for a re-examination of the notions of autonomy and undue pressure in the contexts of patienthood and relational identity. In particular, it examines the characteristics of families and their role in adult patients' decision-making. Building on the feminist conception of the relational self and examining the context of contemporary institutional medicine, this paper argues that family involvement and consideration of family interests can be integral in promoting patients' overall agency. It argues that, in the absence of abuse and neglect, respect for autonomy and agency requires clinicians to abide by patients' expressed wishes.

Different effects of dopaminergic medication on perceptual decision-making in Parkinson's disease as a function of task difficulty and speed-accuracy instructions.

PubMed

Huang, Yu-Ting; Georgiev, Dejan; Foltynie, Tom; Limousin, Patricia; Speekenbrink, Maarten; Jahanshahi, Marjan

2015-08-01

When choosing between two options, sufficient accumulation of information is required to favor one of the options over the other, before a decision is finally reached. To establish the effect of dopaminergic medication on the rate of accumulation of information, decision thresholds and speed-accuracy trade-offs, we tested 14 patients with Parkinson's disease (PD) on and off dopaminergic medication and 14 age-matched healthy controls on two versions of the moving-dots task. One version manipulated the level of task difficulty and hence effort required for decision-making and the other the urgency, requiring decision-making under speed vs. accuracy instructions. The drift diffusion model was fitted to the behavioral data. As expected, the reaction time data revealed an effect of task difficulty, such that the easier the perceptual decision-making task was, the faster the participants responded. PD patients not only made significantly more errors compared to healthy controls, but interestingly they also made significantly more errors ON than OFF medication. The drift diffusion model indicated that PD patients had lower drift rates when tested ON compared to OFF medication, indicating that dopamine levels influenced the quality of information derived from sensory information. On the speed-accuracy task, dopaminergic medication did not directly influence reaction times or error rates. PD patients OFF medication had slower RTs and made more errors with speed than accuracy instructions compared to the controls, whereas such differences were not observed ON medication. PD patients had lower drift rates and higher response thresholds than the healthy controls both with speed and accuracy instructions and ON and OFF medication. For the patients, only non-decision time was higher OFF than ON medication and higher with accuracy than speed instructions. The present results demonstrate that when task difficulty is manipulated, dopaminergic medication impairs perceptual decision

The Importance of the Medical Record: A Critical Professional Responsibility.

PubMed

Ngo, Elizabeth; Patel, Nachiket; Chandrasekaran, Krishnaswamy; Tajik, A Jamil; Paterick, Timothy E

2016-01-01

Comprehensive, detailed documentation in the medical record is critical to patient care and to a physician when allegations of negligence arise. Physicians, therefore, would be prudent to have a clear understanding of this documentation. It is important to understand who is responsible for documentation, what is important to document, when to document, and how to document. Additionally, it should be understood who owns the medical record, the significance of the transition to the electronic medical record, problems and pitfalls when using the electronic medical record, and how the Health Information Technology for Economic and Clinical Health Act affects healthcare providers and health information technology.

Methodologies for Optimum Capital Expenditure Decisions for New Medical Technology

PubMed Central

Landau, Thomas P.; Ledley, Robert S.

1980-01-01

This study deals with the development of a theory and an analytical model to support decisions regarding capital expenditures for complex new medical technology. Formal methodologies and quantitative techniques developed by applied mathematicians and management scientists can be used by health planners to develop cost-effective plans for the utilization of medical technology on a community or region-wide basis. In order to maximize the usefulness of the model, it was developed and tested against multiple technologies. The types of technologies studied include capital and labor-intensive technologies, technologies whose utilization rates vary with hospital occupancy rate, technologies whose use can be scheduled, and limited-use and large-use technologies.

Effect of training problem-solving skill on decision-making and critical thinking of personnel at medical emergencies

PubMed Central

Heidari, Mohammad; Shahbazi, Sara

2016-01-01

Background: The aim of this study was to determine the effect of problem-solving training on decision-making skill and critical thinking in emergency medical personnel. Materials and Methods: This study is an experimental study that performed in 95 emergency medical personnel in two groups of control (48) and experimental (47). Then, a short problem-solving course based on 8 sessions of 2 h during the term, was performed for the experimental group. Of data gathering was used demographic and researcher made decision-making and California critical thinking skills questionnaires. Data were analyzed using SPSS software. Results: The finding revealed that decision-making and critical thinking score in emergency medical personnel are low and problem-solving course, positively affected the personnel’ decision-making skill and critical thinking after the educational program (P < 0.05). Conclusions: Therefore, this kind of education on problem-solving in various emergency medicine domains such as education, research, and management, is recommended. PMID:28149823

Exploring Patient Values in Medical Decision Making: A Qualitative Study

PubMed Central

Lee, Yew Kong; Low, Wah Yun; Ng, Chirk Jenn

2013-01-01

Background Patient decisions are influenced by their personal values. However, there is a lack of clarity and attention on the concept of patient values in the clinical context despite clear emphasis on patient values in evidence-based medicine and shared decision making. The aim of the study was to explore the concept of patient values in the context of making decisions about insulin initiation among people with type 2 diabetes. Methods and Findings We conducted individual in-depth interviews with people with type 2 diabetes who were making decisions about insulin treatment. Participants were selected purposively to achieve maximum variation. A semi-structured topic guide was used to guide the interviews which were audio-recorded and analysed using a thematic approach. We interviewed 21 participants between January 2011 and March 2012. The age range of participants was 28–67 years old. Our sample comprised 9 women and 12 men. Three main themes, ‘treatment-specific values’, ‘life goals and philosophies’, and ‘personal and social background’, emerged from the analysis. The patients reported a variety of insulin-specific values, which were negative and/or positive beliefs about insulin. They framed insulin according to their priorities and philosophies in life. Patients’ decisions were influenced by sociocultural (e.g. religious background) and personal backgrounds (e.g. family situations). Conclusions This study highlighted the need for expanding the current concept of patient values in medical decision making. Clinicians should address more than just values related to treatment options. Patient values should include patients’ priorities, life philosophy and their background. Current decision support tools, such as patient decision aids, should consider these new dimensions when clarifying patient values. PMID:24282518

Exploring patient values in medical decision making: a qualitative study.

PubMed

Lee, Yew Kong; Low, Wah Yun; Ng, Chirk Jenn

2013-01-01

Patient decisions are influenced by their personal values. However, there is a lack of clarity and attention on the concept of patient values in the clinical context despite clear emphasis on patient values in evidence-based medicine and shared decision making. The aim of the study was to explore the concept of patient values in the context of making decisions about insulin initiation among people with type 2 diabetes. We conducted individual in-depth interviews with people with type 2 diabetes who were making decisions about insulin treatment. Participants were selected purposively to achieve maximum variation. A semi-structured topic guide was used to guide the interviews which were audio-recorded and analysed using a thematic approach. We interviewed 21 participants between January 2011 and March 2012. The age range of participants was 28-67 years old. Our sample comprised 9 women and 12 men. Three main themes, 'treatment-specific values', 'life goals and philosophies', and 'personal and social background', emerged from the analysis. The patients reported a variety of insulin-specific values, which were negative and/or positive beliefs about insulin. They framed insulin according to their priorities and philosophies in life. Patients' decisions were influenced by sociocultural (e.g. religious background) and personal backgrounds (e.g. family situations). This study highlighted the need for expanding the current concept of patient values in medical decision making. Clinicians should address more than just values related to treatment options. Patient values should include patients' priorities, life philosophy and their background. Current decision support tools, such as patient decision aids, should consider these new dimensions when clarifying patient values.

Family Matters: Dyadic Agreement in End-of-Life Medical Decision Making

ERIC Educational Resources Information Center

Schmid, Bettina; Allen, Rebecca S.; Haley, Philip P.; DeCoster, Jamie

2010-01-01

Purpose: We examined race/ethnicity and cultural context within hypothetical end-of-life medical decision scenarios and its influence on patient-proxy agreement. Design and Methods: Family dyads consisting of an older adult and 1 family member, typically an adult child, responded to questions regarding the older adult's preferences for…

Partnered Decisions? U.S. Couples and Medical Help-Seeking for Infertility

ERIC Educational Resources Information Center

Johnson, Katherine M.; Johnson, David R.

2009-01-01

We examined male partners' influence on the decision to seek medical help for infertility using the National Study of Fertility Barriers. Building upon an existing help-seeking framework, we incorporated characteristics of both partners from 219 heterosexual couples who had ever perceived a fertility problem. In logistic regression analyses, we…

The Integrated Medical Model - A Risk Assessment and Decision Support Tool for Human Space Flight Missions

NASA Technical Reports Server (NTRS)

Kerstman, Eric; Minard, Charles G.; Saile, Lynn; FreiredeCarvalho, Mary; Myers, Jerry; Walton, Marlei; Butler, Douglas; Lopez, Vilma

2010-01-01

The Integrated Medical Model (IMM) is a decision support tool that is useful to space flight mission planners and medical system designers in assessing risks and optimizing medical systems. The IMM employs an evidence-based, probabilistic risk assessment (PRA) approach within the operational constraints of space flight.

Emotion and Value in the Evaluation of Medical Decision-Making Capacity: A Narrative Review of Arguments

PubMed Central

Hermann, Helena; Trachsel, Manuel; Elger, Bernice S.; Biller-Andorno, Nikola

2016-01-01

Ever since the traditional criteria for medical decision-making capacity (understanding, appreciation, reasoning, evidencing a choice) were formulated, they have been criticized for not taking sufficient account of emotions or values that seem, according to the critics and in line with clinical experiences, essential to decision-making capacity. The aim of this paper is to provide a nuanced and structured overview of the arguments provided in the literature emphasizing the importance of these factors and arguing for their inclusion in competence evaluations. Moreover, a broader reflection on the findings of the literature is provided. Specific difficulties of formulating and measuring emotional and valuational factors are discussed inviting reflection on the possibility of handling relevant factors in a more flexible, case-specific, and context-specific way rather than adhering to a rigid set of operationalized criteria. PMID:27303329

How decision for seeking maternal care is made--a qualitative study in two rural medical districts of Burkina Faso.

PubMed

Somé, Donmozoun Télesphore; Sombié, Issiaka; Meda, Nicolas

2013-02-07

Delay in decision-making to use skilled care during pregnancy and childbirth is an important factor for maternal death in many developing countries. This paper examines how decisions for maternal care are made in two rural communities in Burkina Faso. Focus group discussions (FGDs) and individual interviews (IDIs)) were used to collect information with 30 women in Ouargaye and Diapaga medical districts. All interviews were tape recorded and analyzed using QSR Nvivo 2.0. Decision-making for use of obstetric care in the family follows the logic of the family's management. Husbands, brothers-in-law and parents-in-law make the decision about whether to use a health facility for antenatal care or for delivery. In general, decision-makers are those who can pay, including the woman herself. Payment of care is the responsibility of men, according to women interviewed, because of their social role and status. To increase use of health facilities in Ouargaye and Diapaga, the empowerment of women could be helpful as well as exemption of fees or cost sharing for care.

Individual and work-unit measures of psychological demands and decision latitude and the use of antihypertensive medication.

PubMed

Daugaard, S; Andersen, J H; Grynderup, M B; Stokholm, Z A; Rugulies, R; Hansen, Å M; Kærgaard, A; Mikkelsen, S; Bonde, J P; Thomsen, J F; Christensen, K L; Kolstad, H A

2015-04-01

To analyse whether psychological demands and decision latitude measured on individual and work-unit level were related to prescription of antihypertensive medication. A total of 3,421 women and 897 men within 388 small work units completed a questionnaire concerning psychological working conditions according to the job strain model. Mean levels of psychological demands and decision latitude were computed for each work unit to obtain exposure measures that were less influenced by reporting bias. Dispensed antihypertensive medication prescriptions were identified in The Danish National Prescription Registry. Odds ratios (OR) comparing the highest and lowest third of the population at individual and work-unit level, respectively, were estimated by multilevel logistic regression adjusted for confounders. Psychological demands and decision latitude were tested for interaction. Supplementary analyses of 21 months follow-up were conducted. Among women, increasing psychological demands at individual (adjusted OR 1.54; 95 % CI 1.02-2.33) and work-unit level (adjusted OR 1.41; 95 % CI 1.04-1.90) was significantly associated with purchase of antihypertensive medication. No significant association was found for decision latitude. Follow-up results supported an association with psychological demands but they were not significant. All results for men showed no association. Psychological demands and decision latitude did not interact. High psychological work demands were associated with the purchase of prescribed antihypertensive medication among women. This effect was present on both the work-unit and the individual level. Among men there were no associations. The lack of interaction between psychological demands and decision latitude did not support the job strain model.

The importance of job characteristics in determining medical care-seeking in the Dutch working population, a longitudinal survey study.

PubMed

Steenbeek, Romy

2012-08-31

The working population is ageing, which will increase the number of workers with chronic health complaints, and, as a consequence, the number of workers seeking health care. It is very important to understand factors that influence medical care-seeking in order to control the costs. I will investigate which work characteristics independently attribute to later care-seeking in order to find possibilities to prevent unnecessary or inefficient care-seeking. Data were collected in a longitudinal two-wave study (n = 2305 workers). The outcome measures were visits (yes/no and frequency) to a general practitioner (GP), a physical therapist, a medical specialist and/or a mental health professional. Multivariate regression analyses were carried out separately for men and women for workers with health complaints. In the Dutch working population, personal, health, and work characteristics, but not sickness absence, were associated with later care-seeking. Work characteristics independently attributed to medical care-seeking but only for men and only for the frequency of visits to the GP. Women experience more health complaints and seek health care more often than men. For women, experiencing a work handicap (health complaints that impede work performance) was the only work characteristic associated with more care-seeking (GP). For men, work characteristics that led to less care-seeking were social support by colleagues (GP frequency), high levels of decision latitude (GP frequency) and high levels of social support by the supervisor (medical specialist). Other work characteristics led to more care-seeking: high levels of engagement (GP), full time work (GP frequency) and experiencing a work handicap (physical therapist). We can conclude that personal and health characteristics are most important when explaining medical care-seeking in the Dutch working population. Work characteristics independently attributed to medical care-seeking but only for men and only for the

Patients' perceptions of their "most" and "least" important medications: a retrospective cohort study.

PubMed

Linsky, Amy; Simon, Steven R

2012-11-02

Despite benefits of adherence, little is known about the degree to which patients will express their perceptions of medications as more or less important to take as prescribed. We determined the frequency with which Veteran patients would explicitly identify one of their medications as "most important" or "least important." We conducted a retrospective cohort study of patients from ambulatory clinics at VA Boston from April 2010-July 2011. Patients answered two questions: "Which one of your medicines, if any, do you think is the most important? (if none, please write 'none')" and "Which one of your medicines, if any, do you think is the least important? (if none, please write 'none')." We determined the prevalence of response categories for each question. Our cohort of 104 patients was predominantly male (95%), with a mean of 9 medications (SD 5.7). Regarding their most important medication, 41 patients (39%) identified one specific medication; 26 (25%) selected more than one; 21 (20%) wrote "none"; and 16 (15%) did not answer the question. For their least important medication, 31 Veterans (30%) chose one specific medication; two (2%) chose more than one; 51 (49%) wrote "none"; and 20 (19%) did not directly answer the question. Thirty-five percent of patients did not identify a most important medication, and 68% did not identify a least important medication. Better understanding of how patients prioritize medications and how best to elicit this information will improve patient-provider communication, which may in turn lead to better adherence.

Knowledge discovery from data as a framework to decision support in medical domains

PubMed Central

Gibert, Karina

2009-01-01

Introduction Knowledge discovery from data (KDD) is a multidisciplinary discipline which appeared in 1996 for “non trivial identifying of valid, novel, potentially useful, ultimately understandable patterns in data”. Pre-treatment of data and post-processing is as important as the data exploitation (Data Mining) itself. Different analysis techniques can be properly combined to produce explicit knowledge from data. Methods Hybrid KDD methodologies combining Artificial Intelligence with Statistics and visualization have been used to identify patterns in complex medical phenomena: experts provide prior knowledge (pK); it biases the search of distinguishable groups of homogeneous objects; support-interpretation tools (CPG) assisted experts in conceptualization and labelling of discovered patterns, consistently with pK. Results Patterns of dependency in mental disabilities supported decision-making on legislation of the Spanish Dependency Law in Catalonia. Relationships between type of neurorehabilitation treatment and patterns of response for brain damage are assessed. Patterns of the perceived QOL along time are used in spinal cord lesion to improve social inclusion. Conclusion Reality is more and more complex and classical data analyses are not powerful enough to model it. New methodologies are required including multidisciplinarity and stressing on production of understandable models. Interaction with the experts is critical to generate meaningful results which can really support decision-making, particularly convenient transferring the pK to the system, as well as interpreting results in close interaction with experts. KDD is a valuable paradigm, particularly when facing very complex domains, not well understood yet, like many medical phenomena.

The threat of funding cuts for graduate medical education: survey of decision makers.

PubMed

Kozak, R J; Kazzi, A A; Langdorf, M I; Martinez, C T

1997-07-01

To assess the potential actions of medical school deans, graduate medical education (GME) committee chairs, and hospital chief executive officers (CEOs) regarding future funding reductions for residency training. Specifically, institutions with emergency medicine (EM) residencies were surveyed to see whether EM training was disproportionally at risk for reductions. An anonymous 2-page survey was used. Ninety-eight EM residency programs were identified using the American Medical Association Graduate Medical Education Directory 1994-95. Seventy deans, 102 GME chairs, and 97 hospital CEOs were identified. The survey posed a hypothetical 25% forced reduction in residency positions and asked the decision makers for their responses. Options included: 1) proportional reductions of training positions from all residencies, 2) proportional reductions in either primary care or specialty residency positions, or 3) reduction or elimination of specific training programs. The survey asked for a first and second choice of residencies to be reduced or eliminated from an alphabetical list of 17. The survey elicited explanations for each program reduction. 200 (74%) of 269 surveys were returned. Eighty-four responders selected specific residencies to be reduced or eliminated. EM was selected 8 times, making EM the seventh most vulnerable residency to be targeted for reductions. The decision makers who selected proportional reductions chose to reduce across all residencies 32 times, among only the specialty residencies 129 times, and among only the primary care residencies 3 times. In the setting of anticipated residency cuts, favored proportional reductions in specialty residencies would likely affect EM training. However, most GME decision makers with an existing EM residency program do not consider the EM residency a top choice to be reduced or eliminated.

Stroke, disability, and unconscious bias: interrelationships and over-determination in medical decisions.

PubMed

Sandel, M Elizabeth

2011-01-01

Many factors influence what and how we communicate with patients after stroke. As physicians, we have a responsibility to examine our medical decisions and prognostication regarding each stroke patient. We must understand how many factors come into play in decisions regarding care, including perspectives that reflect the specific training of physicians in various specialties. How the physician responds to the patient with a stroke is highly individual. The more familiar the physician is with stroke recovery and the more time he or she has for individualized and less automatic approaches, the less likely decisions will be reflexive, based on bias. By examining our unconscious biases, we can provide individualized care that gives patients more latitude to create their own stories of recovery.

Recovery and resilience after a nuclear power plant disaster: a medical decision model for managing an effective, timely, and balanced response.

PubMed

Coleman, C Norman; Blumenthal, Daniel J; Casto, Charles A; Alfant, Michael; Simon, Steven L; Remick, Alan L; Gepford, Heather J; Bowman, Thomas; Telfer, Jana L; Blumenthal, Pamela M; Noska, Michael A

2013-04-01

Resilience after a nuclear power plant or other radiation emergency requires response and recovery activities that are appropriately safe, timely, effective, and well organized. Timely informed decisions must be made, and the logic behind them communicated during the evolution of the incident before the final outcome is known. Based on our experiences in Tokyo responding to the Fukushima Daiichi nuclear power plant crisis, we propose a real-time, medical decision model by which to make key health-related decisions that are central drivers to the overall incident management. Using this approach, on-site decision makers empowered to make interim decisions can act without undue delay using readily available and high-level scientific, medical, communication, and policy expertise. Ongoing assessment, consultation, and adaption to the changing conditions and additional information are additional key features. Given the central role of health and medical issues in all disasters, we propose that this medical decision model, which is compatible with the existing US National Response Framework structure, be considered for effective management of complex, large-scale, and large-consequence incidents.

Neonatologists can impede or support parents' participation in decision-making during medical rounds in neonatal intensive care units.

PubMed

Axelin, Anna; Outinen, Jyri; Lainema, Kirsi; Lehtonen, Liisa; Franck, Linda S

2018-05-03

We explored the dynamics of neonatologist-parent communication and decision-making during medical rounds in a level three neonatal intensive care unit. This was a qualitative study, with an ethnographic approach, that was conducted at Turku University Hospital, Finland, from 2013-2014. We recruited eight mothers and seven couples, their 11 singletons and four sets of twins and two neonatologists and observed and video recorded 15 medical rounds. The infants were born at 23+5 to 40+1 weeks and the parents were aged 24-47. The neonatologists and parents were interviewed separately after the rounds. Four patterns of interaction emerged. The collaborative pattern was most consistent, with the ideal of shared decision-making, as the parents' preferences were genuinely and visibly integrated into the treatment decisions. In the neonatologist-led interactional pattern, the decision-making process was only somewhat inclusive of the parents' observations and preferences. The remaining two patterns, emergency and disconnected, were characterised by a paternalistic decision-making model where the parents' observations and preferences had minimal to no influence on the communication or decision-making. The neonatologists played a central role in facilitating parental participation and their interaction during medical rounds were characterised by the level of parent participation in decision-making. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

[Knowledge, trust, and the decision to donate organs : A comparison of medical students and students of other disciplines in Germany].

PubMed

Terbonssen, T; Settmacher, U; Dirsch, O; Dahmen, U

2018-02-01

. The higher level of knowledge and trust demonstrated by the medical students was associated with a higher rate of written decisions to donate organs. In contrast, the lower level of knowledge and trust observed in the non-medical students was associated with a lower rate of organ donor cards. Interestingly, in the group of non-medical students, the decision regarding organ donation was associated with a higher level of trust, but not with a higher level of knowledge. It would appear that knowledge, trust, and the decision to donate organs are closely related. In cases of a low level of knowledge, confidence is even more important. Therefore, organ donation campaigns should focus on increasing knowledge and fostering trust.

Within-Gender Differences in Medical Decision Making Among Male Carriers of the BRCA Genetic Mutation for Hereditary Breast Cancer

PubMed Central

Hesse-Biber, Sharlene; An, Chen

2015-01-01

An intersectional approach was used to understand sex/gender differences in men’s health decisions with regard to hereditary breast cancer (BRCA). A sequential explanatory mixed method design was employed consisting of an online survey with a convenience sample of 101 men who tested positive for the breast cancer mutation following up with an in-depth interview with a subsample of 26 males who participated in the survey. The survey results revealed that 70.3% (n = 45) considered “Family Risk” as the primary reason for getting BRCA tested; 21.9% (n = 14) considered “Medical Considerations,” and 7.8% (n = 5) considered “Social Support” as their primary reason. Male participants who were 50 years old or younger or who did not have children were more likely to consider medical reasons as the primary reason to get tested. In terms of self-concept, younger men were more stigmatized than their older counterparts; married men felt a greater loss of control with regard to their BRCA-positive mutation diagnosis than single men; and professional men as a whole felt more vulnerable to the negative influences of the disease than those who had already retired. Regression analysis results indicated that negative self-concept was strongly related to sampled males’ BRCA involvement 6 months after testing. Applying an intersectional approach to health care, decision-making outcomes among BRCA-positive mutation males provides an important lens for ascertaining the within-sex/gender demographic and psychosocial factors that affect the diversity of men’s pretesting and posttesting medical decisions. PMID:26468160

Veterinary decision making in relation to metritis--a qualitative approach to understand the background for variation and bias in veterinary medical records.

PubMed

Lastein, Dorte B; Vaarst, Mette; Enevoldsen, Carsten

2009-08-30

Results of analyses based on veterinary records of animal disease may be prone to variation and bias, because data collection for these registers relies on different observers in different settings as well as different treatment criteria. Understanding the human influence on data collection and the decisions related to this process may help veterinary and agricultural scientists motivate observers (veterinarians and farmers) to work more systematically, which may improve data quality. This study investigates qualitative relations between two types of records: 1) 'diagnostic data' as recordings of metritis scores and 2) 'intervention data' as recordings of medical treatment for metritis and the potential influence on quality of the data. The study is based on observations in veterinary dairy practice combined with semi-structured research interviews of veterinarians working within a herd health concept where metritis diagnosis was described in detail. The observations and interviews were analysed by qualitative research methods to describe differences in the veterinarians' perceptions of metritis diagnosis (scores) and their own decisions related to diagnosis, treatment, and recording. The analysis demonstrates how data quality can be affected during the diagnostic procedures, as interaction occurs between diagnostics and decisions about medical treatments. Important findings were when scores lacked consistency within and between observers (variation) and when scores were adjusted to the treatment decision already made by the veterinarian (bias). The study further demonstrates that veterinarians made their decisions at 3 different levels of focus (cow, farm, population). Data quality was influenced by the veterinarians' perceptions of collection procedures, decision making and their different motivations to collect data systematically. Both variation and bias were introduced into the data because of veterinarians' different perceptions of and motivations for

Expert and non-expert knowledge in medical practice.

PubMed

Nordin, I

2000-01-01

One problematic aspect of the rationality of medical practice concerns the relation between expert knowledge and non-expert knowledge. In medical practice it is important to match medical knowledge with the self-knowledge of the individual patient. This paper tries to study the problem of such matching by describing a model for technological paradigms and comparing it with an ideal of technological rationality. The professionalised experts tend to base their decisions and actions mostly on medical knowledge while the rationality of medicine also involves just as important elements of the personal evaluation and knowledge of the patients. Since both types of knowledge are necessary for rational decisions, the gap between the expert and the non-expert has to be bridged in some way. A solution to the problem is suggested in terms of pluralism, with the patient as ultimate decision-maker.

[Medical end-of-life decisions and assisted suicide].

PubMed

Bosshard, Georg

2008-07-01

Medical end-of-life decisions that potentially shorten life (Sterbehilfe) are normally divided into four categories: Passive Sterbehilfe refers to withholding or withdrawing life-prolonging measures, indirect Sterbehilfe refers to the use of agents such as opioids or sedatives to alleviate symptoms of a terminally ill patient, assisted suicide (Suizidbeihilfe or Beihilfe zum Suizid) refers to prescribing and/or supplying a lethal drug in order to help someone to end his own life, and active euthanasia - which is illegal in any circumstances - means a doctor actively ending a patients life. In passive and indirect euthanasia, the will of a competent patient, or the presumed will of an incompetent patient respectively, is crucial. Assisted suicide is not illegal according to the Swiss Penal Code as long as there are no motives of self-interest of the individual assisting, and the individual assisted has decisional capacity. However, for doctors participating in assisted suicide, specific requirements of medical due care have to be met. What this means in the context of assisted suicide has recently been elaborated by the Swiss Federal Court of Justice.

The Integrated Medical Model: A Decision Support Tool for In-flight Crew Health Care

NASA Technical Reports Server (NTRS)

Butler, Doug

2009-01-01

This viewgraph presentation reviews the development of an Integrated Medical Model (IMM) decision support tool for in-flight crew health care safety. Clinical methods, resources, and case scenarios are also addressed.

Refusal to medical interventions.

PubMed

Palacios, G; Herreros, B; Pacho, E

2014-10-01

Refusal to medical interventions is the not acceptance, voluntary and free, of an indicated medical intervention. What the physician should do in case of refusal? It is understandable that the rejection of a validated medical intervention is difficult to accept by the responsible physician when raises the conflict protection of life versus freedom of choice. Therefore it is important to follow some steps to incorporate the most relevant aspects of the conflict. These steps include: 1) Give complete information to patients, informing on possible alternatives, 2) determine whether the patient can decide (age, competency and level of capacity), 3) to ascertain whether the decision is free, 4) analyze the decision with the patient, 5) to persuade, 6) if the patient kept in the rejection decision, consider conscientious objection, 7) take the decision based on the named criteria, 8) finally, if the rejection is accepted, offer available alternatives. Copyright © 2013 Elsevier España, S.L.U. All rights reserved.

Why shared decision making is not good enough: lessons from patients.

PubMed

Olthuis, Gert; Leget, Carlo; Grypdonck, Mieke

2014-07-01

A closer look at the lived illness experiences of medical professionals themselves shows that shared decision making is in need of a logic of care. This paper underlines that medical decision making inevitably takes place in a messy and uncertain context in which sharing responsibilities may impose a considerable burden on patients. A better understanding of patients' lived experiences enables healthcare professionals to attune to what individual patients deem important in their lives.This will contribute to making medical decisions in a good and caring manner, taking into account the lived experience of being ill.

Visual analytics in medical education: impacting analytical reasoning and decision making for quality improvement.

PubMed

Vaitsis, Christos; Nilsson, Gunnar; Zary, Nabil

2015-01-01

The medical curriculum is the main tool representing the entire undergraduate medical education. Due to its complexity and multilayered structure it is of limited use to teachers in medical education for quality improvement purposes. In this study we evaluated three visualizations of curriculum data from a pilot course, using teachers from an undergraduate medical program and applying visual analytics methods. We found that visual analytics can be used to positively impacting analytical reasoning and decision making in medical education through the realization of variables capable to enhance human perception and cognition on complex curriculum data. The positive results derived from our evaluation of a medical curriculum and in a small scale, signify the need to expand this method to an entire medical curriculum. As our approach sustains low levels of complexity it opens a new promising direction in medical education informatics research.

Legal Briefing: Adult Orphans and the Unbefriended: Making Medical Decisions for Unrepresented Patients without Surrogates.

PubMed

Pope, Thaddeus Mason

2015-01-01

This issue's "Legal Briefing" column covers recent legal developments involving medical decision making for incapacitated patients who have no available legally authorized surrogate decision maker. These individuals are frequently referred to either as "adult orphans" or as "unbefriended," "isolated," or "unrepresented" patients. The challenges involved in obtaining consent for medical treatment on behalf of these individuals have been the subject of major policy reports. Indeed, caring for the unbefriended has even been described as the "single greatest category of problems" encountered in bioethics consultation. In 2012, JCE published a comprehensive review of the available mechanisms by which to make medical decisions for the unbefriended. The purpose of this "Legal Briefing" is to update the 2012 study. Accordingly, this "Legal Briefing" collects and describes significant legal developments from only the past three years. My basic assessment has not changed. "Existing mechanisms to address the issue of decision making for the unbefriended are scant and not uniform." Most facilities are "muddling through on an ad hoc basis." But the situation is not wholly negative. There have been a number of promising new initiatives. I group these developments into the following seven categories: 1. Increased Attention and Discussion 2. Prevention through Better Advance Care Planning 3. Prevention through Expanded Default Surrogate Lists 4. Statutorily Authorized Intramural Mechanisms 5. California Litigation Challenging the Team Approach 6. Public Guardianship 7. Improving Existing Guardianship Processes. Copyright 2015 The Journal of Clinical Ethics. All rights reserved.

Epilepsy and social security: general aspects of the insured claimants and medical decisions.

PubMed

Ferreira, Lisiane Seguti; Palhares, Dario; Gava, Marília; Seguti, Vladimir Ferreira; Marasciulo, Antônio Carlos Estima

2013-01-01

Epilepsy affects adults at productive age and interferes with their ability to work. However, the granting of social security benefits to these patients has not received sufficient attention. This article aims to provide a profile of individuals with a previous diagnosis of epilepsy that file claims for social security benefits and a profile of the medical advisory decisions that support the concession of these benefits. A sample of thirty individuals with illness-related problems due to epilepsy was selected from the claimants that receive Social Security Incapacity/Sickness benefits. An exploratory data analysis of the 188 Social Security medical files of the thirty claimants was performed using the clinical and epidemiological information and the medical advisory criteria. The mean age of the claimants was 39 years and most of them were males in jobs that do not require a lot of schooling. The first claim was filed within an average of four years of employment. On average, each worker files a claim every three months, which entitles him/her to receive incapacity/sickness benefits for seventeen months. The frequency of seizures and the medications used by the claimants were registered in 60% of the medical files. In addition, the description of the physical and neurological exam was incomplete in 50% of the files. Furthermore, 60% of the files did not include the argument or the clinical evidence that was used to justify the concession of a benefit. The medical advisory decisions on epileptic workers tend to be inconsistent, overly lenient and generally lacking in clinical evidence. The disparities among the granted benefits indicate the need for the National Social Security System to review and draft specific guidelines for epilepsy.

A qualitative, exploratory study of nurses' decision-making when interrupted during medication administration within the Paediatric Intensive Care Unit.

PubMed

Bower, Rachel A; Coad, Jane E; Manning, Joseph C; Pengelly, Theresa A

2018-02-01

In the paediatric intensive care unit (PICU), medication administration is challenging. Empirical studies demonstrate that interruptions occur frequently and that nurses are fundamental in the delivery of medication. However, little is known about nurse's decision making when interrupted during medication administration. Therefore, the objective is to understand decision making when interrupted during medication administration within the PICU. A qualitative study incorporating non-participant observation and audio recorded semi-structured interviews. A convenience sample of ten PICU nurses were interviewed. Each interview schedule was informed by two hours of observation which involved a further 29 PICU nurses. Data was analysed using Framework Analysis. A regional PICU located in a university teaching hospital in the United Kingdom. Analysis resulted in four overarching themes: (1) Guiding the medication process, (2) Concentration, focus and awareness, (3) Influences on interruptions (4) Impact and recovery CONCLUSION: Medication administration within the PICU is an essential but complex activity. Interruptions can impact on focus and concentration which can contribute to patient harm. Decision making by PICU nurses is influenced by interruption awareness, fluctuating levels of concentration, and responding to critically ill patient and families' needs. Copyright © 2017 Elsevier Ltd. All rights reserved.

Older Adults' Use of Online and Offline Sources of Health Information and Constructs of Reliance and Self-Efficacy for Medical Decision Making.

PubMed

Hall, Amanda K; Bernhardt, Jay M; Dodd, Virginia

2015-01-01

We know little about older adults' use of online and offline health information sources for medical decision making despite increasing numbers of older adults who report using the Internet for health information to aid in patient-provider communication and medical decision making. Therefore we investigated older adult users and nonusers of online and offline sources of health information and factors related to medical decision making. Survey research was conducted using random digit dialing of Florida residents' landline telephones. The Decision Self-Efficacy Scale and the Reliance Scale were used to measure relationships between users and nonusers of online health information. Study respondents were 225 older adults (age range = 50-92 years, M = 68.9, SD = 10.4), which included users (n = 105) and nonusers (n = 119) of online health information. Users and nonusers differed in frequency and types of health sources sought. Users of online health information preferred a self-reliant approach and nonusers of online health information preferred a physician-reliant approach to involvement in medical decisions on the Reliance Scale. This study found significant differences between older adult users and nonusers of online and offline sources of health information and examined factors related to online health information engagement for medical decision making.

Older adults use of online and offline sources of health information and constructs of reliance and self-efficacy for medical decision making

PubMed Central

Hall, Amanda K.; Bernhardt, Jay M.; Dodd, Virginia

2016-01-01

Background Little is known about older adults’ use of online and offline health information sources for medical decision-making despite increasing numbers of older adults who report using the Internet for health information to aid in patient/provider communication and medical decision-making. Objective To investigate older adult users and nonusers of online and offline sources of health information and factors related to medical decision-making. Methods Survey research was conducted using random-digit-dialing of Florida residents’ landline telephones. The Decision Self-Efficacy Scale and the Reliance Scale were used to measure relationships between users and nonusers of online health information. Results Study respondents were 225 older adults (age range 50–92, M = 68.9, SD = 10.4), which included users (n = 105, 46.7%) and nonusers (n = 119, 52.9%) of online health information. Users and nonusers differed in frequency and types of health sources sought. Users of online health information preferred a self-reliant approach and nonusers of online health information preferred a physician-reliant approach to involvement in medical decisions on the Reliance Scale. Conclusion This study found significant differences between older adult users and nonusers of online and offline sources of health information and examined factors related to online health information engagement for medical decision-making. PMID:26054777

The Role of Patients: Shared Decision-Making.

PubMed

Beers, Emily; Lee Nilsen, Marci; Johnson, Jonas T

2017-08-01

Shared decision-making affords patients and their families the autonomy to make difficult decisions after receiving comprehensive information about medical facts and treatment options. It is essential that patients' values are respected. The essential steps include first informing patients of the need for a decision, then explaining the various facts involved; after which, it is important to elicit patients' preferences and goals. Once the treatment options and outcomes important to patients are identified, an actual decision can be made. This activity is complex and requires a commitment of time and is enhanced through employment of a multidisciplinary team approach. Copyright © 2017 Elsevier Inc. All rights reserved.

A qualitative study of community nurses' decision-making around the anticipatory prescribing of end-of-life medications.

PubMed

Bowers, Ben; Redsell, Sarah A

2017-10-01

The aim of this study was to explore community nurses' decision-making processes around the prescribing of anticipatory medications for people who are dying. Community nurses frequently initiate the prescribing of anticipatory medications to help control symptoms in those who are dying. However, little is known about their decision-making processes in relation to when they instigate anticipatory prescribing and their discussions with families and General Practitioners. A qualitative interpretive descriptive enquiry. A purposive sample of 11 Community Palliative Nurses and District Nurses working in one geographical area participated. Data were collected between March and June 2016 via audio recorded semi-structured interviews and analysed inductively using Braun and Clarke's thematic analysis. Three themes were identified: (1) Drugs as a safety net. Anticipatory medications give nurses a sense of control in last days of life symptom management; (2) Reading the situation. The nurse judges when to introduce conversations around anticipatory medications, balancing the need for discussion with the dying person and their family's likely response; (3) Playing the game. The nurse owns the decision to initiate anticipatory medication prescribing and carefully negotiates with the General Practitioner. Nurses view pain control through prescribed medication as key to symptom management for dying people. Consequently, they own the role of ascertaining when to initiate discussions with families about anticipatory medicines. Nurses believe they advocate for dying person and their families' needs and lead negotiations with General Practitioners for medications to go into the home. This nurse led care alters the traditional boundaries of the General Practitioners-nurse professional relationship. © 2017 John Wiley & Sons Ltd.

Avoiding bias in medical ethical decision-making. Lessons to be learnt from psychology research.

PubMed

Albisser Schleger, Heidi; Oehninger, Nicole R; Reiter-Theil, Stella

2011-05-01

When ethical decisions have to be taken in critical, complex medical situations, they often involve decisions that set the course for or against life-sustaining treatments. Therefore the decisions have far-reaching consequences for the patients, their relatives, and often for the clinical staff. Although the rich psychology literature provides evidence that reasoning may be affected by undesired influences that may undermine the quality of the decision outcome, not much attention has been given to this phenomenon in health care or ethics consultation. In this paper, we aim to contribute to the sensitization of the problem of systematic reasoning biases by showing how exemplary individual and group biases can affect the quality of decision-making on an individual and group level. We are addressing clinical ethicists as well as clinicians who guide complex decision-making processes of ethical significance. Knowledge regarding exemplary group psychological biases (e.g. conformity bias), and individual biases (e.g. stereotypes), will be taken from the disciplines of social psychology and cognitive decision science and considered in the field of ethical decision-making. Finally we discuss the influence of intuitive versus analytical (systematical) reasoning on the validity of ethical decision-making.

The role of depression pharmacogenetic decision support tools in shared decision making.

PubMed

Arandjelovic, Katarina; Eyre, Harris A; Lenze, Eric; Singh, Ajeet B; Berk, Michael; Bousman, Chad

2017-10-29

Patients discontinue antidepressant medications due to lack of knowledge, unrealistic expectations, and/or unacceptable side effects. Shared decision making (SDM) invites patients to play an active role in their treatment and may indirectly improve outcomes through enhanced engagement in care, adherence to treatment, and positive expectancy of medication outcomes. We believe decisional aids, such as pharmacogenetic decision support tools (PDSTs), facilitate SDM in the clinical setting. PDSTs may likewise predict drug tolerance and efficacy, and therefore adherence and effectiveness on an individual-patient level. There are several important ethical considerations to be navigated when integrating PDSTs into clinical practice. The field requires greater empirical research to demonstrate clinical utility, and the mechanisms thereof, as well as exploration of the ethical use of these technologies.

Value judgements in the decision-making process for the elderly patient.

PubMed

Ubachs-Moust, J; Houtepen, R; Vos, R; ter Meulen, R

2008-12-01

The question of whether old age should or should not play a role in medical decision-making for the elderly patient is regularly debated in ethics and medicine. In this paper we investigate exactly how age influences the decision-making process. To explore the normative argumentation in the decisions regarding an elderly patient we make use of the argumentation model advanced by Toulmin. By expanding the model in order to identify normative components in the argumentation process it is possible to analyse the way that age-related value judgements influence the medical decision-making process. We apply the model to practice descriptions made by medical students after they had attended consultations and meetings in medical practice during their clinical training. Our results show the pervasive character of age-related value judgements. They influence the physician's decision in several ways and at several points in the decision-making process. Such explicit value judgements were not exclusively used for arguments against further diagnosis or treatment of older patients. We found no systematic "ageist" pattern in the clinical decisions by physicians. Since age plays such an important, yet hidden role in the medical decision-making process, we make a plea for revealing such normative argumentation in order to gain transparency and accountability in this process. An explicit deliberative approach will make the medical decision-making process more transparent and improve the physician-patient relationship, creating confidence and trust, which are at the heart of medical practice.

To Medicate or Not to Medicate?: The Decision-Making Process of Western Australian Parents Following Their Child's Diagnosis with an Attention Deficit Hyperactivity Disorder

ERIC Educational Resources Information Center

Taylor, Myra; O'Donoghue, Tom; Houghton, Stephen

2006-01-01

This article examines the decision-making processes that Western Australian parents utilise when deciding whether to medicate or not to medicate their child diagnosed with Attention Deficit Hyperactivity Disorder. Thirty-three parents (five fathers and 28 mothers) from a wide range of socio-economic status suburbs in Perth, Western Australia were…

DXplain: a Web-based diagnostic decision support system for medical students.

PubMed

London, S

1998-01-01

DXplain is a diagnostic decision support program, with a new World Wide Web interface, designed to help medical students and physicians formulate differential diagnoses based on clinical findings. It covers over 2000 diseases and 5000 clinical manifestations. DXplain suggests possible diagnoses, and provides brief descriptions of every disease in the database. Not all diseases are included, nor does DXplain take into account preexisting conditions or the chronological sequence of clinical manifestations. Despite these limitations, it is a useful educational tool, particularly for problem-based learning (PBL) cases and for students in clinical rotations, as it fills a niche not adequately covered by MEDLINE or medical texts. The system is relatively self-explanatory, requiring little or no end-user training. Medical libraries offering, or planning to offer, their users access to Web-based materials and resources may find this system a valuable addition to their electronic collections. Should it prove popular with the local users, provision of access may also establish or enhance the library's image as a partner in medical education.

My Lived Experiences Are More Important Than Your Probabilities: The Role of Individualized Risk Estimates for Decision Making about Participation in the Study of Tamoxifen and Raloxifene (STAR).

PubMed

Holmberg, Christine; Waters, Erika A; Whitehouse, Katie; Daly, Mary; McCaskill-Stevens, Worta

2015-11-01

Decision-making experts emphasize that understanding and using probabilistic information are important for making informed decisions about medical treatments involving complex risk-benefit tradeoffs. Yet empirical research demonstrates that individuals may not use probabilities when making decisions. To explore decision making and the use of probabilities for decision making from the perspective of women who were risk-eligible to enroll in the Study of Tamoxifen and Raloxifene (STAR). We conducted narrative interviews with 20 women who agreed to participate in STAR and 20 women who declined. The project was based on a narrative approach. Analysis included the development of summaries of each narrative, and thematic analysis with developing a coding scheme inductively to code all transcripts to identify emerging themes. Interviewees explained and embedded their STAR decisions within experiences encountered throughout their lives. Such lived experiences included but were not limited to breast cancer family history, a personal history of breast biopsies, and experiences or assumptions about taking tamoxifen or medicines more generally. Women's explanations of their decisions about participating in a breast cancer chemoprevention trial were more complex than decision strategies that rely solely on a quantitative risk-benefit analysis of probabilities derived from populations In addition to precise risk information, clinicians and risk communicators should recognize the importance and legitimacy of lived experience in individual decision making. © The Author(s) 2015.

Medical ethics: a rational approach to patient management.

PubMed

Livadas, Gerry

2002-01-01

Physicians make their decisions based upon scientific evidence with their first consideration being the Hippocratic axiom 'not to do harm'. In practice, a number of non-medical issues influence this process and generate conflicting judgments. We analyze these issues that form the context of medical ethics which is perceived as a subject wider than morality. It is also a religious, social, political, economic, legal and cultural issue. Therefore, the patient, physician and other professionals play important roles in the decision-making. The final decision is not a decision based on medical textbooks, but is rational in that it is based on reason for the benefit of the individual. Copyright 2002 S. Karger AG, Basel

A Representation for Gaining Insight into Clinical Decision Models

PubMed Central

Jimison, Holly B.

1988-01-01

For many medical domains uncertainty and patient preferences are important components of decision making. Decision theory is useful as a representation for such medical models in computer decision aids, but the methodology has typically had poor performance in the areas of explanation and user interface. The additional representation of probabilities and utilities as random variables serves to provide a framework for graphical and text insight into complicated decision models. The approach allows for efficient customization of a generic model that describes the general patient population of interest to a patient- specific model. Monte Carlo simulation is used to calculate the expected value of information and sensitivity for each model variable, thus providing a metric for deciding what to emphasize in the graphics and text summary. The computer-generated explanation includes variables that are sensitive with respect to the decision or that deviate significantly from what is typically observed. These techniques serve to keep the assessment and explanation of the patient's decision model concise, allowing the user to focus on the most important aspects for that patient.

Interpretation of 'Unnatural death' in coronial law: A review of the English legal process of decision making, statutory interpretation, and case law: The implications for medical cases and coronial consistency.

PubMed

Harris, Andrew; Walker, Andrew

2018-04-23

The article examines the decision-making process for medical reporting of deaths to a coroner and the statutory basis for coronial decisions whether to investigate. It analyses what is published about the consistency of decision making of coroners and discusses what should be the legal basis for determining whether a particular death is natural or unnatural in English law. There is a review of English case law, including the significance of Touche and Benton and the development of 'unnatural' as a term of art, which informs what the courts have held to be an unnatural death. What case law indicates about multiple causes and the significance of the wording in the Coroners & Justice Act 2009 that triggers an investigation are considered. It highlights the importance of considering the medical cause of death and to what extent information other than the initial death report is required, before making the decision that the coroner's duty to open an investigation is triggered. The article concludes that a two-stage test is required. Firstly, is the cause of death medically unnatural? Secondly, whether the circumstances themselves are unnatural or such as to make a medically natural cause of death unnatural. If the coroner has reason to suspect the medical cause of death is unnatural per se the statutory duty to investigate will be engaged, regardless of the circumstances.

Are elderly people with co-morbidities involved adequately in medical decision making when hospitalised? A cross-sectional survey.

PubMed

Ekdahl, Anne W; Andersson, Lars; Wiréhn, Ann-Britt; Friedrichsen, Maria

2011-08-18

Medical decision making has long been in focus, but little is known of the preferences and conditions for elderly people with co-morbidities to participate in medical decision making. The main objective of the present study was to investigate the preferred and the actual degree of control, i.e. the role elderly people with co-morbidities wish to assume and actually had with regard to information and participation in medical decision making during their last stay in hospital.This study was a cross-sectional survey including three Swedish hospitals with acute admittance. The participants were patients aged 75 years and above with three or more diagnoses according to the International Classification of Diseases (ICD-10) and three or more hospitalisations during the last year. We used a questionnaire combined with a telephone interview, using the Control Preference Scale to measure each participant's preferred and actual role in medical decision making during their last stay in hospital. Additional questions were asked about barriers to participation in decision making and preferred information seeking role. The results are presented with descriptive statistics with kappa weights. Of the 297 elderly patients identified, 52.5% responded (n = 156, 46.5% male). Mean age was 83.1 years. Of the respondents, 42 of 153 patients said that they were not asked for their opinion (i.e. no shared decision making). Among the other 111 patients, 49 had their exact preferred level of participation, 37 had less participation than they would have preferred, and 23 had more responsibility than they would have preferred. Kappa statistics showed a moderate agreement between preferred and actual role (κw = 0.57; 95% CI: 0.45-0.69). Most patients wanted to be given more information without having to ask. There was no correlation between age, gender, or education and preferred role. 35% of the patients agreed that they experienced some of the various barriers to decision making that they

Implementation Pearls from a New Guidebook on Improving Medication Use and Outcomes with Clinical Decision Support

PubMed Central

Sirajuddin, Anwar M; Osheroff, Jerome A.; Sittig, Dean F.; Chuo, John; Velasco, Ferdinand; Collins, David A.

2012-01-01

Effective clinical decision support (CDS) is essential for addressing healthcare performance improvement imperatives, but care delivery organizations (CDO) typically struggle with CDS deployment. Ensuring safe and effective medication delivery to patients is a central focus of CDO performance improvement efforts, and this article provides an overview of best-practice strategies for applying CDS to these goals. The strategies discussed are drawn from a new guidebook, co-published and co-sponsored by more than a dozen leading organizations. Developed by scores of CDS implementers and experts, the guidebook outlines key steps and success factors for applying CDS to medication management. A central thesis is that improving outcomes with CDS interventions requires that the CDS five rights be addressed successfully. That is, the interventions must deliver the right information, to the right person, in the right format, through the right channel, at the right point in workflow. This paper provides further details about these CDS five rights, and highlights other important strategies for successful CDS programs. PMID:19894486

Emergency medical service provider decision-making in out of hospital cardiac arrest: an exploratory study.

PubMed

Brandling, J; Kirby, K; Black, S; Voss, S; Benger, J

2017-07-25

There are approximately 60,000 out-of-hospital cardiac arrests (OHCA) in the United Kingdom (UK) each year. Within the UK there are well-established clinical practice guidelines that define when resuscitation should be commenced in OHCA, and when resuscitation should cease. Background literature indicates that decision-making in the commencement and cessation of resuscitation efforts in OHCA is complex, and not comprehensively understood. No relevant research from the UK has been published to date and this research study seeks to explore the influences on UK Emergency Medical Service (EMS) provider decision-making when commencing and ceasing resuscitation attempts in OHCA. The aim of this research to explore the influences on UK Emergency Medical Services provider decision-making when commencing and ceasing resuscitation attempts in OHCA. Four focus groups were convened with 16 clinically active EMS providers. Four case vignettes were discussed to explore decision-making within the focus groups. Thematic analysis was used to analyse transcripts. This research found that there are three stages in the decision-making process when EMS providers consider whether to commence or cease resuscitation attempts in OHCA. These stages are: the call; arrival on scene; the protocol. Influential factors present at each of the three stages can lead to different decisions and variability in practice. These influences are: factual information available to the EMS provider; structural factors such as protocol, guidance and research; cultural beliefs and values; interpersonal factors; risk factors; personal values and beliefs. An improved understanding of the circumstantial, individual and interpersonal factors that mediate the decision-making process in clinical practice could inform the development of more effective clinical guidelines, education and clinical decision support in OHCA. These changes have the potential to lead to greater consistency. and EMS provider confidence, with

Innovative medical devices and hospital decision making: a study comparing the views of hospital pharmacists and physicians.

PubMed

Billaux, Mathilde; Borget, Isabelle; Prognon, Patrice; Pineau, Judith; Martelli, Nicolas

2016-06-01

Objectives Many university hospitals have developed local health technology assessment processes to guide informed decisions about new medical devices. However, little is known about stakeholders' perceptions and assessment of innovative devices. Herein, we investigated the perceptions regarding innovative medical devices of their chief users (physicians and surgeons), as well as those of hospital pharmacists, because they are responsible for the purchase and management of sterile medical devices. We noted the evaluation criteria used to assess and select new medical devices and suggestions for improving local health technology assessment processes indicated by the interviewees. Methods We randomly selected 18 physicians and surgeons (nine each) and 18 hospital pharmacists from 18 French university hospitals. Semistructured interviews were conducted between October 2012 and August 2013. Responses were coded separately by two researchers. Results Physicians and surgeons frequently described innovative medical devices as 'new', 'safe' and 'effective', whereas hospital pharmacists focused more on economic considerations and considered real innovative devices to be those for which no equivalent could be found on the market. No significant difference in evaluation criteria was found between these groups of professionals. Finally, hospital pharmacists considered the management of conflicts of interests in local health technology assessment processes to be an issue, whereas physicians and surgeons did not. Conclusions The present study highlights differences in perceptions related to professional affiliation. The findings suggest several ways in which current practices for local health technology assessment in French university hospitals could be improved and studied. What is known about the topic? Hospitals are faced with ever-growing demands for innovative and costly medical devices. To help hospital management deal with technology acquisition issues, hospital

How to introduce medical ethics at the bedside - Factors influencing the implementation of an ethical decision-making model.

PubMed

Meyer-Zehnder, Barbara; Albisser Schleger, Heidi; Tanner, Sabine; Schnurrer, Valentin; Vogt, Deborah R; Reiter-Theil, Stella; Pargger, Hans

2017-02-23

As the implementation of new approaches and procedures of medical ethics is as complex and resource-consuming as in other fields, strategies and activities must be carefully planned to use the available means and funds responsibly. Which facilitators and barriers influence the implementation of a medical ethics decision-making model in daily routine? Up to now, there has been little examination of these factors in this field. A medical ethics decision-making model called METAP was introduced on three intensive care units and two geriatric wards. An evaluation study was performed from 7 months after deployment of the project until two and a half years. Quantitative and qualitative methods including a questionnaire, semi-structured face-to-face and group-interviews were used. Sixty-three participants from different professional groups took part in 33 face-to-face and 9 group interviews, and 122 questionnaires could be analysed. The facilitating factors most frequently mentioned were: acceptance and presence of the model, support given by the medical and nursing management, an existing or developing (explicit) ethics culture, perception of a need for a medical ethics decision-making model, and engaged staff members. Lack of presence and acceptance, insufficient time resources and staff, poor inter-professional collaboration, absence of ethical competence, and not recognizing ethical problems were identified as inhibiting the implementation of the METAP model. However, the results of the questionnaire as well as of explicit inquiry showed that the respondents stated to have had enough time and staff available to use METAP if necessary. Facilitators and barriers of the implementation of a medical ethics decision-making model are quite similar to that of medical guidelines. The planning for implementing an ethics model or guideline can, therefore, benefit from the extensive literature and experience concerning the implementation of medical guidelines. Lack of time and

Dual Processing Model for Medical Decision-Making: An Extension to Diagnostic Testing

PubMed Central

Tsalatsanis, Athanasios; Hozo, Iztok; Kumar, Ambuj; Djulbegovic, Benjamin

2015-01-01

Dual Processing Theories (DPT) assume that human cognition is governed by two distinct types of processes typically referred to as type 1 (intuitive) and type 2 (deliberative). Based on DPT we have derived a Dual Processing Model (DPM) to describe and explain therapeutic medical decision-making. The DPM model indicates that doctors decide to treat when treatment benefits outweigh its harms, which occurs when the probability of the disease is greater than the so called “threshold probability” at which treatment benefits are equal to treatment harms. Here we extend our work to include a wider class of decision problems that involve diagnostic testing. We illustrate applicability of the proposed model in a typical clinical scenario considering the management of a patient with prostate cancer. To that end, we calculate and compare two types of decision-thresholds: one that adheres to expected utility theory (EUT) and the second according to DPM. Our results showed that the decisions to administer a diagnostic test could be better explained using the DPM threshold. This is because such decisions depend on objective evidence of test/treatment benefits and harms as well as type 1 cognition of benefits and harms, which are not considered under EUT. Given that type 1 processes are unique to each decision-maker, this means that the DPM threshold will vary among different individuals. We also showed that when type 1 processes exclusively dominate decisions, ordering a diagnostic test does not affect a decision; the decision is based on the assessment of benefits and harms of treatment. These findings could explain variations in the treatment and diagnostic patterns documented in today’s clinical practice. PMID:26244571

Dual Processing Model for Medical Decision-Making: An Extension to Diagnostic Testing.

PubMed

Tsalatsanis, Athanasios; Hozo, Iztok; Kumar, Ambuj; Djulbegovic, Benjamin

2015-01-01

Dual Processing Theories (DPT) assume that human cognition is governed by two distinct types of processes typically referred to as type 1 (intuitive) and type 2 (deliberative). Based on DPT we have derived a Dual Processing Model (DPM) to describe and explain therapeutic medical decision-making. The DPM model indicates that doctors decide to treat when treatment benefits outweigh its harms, which occurs when the probability of the disease is greater than the so called "threshold probability" at which treatment benefits are equal to treatment harms. Here we extend our work to include a wider class of decision problems that involve diagnostic testing. We illustrate applicability of the proposed model in a typical clinical scenario considering the management of a patient with prostate cancer. To that end, we calculate and compare two types of decision-thresholds: one that adheres to expected utility theory (EUT) and the second according to DPM. Our results showed that the decisions to administer a diagnostic test could be better explained using the DPM threshold. This is because such decisions depend on objective evidence of test/treatment benefits and harms as well as type 1 cognition of benefits and harms, which are not considered under EUT. Given that type 1 processes are unique to each decision-maker, this means that the DPM threshold will vary among different individuals. We also showed that when type 1 processes exclusively dominate decisions, ordering a diagnostic test does not affect a decision; the decision is based on the assessment of benefits and harms of treatment. These findings could explain variations in the treatment and diagnostic patterns documented in today's clinical practice.

A typology of preferences for participation in healthcare decision making.

PubMed

Flynn, Kathryn E; Smith, Maureen A; Vanness, David

2006-09-01

Classifying patients as "active" or "passive" with regard to healthcare decision making is misleading, since patients have different desires for different components of the decision-making process. Distinguishing patients' desired roles is an essential step towards promoting care that respects and responds to individual patients' preferences. We included items on the 2004 Wisconsin Longitudinal Study mail survey measuring preferences for four components of the decision-making process: physician knowledge of patient medical history, physician disclosure of treatment choices, discussion of treatment choices, and selection of treatment choice. We characterized preference types for 5199 older adults using cluster analysis. Ninety-six percent of respondents are represented by four preference types, all of which prefer maximal information exchange with physicians. Fifty-seven percent of respondents wanted to retain personal control over important medical decisions ("autonomists"). Among the autonomists, 81% preferred to discuss treatment choices with their physician. Thirty-nine percent of respondents wanted their physician to make important medical decisions ("delegators"). Among the delegators, 41% preferred to discuss treatment choices. Female gender, higher educational attainment, better self-rated health, fewer prescription medications, and having a shorter duration at a usual place of care predicted a significantly higher probability of the most active involvement in discussing and selecting treatment choices. The overwhelming majority of older adults want to be given treatment options and have their physician know everything about their medical history; however, there are substantial differences in how they want to be involved in discussing and selecting treatments.

The transition from resident to private practice--important financial decisions.

PubMed

Wherry, Jeffrey E; Thomalla, Kenneth

2008-02-01

A newly graduated resident faces many new challenges in the first year of practice. Foremost among these is how to handle the newfound wealth that typically accompanies the transition from residency to a successful practice. The ramifications of these decisions are not insignificant. This article explains the important financial considerations a new practitioner must face in the transition from resident to private practice.

Medical Decision Making for Patients Without Proxies: The Effect of Personal Experience in the Deliberative Process.

PubMed

Robichaud, Allyson L

2015-01-01

The number of admissions to hospitals of patients without a proxy decision maker is rising. Very often these patients need fairly immediate medical intervention for which informed consent--or informed refusal--is required. Many have recommended that there be a process in place to make these decisions, and that it include a variety of perspectives. People are particularly wary of relying solely on medical staff to make these decisions. The University Hospitals Case Medical Center recruits community members from its Ethics Committee to serve on a subcommittee, the Patients Without Proxies (PWP) Committee, which works with medical staff during the decision-making process for these patients. Generally, the community members go to the bedside to observe patients. This article looks at how those unused to observing hospitalized patients who are sick and/or dying are affected, comparing them to mock jurors in a research study who are exposed to graphic photographs related to a fabricated crime scene. Judgments made by the mock jurors are affected by viewing such images. The personal experience of witnessing unfamiliar and shocking scenes affects their subsequent judgments. While it may be difficult to tease out whether observing patients causes PWP members to be benefited or harmed, they are affected by what they see. If a variety of perspectives is desirable to reduce possible bias or error, this article argues that at least one community member should refrain from seeing the patient in order to add a different and valuable voice to the decision-making process. Members of the subcommittee base their judgments on the various kinds of information available. Sometimes the things they see, hear, or feel may affect them particularly deeply, and affect their judgments as well. In this article I explore the idea that something like this may be happening in a particular kind of clinical ethics case consultation. Copyright 2015 The Journal of Clinical Ethics. All rights reserved.

Medication communication through documentation in medical wards: knowledge and power relations.

PubMed

Liu, Wei; Manias, Elizabeth; Gerdtz, Marie

2014-09-01

Health professionals communicate with each other about medication information using different forms of documentation. This article explores knowledge and power relations surrounding medication information exchanged through documentation among nurses, doctors and pharmacists. Ethnographic fieldwork was conducted in 2010 in two medical wards of a metropolitan hospital in Australia. Data collection methods included participant observations, field interviews, video-recordings, document retrieval and video reflexive focus groups. A critical discourse analytic framework was used to guide data analysis. The written medication chart was the main means of communicating medication decisions from doctors to nurses as compared to verbal communication. Nurses positioned themselves as auditors of the medication chart and scrutinised medical prescribing to maintain the discourse of patient safety. Pharmacists utilised the discourse of scientific judgement to guide their decision-making on the necessity of verbal communication with nurses and doctors. Targeted interdisciplinary meetings involving nurses, doctors and pharmacists should be organised in ward settings to discuss the importance of having documented medication information conveyed verbally across different disciplines. Health professionals should be encouraged to proactively seek out each other to relay changes in medication regimens and treatment goals. © 2013 John Wiley & Sons Ltd.

Hypermedia or Hyperchaos: Using HyperCard to Teach Medical Decision Making

PubMed Central

Smith, W.R.; Hahn, J.S.

1989-01-01

HyperCard presents an uncoventional instructional environment for educators and students, in that it is nonlinear, nonsequential, and it provides innumerable choices of learning paths to learners. The danger of this environment is that it may frustrate learners whose cognitive and learning styles do not match this environment. Leaners who prefer guided learning rather than independent exploration may become distracted or disoriented by this environment, lost in “hyperspace.” In the context of medical education, these ill-matched styles may produce some physicians who have not mastered skills essential to the practice of medicine. The authors have sought to develop a HyperCard learning environment consisting of related programs that teach medical decision making. The environment allows total learner control until the learner demonstrates a need for guidance in order to achieve the essential objectives of the program. A discussion follows of the implications of hypermedia for instructional design and medical education.

A preface on advances in diagnostics for infectious and parasitic diseases: detecting parasites of medical and veterinary importance.

PubMed

Stothard, J Russell; Adams, Emily

2014-12-01

There are many reasons why detection of parasites of medical and veterinary importance is vital and where novel diagnostic and surveillance tools are required. From a medical perspective alone, these originate from a desire for better clinical management and rational use of medications. Diagnosis can be at the individual-level, at close to patient settings in testing a clinical suspicion or at the community-level, perhaps in front of a computer screen, in classification of endemic areas and devising appropriate control interventions. Thus diagnostics for parasitic diseases has a broad remit as parasites are not only tied with their definitive hosts but also in some cases with their vectors/intermediate hosts. Application of current diagnostic tools and decision algorithms in sustaining control programmes, or in elimination settings, can be problematic and even ill-fitting. For example in resource-limited settings, are current diagnostic tools sufficiently robust for operational use at scale or are they confounded by on-the-ground realities; are the diagnostic algorithms underlying public health interventions always understood and well-received within communities which are targeted for control? Within this Special Issue (SI) covering a variety of diseases and diagnostic settings some answers are forthcoming. An important theme, however, throughout the SI is to acknowledge that cross-talk and continuous feedback between development and application of diagnostic tests is crucial if they are to be used effectively and appropriately.

Veterinary decision making in relation to metritis - a qualitative approach to understand the background for variation and bias in veterinary medical records

PubMed Central

Lastein, Dorte B; Vaarst, Mette; Enevoldsen, Carsten

2009-01-01

Background Results of analyses based on veterinary records of animal disease may be prone to variation and bias, because data collection for these registers relies on different observers in different settings as well as different treatment criteria. Understanding the human influence on data collection and the decisions related to this process may help veterinary and agricultural scientists motivate observers (veterinarians and farmers) to work more systematically, which may improve data quality. This study investigates qualitative relations between two types of records: 1) 'diagnostic data' as recordings of metritis scores and 2) 'intervention data' as recordings of medical treatment for metritis and the potential influence on quality of the data. Methods The study is based on observations in veterinary dairy practice combined with semi-structured research interviews of veterinarians working within a herd health concept where metritis diagnosis was described in detail. The observations and interviews were analysed by qualitative research methods to describe differences in the veterinarians' perceptions of metritis diagnosis (scores) and their own decisions related to diagnosis, treatment, and recording. Results The analysis demonstrates how data quality can be affected during the diagnostic procedures, as interaction occurs between diagnostics and decisions about medical treatments. Important findings were when scores lacked consistency within and between observers (variation) and when scores were adjusted to the treatment decision already made by the veterinarian (bias). The study further demonstrates that veterinarians made their decisions at 3 different levels of focus (cow, farm, population). Data quality was influenced by the veterinarians' perceptions of collection procedures, decision making and their different motivations to collect data systematically. Conclusion Both variation and bias were introduced into the data because of veterinarians' different

Importance of Pharmaceutical Training and Clinical Research at Medical Facilities.

PubMed

Myotoku, Michiaki

2017-01-01

To respond to advancements in medical techniques, and to address the separation of medical and dispensary practices, clinical professors are required to educate human resource staff to become highly-skilled pharmacists. For this purpose, it is extremely important for these professors to learn about cutting-edge practical skills and knowledge, as well as to advance their expertise. In addition, they need to conduct clinical research in cooperation with relevant facilities. As our university does not have its own hospital or pharmacy, it is important to provide training for clinical professors in clinical facilities. Such training mainly involves medical teams' in-hospital rounds and participation in conferences (nutrition support team; NST), operation of the pharmacy department, and intervention targeting improvement in the department's duties. We have conducted collaborative studies, provided research instructions, implemented studies aimed at improving the department's work (pharmacists appointed on wards at all times to ensure medical safety) as well as studies regarding team medical care (nutritional evaluation during outpatient chemotherapy), and resolved issues regarding this work (drug solution mixability in a hand-held constant infusion pump, and a safe pump-filling methods). Thus, it has become possible to keep track of the current state of a pharmacists' work within team medical care, to access information about novel drugs, to view clinical and prescription-claim data, to cooperate with other professionals (e.g., doctors and nurses), to promote pharmacists' self-awareness of their roles in cooperative medical practice, and to effectively maintain the hospital's clinical settings.

Decision-making capacity for treatment in psychiatric and medical in-patients: cross-sectional, comparative study†

PubMed Central

Owen, Gareth S.; Szmukler, George; Richardson, Genevra; David, Anthony S.; Raymont, Vanessa; Freyenhagen, Fabian; Martin, Wayne; Hotopf, Matthew

2013-01-01

Background Is the nature of decision-making capacity (DMC) for treatment significantly different in medical and psychiatric patients? Aims To compare the abilities relevant to DMC for treatment in medical and psychiatric patients who are able to communicate a treatment choice. Method A secondary analysis of two cross-sectional studies of consecutive admissions: 125 to a psychiatric hospital and 164 to a medical hospital. The MacArthur Competence Assessment Tool - Treatment and a clinical interview were used to assess decision-making abilities (understanding, appreciating and reasoning) and judgements of DMC. We limited analysis to patients able to express a choice about treatment and stratified the analysis by low and high understanding ability. Results Most people scoring low on understanding were judged to lack DMC and there was no difference by hospital (P = 0.14). In both hospitals there were patients who were able to understand yet lacked DMC (39% psychiatric v. 13% medical in-patients, P<0.001). Appreciation was a better ‘test’ of DMC in the psychiatric hospital (where psychotic and severe affective disorders predominated) (P<0.001), whereas reasoning was a better test of DMC in the medical hospital (where cognitive impairment was common) (P = 0.02). Conclusions Among those with good understanding, the appreciation ability had more salience to DMC for treatment in a psychiatric setting and the reasoning ability had more salience in a medical setting. PMID:23969482

Police officer response to the injured officer: a survey-based analysis of medical care decisions.

PubMed

Sztajnkrycer, Matthew D; Callaway, David W; Baez, Amado Alejandro

2007-01-01

No widely accepted, specialized medical training exists for police officers confronted with medical emergencies while under conditions of active threat. The purpose of this study was to assess medical decision-making capabilities of law enforcement personnel under these circumstances. Web-based surveys were administered to all sworn officers within the county jurisdiction. Thirty-eight key actions were predetermined for nine injured officer scenarios, with each correct action worth one point. Descriptive statistics and t-tests were used to analyze results. Ninety-seven officers (65.1% response rate) responded to the survey. The majority of officers (68.0%) were trained to the first-responder level. Overall mean score for the scenarios was 15.5 +/- 3.6 (range 7-25). A higher level of medical training (EMT-B/P versus first responder) was associated with a higher mean score (16.6 +/- 3.4, p = 0.05 vs. 15.0 +/- 3.6, p = 0.05). Tactical unit assignment was associated with a lower score compared with non-assigned officers (13.5 +/- 2.9 vs. 16.0 +/- 3.6, p = 0.0085). No difference was noted based upon previous military experience. Ninety-two percent of respondents expressed interest in a law enforcement-oriented advanced first-aid course. Tactical medical decision-making capability, as assessed through the nine scenarios, was sub-optimal. In this post 9/11 era, development of law enforcement-specific medical training appears appropriate.

Reading the medical record. I. Analysis of physicians' ways of reading the medical record.

PubMed

Nygren, E; Henriksson, P

1992-01-01

Physicians were interviewed about their routines in everyday use of the medical record. From the interviews, we conclude that the medical record is a well functioning working instrument for the experienced physician. Using the medical record as a basis for decision making involves interpretation of format, layout and other textural features of the type-written data. Interpretation of these features provides effective guidance in the process of searching, reading and assessing the relevance of different items of information in the record. It seems that this is a skill which is an integrated part of diagnostic expertise. This skill plays an important role in decision making based on the large amount of information about a patient, which is exhibited to the reader in the medical record. This finding has implications for the design of user interfaces for reading computerized medical records.

Workers' decisions to take-up offered health insurance coverage: assessing the importance of out-of-pocket premium costs.

PubMed

Cooper, Philip F; Vistnes, Jessica

2003-07-01

Many proposed policy initiatives involve subsidies directed toward encouraging employers to offer coverage and toward workers to encourage enrollment in offered plans. Given that insurance coverage reflects employers' decisions to offer coverage, eligibility requirements for such coverage, and employees' take-up decisions, all three elements are important when considering mechanisms to decrease the number of uninsured individuals. In this study, we examine the relationship between workers' decisions to take-up offers of health insurance and annual out-of-pocket contributions, total premiums, and employer and workforce characteristics. We model the take-up decision using cross-sectional data from approximately 18,000 establishments per year from the 1997 to 1999 Medical Expenditure Panel Survey - Insurance Component. We find that workers are less likely to enroll in coverage as single employee contributions increase. Our results for family contributions are much smaller than for single contributions and are not statistically significant in all years. Our simulation results suggest that reducing employee contribution levels for single coverage from existing levels in 1999 to zero would yield an increase in take-up rates of roughly 6% points in establishments that had required a positive level of contributions. Our results also indicate that of the 13.8 million private sector workers who decline coverage from their employers, 2.5 million would potentially enroll in employer-sponsored coverage if the cost of single coverage were to fall to zero. Reducing employee contributions will increase take-up rates; however, even when employees pay nothing for their coverage, some employees elect not to enroll.

Medical Expenses Matter Most for the Poor: Evidence from a Vietnamese Medical Survey.

PubMed

Vuong, Quan Hoang

2016-12-01

Less developed countries, Vietnam included, face serious challenges of inefficient diagnosis, inaccessibility to healthcare facilities, and high medical expenses. Information on medical costs, technical and professional capabilities of healthcare providers and service deliveries becomes influential when it comes to patients' decision on choices of healthcare providers. The study employs a data set containing 1,459 observations collected from a survey on Vietnamese patients in late 2015. The standard categorical data analysis is performed to provide statistical results, yielding insights from the empirical data. Patients' socioeconomic status (SES) is found to be associated with the degree of significance of key factors (i.e., medical costs, professional capabilities and service deliveries), but medical expenses are the single most important factor that influence a decision by the poor, 2.28 times as critical as the non-poor. In contrary, the non-poor tend to value technical capabilities and services more, with odds ratios being 1.54 and 1.32, respectively. There exists a risk for the poor in decision making based on medical expenses solely. The solution may rest with: a) improved health insurance mechanism; and, b) obtaining additional revenues from value-added services, which can help defray the poor's financial burdens.

Retrieval of publications addressing shared decision making: an evaluation of full-text searches on medical journal websites.

PubMed

Blanc, Xavier; Collet, Tinh-Hai; Auer, Reto; Iriarte, Pablo; Krause, Jan; Légaré, France; Cornuz, Jacques; Clair, Carole

2015-04-07

Full-text searches of articles increase the recall, defined by the proportion of relevant publications that are retrieved. However, this method is rarely used in medical research due to resource constraints. For the purpose of a systematic review of publications addressing shared decision making, a full-text search method was required to retrieve publications where shared decision making does not appear in the title or abstract. The objective of our study was to assess the efficiency and reliability of full-text searches in major medical journals for identifying shared decision making publications. A full-text search was performed on the websites of 15 high-impact journals in general internal medicine to look up publications of any type from 1996-2011 containing the phrase "shared decision making". The search method was compared with a PubMed search of titles and abstracts only. The full-text search was further validated by requesting all publications from the same time period from the individual journal publishers and searching through the collected dataset. The full-text search for "shared decision making" on journal websites identified 1286 publications in 15 journals compared to 119 through the PubMed search. The search within the publisher-provided publications of 6 journals identified 613 publications compared to 646 with the full-text search on the respective journal websites. The concordance rate was 94.3% between both full-text searches. Full-text searching on medical journal websites is an efficient and reliable way to identify relevant articles in the field of shared decision making for review or other purposes. It may be more widely used in biomedical research in other fields in the future, with the collaboration of publishers and journals toward open-access data.

A model-driven privacy compliance decision support for medical data sharing in Europe.

PubMed

Boussi Rahmouni, H; Solomonides, T; Casassa Mont, M; Shiu, S; Rahmouni, M

2011-01-01

Clinical practitioners and medical researchers often have to share health data with other colleagues across Europe. Privacy compliance in this context is very important but challenging. Automated privacy guidelines are a practical way of increasing users' awareness of privacy obligations and help eliminating unintentional breaches of privacy. In this paper we present an ontology-plus-rules based approach to privacy decision support for the sharing of patient data across European platforms. We use ontologies to model the required domain and context information about data sharing and privacy requirements. In addition, we use a set of Semantic Web Rule Language rules to reason about legal privacy requirements that are applicable to a specific context of data disclosure. We make the complete set invocable through the use of a semantic web application acting as an interactive privacy guideline system can then invoke the full model in order to provide decision support. When asked, the system will generate privacy reports applicable to a specific case of data disclosure described by the user. Also reports showing guidelines per Member State may be obtained. The advantage of this approach lies in the expressiveness and extensibility of the modelling and inference languages adopted and the ability they confer to reason with complex requirements interpreted from high level regulations. However, the system cannot at this stage fully simulate the role of an ethics committee or review board.

Ignoring the data and endangering children: why the mature minor standard for medical decision making must be abandoned.

PubMed

Cherry, Mark J

2013-06-01

In Roper v. Simmons (2005) the United States Supreme Court announced a paradigm shift in jurisprudence. Drawing specifically on mounting scientific evidence that adolescents are qualitatively different from adults in their decision-making capacities, the Supreme Court recognized that adolescents are not adults in all but age. The Court concluded that the overwhelming weight of the psychological and neurophysiological data regarding brain maturation supports the conclusion that adolescents are qualitatively different types of agents than adult persons. The Supreme Court further solidified its position regarding adolescents as less than fully mature and responsible decisionmakers in Graham v. Florida (2010) and Miller v. Alabama (2012). In each case, the Court concluded that the scientific evidence does not support the conclusion that children under 18 years of age possess adult capacities for personal agency, rationality, and mature choice. This study explores the implications of the Supreme Court decisions in Roper v. Simmons, Graham v. Florida, and Miller v. Alabama for the "mature minor" standard for medical decision making. It argues that the Supreme Court's holdings in Roper, Graham, and Miller require no less than a radical reassessment of how healthcare institutions, courts of law, and public policy are obliged to regard minors as medical decisionmakers. The "mature minor" standard for medical decision making must be abandoned.

Shared decision-making and decision support: their role in obstetrics and gynecology.

PubMed

Tucker Edmonds, Brownsyne

2014-12-01

To discuss the role for shared decision-making in obstetrics/gynecology and to review evidence on the impact of decision aids on reproductive health decision-making. Among the 155 studies included in a 2014 Cochrane review of decision aids, 31 (29%) addressed reproductive health decisions. Although the majority did not show evidence of an effect on treatment choice, there was a greater uptake of mammography in selected groups of women exposed to decision aids compared with usual care; and a statistically significant reduction in the uptake of hormone replacement therapy among detailed decision aid users compared with simple decision aid users. Studies also found an effect on patient-centered outcomes of care, such as medication adherence, quality-of-life measures, and anxiety scores. In maternity care, only decision analysis tools affected final treatment choice, and patient-directed aids yielded no difference in planned mode of birth after cesarean. There is untapped potential for obstetricians/gynecologists to optimize decision support for reproductive health decisions. Given the limited evidence-base guiding practice, the preference-sensitive nature of reproductive health decisions, and the increase in policy efforts and financial incentives to optimize patients' satisfaction, it is increasingly important for obstetricians/gynecologists to appreciate the role of shared decision-making and decision support in providing patient-centered reproductive healthcare.

Participation in medical decision-making across Europe: An international longitudinal multicenter study.

PubMed

Bär Deucher, A; Hengartner, M P; Kawohl, W; Konrad, J; Puschner, B; Clarke, E; Slade, M; Del Vecchio, V; Sampogna, G; Égerházi, A; Süveges, Á; Krogsgaard Bording, M; Munk-Jørgensen, P; Rössler, W

2016-05-01

The purpose of this paper was to examine national differences in the desire to participate in decision-making of people with severe mental illness in six European countries. The data was taken from a European longitudinal observational study (CEDAR; ISRCTN75841675). A sample of 514 patients with severe mental illness from the study centers in Ulm, Germany, London, England, Naples, Italy, Debrecen, Hungary, Aalborg, Denmark and Zurich, Switzerland were assessed as to desire to participate in medical decision-making. Associations between desire for participation in decision-making and center location were analyzed with generalized estimating equations. We found large cross-national differences in patients' desire to participate in decision-making, with the center explaining 47.2% of total variance in the desire for participation (P<0.001). Averaged over time and independent of patient characteristics, London (mean=2.27), Ulm (mean=2.13) and Zurich (mean=2.14) showed significantly higher scores in desire for participation, followed by Aalborg (mean=1.97), where scores were in turn significantly higher than in Debrecen (mean=1.56). The lowest scores were reported in Naples (mean=1.14). Over time, the desire for participation in decision-making increased significantly in Zurich (b=0.23) and decreased in Naples (b=-0.14). In all other centers, values remained stable. This study demonstrates that patients' desire for participation in decision-making varies by location. We suggest that more research attention be focused on identifying specific cultural and social factors in each country to further explain observed differences across Europe. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

Medical Waste Disposal Method Selection Based on a Hierarchical Decision Model with Intuitionistic Fuzzy Relations

PubMed Central

Qian, Wuyong; Wang, Zhou-Jing; Li, Kevin W.

2016-01-01

Although medical waste usually accounts for a small fraction of urban municipal waste, its proper disposal has been a challenging issue as it often contains infectious, radioactive, or hazardous waste. This article proposes a two-level hierarchical multicriteria decision model to address medical waste disposal method selection (MWDMS), where disposal methods are assessed against different criteria as intuitionistic fuzzy preference relations and criteria weights are furnished as real values. This paper first introduces new operations for a special class of intuitionistic fuzzy values, whose membership and non-membership information is cross ratio based ]0, 1[-values. New score and accuracy functions are defined in order to develop a comparison approach for ]0, 1[-valued intuitionistic fuzzy numbers. A weighted geometric operator is then put forward to aggregate a collection of ]0, 1[-valued intuitionistic fuzzy values. Similar to Saaty’s 1–9 scale, this paper proposes a cross-ratio-based bipolar 0.1–0.9 scale to characterize pairwise comparison results. Subsequently, a two-level hierarchical structure is formulated to handle multicriteria decision problems with intuitionistic preference relations. Finally, the proposed decision framework is applied to MWDMS to illustrate its feasibility and effectiveness. PMID:27618082

Medical Waste Disposal Method Selection Based on a Hierarchical Decision Model with Intuitionistic Fuzzy Relations.

PubMed

Qian, Wuyong; Wang, Zhou-Jing; Li, Kevin W

2016-09-09

Although medical waste usually accounts for a small fraction of urban municipal waste, its proper disposal has been a challenging issue as it often contains infectious, radioactive, or hazardous waste. This article proposes a two-level hierarchical multicriteria decision model to address medical waste disposal method selection (MWDMS), where disposal methods are assessed against different criteria as intuitionistic fuzzy preference relations and criteria weights are furnished as real values. This paper first introduces new operations for a special class of intuitionistic fuzzy values, whose membership and non-membership information is cross ratio based ]0, 1[-values. New score and accuracy functions are defined in order to develop a comparison approach for ]0, 1[-valued intuitionistic fuzzy numbers. A weighted geometric operator is then put forward to aggregate a collection of ]0, 1[-valued intuitionistic fuzzy values. Similar to Saaty's 1-9 scale, this paper proposes a cross-ratio-based bipolar 0.1-0.9 scale to characterize pairwise comparison results. Subsequently, a two-level hierarchical structure is formulated to handle multicriteria decision problems with intuitionistic preference relations. Finally, the proposed decision framework is applied to MWDMS to illustrate its feasibility and effectiveness.

The attitudes of medical students in Europe toward the clinical importance of embryology.

PubMed

Moxham, Bernard John; Emmanouil-Nikoloussi, Elpida; Standley, Henrietta; Brenner, Erich; Plaisant, Odile; Brichova, Hana; Pais, Diogo; Stabile, Isobel; Borg, Jordy; Chirculescu, Andy

2016-03-01

Although there have been many studies reporting the attitudes of medical students to the clinical importance of gross anatomy, little is known about their opinions concerning the clinical importance of embryology. Using Thurstone and Chave methods to assess attitudes, nearly 1,600 medical students across Europe in the early stages of their training provided responses to a survey that tested the hypothesis that they do not regard embryology as highly clinically relevant. Indeed, we further proposed that student attitudes to gross anatomy are much more positive than those toward embryology. Our findings show that our hypotheses hold, regardless of the university and country surveyed and regardless of the teaching methods employed for embryology. Clearly, embryology has a significant part to play in medical education in terms of understanding prenatal life, of appreciating how the organization of the mature human body has developed, and of providing essential information for general medical practice, obstetrics and pediatrics, and teratology. However, while newly recruited medical students understand the importance of gross anatomy in the development of professional competence, understanding the importance of embryology requires teachers, medical educationalists, and devisors of medical curricula to pay special attention to informing students of the significant role played by embryology in attaining clinical competence and achieving the knowledge and understanding of the biomedical sciences that underpins becoming a learned member of a health care profession. © 2015 Wiley Periodicals, Inc.

Public health policy decisions on medical innovations: what role can early economic evaluation play?

PubMed

Hartz, Susanne; John, Jürgen

2009-02-01

Our contribution aims to explore the different ways in which early economic data can inform public health policy decisions on new medical technologies. A literature research was conducted to detect methodological contributions covering the health policy perspective. Early economic data on new technologies can support public health policy decisions in several ways. Embedded in horizon scanning and HTA activities, it adds to monitoring and assessment of innovations. It can play a role in the control of technology diffusion by informing coverage and reimbursement decisions as well as the direct public promotion of healthcare technologies, leading to increased efficiency. Major problems include the uncertainty related to economic data at early stages as well as the timing of the evaluation of an innovation. Decision-makers can benefit from the information supplied by early economic data, but the actual use in practice is difficult to determine. Further empirical evidence should be gathered, while the use could be promoted by further standardization.

Initiating decision-making in neurology consultations: 'recommending' versus 'option-listing' and the implications for medical authority.

PubMed

Toerien, Merran; Shaw, Rebecca; Reuber, Markus

2013-07-01

This article compares two practices for initiating treatment decision-making, evident in audio-recorded consultations between a neurologist and 13 patients in two hospital clinics in the UK. We call these 'recommending' and 'option-listing'. The former entails making a proposal to do something; the latter entails the construction of a list of options. Using conversation analysis (CA), we illustrate each, showing that the distinction between these two practices matters to participants. Our analysis centres on two distinctions between the practices: epistemic differences and differences in the slots each creates for the patient's response. Considering the implications of our findings for understanding medical authority, we argue that option-listing - relative to recommending - is a practice whereby clinicians work to relinquish a little of their authority. This article contributes, then, to a growing body of CA work that offers a more nuanced, tempered account of medical authority than is typically portrayed in the sociological literature. We argue that future CA studies should map out the range of ways - in addition to recommending - in which treatment decision-making is initiated by clinicians. This will allow for further evidence-based contributions to debates on the related concepts of patient participation, choice, shared decision-making and medical authority. © 2013 The Authors. Sociology of Health & Illness © 2013 Foundation for the Sociology of Health & Illness/John Wiley & Sons Ltd.

Robot decisions: on the importance of virtuous judgment in clinical decision making.

PubMed

Gelhaus, Petra

2011-10-01

The aim of this article is to argue for the necessity of emotional professional virtues in the understanding of good clinical practice. This understanding is required for a proper balance of capacities in medical education and further education of physicians. For this reason an ideal physician, incarnating the required virtues, skills and knowledge is compared with a non-emotional robot that is bound to moral rules. This fictive confrontation is meant to clarify why certain demands on the personality of the physician are justified, in addition to a rule- and principle-based moral orientation and biomedical knowledge and skills. Philosophical analysis of thought experiments inspired by science fiction literature by Isaac Asimov. Although prima facie a rule-oriented robot seems more reliable and trustworthy, the complexity of clinical judgment is not met by an encompassing and never contradictory set of rules from which one could logically derive decisions. There are different ways how the robot could still work, but at the cost of the predictability of its behaviour and its moral orientation. In comparison, a virtuous human doctor who is also bound to these rules, although less strictly, will more reliably keep at moral objectives, be understandable, be more flexible in case the rules come to their limits, and will be more predictable in these critical situations. Apart from these advantages of the virtuous human doctor referring to her own person, the most problematic deficit of the robot is its lacking deeper understanding of the inner mental events of patients which makes good contact, good communication and good influence impossible. Although an infallibly rule-oriented robot seems more reliable at first view, in situations that require complex decisions like clinical practice the agency of a moral human person is more trustworthy. Furthermore, the understanding of the patient's emotions must remain insufficient for a non-emotional, non-human being. Because

A Clinical Decision Support Engine Based on a National Medication Repository for the Detection of Potential Duplicate Medications: Design and Evaluation.

PubMed

Yang, Cheng-Yi; Lo, Yu-Sheng; Chen, Ray-Jade; Liu, Chien-Tsai

2018-01-19

A computerized physician order entry (CPOE) system combined with a clinical decision support system can reduce duplication of medications and thus adverse drug reactions. However, without infrastructure that supports patients' integrated medication history across health care facilities nationwide, duplication of medication can still occur. In Taiwan, the National Health Insurance Administration has implemented a national medication repository and Web-based query system known as the PharmaCloud, which allows physicians to access their patients' medication records prescribed by different health care facilities across Taiwan. This study aimed to develop a scalable, flexible, and thematic design-based clinical decision support (CDS) engine, which integrates a national medication repository to support CPOE systems in the detection of potential duplication of medication across health care facilities, as well as to analyze its impact on clinical encounters. A CDS engine was developed that can download patients' up-to-date medication history from the PharmaCloud and support a CPOE system in the detection of potential duplicate medications. When prescribing a medication order using the CPOE system, a physician receives an alert if there is a potential duplicate medication. To investigate the impact of the CDS engine on clinical encounters in outpatient services, a clinical encounter log was created to collect information about time, prescribed drugs, and physicians' responses to handling the alerts for each encounter. The CDS engine was installed in a teaching affiliate hospital, and the clinical encounter log collected information for 3 months, during which a total of 178,300 prescriptions were prescribed in the outpatient departments. In all, 43,844/178,300 (24.59%) patients signed the PharmaCloud consent form allowing their physicians to access their medication history in the PharmaCloud. The rate of duplicate medication was 5.83% (1843/31,614) of prescriptions. When

Role modelling in medical education: the importance of teaching skills.

PubMed

Burgess, Annette; Oates, Kim; Goulston, Kerry

2016-04-01

By observation of role models, and participation in activities, students develop their attitudes, values and professional competencies. Literature suggests that clinical skills and knowledge, personality, and teaching skills are three main areas that students consider central to the identification of positive role models. The aim of this study was to explore junior medical students' opinions of the ideal attributes of a good role model in clinical tutors. The study was conducted with one cohort (n = 301) of students who had completed year 1 of the medical programme in 2013. All students were asked to complete a questionnaire regarding the ideal attributes of a good role model in a clinical tutor. The questionnaire consisted of seven closed items and one open-ended question. The response rate to the questionnaire was 265/301 (88%). Although students found all three key areas important in a good role model, students emphasised the importance of excellence in teaching skills. Specifically, students see good role models as being able to provide a constructive learning environment, a good understanding of the curriculum and an ability to cater to the learning needs of all students. Students see good role models as being able to provide a constructive learning environment While acknowledging the importance of a patient-centred approach, as well as clinical knowledge and skills, our findings reinforce the importance of the actual teaching abilities of role models within medical education. © 2015 John Wiley & Sons Ltd.

Medical end-of-life decisions in Switzerland 2001 and 2013: Who is involved and how does the decision-making capacity of the patient impact?

PubMed

Schmid, Margareta; Zellweger, Ueli; Bosshard, Georg; Bopp, Matthias

2016-01-01

In Switzerland, the prevalence of medical end-of-life practices had been assessed on a population level only once - in 2001 - until in 2013/14 an identical study was conducted. We aimed to compare the results of the 2001 and 2013 studies with a special focus on shared decision-making and patients' decision-making capacity. Our study encompassed a 21.3% sample of deaths among residents of the German-speaking part of Switzerland aged 1 year or older. From 4998 mailed questionnaires, 3173 (63.5%) were returned. All data were weighted to adjust for age- and sex-specific differences in response rates. Cases with at least one reported end-of-life practice significantly increased from 74.5% (2001) to 82.3% (2013) of all deaths eligible for an end-of-life decision (p <0.001). In 51.2% there was a combination of at least two different end-of-life decisions in one case. In relation to discussion with patients or relatives and otherwise expressed preferences of the patient, 76.5% (74.5-78.4%) of all cases with reported medical end-of-life practice in 2013 (2001: 74.4%) relied on shared decision-making, varying from 79.8% (76.5-82.7%) among not at all capable patients to 87.8% (85.0-90.2%) among fully capable patients. In contrast to a generally increasing trend, the prevalence of end-of-life practices discussed with fully capable patients decreased from 79.0% (75.3-82.3%) in 2001 to 73.2% (69.6-76.0%) in 2013 (p = 0.037). Despite a generally high incidence of end-of-life practices in Switzerland, there remains potential for further improvement in shared decision-making. Efforts to motivate physicians to involve patients and relatives may be a win-win situation.

Return to play after hamstring injuries in football (soccer): a worldwide Delphi procedure regarding definition, medical criteria and decision-making.

PubMed

van der Horst, Nick; Backx, Fjg; Goedhart, Edwin A; Huisstede, Bionka Ma

2017-11-01

There are three major questions about return to play (RTP) after hamstring injuries: How should RTP be defined? Which medical criteria should support the RTP decision? And who should make the RTP decision? The study aimed to provide a clear RTP definition and medical criteria for RTP and to clarify RTP consultation and responsibilities after hamstring injury. The study used the Delphi procedure. The results of a systematic review were used as a starting point for the Delphi procedure. Fifty-eight experts in the field of hamstring injury management selected by 28 FIFA Medical Centres of Excellence worldwide participated. Each Delphi round consisted of a questionnaire, an analysis and an anonymised feedback report. After four Delphi rounds, with more than 83% response for each round, consensus was achieved that RTP should be defined as 'the moment a player has received criteria-based medical clearance and is mentally ready for full availability for match selection and/or full training'. The experts reached consensus on the following criteria to support the RTP decision: medical staff clearance, absence of pain on palpation, absence of pain during strength and flexibility testing, absence of pain during/after functional testing, similar hamstring flexibility, performance on field testing, and psychological readiness. It was also agreed that RTP decisions should be based on shared decision-making, primarily via consultation with the athlete, sports physician, physiotherapist, fitness trainer and team coach. The consensus regarding aspects of RTP should provide clarity and facilitate the assessment of when RTP is appropriate after hamstring injury, so as to avoid or reduce the risk of injury recurrence because of a premature RTP. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Racial, gender, and socioeconomic status bias in senior medical student clinical decision-making: a national survey.

PubMed

Williams, Robert L; Romney, Crystal; Kano, Miria; Wright, Randy; Skipper, Betty; Getrich, Christina M; Sussman, Andrew L; Zyzanski, Stephen J

2015-06-01

Research suggests stereotyping by clinicians as one contributor to racial and gender-based health disparities. It is necessary to understand the origins of such biases before interventions can be developed to eliminate them. As a first step toward this understanding, we tested for the presence of bias in senior medical students. The purpose of the study was to determine whether bias based on race, gender, or socioeconomic status influenced clinical decision-making among medical students. We surveyed seniors at 84 medical schools, who were required to choose between two clinically equivalent management options for a set of cardiac patient vignettes. We examined variations in student recommendations based on patient race, gender, and socioeconomic status. The study included senior medical students. We investigated the percentage of students selecting cardiac procedural options for vignette patients, analyzed by patient race, gender, and socioeconomic status. Among 4,603 returned surveys, we found no evidence in the overall sample supporting racial or gender bias in student clinical decision-making. Students were slightly more likely to recommend cardiac procedural options for black (43.9 %) vs. white (42 %, p = .03) patients; there was no difference by patient gender. Patient socioeconomic status was the strongest predictor of student recommendations, with patients described as having the highest socioeconomic status most likely to receive procedural care recommendations (50.3 % vs. 43.2 % for those in the lowest socioeconomic status group, p < .001). Analysis by subgroup, however, showed significant regional geographic variation in the influence of patient race and gender on decision-making. Multilevel analysis showed that white female patients were least likely to receive procedural recommendations. In the sample as a whole, we found no evidence of racial or gender bias in student clinical decision-making. However, we did find evidence of bias with regard to the

Identification and Prioritization of Important Attributes of Disease-Modifying Drugs in Decision Making among Patients with Multiple Sclerosis: A Nominal Group Technique and Best-Worst Scaling.

PubMed

Kremer, Ingrid E H; Evers, Silvia M A A; Jongen, Peter J; van der Weijden, Trudy; van de Kolk, Ilona; Hiligsmann, Mickaël

2016-01-01

Understanding the preferences of patients with multiple sclerosis (MS) for disease-modifying drugs and involving these patients in clinical decision making can improve the concordance between medical decisions and patient values and may, subsequently, improve adherence to disease-modifying drugs. This study aims first to identify which characteristics-or attributes-of disease-modifying drugs influence patients´ decisions about these treatments and second to quantify the attributes' relative importance among patients. First, three focus groups of relapsing-remitting MS patients were formed to compile a preliminary list of attributes using a nominal group technique. Based on this qualitative research, a survey with several choice tasks (best-worst scaling) was developed to prioritize attributes, asking a larger patient group to choose the most and least important attributes. The attributes' mean relative importance scores (RIS) were calculated. Nineteen patients reported 34 attributes during the focus groups and 185 patients evaluated the importance of the attributes in the survey. The effect on disease progression received the highest RIS (RIS = 9.64, 95% confidence interval: [9.48-9.81]), followed by quality of life (RIS = 9.21 [9.00-9.42]), relapse rate (RIS = 7.76 [7.39-8.13]), severity of side effects (RIS = 7.63 [7.33-7.94]) and relapse severity (RIS = 7.39 [7.06-7.73]). Subgroup analyses showed heterogeneity in preference of patients. For example, side effect-related attributes were statistically more important for patients who had no experience in using disease-modifying drugs compared to experienced patients (p < .001). This study shows that, on average, patients valued effectiveness and unwanted effects as most important. Clinicians should be aware of the average preferences but also that attributes of disease-modifying drugs are valued differently by different patients. Person-centred clinical decision making would be needed and requires eliciting

A Clinical Decision Support Engine Based on a National Medication Repository for the Detection of Potential Duplicate Medications: Design and Evaluation

PubMed Central

Yang, Cheng-Yi; Lo, Yu-Sheng; Chen, Ray-Jade

2018-01-01

Background A computerized physician order entry (CPOE) system combined with a clinical decision support system can reduce duplication of medications and thus adverse drug reactions. However, without infrastructure that supports patients’ integrated medication history across health care facilities nationwide, duplication of medication can still occur. In Taiwan, the National Health Insurance Administration has implemented a national medication repository and Web-based query system known as the PharmaCloud, which allows physicians to access their patients’ medication records prescribed by different health care facilities across Taiwan. Objective This study aimed to develop a scalable, flexible, and thematic design-based clinical decision support (CDS) engine, which integrates a national medication repository to support CPOE systems in the detection of potential duplication of medication across health care facilities, as well as to analyze its impact on clinical encounters. Methods A CDS engine was developed that can download patients’ up-to-date medication history from the PharmaCloud and support a CPOE system in the detection of potential duplicate medications. When prescribing a medication order using the CPOE system, a physician receives an alert if there is a potential duplicate medication. To investigate the impact of the CDS engine on clinical encounters in outpatient services, a clinical encounter log was created to collect information about time, prescribed drugs, and physicians’ responses to handling the alerts for each encounter. Results The CDS engine was installed in a teaching affiliate hospital, and the clinical encounter log collected information for 3 months, during which a total of 178,300 prescriptions were prescribed in the outpatient departments. In all, 43,844/178,300 (24.59%) patients signed the PharmaCloud consent form allowing their physicians to access their medication history in the PharmaCloud. The rate of duplicate medication was 5

An Interactive Medical Knowledge Assistant

NASA Astrophysics Data System (ADS)

Czejdo, Bogdan D.; Baszun, Mikolaj

This paper describes an interactive medical knowledge assistant that can help a doctor or a patient in making important health related decisions. The system is Web based and consists of several modules, including a medical knowledge base, a doctor interface module, patient interface module and a the main module of the medical knowledge assistant. The medical assistant is designed to help interpret the fuzzy data using rough sets approach. The patient interface includes sub-system for real time monitoring of patients' health parameters and sending them to the main module of the medical knowledge assistant.

"Do your homework…and then hope for the best": the challenges that medical tourism poses to Canadian family physicians' support of patients' informed decision-making.

PubMed

Snyder, Jeremy; Crooks, Valorie A; Johnston, Rory; Dharamsi, Shafik

2013-09-22

Medical tourism-the practice where patients travel internationally to privately access medical care-may limit patients' regular physicians' abilities to contribute to the informed decision-making process. We address this issue by examining ways in which Canadian family doctors' typical involvement in patients' informed decision-making is challenged when their patients engage in medical tourism. Focus groups were held with family physicians practicing in British Columbia, Canada. After receiving ethics approval, letters of invitation were faxed to family physicians in six cities. 22 physicians agreed to participate and focus groups ranged from two to six participants. Questions explored participants' perceptions of and experiences with medical tourism. A coding scheme was created using inductive and deductive codes that captured issues central to analytic themes identified by the investigators. Extracts of the coded data that dealt with informed decision-making were shared among the investigators in order to identify themes. Four themes were identified, all of which dealt with the challenges that medical tourism poses to family physicians' abilities to support medical tourists' informed decision-making. Findings relevant to each theme were contrasted against the existing medical tourism literature so as to assist in understanding their significance. Four key challenges were identified: 1) confusion and tensions related to the regular domestic physician's role in decision-making; 2) tendency to shift responsibility related to healthcare outcomes onto the patient because of the regular domestic physician's reduced role in shared decision-making; 3) strains on the patient-physician relationship and corresponding concern around the responsibility of the foreign physician; and 4) regular domestic physicians' concerns that treatments sought abroad may not be based on the best available medical evidence on treatment efficacy. Medical tourism is creating new challenges for

Ireland's medical brain drain: migration intentions of Irish medical students.

PubMed

Gouda, Pishoy; Kitt, Kevin; Evans, David S; Goggin, Deirdre; McGrath, Deirdre; Last, Jason; Hennessy, Martina; Arnett, Richard; O'Flynn, Siun; Dunne, Fidelma; O'Donovan, Diarmuid

2015-03-12

To provide the optimum level of healthcare, it is important that the supply of well-trained doctors meets the demand. However, despite many initiatives, Ireland continues to have a shortfall of physicians, which has been projected to persist. Our study aimed to investigate the migration intentions of Irish medical students and identify the factors that influence their decisions in order to design appropriate interventions to sustain the supply of trained doctors in order to maintain a viable medical system. An online cross-sectional survey was undertaken of all Irish medical students studying in the Republic of Ireland. The survey included nominal, ordinal, and scale items to determine migration intentions, factors influencing their decisions, and understanding of the Irish healthcare system. A total of 2 273 medical students responded (37% response rate), of whom 1 519 were classified as Irish medical students (having completed secondary school in Ireland). Of these, 88% indicated they were either definitely migrating or contemplating migrating following graduation or completion of the pre-registration intern year. Forty percent expressed an intention of returning to Ireland within 5 years. The factors most influencing their decision to leave were career opportunities (85%), working conditions (83%), and lifestyle (80%). The migration intentions expressed in this study predict an immediate and severe threat to the sustainability of the Irish healthcare service. Urgent interventions such as providing information about career options and specialty training pathways are required. These must begin in the undergraduate phase and continue in postgraduate training and are needed to retain medical school graduates.

Learning and Decision Making in Groups

ERIC Educational Resources Information Center

Rahimian, M. Amin

2017-01-01

Many important real-world decision-making problems involve group interactions among individuals with purely informational interactions. Such situations arise for example in jury deliberations, expert committees, medical diagnoses, etc. We model the purely informational interactions of group members, where they receive private information and act…

[Cost-conscious medical decisions. Normative guidance within the conflicting demands of ethics and economics].

PubMed

Marckmann, G; In der Schmitten, J

2014-05-01

Under the current conditions in the health care system, physicians inevitably have to take responsibility for the cost dimension of their decisions on the level of single cases. This article, therefore, discusses the question how physicians can integrate cost considerations into their clinical decisions at the microlevel in a medically rational and ethically justified way. We propose a four-step model for "ethical cost-consciousness": (1) forego ineffective interventions as required by good evidence-based medicine, (2) respect individual patient preferences, (3) minimize the diagnostic and therapeutic effort to achieve a certain treatment goal, and (4) forego expensive interventions that have only a small or unlikely (net) benefit for the patient. Steps 1-3 are ethically justified by the principles of beneficence, nonmaleficence, and respect for autonomy, step 4 by the principles of justice. For decisions on step 4, explicit cost-conscious guidelines should be developed locally or regionally. Following the four-step model can contribute to ethically defensible, cost-conscious decision-making at the microlevel. In addition, physicians' rationing decisions should meet basic standards of procedural fairness. Regular cost-case discussions and clinical ethics consultation should be available as decision support. Implementing step 4, however, requires first of all a clear political legitimation with the corresponding legal framework.

The Integrated Medical Model: A Risk Assessment and Decision Support Tool for Human Space Flight Missions

NASA Technical Reports Server (NTRS)

Kerstman, Eric L.; Minard, Charles; FreiredeCarvalho, Mary H.; Walton, Marlei E.; Myers, Jerry G., Jr.; Saile, Lynn G.; Lopez, Vilma; Butler, Douglas J.; Johnson-Throop, Kathy A.

2011-01-01

This slide presentation reviews the Integrated Medical Model (IMM) and its use as a risk assessment and decision support tool for human space flight missions. The IMM is an integrated, quantified, evidence-based decision support tool useful to NASA crew health and mission planners. It is intended to assist in optimizing crew health, safety and mission success within the constraints of the space flight environment for in-flight operations. It uses ISS data to assist in planning for the Exploration Program and it is not intended to assist in post flight research. The IMM was used to update Probability Risk Assessment (PRA) for the purpose of updating forecasts for the conditions requiring evacuation (EVAC) or Loss of Crew Life (LOC) for the ISS. The IMM validation approach includes comparison with actual events and involves both qualitative and quantitaive approaches. The results of these comparisons are reviewed. Another use of the IMM is to optimize the medical kits taking into consideration the specific mission and the crew profile. An example of the use of the IMM to optimize the medical kits is reviewed.

The Importance of Nonlinear Transformations Use in Medical Data Analysis.

PubMed

Shachar, Netta; Mitelpunkt, Alexis; Kozlovski, Tal; Galili, Tal; Frostig, Tzviel; Brill, Barak; Marcus-Kalish, Mira; Benjamini, Yoav

2018-05-11

The accumulation of data and its accessibility through easier-to-use platforms will allow data scientists and practitioners who are less sophisticated data analysts to get answers by using big data for many purposes in multiple ways. Data scientists working with medical data are aware of the importance of preprocessing, yet in many cases, the potential benefits of using nonlinear transformations is overlooked. Our aim is to present a semi-automated approach of symmetry-aiming transformations tailored for medical data analysis and its advantages. We describe 10 commonly encountered data types used in the medical field and the relevant transformations for each data type. Data from the Alzheimer's Disease Neuroimaging Initiative study, Parkinson's disease hospital cohort, and disease-simulating data were used to demonstrate the approach and its benefits. Symmetry-targeted monotone transformations were applied, and the advantages gained in variance, stability, linearity, and clustering are demonstrated. An open source application implementing the described methods was developed. Both linearity of relationships and increase of stability of variability improved after applying proper nonlinear transformation. Clustering simulated nonsymmetric data gave low agreement to the generating clusters (Rand value=0.681), while capturing the original structure after applying nonlinear transformation to symmetry (Rand value=0.986). This work presents the use of nonlinear transformations for medical data and the importance of their semi-automated choice. Using the described approach, the data analyst increases the ability to create simpler, more robust and translational models, thereby facilitating the interpretation and implementation of the analysis by medical practitioners. Applying nonlinear transformations as part of the preprocessing is essential to the quality and interpretability of results. ©Netta Shachar, Alexis Mitelpunkt, Tal Kozlovski, Tal Galili, Tzviel Frostig, Barak

78 FR 30331 - Importer of Controlled Substances; Notice of Registration; Meridian Medical Technologies

Federal Register 2010, 2011, 2012, 2013, 2014

2013-05-22

... Registration; Meridian Medical Technologies By Notice dated March 7, 2012, and published in the Federal Register on March 13, 2013, 78 FR 15974, Meridian Medical Technologies, 2555 Hermelin Drive, St. Louis... that the registration of Meridian Medical Technologies to import the basic class of controlled...

A Thin Layer Chromatography Laboratory Experiment of Medical Importance

ERIC Educational Resources Information Center

Sharma, Loretta; Desai, Ankur; Sharma, Ajit

2006-01-01

A thin layer chromatography experiment of medical importance is described. The experiment involves extraction of lipids from simulated amniotic fluid samples followed by separation, detection, and scanning of the lecithin and sphingomyelin bands on TLC plates. The lecithin-to-sphingomyelin ratio is calculated. The clinical significance of this…

Parent Perspectives on the Decision to Initiate Medication Treatment of Attention-Deficit/Hyperactivity Disorder

PubMed Central

Pappadopulos, Elizabeth; Katsiotas, Nikki J.; Berest, Alison; Jensen, Peter S.; Kafantaris, Vivian

2012-01-01

Abstract Objectives Despite substantial evidence supporting the efficacy of stimulant medication for children with attention-deficit/hyperactivity disorder (ADHD), adherence to stimulant treatment is often suboptimal. Applying social/cognitive theories to understanding and assessing parent attitudes toward initiating medication may provide insight into factors influencing parent decisions to follow ADHD treatment recommendations. This report describes results from formative research that used focus groups to obtain parent input to guide development of a provider-delivered intervention to improve adherence to stimulants. Methods Participants were caregivers of children with ADHD who were given a stimulant treatment recommendation. Focus groups were recorded and transcribed verbatim. Data were analyzed by inductive, grounded theory methods as well as a deductive analytic strategy using an adapted version of the Unified Theory of Behavior Change to organize and understand parent accounts. Results Five groups were conducted with 27 parents (mean child age=9.35 years; standard deviation [SD]=2.00), mean time since diagnosis=3.33 years (SD=2.47). Most parents (81.5%) had pursued stimulant treatment. Inductive analysis revealed 17 attitudes facilitating adherence and 25 barriers. Facilitators included parent beliefs that medication treatment resulted in multiple functional gains and that treatment was imperative for their children's safety. Barriers included fears of personality changes and medication side effects. Complex patterns of parent adherence to medication regimens were also identified, as well as preferences for psychiatrists who were diagnostically expert, gave psychoeducation using multiple modalities, and used a chronic illness metaphor to explain ADHD. Theory-based analyses revealed conflicting expectancies about treatment risks and benefits, significant family pressures to avoid medication, guilt and concern that their children required medication, and

Parent perspectives on the decision to initiate medication treatment of attention-deficit/hyperactivity disorder.

PubMed

Coletti, Daniel J; Pappadopulos, Elizabeth; Katsiotas, Nikki J; Berest, Alison; Jensen, Peter S; Kafantaris, Vivian

2012-06-01

Despite substantial evidence supporting the efficacy of stimulant medication for children with attention-deficit/hyperactivity disorder (ADHD), adherence to stimulant treatment is often suboptimal. Applying social/cognitive theories to understanding and assessing parent attitudes toward initiating medication may provide insight into factors influencing parent decisions to follow ADHD treatment recommendations. This report describes results from formative research that used focus groups to obtain parent input to guide development of a provider-delivered intervention to improve adherence to stimulants. Participants were caregivers of children with ADHD who were given a stimulant treatment recommendation. Focus groups were recorded and transcribed verbatim. Data were analyzed by inductive, grounded theory methods as well as a deductive analytic strategy using an adapted version of the Unified Theory of Behavior Change to organize and understand parent accounts. Five groups were conducted with 27 parents (mean child age=9.35 years; standard deviation [SD]=2.00), mean time since diagnosis=3.33 years (SD=2.47). Most parents (81.5%) had pursued stimulant treatment. Inductive analysis revealed 17 attitudes facilitating adherence and 25 barriers. Facilitators included parent beliefs that medication treatment resulted in multiple functional gains and that treatment was imperative for their children's safety. Barriers included fears of personality changes and medication side effects. Complex patterns of parent adherence to medication regimens were also identified, as well as preferences for psychiatrists who were diagnostically expert, gave psychoeducation using multiple modalities, and used a chronic illness metaphor to explain ADHD. Theory-based analyses revealed conflicting expectancies about treatment risks and benefits, significant family pressures to avoid medication, guilt and concern that their children required medication, and distorted ideas about treatment risks

[The Role and Function of Informatics Nurses in Information Technology Decision-Making].

PubMed

Lee, Tso-Ying

2017-08-01

The medical environment has changed greatly with the coming of the information age, and, increasingly, the operating procedures for medical services have been altered in keeping with the trend toward mobile, paperless services. Informatization has the potential to improve the working efficiency of medical personnel, enhance patient care safety, and give medical organizations a positive image. Informatics nurses play an important role in the decision-making processes that accompany informatization. As one of the decision-making links in the information technology lifecycle, this role affects the success of the development and operation of information systems. The present paper examines the functions and professional knowledge that informatics nurses must possess during the technology lifecycle, the four stages of which include: planning, analysis, design/development/revision, and implementation/assessment/support/maintenance. The present paper further examines the decision-making shortcomings and errors that an informatics nurses may make during the decision-making process. We hope that this paper will serve as an effective and useful reference for informatics nurses during the informatization decision-making process.

[Decision analysis--a novel approach for calculating the cost-efficiency of medical tests].

PubMed

Becher, J

2008-09-01

Before issuing an insurance policy (e.g. life, disability, critical illness), insurers will usually carry out a medical risk assessment in order to prevent adverse selection. Often, the health questions in the application form will not be sufficient for this purpose since most applicants are not well-versed in medical science and terminology. If the insurer needs additional medical information such as a private medical attendant's report or current laboratory tests, however, costs will be incurred, which usually have to be paid by the insurer. What is the minimum sum insured which makes it worthwhile for the insurer to conduct certain screening tests, for example? Both the costs of medical screening and the associated savings are difficult to measure and involve a variety of different factors. Moreover, most parameters can only be estimated with limited accuracy. Therefore, we have developed a new calculation model using a decision-analysis approach. The new model makes it possible to analyse complex situations while taking into account the uncertainty of parameter estimation. Our findings show that in Germany, for instance, current sum thresholds for older applicants could in many cases be lowered and would still be cost-effective.

77 FR 31388 - Importer of Controlled Substances; Notice of Registration; Meridian Medical Technologies

Federal Register 2010, 2011, 2012, 2013, 2014

2012-05-25

... Registration; Meridian Medical Technologies By Notice dated March 23, 2012, and published in the Federal Register on April 2, 2012, 77 FR 19716, Meridian Medical Technologies, 2555 Hermelin Drive, St. Louis...) and 952(a), and determined that the registration of Meridian Medical Technologies to import the basic...

The science of medical decision making: neurosurgery, errors, and personal cognitive strategies for improving quality of care.

PubMed

Fargen, Kyle M; Friedman, William A

2014-01-01

During the last 2 decades, there has been a shift in the U.S. health care system towards improving the quality of health care provided by enhancing patient safety and reducing medical errors. Unfortunately, surgical complications, patient harm events, and malpractice claims remain common in the field of neurosurgery. Many of these events are potentially avoidable. There are an increasing number of publications in the medical literature in which authors address cognitive errors in diagnosis and treatment and strategies for reducing such errors, but these are for the most part absent in the neurosurgical literature. The purpose of this article is to highlight the complexities of medical decision making to a neurosurgical audience, with the hope of providing insight into the biases that lead us towards error and strategies to overcome our innate cognitive deficiencies. To accomplish this goal, we review the current literature on medical errors and just culture, explain the dual process theory of cognition, identify common cognitive errors affecting neurosurgeons in practice, review cognitive debiasing strategies, and finally provide simple methods that can be easily assimilated into neurosurgical practice to improve clinical decision making. Copyright © 2014 Elsevier Inc. All rights reserved.

Emerging medical informatics with case-based reasoning for aiding clinical decision in multi-agent system.

PubMed

Shen, Ying; Colloc, Joël; Jacquet-Andrieu, Armelle; Lei, Kai

2015-08-01

This research aims to depict the methodological steps and tools about the combined operation of case-based reasoning (CBR) and multi-agent system (MAS) to expose the ontological application in the field of clinical decision support. The multi-agent architecture works for the consideration of the whole cycle of clinical decision-making adaptable to many medical aspects such as the diagnosis, prognosis, treatment, therapeutic monitoring of gastric cancer. In the multi-agent architecture, the ontological agent type employs the domain knowledge to ease the extraction of similar clinical cases and provide treatment suggestions to patients and physicians. Ontological agent is used for the extension of domain hierarchy and the interpretation of input requests. Case-based reasoning memorizes and restores experience data for solving similar problems, with the help of matching approach and defined interfaces of ontologies. A typical case is developed to illustrate the implementation of the knowledge acquisition and restitution of medical experts. Copyright © 2015 Elsevier Inc. All rights reserved.

MEDICAL AND LEGAL ISSUES OF THE DECISIONS RENDERED BY THE EUROPEAN COURT OF HUMAN RIGHTS.

PubMed

Chakhvadze, B; Chakhvadze, G

2017-01-01

The European Convention on Human rights is a document that protects human rights and fundamental freedoms of individuals, and the European Court of Human Rights and its case-law makes a convention a powerful instrument to meet the new challenges of modernity and protect the principles of rule of law and democracy. This is important, particularly for young democracies, including Georgia. The more that Georgia is a party to this convention. Article 3 of the convention deals with torture, inhuman and degrading treatment, while article 8 deals with private life, home and correspondence. At the same time, the international practice of the European court of human rights shows that these articles are often used with regard to medical rights. The paper highlights the most recent and interesting cases from the case-law of the ECHR, in which the courts conclusions are based solely on the European Convention on Human Rights. In most instances, the European Court of Human Rights uses the principle of democracy with regard to medical rights. The European court of human rights considers medical rights as moral underpinning rights. Particularly in every occasion, the European Court of Human Rights acknowledges an ethical dimension of these rights. In most instances, it does not matter whether a plaintiff is a free person or prisoner, the European court of human rights make decisions based on fundamental human rights and freedoms of individuals.

From complex questionnaire and interviewing data to intelligent Bayesian Network models for medical decision support

PubMed Central

Constantinou, Anthony Costa; Fenton, Norman; Marsh, William; Radlinski, Lukasz

2016-01-01

Objectives 1) To develop a rigorous and repeatable method for building effective Bayesian network (BN) models for medical decision support from complex, unstructured and incomplete patient questionnaires and interviews that inevitably contain examples of repetitive, redundant and contradictory responses; 2) To exploit expert knowledge in the BN development since further data acquisition is usually not possible; 3) To ensure the BN model can be used for interventional analysis; 4) To demonstrate why using data alone to learn the model structure and parameters is often unsatisfactory even when extensive data is available. Method The method is based on applying a range of recent BN developments targeted at helping experts build BNs given limited data. While most of the components of the method are based on established work, its novelty is that it provides a rigorous consolidated and generalised framework that addresses the whole life-cycle of BN model development. The method is based on two original and recent validated BN models in forensic psychiatry, known as DSVM-MSS and DSVM-P. Results When employed with the same datasets, the DSVM-MSS demonstrated competitive to superior predictive performance (AUC scores 0.708 and 0.797) against the state-of-the-art (AUC scores ranging from 0.527 to 0.705), and the DSVM-P demonstrated superior predictive performance (cross-validated AUC score of 0.78) against the state-of-the-art (AUC scores ranging from 0.665 to 0.717). More importantly, the resulting models go beyond improving predictive accuracy and into usefulness for risk management purposes through intervention, and enhanced decision support in terms of answering complex clinical questions that are based on unobserved evidence. Conclusions This development process is applicable to any application domain which involves large-scale decision analysis based on such complex information, rather than based on data with hard facts, and in conjunction with the incorporation of

From complex questionnaire and interviewing data to intelligent Bayesian network models for medical decision support.

PubMed

Constantinou, Anthony Costa; Fenton, Norman; Marsh, William; Radlinski, Lukasz

2016-02-01

(1) To develop a rigorous and repeatable method for building effective Bayesian network (BN) models for medical decision support from complex, unstructured and incomplete patient questionnaires and interviews that inevitably contain examples of repetitive, redundant and contradictory responses; (2) To exploit expert knowledge in the BN development since further data acquisition is usually not possible; (3) To ensure the BN model can be used for interventional analysis; (4) To demonstrate why using data alone to learn the model structure and parameters is often unsatisfactory even when extensive data is available. The method is based on applying a range of recent BN developments targeted at helping experts build BNs given limited data. While most of the components of the method are based on established work, its novelty is that it provides a rigorous consolidated and generalised framework that addresses the whole life-cycle of BN model development. The method is based on two original and recent validated BN models in forensic psychiatry, known as DSVM-MSS and DSVM-P. When employed with the same datasets, the DSVM-MSS demonstrated competitive to superior predictive performance (AUC scores 0.708 and 0.797) against the state-of-the-art (AUC scores ranging from 0.527 to 0.705), and the DSVM-P demonstrated superior predictive performance (cross-validated AUC score of 0.78) against the state-of-the-art (AUC scores ranging from 0.665 to 0.717). More importantly, the resulting models go beyond improving predictive accuracy and into usefulness for risk management purposes through intervention, and enhanced decision support in terms of answering complex clinical questions that are based on unobserved evidence. This development process is applicable to any application domain which involves large-scale decision analysis based on such complex information, rather than based on data with hard facts, and in conjunction with the incorporation of expert knowledge for decision support

Chapter 3: choosing the important outcomes for a systematic review of a medical test.

PubMed

Segal, Jodi B

2012-06-01

In this chapter of the Evidence-based Practice Centers Methods Guide for Medical Tests, we describe how the decision to use a medical test generates a broad range of outcomes and that each of these outcomes should be considered for inclusion in a systematic review. Awareness of these varied outcomes affects how a decision maker balances the benefits and risks of the test; therefore, a systematic review should present the evidence on these diverse outcomes. The key outcome categories include clinical management outcomes and direct health effects; emotional, social, cognitive, and behavioral responses to testing; legal and ethical outcomes, and costs. We describe the challenges of incorporating these outcomes in a systematic review, suggest a framework for generating potential outcomes for inclusion, and describe the role of stakeholders in choosing the outcomes for study. Finally, we give examples of systematic reviews that either included a range of outcomes or that might have done so. The following are the key messages in this chapter: Consider both the outcomes that are relevant to the process of testing and those that are relevant to the results of the test. Consider inclusion of outcomes in all five domains: clinical management effects, direct test effects; emotional, social, cognitive and behavioral effects; legal and ethical effects, and costs. Consider to which group the outcomes of testing are most relevant. Given resource limitations, prioritize which outcomes to include. This decision depends on the needs of the stakeholder(s), who should be assisted in prioritizing the outcomes for inclusion.

Assessment and importance of personality disorders in medical patients: an update.

PubMed

Dhossche, D M; Shevitz, S A

1999-06-01

Personality disorders in medical patients have received less attention than depression, anxiety, or somatization. We conducted a selective literature search to assess the role of personality disorders in medical patients. Review of recent studies suggests a high prevalence and morbidity of personality disorders in medical populations. Important correlates in selected groups are depression, somatization, noncompliance, sexual risk taking, and substance abuse. Difficulties in physician-patient relationships are also frequently reported. Psychiatric interventions are considered beneficial, though no single treatment of choice is available. We recommend that physicians consider the possibility of personality disorders in medical patients to choose appropriate treatments for selected symptoms. Training in interviewing skills may enhance recognition of personality disorders and management of associated psychiatric conditions.

Parental decision-making for medically complex infants and children: an integrated literature review.

PubMed

Allen, Kimberly A

2014-09-01

Many children with life-threatening conditions who would have died at birth are now surviving months to years longer than previously expected. Understanding how parents make decisions is necessary to prevent parental regret about decision-making, which can lead to psychological distress, decreased physical health, and decreased quality of life for the parents. The aim of this integrated literature review was to describe possible factors that affect parental decision-making for medically complex children. The critical decisions included continuation or termination of a high-risk pregnancy, initiation of life-sustaining treatments such as resuscitation, complex cardiothoracic surgery, use of experimental treatments, end-of-life care, and limitation of care or withdrawal of support. PubMed, Cumulative Index of Nursing and Allied Health Literature, and PsycINFO were searched using the combined key terms 'parents and decision-making' to obtain English language publications from 2000 to June 2013. The findings from each of the 31 articles retained were recorded. The strengths of the empirical research reviewed are that decisions about initiating life support and withdrawing life support have received significant attention. Researchers have explored how many different factors impact decision-making and have used multiple different research designs and data collection methods to explore the decision-making process. These initial studies lay the foundation for future research and have provided insight into parental decision-making during times of crisis. Studies must begin to include both parents and providers so that researchers can evaluate how decisions are made for individual children with complex chronic conditions to understand the dynamics between parents and parent-provider relationships. The majority of studies focused on one homogenous diagnostic group of premature infants and children with complex congenital heart disease. Thus comparisons across other child

“Do your homework…and then hope for the best”: the challenges that medical tourism poses to Canadian family physicians’ support of patients’ informed decision-making

PubMed Central

2013-01-01

Background Medical tourism—the practice where patients travel internationally to privately access medical care—may limit patients’ regular physicians’ abilities to contribute to the informed decision-making process. We address this issue by examining ways in which Canadian family doctors’ typical involvement in patients’ informed decision-making is challenged when their patients engage in medical tourism. Methods Focus groups were held with family physicians practicing in British Columbia, Canada. After receiving ethics approval, letters of invitation were faxed to family physicians in six cities. 22 physicians agreed to participate and focus groups ranged from two to six participants. Questions explored participants’ perceptions of and experiences with medical tourism. A coding scheme was created using inductive and deductive codes that captured issues central to analytic themes identified by the investigators. Extracts of the coded data that dealt with informed decision-making were shared among the investigators in order to identify themes. Four themes were identified, all of which dealt with the challenges that medical tourism poses to family physicians’ abilities to support medical tourists’ informed decision-making. Findings relevant to each theme were contrasted against the existing medical tourism literature so as to assist in understanding their significance. Results Four key challenges were identified: 1) confusion and tensions related to the regular domestic physician’s role in decision-making; 2) tendency to shift responsibility related to healthcare outcomes onto the patient because of the regular domestic physician’s reduced role in shared decision-making; 3) strains on the patient-physician relationship and corresponding concern around the responsibility of the foreign physician; and 4) regular domestic physicians’ concerns that treatments sought abroad may not be based on the best available medical evidence on treatment

Contemporary evidence-based practice in Canadian emergency medical services: a vision for integrating evidence into clinical and policy decision-making.

PubMed

Jensen, Jan L; Travers, Andrew H

2017-05-01

Nationally, emphasis on the importance of evidence-based practice (EBP) in emergency medicine and emergency medical services (EMS) has continuously increased. However, meaningful incorporation of effective and sustainable EBP into clinical and administrative decision-making remains a challenge. We propose a vision for EBP in EMS: Canadian EMS clinicians and leaders will understand and use the best available evidence for clinical and administrative decision-making, to improve patient health outcomes, the capability and quality of EMS systems of care, and safety of patients and EMS professionals. This vision can be implemented with the use of a structure, process, system, and outcome taxonomy to identify current barriers to true EBP, to recognize the opportunities that exist, and propose corresponding recommended strategies for local EMS agencies and at the national level. Framing local and national discussions with this approach will be useful for developing a cohesive and collaborative Canadian EBP strategy.

The medically important aerobic actinomycetes: epidemiology and microbiology.

PubMed Central

McNeil, M M; Brown, J M

1994-01-01

The aerobic actinomycetes are soil-inhabiting microorganisms that occur worldwide. In 1888, Nocard first recognized the pathogenic potential of this group of microorganisms. Since then, several aerobic actinomycetes have been a major source of interest for the commercial drug industry and have proved to be extremely useful microorganisms for producing novel antimicrobial agents. They have also been well known as potential veterinary pathogens affecting many different animal species. The medically important aerobic actinomycetes may cause significant morbidity and mortality, in particular in highly susceptible severely immunocompromised patients, including transplant recipients and patients infected with human immunodeficiency virus. However, the diagnosis of these infections may be difficult, and effective antimicrobial therapy may be complicated by antimicrobial resistance. The taxonomy of these microorganisms has been problematic. In recent revisions of their classification, new pathogenic species have been recognized. The development of additional and more reliable diagnostic tests and of a standardized method for antimicrobial susceptibility testing and the application of molecular techniques for the diagnosis and subtyping of these microorganisms are needed to better diagnose and treat infected patients and to identify effective control measures for these unusual pathogens. We review the epidemiology and microbiology of the major medically important aerobic actinomycetes. Images PMID:7923055

A survey of decision tree classifier methodology

NASA Technical Reports Server (NTRS)

Safavian, S. R.; Landgrebe, David

1991-01-01

Decision tree classifiers (DTCs) are used successfully in many diverse areas such as radar signal classification, character recognition, remote sensing, medical diagnosis, expert systems, and speech recognition. Perhaps the most important feature of DTCs is their capability to break down a complex decision-making process into a collection of simpler decisions, thus providing a solution which is often easier to interpret. A survey of current methods is presented for DTC designs and the various existing issues. After considering potential advantages of DTCs over single-state classifiers, subjects of tree structure design, feature selection at each internal node, and decision and search strategies are discussed.

A survey of decision tree classifier methodology

NASA Technical Reports Server (NTRS)

Safavian, S. Rasoul; Landgrebe, David

1990-01-01

Decision Tree Classifiers (DTC's) are used successfully in many diverse areas such as radar signal classification, character recognition, remote sensing, medical diagnosis, expert systems, and speech recognition. Perhaps, the most important feature of DTC's is their capability to break down a complex decision-making process into a collection of simpler decisions, thus providing a solution which is often easier to interpret. A survey of current methods is presented for DTC designs and the various existing issue. After considering potential advantages of DTC's over single stage classifiers, subjects of tree structure design, feature selection at each internal node, and decision and search strategies are discussed.

Beyond Bioethics: A Child Rights-Based Approach to Complex Medical Decision-Making.

PubMed

Wade, Katherine; Melamed, Irene; Goldhagen, Jeffrey

2016-01-01

This analysis adopts a child rights approach-based on the principles, standards, and norms of child rights and the U.N. Convention on the Rights of the Child (CRC)-to explore how decisions could be made with regard to treatment of a severely impaired infant (Baby G). While a child rights approach does not provide neat answers to ethically complex issues, it does provide a framework for decision-making in which the infant is viewed as an independent rights-holder. The state has obligations to develop the capacity of those who make decisions for infants in such situations to meet their obligations to respect, protect, and fulfill their rights as delineated in the CRC. Furthermore, a child rights approach requires procedural clarity and transparency in decision-making processes. As all rights in the CRC are interdependent and indivisible, all must be considered in the process of ethical decision-making, and the reasons for decisions must be delineated by reference to how these rights were considered. It is also important that decisions that are made in this context be monitored and reviewed to ensure consistency. A rights-based framework ensures decision-making is child-centered and that there are transparent criteria and legitimate procedures for making decisions regarding the child's most basic human right: the right to life, survival, and development.

[Plea for more attention to the importance of gender during medical training].

PubMed

de Kroon, C D; Scheele, F

2008-10-04

Gender is an important factor in disease and health. Male and female patients with the same disease may present with different complaints. This is especially true in cardiology. Basic medical training should specifically address this topic. Moreover, the gender of the physician is an important factor in patient care. Physicians are unaware of the influence of their gender on their performance. Reflective practice is an essential educational tool in modern specialist training. As medical specialist training in The Netherlands is being modernized at present, this may be the perfect time for physicians to become aware of their gender and its impact on their performance. This will improve medical care for both male and female patients by male and female doctors.

[The growing importance of ethics in medical care and research].

PubMed

Sass, Hans-Martin

2009-01-01

The integration of medical humanities into future patient care and medical research will become as importance for trust, care and health as the natural sciences were during the last 100 years. In particular, improvements of lay health literacy and responsibility, new forms of physician-nurse partnership and expert-lay interaction, also revisions of clinical research towards models of informed contract will improve trust and health on a global scale, allow for healthier and happier citizens and populations and eventually might reduce health care costs.

Semantics-based plausible reasoning to extend the knowledge coverage of medical knowledge bases for improved clinical decision support.

PubMed

Mohammadhassanzadeh, Hossein; Van Woensel, William; Abidi, Samina Raza; Abidi, Syed Sibte Raza

2017-01-01

Capturing complete medical knowledge is challenging-often due to incomplete patient Electronic Health Records (EHR), but also because of valuable, tacit medical knowledge hidden away in physicians' experiences. To extend the coverage of incomplete medical knowledge-based systems beyond their deductive closure, and thus enhance their decision-support capabilities, we argue that innovative, multi-strategy reasoning approaches should be applied. In particular, plausible reasoning mechanisms apply patterns from human thought processes, such as generalization, similarity and interpolation, based on attributional, hierarchical, and relational knowledge. Plausible reasoning mechanisms include inductive reasoning , which generalizes the commonalities among the data to induce new rules, and analogical reasoning , which is guided by data similarities to infer new facts. By further leveraging rich, biomedical Semantic Web ontologies to represent medical knowledge, both known and tentative, we increase the accuracy and expressivity of plausible reasoning, and cope with issues such as data heterogeneity, inconsistency and interoperability. In this paper, we present a Semantic Web-based, multi-strategy reasoning approach, which integrates deductive and plausible reasoning and exploits Semantic Web technology to solve complex clinical decision support queries. We evaluated our system using a real-world medical dataset of patients with hepatitis, from which we randomly removed different percentages of data (5%, 10%, 15%, and 20%) to reflect scenarios with increasing amounts of incomplete medical knowledge. To increase the reliability of the results, we generated 5 independent datasets for each percentage of missing values, which resulted in 20 experimental datasets (in addition to the original dataset). The results show that plausibly inferred knowledge extends the coverage of the knowledge base by, on average, 2%, 7%, 12%, and 16% for datasets with, respectively, 5%, 10%, 15

Medical Decisions of Pediatric Residents Turn Riskier after a 24-Hour Call with No Sleep.

PubMed

Aran, Adi; Wasserteil, Netanel; Gross, Itai; Mendlovic, Joseph; Pollak, Yehuda

2017-01-01

Despite a gradual reduction in the workload during residency, 24-hour calls are still an integral part of most training programs. While sleep deprivation increases the risk propensity, the impact on medical risk taking has not been studied. This study aimed to assess the clinical decision making and psychomotor performance of pediatric residents following a limited nap time during a 24-hour call. A neurocognitive battery (IntegNeuro) and a medical decision questionnaire were completed by 44 pediatric residents at 2 time points: after a 24-hour call and following 3 nights with no calls (sleep ≥5 hours). To monitor sleep, residents wore actigraphs and completed sleep logs. Nap time during the shift was <1 hour in 14 cases (32%), 1 to 2 hours in 16 cases (35%), and 2 to 3 hours in 14 cases (32%). Residents who napped less than 1 hour chose the riskier medical option in 50% of cases compared with 36% when answering the same questionnaire after 3 nights with no calls (P = 0.002). This effect was not found in residents who napped 1 to 2 hours (no change in risk taking) or 2 to 3 hours (4% decreased risk taking) (difference between groups, P = 0.001). Risk-taking tendency inversely correlated with sustained attention scores (Pearson = -0.433, P = 0.003). Sustained attention was the neurocognitive domain most affected by sleep deprivation (effect size = 0.29, P = 0.025). This study suggests that residents napping less than an hour during a night shift are prone to riskier clinical decisions. Hence, enabling residents to nap at least 1 hour during shifts is recommended. © The Author(s) 2016.

Why teaching empathy is important for the medical degree.

PubMed

Díez-Goñi, N; Rodríguez-Díez, M C

Empathy is a basic skill in the exercise of medicine and increases patient and physician satisfaction and improves clinical results. However, the teaching of empathy is poorly covered in the teaching plans. A number of studies have observed a reduction in empathy during the final training courses. The reasons for this decline include, the students' excessive academic workload, the prioritisation of acquiring medical expertise over humanistic knowledge, the patient load in hospitals and health centres and the physicians' need to distance themselves from their patients. Nevertheless, intervention studies through simulation with standardised patients have shown an increase in empathy in students, which can be evaluated through the Jefferson scales: JSE-S and JSPPPE. The teaching of empathy to medical students is an important commitment in the curricular programs of medical schools. Copyright © 2017 Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI). All rights reserved.

Impact of discharge planning decision support on time to readmission among older adult medical patients.

PubMed

Bowles, Kathryn H; Hanlon, Alexandra; Holland, Diane; Potashnik, Sheryl L; Topaz, Maxim

2014-01-01

Hospital clinicians are overwhelmed with the volume of patients churning through the health care systems. The study purpose was to determine whether alerting case managers about high-risk patients by supplying decision support results in better discharge plans as evidenced by time to first hospital readmission. Four medical units at one urban, university medical center. A quasi-experimental study including a usual care and experimental phase with hospitalized English-speaking patients aged 55 years and older. The intervention included using an evidence-based screening tool, the Discharge Decision Support System (D2S2), that supports clinicians' discharge referral decision making by identifying high-risk patients upon admission who need a referral for post-acute care. The usual care phase included collection of the D2S2 information, but not sharing the information with case managers. The experimental phase included data collection and then sharing the results with the case managers. The study compared time to readmission between index discharge date and 30 and 60 days in patients in both groups (usual care vs. experimental). After sharing the D2S2 results, the percentage of referral or high-risk patients readmitted by 30 and 60 days decreased by 6% and 9%, respectively, representing a 26% relative reduction in readmissions for both periods. Supplying decision support to identify high-risk patients recommended for postacute referral is associated with better discharge plans as evidenced by an increase in time to first hospital readmission. The tool supplies standardized information upon admission allowing more time to work with high-risk admissions.

Teaching Medical Students the Important Connection between Communication and Clinical Reasoning

PubMed Central

Windish, Donna M; Price, Eboni G; Clever, Sarah L; Magaziner, Jeffrey L; Thomas, Patricia A

2005-01-01

Background Medical students are rarely taught how to integrate communication and clinical reasoning. Not understanding the relation between these skills may lead students to undervalue the connection between psychosocial and biomedical aspects of patient care. Objective To improve medical students' communication and clinical reasoning and their appreciation of how these skills interrelate in medical practice. Design In 2003, we conducted a randomized trial of a curricular intervention at Johns Hopkins University School of Medicine. In a 6-week course, participants learned communication and clinical reasoning skills in an integrative fashion using small group exercises with role-play, reflection and feedback through a structured iterative reflective process. Participants Second-year medical students. Measurements All students interviewed standardized patients who evaluated their communication skills in establishing rapport, data gathering and patient education/counseling on a 5-point scale (1=poor; 5=excellent). We assessed clinical reasoning through the number of correct problems listed and differential diagnoses generated and the Diagnostic Thinking Inventory. Students rated the importance of learning these skills in an integrated fashion. Results Standardized patients rated curricular students more favorably in establishing rapport (4.1 vs 3.9; P=.05). Curricular participants listed more psychosocial history items on their problem lists (65% of curricular students listing ≥1 item vs 44% of controls; P=.008). Groups did not differ significantly in other communication or clinical reasoning measures. Ninety-five percent of participants rated the integration of these skills as important. Conclusions Intervention students performed better in certain communication and clinical reasoning skills. These students recognized the importance of biomedical and psychosocial issues in patient care. Educators may wish to teach the integration of these skills early in medical

Protecting medical data for decision-making analyses.

PubMed

Brumen, Bostjan; Welzer, Tatjana; Druzovec, Marjan; Golob, Izidor; Jaakkola, Hannu; Rozman, Ivan; Kubalík, Jiri

2005-02-01

In this paper, we present a procedure for data protection, which can be applied before any model building based analyses are performed. In medical environments, abundant data exist, but because of the lack of knowledge, they are rarely analyzed, although they hide valuable and often life-saving knowledge. To be able to analyze the data, the analyst needs to have a full access to the relevant sources, but this may be in the direct contradiction with the demand that data remain secure, and more importantly in medical area, private. This is especially the case if the data analyst is outsourced and not directly affiliated with the data owner. We address this issue and propose a solution where the model-building process is still possible while data are better protected. We consider the case where the distributions of original data values are preserved while the values themselves change, so that the resulting model is equivalent to the one built with original data.

A survey of views and practice patterns of dialysis medical directors toward end-of-life decision making for patients with end-stage renal disease.

PubMed

Fung, Enrica; Slesnick, Nate; Kurella Tamura, Manjula; Schiller, Brigitte

2016-07-01

Patients with end-stage renal disease report infrequent end-of-life discussions, and nephrology trainees report feeling unprepared for end-of-life decision making, but the views of dialysis medical directors have not been studied. Our objective is to understand dialysis medical directors' views and practice patterns on end-of-life decision making for patients with ESRD. We administered questionnaires to dialysis medical directors during medical director meetings of three different dialysis organizations in 2013. Survey questions corresponded to recommendations from the Renal Physicians Association clinical practice guidelines on initiation and withdrawal of dialysis. There were 121 medical director respondents from 28 states. The majority of respondents felt "very prepared" (66%) or "somewhat prepared" (29%) to participate in end-of-life decisions and most (80%) endorsed a model of shared decision making. If asked to do so, 70% of the respondents provided prognostic information "often" or "nearly always." For patients with a poor prognosis, 36% of respondents would offer a time-limited trial of dialysis "often" or "nearly always", while 56% of respondents would suggest withdrawal from dialysis "often" or "nearly always" for those with a poor prognosis currently receiving dialysis therapy. Patient resistance and fear of taking away hope were the most commonly cited barriers to end-of-life discussions. Views and reported practice patterns of medical directors are consistent with clinical practice guidelines for end-of-life decision making for patients with end-stage renal disease but inconsistent with patient perceptions. © The Author(s) 2016.

Exploring Oral Cancer Patients' Preference in Medical Decision Making and Quality of Life.

PubMed

Cheng, Sun-Long; Liao, Hsien-Hua; Shueng, Pei-Wei; Lee, Hsi-Chieh; Cheewakriangkrai, Chalong; Chang, Chi-Chang

2017-01-01

Little is known about the clinical effects of shared medical decision making (SMDM) associated with quality of life about oral cancer? To understand patients who occurred potential cause of SMDM and extended to explore the interrelated components of quality of life for providing patients with potential adaptation of early assessment. All consenting patients completed the SMDM questionnaire and 36-Item Short Form (SF-36). Regression analyses were conducted to find predictors of quality of life among oral cancer patients. The proposed model predicted 57.4% of the variance in patients' SF-36 Mental Component scores. Patient mental component summary scores were associated with smoking habit (β=-0.3449, p=0.022), autonomy (β=-0.226, p=0.018) and Control preference (β=-0.388, p=0.007). The proposed model predicted 42.6% of the variance in patients' SF-36 Physical component scores. Patient physical component summary scores were associated with higher education (β=0.288, p=0.007), employment status (β=-0.225, p=0.033), involvement perceived (β=-0.606, p=0.011) and Risk communication (β=-0.558, p=0.019). Future research is necessary to determine whether oral cancer patients would benefit from early screening and intervention to address shared medical decision making.

Re-Thinking the Role of the Family in Medical Decision-Making.

PubMed

Cherry, Mark J

2015-08-01

This paper challenges the foundational claim that the human family is no more than a social construction. It advances the position that the family is a central category of experience, being, and knowledge. Throughout, the analysis argues for the centrality of the family for human flourishing and, consequently, for the importance of sustaining (or reestablishing) family-oriented practices within social policy, such as more family-oriented approaches to consent to medical treatment. Where individually oriented approaches to medical decision-making accent an ethos of isolated personal autonomy family-oriented approaches acknowledge the central social and moral reality of the family. I argue that the family ought to be appreciated as more than a mere network of personal relations and individual undertakings; the family possesses a being that is social and moral such that it realizes a particular structure of human good and sustains the necessary conditions for core areas of human flourishing. Moreover, since the family exists as a nexus of face-to-face relationships, the consent of persons, including adults, to be members of a particular family, subject to its own respective account of family sovereignty, is significantly more amply demonstrated than the consent of citizens to be under the authority of a particular state. As a result, in the face of a general Western bioethical affirmation of the autonomy of individuals, as if adults and children were morally and socially isolated agents, this paper argues that social space must nevertheless be made for families to choose on behalf of their own members. © The Author 2015. Published by Oxford University Press, on behalf of the Journal of Medicine and Philosophy Inc. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

The potential for intelligent decision support systems to improve the quality and consistency of medication reviews.

PubMed

Bindoff, I; Stafford, A; Peterson, G; Kang, B H; Tenni, P

2012-08-01

Drug-related problems (DRPs) are of serious concern worldwide, particularly for the elderly who often take many medications simultaneously. Medication reviews have been demonstrated to improve medication usage, leading to reductions in DRPs and potential savings in healthcare costs. However, medication reviews are not always of a consistently high standard, and there is often room for improvement in the quality of their findings. Our aim was to produce computerized intelligent decision support software that can improve the consistency and quality of medication review reports, by helping to ensure that DRPs relevant to a patient are overlooked less frequently. A system that largely achieved this goal was previously published, but refinements have been made. This paper examines the results of both the earlier and newer systems. Two prototype multiple-classification ripple-down rules medication review systems were built, the second being a refinement of the first. Each of the systems was trained incrementally using a human medication review expert. The resultant knowledge bases were analysed and compared, showing factors such as accuracy, time taken to train, and potential errors avoided. The two systems performed well, achieving accuracies of approximately 80% and 90%, after being trained on only a small number of cases (126 and 244 cases, respectively). Through analysis of the available data, it was estimated that without the system intervening, the expert training the first prototype would have missed approximately 36% of potentially relevant DRPs, and the second 43%. However, the system appeared to prevent the majority of these potential expert errors by correctly identifying the DRPs for them, leaving only an estimated 8% error rate for the first expert and 4% for the second. These intelligent decision support systems have shown a clear potential to substantially improve the quality and consistency of medication reviews, which should in turn translate into

The impact of mass media health communication on health decision-making and medical advice-seeking behavior of u.s. Hispanic population.

PubMed

De Jesus, Maria

2013-01-01

Mass media health communication has enormous potential to drastically alter how health-related information is disseminated and obtained by different populations. However, there is little evidence regarding the influence of media channels on health decision-making and medical advice-seeking behaviors among the Hispanic population. The Pew 2007 Hispanic Healthcare Survey was used to test the hypothesis that the amount of mass media health communication (i.e., quantity of media-based health information received) is more likely to influence Hispanic adults' health decision-making and medical advice-seeking behavior compared to health literacy and language proficiency variables. Results indicated that quantity of media-based health information is positively associated with health decision-making and medical advice-seeking behavior above and beyond the influence of health literacy and English and Spanish language proficiency. In a context where physician-patient dynamics are increasingly shifting from a passive patient role model to a more active patient role model, media-based health information can serve as an influential cue to action, prompting Hispanic individuals to make certain health-related decisions and to seek more health advice and information from a health provider. Study implications are discussed.

Recovery of medically important microorganisms from Apollo astronauts

NASA Technical Reports Server (NTRS)

Taylor, G. R.

1974-01-01

Microbiological samples were obtained from the crewmembers of the Apollo 13, 14, 15, 16, and 17 spaceflights. These specimens were analyzed for the presence of medically important microorganisms with Staphylococcus aureus, Pseudomonas aeruginosa, Tricophyton mentagrophytes, Tricophyton rubrum, and Candida albicans being discussed in detail. Preflight isolation of crewmembers was found to coincide with a complete absence of inflight disease events and is recommended for future spaceflights. No autoinfection response (microbial shock) occurred after any of the reported spaceflights.

Evaluation of EMERGE, a Medical Decision Making Aid for Analysis of Chest Pain

PubMed Central

Hudson, Donna L.; Cohen, Moses E.; Deedwania, Prakash C.; Watson, Patricia E.

1983-01-01

EMERGE, a rule-based medical decision making aid for analysis of chest pain in the emergency room, was evaluated using retrospective patient data. The analysis consisted of two phases. In the initial phase, patient cases were run in order to make minor modifications and adjustments in the criteria used for determination of admission. In the second phase, patient cases were analyzed to determine the effectiveness of the EMERGE system in arriving at the proper conclusion.

A Case Study of Career Emegency Medical Technicians: Factors That Influenced Their Decision to Stay

ERIC Educational Resources Information Center

Miller, Denine V.

2013-01-01

This case study (Stake, 1995) examined the perceptions of long-term Emergency Medical Technicians (EMTs) to identify factors influencing their decision to remain employed as EMTs for the duration of a career. EMT retention plans frequently utilize data from either employee exit interviews or workers with intent to leave, and since privacy law…

[Computing in medical practice].

PubMed

Wechsler, Rudolf; Anção, Meide S; de Campos, Carlos José Reis; Sigulem, Daniel

2003-05-01

Currently, information technology is part of several aspects of our daily life. The objective of this paper is to analyze and discuss the use of information technology in both medical education and/or medical practice. Information was gathered through non-systematic bibliographic review, including articles, official regulations, book chapters and annals. Direct search and search of electronic databanks in Medline and Lilacs databases were also performed. This paper was structured in topics. First, there is a discussion on the electronic medical record. The following aspects are presented: history, functions, costs, benefits, ethical and legal issues, and positive and negative characteristics. Medical decision-support systems are also evaluated in view of the huge amount of information produced every year regarding healthcare. The impact of the Internet on the production and diffusion of knowledge is also analyzed. Telemedicine is assessed, since it presents new challenges to medical practice, and raises important ethical issues such as "virtual medical consultation." Finally, a practical experience of modernization of a pediatric outpatient center by the introduction of computers and telecommunication tools is described. Medical computing offers tools and instruments that support the administrative organization of medical visits, gather, store and process patient's data, generate diagnoses, provide therapeutical advice and access to information in order to improve medical knowledge and to make it available whenever and wherever adequate decision-making is required.

Deferred Personal Life Decisions of Women Physicians.

PubMed

Bering, Jamie; Pflibsen, Lacey; Eno, Cassie; Radhakrishnan, Priya

2018-05-01

Inadequate work-life balance can have significant implications regarding individual performance, retention, and on the future of the workforce in medicine. The purpose of this study was to determine whether women physicians defer personal life decisions in pursuit of their medical career. We conducted a survey study of women physicians ages 20-80 from various medical specialties using a combination of social media platforms and women physicians' professional listservs with 801 survey responses collected from May through November 2015. The primary endpoint was whether women physicians deferred personal life decisions in pursuit of their medical career. Secondary outcomes include types of decisions deferred and correlations with age, hours worked per week, specialty, number of children, and career satisfaction. Respondents were categorized into deferred and nondeferred groups. Personal decision deferments were reported by 64% of respondents. Of these, 86% reported waiting to have children and 22% reported waiting to get married. Finally, while 85% of women in the nondeferment group would choose medicine again as a career, only 71% of women in the deferment group would do so (p < 0.0001). Physicians who would choose medicine again cited reasons such as career satisfaction, positive patient interactions, and intellectual stimulation, whereas those who would not choose medicine again reported poor work-life balance, decreasing job satisfaction, and insurance/administrative burden. The results of this survey have significant implications on the future of the workforce in medicine. Overall, our analysis shows that 64% of women physicians defer important life decisions in pursuit of their medical career. With an increase in the number of women physicians entering the workforce, lack of support and deferred personal decisions have a potential negative impact on individual performance and retention. Employers must consider the economic impact and potential workforce

Exploration Clinical Decision Support System: Medical Data Architecture

NASA Technical Reports Server (NTRS)

Lindsey, Tony; Shetye, Sandeep; Shaw, Tianna (Editor)

2016-01-01

The Exploration Clinical Decision Support (ECDS) System project is intended to enhance the Exploration Medical Capability (ExMC) Element for extended duration, deep-space mission planning in HRP. A major development guideline is the Risk of "Adverse Health Outcomes & Decrements in Performance due to Limitations of In-flight Medical Conditions". ECDS attempts to mitigate that Risk by providing crew-specific health information, actionable insight, crew guidance and advice based on computational algorithmic analysis. The availability of inflight health diagnostic computational methods has been identified as an essential capability for human exploration missions. Inflight electronic health data sources are often heterogeneous, and thus may be isolated or not examined as an aggregate whole. The ECDS System objective provides both a data architecture that collects and manages disparate health data, and an active knowledge system that analyzes health evidence to deliver case-specific advice. A single, cohesive space-ready decision support capability that considers all exploration clinical measurements is not commercially available at present. Hence, this Task is a newly coordinated development effort by which ECDS and its supporting data infrastructure will demonstrate the feasibility of intelligent data mining and predictive modeling as a biomedical diagnostic support mechanism on manned exploration missions. The initial step towards ground and flight demonstrations has been the research and development of both image and clinical text-based computer-aided patient diagnosis. Human anatomical images displaying abnormal/pathological features have been annotated using controlled terminology templates, marked-up, and then stored in compliance with the AIM standard. These images have been filtered and disease characterized based on machine learning of semantic and quantitative feature vectors. The next phase will evaluate disease treatment response via quantitative linear

[The importance of the Czech Medical Society yesterday and today].

PubMed

Fejfar, Z

1992-10-23

Fourteen physicians headed by Jan Evangelista Purkynĕ signed the proposed by-laws of the Czech medical society in october 1861. Emperor's approval was received 26th june 1862 and in july Purkynĕ was elected the first president. The same illuminated personalities were the founders of the Casopis lékarů ceských--the Czech medical Journal which has remained the most important Czech periodical until the present time. The aims of the Society were to cultivate medical science and promote Czech language in medicine. Weekly scientific sessions, medical periodical and publication of monographs related to medicine were the means how to achieve the aims. The Czech Medical Society became soon the centre of medical science in Bohemia. Its members were among the foremost fighters for the use of Czech language in Charles university and their relentless effort helped much to the establishment of the Czech Univerzity in 1882 and Czech medical faculty a year later. In subsequent years the Society was also involved in professional problems related to social health insurance, medical fees, ethical problems and other relevant questions such as the establishment of medical chambers. The activity of the Czech medical Society was never interrupted during its 130 years of existence, although there were several difficult periods in its life, mainly during the first and second world war and also in the past 40 years. In spite of the atomization of medicine the Czech medical Society has been continuing its eminent mission to create communication and establish close links between the medical science and practical medicine by systematically bringing new knowledge in medicine and biology to general physicians and by putting together physicians, surgeons and basic scientists. The task for the future is seen in optimal transfer of new knowledge and ideas from scientists to practicians and vice versa; and to take care of the highest possible moral and ethical standard required for humane

Identification and Prioritization of Important Attributes of Disease-Modifying Drugs in Decision Making among Patients with Multiple Sclerosis: A Nominal Group Technique and Best-Worst Scaling

PubMed Central

Kremer, Ingrid E. H.; van der Weijden, Trudy; van de Kolk, Ilona

2016-01-01

Objectives Understanding the preferences of patients with multiple sclerosis (MS) for disease-modifying drugs and involving these patients in clinical decision making can improve the concordance between medical decisions and patient values and may, subsequently, improve adherence to disease-modifying drugs. This study aims first to identify which characteristics–or attributes–of disease-modifying drugs influence patients´ decisions about these treatments and second to quantify the attributes’ relative importance among patients. Methods First, three focus groups of relapsing-remitting MS patients were formed to compile a preliminary list of attributes using a nominal group technique. Based on this qualitative research, a survey with several choice tasks (best-worst scaling) was developed to prioritize attributes, asking a larger patient group to choose the most and least important attributes. The attributes’ mean relative importance scores (RIS) were calculated. Results Nineteen patients reported 34 attributes during the focus groups and 185 patients evaluated the importance of the attributes in the survey. The effect on disease progression received the highest RIS (RIS = 9.64, 95% confidence interval: [9.48–9.81]), followed by quality of life (RIS = 9.21 [9.00–9.42]), relapse rate (RIS = 7.76 [7.39–8.13]), severity of side effects (RIS = 7.63 [7.33–7.94]) and relapse severity (RIS = 7.39 [7.06–7.73]). Subgroup analyses showed heterogeneity in preference of patients. For example, side effect-related attributes were statistically more important for patients who had no experience in using disease-modifying drugs compared to experienced patients (p < .001). Conclusions This study shows that, on average, patients valued effectiveness and unwanted effects as most important. Clinicians should be aware of the average preferences but also that attributes of disease-modifying drugs are valued differently by different patients. Person-centred clinical

Computerized Decision Aids for Shared Decision Making in Serious Illness: Systematic Review.

PubMed

Staszewska, Anna; Zaki, Pearl; Lee, Joon

2017-10-06

Shared decision making (SDM) is important in achieving patient-centered care. SDM tools such as decision aids are intended to inform the patient. When used to assist in decision making between treatments, decision aids have been shown to reduce decisional conflict, increase ease of decision making, and increase modification of previous decisions. The purpose of this systematic review is to assess the impact of computerized decision aids on patient-centered outcomes related to SDM for seriously ill patients. PubMed and Scopus databases were searched to identify randomized controlled trials (RCTs) that assessed the impact of computerized decision aids on patient-centered outcomes and SDM in serious illness. Six RCTs were identified and data were extracted on study population, design, and results. Risk of bias was assessed by a modified Cochrane Risk of Bias Tool for Quality Assessment of Randomized Controlled Trials. Six RCTs tested decision tools in varying serious illnesses. Three studies compared different computerized decision aids against each other and a control. All but one study demonstrated improvement in at least one patient-centered outcome. Computerized decision tools may reduce unnecessary treatment in patients with low disease severity in comparison with informational pamphlets. Additionally, electronic health record (EHR) portals may provide the opportunity to manage care from the home for individuals affected by illness. The quality of decision aids is of great importance. Furthermore, satisfaction with the use of tools is associated with increased patient satisfaction and reduced decisional conflict. Finally, patients may benefit from computerized decision tools without the need for increased physician involvement. Most computerized decision aids improved at least one patient-centered outcome. All RCTs identified were at a High Risk of Bias or Unclear Risk of Bias. Effort should be made to improve the quality of RCTs testing SDM aids in serious

The importance of educational theories for facilitating learning when using technology in medical education.

PubMed

Sandars, John; Patel, Rakesh S; Goh, Poh Sun; Kokatailo, Patricia K; Lafferty, Natalie

2015-01-01

There is an increasing use of technology for teaching and learning in medical education but often the use of educational theory to inform the design is not made explicit. The educational theories, both normative and descriptive, used by medical educators determine how the technology is intended to facilitate learning and may explain why some interventions with technology may be less effective compared with others. The aim of this study is to highlight the importance of medical educators making explicit the educational theories that inform their design of interventions using technology. The use of illustrative examples of the main educational theories to demonstrate the importance of theories informing the design of interventions using technology. Highlights the use of educational theories for theory-based and realistic evaluations of the use of technology in medical education. An explicit description of the educational theories used to inform the design of an intervention with technology can provide potentially useful insights into why some interventions with technology are more effective than others. An explicit description is also an important aspect of the scholarship of using technology in medical education.

The role of the autopsy in medical malpractice cases, I: a review of 99 appeals court decisions.

PubMed

Bove, Kevin E; Iery, Clare

2002-09-01

Fear that damaging information from autopsy may be introduced as evidence in lawsuits alleging medical malpractice is often cited as one factor contributing to the decline in autopsy rates. To determine how autopsy information influences the outcome of medical malpractice litigation. We studied state court records in 99 cases of medical malpractice adjudicated from 1970 to the present to assess the role of information from autopsies in the outcomes. The 3 largest groups defined by cause of death at autopsy were acute pulmonary embolism, acute cardiovascular disease, and drug overdose/interaction. Findings for defendant physicians outnumbered medical negligence in the original trial proceedings by a 3:1 margin. The appellate courts affirmed 51 acquittals and 19 findings of negligence, and reversed the original trial court decision in 29 cases for technical reasons. We found no significant relationship between accuracy of clinical diagnosis (using the autopsy standard) and outcome of a suit charging medical negligence. Even when a major discrepancy existed between the autopsy diagnosis and the clinical diagnosis, and the unrecognized condition was deemed treatable, defendant physicians were usually exonerated. Moreover, major diagnostic discrepancies were relatively uncommon in suits in which a physician was found to be negligent. Conversely, in about 20% of cases, autopsy findings were helpful to defendant physicians. Our study confirms that a finding of medical negligence is based on standard-of-care issues rather than accuracy of clinical diagnosis. Autopsy findings may appear to be neutral or favorable to either the plaintiff or the defendant, but are typically not the crux of a successful legal argument for either side in a malpractice action. We conclude that fear of autopsy findings has no rational basis and is an important obstacle to uninhibited outcomes analysis.

[Subjectivity, decision and neurodegenerative diseases: reflexions on the role of the clinical psychologist in medical decision making].

PubMed

Brocq, H; Liarte, A; Soriani, M-H; Desnuelle, C

2013-01-01

Should a patient be forced to accept a treatment, especially when suffering from a neurodegenerative disease? We argue that physicians, nurses and care givers should instead accept his or her choice in accordance with the principle that every patient is an autonomous person able to make a choice, even in case of declined cognition. Beside the legal obligation, we suggest a theoretical approach and focus on the practical impacts of the patient's decision. Our objective is to promote the value of ethical doubt and attentive listening to individual opinions, so as to improve the quality of the medical staff's work and reduce patients' distress when affected by fatal diseases. Copyright © 2013 Elsevier Masson SAS. All rights reserved.

Influences on decision making among primiparous women choosing elective caesarean section in the absence of medical indications: findings from a qualitative investigation.