Debate about whether and when to accommodate patient requests for concordant clinicians should co... more Debate about whether and when to accommodate patient requests for concordant clinicians should consider evidence. This article examines how existing evidence could be used to interpret or inform ethical arguments about whether to accommodate such requests. Studies on patient-clinician concordance yield mixed and inconclusive results. Concordance might contribute to increased patient satisfaction and trust, but these results are not consistent and could be the result of clinicians' communication skills. Given this evidence and the risk of social harm in honoring concordance requests, this article argues that patients' concordance requests should be honored only when health care services would be denied to a patient, such as in a case of a clinician's conscientious objection to providing a service. All other requests should be scrutinized for a reasonable ethical justification. Concordance Requests In this article, we review evidence about patient-clinician concordance-that is, shared characteristics like gender, race, or socioeconomic status-and discuss how it bears on the debate about whether to accommodate patients' requests for clinicians with specific characteristics. Patients may request a clinician with a specific characteristic for a variety of reasons, including personal preference, religious values, or assumptions about who provides the best care. Some might argue that patients, as the vulnerable party, ought to have their requests accommodated but draw a line when preferences are based on socially unacceptable reasons grounded in prejudice, sexism, or racism.
In shared decision-making (SDM), patient and physician deliberate together on the basis of shared... more In shared decision-making (SDM), patient and physician deliberate together on the basis of shared evidence, supporting the patient's choice among multiple options, informed by her values and preferences. One factor complicating the implementation of SDM is uncertainty, which has long been recognized in medicine but perhaps not sufficiently addressed in the context of SDM. In order to ensure that SDM can be realistically applied to realworld clinical encounters, the issue of uncertainty should be recognized and explicitly incorporated into SDM strategies. Here we propose practical approaches, based in doctor-patient communication science and bioethics, that may be of help for incorporating the uncertainty factor into SDM in the context of the doctor-patient encounter. We also discuss how decision aids might be more widely applicable through routinely acknowledging the preference sensitivity of decisions and supplementing these tools with a discussion of uncertainty.
Background: Patients with diabetes mellitus need information about the effectiveness of innovatio... more Background: Patients with diabetes mellitus need information about the effectiveness of innovations in insulin delivery and glucose monitoring. Purpose: To review how intensive insulin therapy (multiple daily injections [MDI] vs. rapid-acting analogue-based continuous subcutaneous insulin infusion [CSII]) or method of monitoring (selfmonitoring of blood glucose [SMBG] vs. real-time continuous glucose monitoring [rt-CGM]) affects outcomes in types 1 and 2 diabetes mellitus. Data Sources: MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials through February 2012 without language restrictions. Study Selection: 33 randomized, controlled trials in children or adults that compared CSII with MDI (n ϭ 19), rt-CGM with SMBG (n ϭ 10), or sensor-augmented insulin pump use with MDI and SMBG (n ϭ 4). Data Extraction: 2 reviewers independently evaluated studies for eligibility and quality and serially abstracted data. Data Synthesis: In randomized, controlled trials, MDI and CSII showed similar effects on hemoglobin A 1c (HbA 1c) levels and severe hypoglycemia in children or adults with type 1 diabetes mellitus and adults with type 2 diabetes mellitus. In adults with type 1 diabetes mellitus, HbA 1c levels decreased more with CSII than with MDI, but 1 study heavily influenced these results. Compared with SMBG, rt-CGM achieved a lower HbA 1c level (between-group difference of change, Ϫ0.26% [95% CI, Ϫ0.33% to Ϫ0.19%]) without any difference in severe hypoglycemia. Sensor-augmented insulin pump use decreased HbA 1c levels more than MDI and SMBG did in persons with type 1 diabetes mellitus (between-group difference of change, Ϫ0.68% [CI, Ϫ0.81% to Ϫ0.54%]). Little evidence was available on other outcomes. Limitation: Many studies were small, of short duration, and limited to white persons with type 1 diabetes mellitus. Conclusion: Continuous subcutaneous insulin infusion and MDI have similar effects on glycemic control and hypoglycemia, except CSII has a favorable effect on glycemic control in adults with type 1 diabetes mellitus. For glycemic control, rt-CGM is superior to SMBG and sensor-augmented insulin pumps are superior to MDI and SMBG without increasing the risk for hypoglycemia.
During the Coronavirus (COVID-19) pandemic, in-person interpreters have been deemed “nonessential... more During the Coronavirus (COVID-19) pandemic, in-person interpreters have been deemed “nonessential,” and thus eliminated to minimize viral exposure and conserve personal protective equipment. Considering alarming patterns of interpreter underuse, we evaluate how substitution for remote modalities (telephone or video) may exacerbate existing inequalities for patients with limited English proficiency. The inherent intimacy, dynamic physicality, and cultural nuances of labor and delivery pose unique communication challenges. Using clinical scenarios, we illustrate the vital role interpreters have in providing accessible obstetric care. We argue that eliminating in-person interpreters in this setting is not justified by COVID-related harms given the potential to exacerbate underlying health disparities.
In the light of US Central Intelligence Agency guidelines that limited routine care of detainees ... more In the light of US Central Intelligence Agency guidelines that limited routine care of detainees to promote torture, Zackary Berger and colleagues call for sanctions against health professionals who cooperate
e21558 Background: Patient-physician communication is important to cancer care. The National Coal... more e21558 Background: Patient-physician communication is important to cancer care. The National Coalition for Cancer Survivorship developed the Know Yourself Tool, a 2-page form, to improve patients’ understanding of goals of care and clinicians’ understanding of patients’ priorities/expectations. We assessed the Tool’s use and usefulness. Methods: This mixed-methods study at an academic cancer center recruited 1 medical, 1 radiation, and 1 surgical oncologist for each of 5 cancer types: breast, lung, gastrointestinal, genitourinary, head & neck. For each clinician (n = 15), we recruited 2 control patients to observe usual care (n = 30) and then 4 intervention patients who were provided the Tool (n = 60); eligible patients were at a decision point in their care. Data were collected for the decision making visit via patient and physician post-visit surveys analyzed descriptively and visit recordings/transcripts to analyze: 1) option presentation 2) patient preference assessment 3) share...
Background: Little is known about how hospitalized patients share decisions with physicians. Meth... more Background: Little is known about how hospitalized patients share decisions with physicians. Methods: We conducted an observational study of patient-doctor communication on an inpatient medicine service among 18 hospitalized patients and 9 physicians. A research assistant (RA) approached newly hospitalized patients and their physicians before morning rounds and obtained consent. The RA audio recorded morning rounds, and then separately interviewed both patient and physician. Coding was done using integrated analysis. Results: Most patients were white (61%) and half were female. Most physicians were male (66%) and of Southeast Asian descent (66%). All physicians explained the plan of care to the patients; most believed that their patient understood. However, many patients did not. Physicians rarely asked the patient for their opinion. In all those cases, the decision had been made previously by the doctors. No decisions were made with the patient. Patients sometimes disagreed. Conclusions: Shared decision-making may not be the norm in hospital care. Although physicians do explain treatment plans, many hospitalized patients do not understand enough to share in decisions. When patients do assert their opinion, it can result in conflict. Practice implications: Some hospitalized patients are interested in discussing treatment. Improving hospital communication can foster patient autonomy.
3. Borradaile KE, Sherman S, Vander Veur SS, et al. Snacking in children: the role of urban corne... more 3. Borradaile KE, Sherman S, Vander Veur SS, et al. Snacking in children: the role of urban corner stores. Pediatrics. 2009; 124 (5): 1293-1298. 4. Lucan SC, Karpyn A, Sherman S. Storing empty calories and chronic disease risk: snack-food products, nutritive content, and manufacturers in Philadelphia corner stores. J Urban Health. 2010; 87 (3): 394-409. 5. The White House, Office of the First Lady. First Lady Michelle Obama announces nationwide commitments to provide millions of people access to healthy, affordable food in ...
Patient centred diagnosis: sharing diagnostic decisions with patients in clinical practice Shared... more Patient centred diagnosis: sharing diagnostic decisions with patients in clinical practice Shared decision making for diagnostic decisions is understudied and differs from treatment decision making. Zackary D Berger and colleagues discuss how uncertainty and stakes should shape the conversation
As the COVID-19 pandemic worsens in the United States [1], colleges that have invited students ba... more As the COVID-19 pandemic worsens in the United States [1], colleges that have invited students back for the fall are finalizing mitigation plans to lessen the spread of SARS-CoV-2. Even though students have largely been away from campuses over the summer, several outbreaks associated with colleges have already occurred [2], foreshadowing the scale of infection that could result from hundreds of thousands of students returning to college towns and cities. While many institutions have released return-to-campus plans designed to reduce viral spread and to rapidly identify outbreaks should they occur, in many cases communications by college administrators have been opaque. To contribute to an evaluation of university preparedness for the COVID-19 pandemic, we assessed a crucial element: COVID-19 on-campus testing. We examined testing plans at more than 500 colleges and universities throughout the US, and collated statistics, as well as narratives from publicly facing websites. We discov...
Medicine is not merely a job that requires technical expertise, but a profession concerned with m... more Medicine is not merely a job that requires technical expertise, but a profession concerned with making the best decisions and recommendations with reference to, and in consultation with, the patient. This means that the skill set required for healthcare professionals in order to provide good care is a combination of scientific knowledge, technical aptitude, and affective qualities or virtues such as compassion and empathy.
Introduction: Management of cancer is often characterized by difficult decisions. The National Co... more Introduction: Management of cancer is often characterized by difficult decisions. The National Coalition for Cancer Survivorship (NCCS) has developed the "Know Yourself" tool, a question prompt list (QPL) to enable patients to participate in these decisions. Methods: We investigated the feasibility of using the NCCS tool by oncologists and their patients with cancer in a before-and-after pilot study at a tertiary medical center. We also measured patient reported decision preparedness, anxiety, satisfaction with care, trust in physician, discussion of care with their primary care physician (PCP), and general state of health, and solicited feedback from clinicians and patients on use of the form. Results: Ninety patients and fifteen clinicians participated. Most patients reported the Tool was easy to use (91%) and would recommend it to others (73%) however fewer reported discussing the Tool at the visit (31%) or felt that it improved the quality of care (45%) or communication with the oncologist (56%). Clinicians reported Tool use in only 16 of 60 visits (27%); in these visits the Tool was helpful in identifying areas of concern (74%), guiding the clinical interaction (67%), promoting communication (62%), identifying areas of need (70%), and improving quality of care (71%). Decision preparedness, trust in physicians, uncertainty about care, anxiety, patient satisfaction and discussion of care with the PCP was unchanged with Tool use compared to non-use. Conclusions: The Know Yourself tool had poor uptake but was favorably received among both patients and clinicians who used it. These findings suggest some patients could benefit from QPLs. Future work should test how implementation strategies might achieve greater use.
We discuss the role of prior authorization (PA) in supporting patient-centered care (PCC) by dire... more We discuss the role of prior authorization (PA) in supporting patient-centered care (PCC) by directing health system resources and thus the ability to better meet the needs of individual patients. We begin with an account of PCC as a standard that should be aimed for in patient care. In order to achieve widespread PCC, appropriate resource management is essential in a healthcare system. This brings us to PA, and we present an idealized view of PA in order to argue how at its best, it can contribute to the provision of PCC. PA is a means of cost saving and as such it has mixed success. The example of the US demonstrates how implementation of PA has increased health inequalities whereas best practice has the potential to reduce them. In contrast, systems of universal coverage, like those in Europe, may use the cost savings of PA to better address individuals' care and PCC. The conclusion we offer therefore is an optimistic one, pointing towards areas of supportive overlap between PCC and PA where usually the incongruities are most evident.
Debate about whether and when to accommodate patient requests for concordant clinicians should co... more Debate about whether and when to accommodate patient requests for concordant clinicians should consider evidence. This article examines how existing evidence could be used to interpret or inform ethical arguments about whether to accommodate such requests. Studies on patient-clinician concordance yield mixed and inconclusive results. Concordance might contribute to increased patient satisfaction and trust, but these results are not consistent and could be the result of clinicians' communication skills. Given this evidence and the risk of social harm in honoring concordance requests, this article argues that patients' concordance requests should be honored only when health care services would be denied to a patient, such as in a case of a clinician's conscientious objection to providing a service. All other requests should be scrutinized for a reasonable ethical justification. Concordance Requests In this article, we review evidence about patient-clinician concordance-that is, shared characteristics like gender, race, or socioeconomic status-and discuss how it bears on the debate about whether to accommodate patients' requests for clinicians with specific characteristics. Patients may request a clinician with a specific characteristic for a variety of reasons, including personal preference, religious values, or assumptions about who provides the best care. Some might argue that patients, as the vulnerable party, ought to have their requests accommodated but draw a line when preferences are based on socially unacceptable reasons grounded in prejudice, sexism, or racism.
In shared decision-making (SDM), patient and physician deliberate together on the basis of shared... more In shared decision-making (SDM), patient and physician deliberate together on the basis of shared evidence, supporting the patient's choice among multiple options, informed by her values and preferences. One factor complicating the implementation of SDM is uncertainty, which has long been recognized in medicine but perhaps not sufficiently addressed in the context of SDM. In order to ensure that SDM can be realistically applied to realworld clinical encounters, the issue of uncertainty should be recognized and explicitly incorporated into SDM strategies. Here we propose practical approaches, based in doctor-patient communication science and bioethics, that may be of help for incorporating the uncertainty factor into SDM in the context of the doctor-patient encounter. We also discuss how decision aids might be more widely applicable through routinely acknowledging the preference sensitivity of decisions and supplementing these tools with a discussion of uncertainty.
Background: Patients with diabetes mellitus need information about the effectiveness of innovatio... more Background: Patients with diabetes mellitus need information about the effectiveness of innovations in insulin delivery and glucose monitoring. Purpose: To review how intensive insulin therapy (multiple daily injections [MDI] vs. rapid-acting analogue-based continuous subcutaneous insulin infusion [CSII]) or method of monitoring (selfmonitoring of blood glucose [SMBG] vs. real-time continuous glucose monitoring [rt-CGM]) affects outcomes in types 1 and 2 diabetes mellitus. Data Sources: MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials through February 2012 without language restrictions. Study Selection: 33 randomized, controlled trials in children or adults that compared CSII with MDI (n ϭ 19), rt-CGM with SMBG (n ϭ 10), or sensor-augmented insulin pump use with MDI and SMBG (n ϭ 4). Data Extraction: 2 reviewers independently evaluated studies for eligibility and quality and serially abstracted data. Data Synthesis: In randomized, controlled trials, MDI and CSII showed similar effects on hemoglobin A 1c (HbA 1c) levels and severe hypoglycemia in children or adults with type 1 diabetes mellitus and adults with type 2 diabetes mellitus. In adults with type 1 diabetes mellitus, HbA 1c levels decreased more with CSII than with MDI, but 1 study heavily influenced these results. Compared with SMBG, rt-CGM achieved a lower HbA 1c level (between-group difference of change, Ϫ0.26% [95% CI, Ϫ0.33% to Ϫ0.19%]) without any difference in severe hypoglycemia. Sensor-augmented insulin pump use decreased HbA 1c levels more than MDI and SMBG did in persons with type 1 diabetes mellitus (between-group difference of change, Ϫ0.68% [CI, Ϫ0.81% to Ϫ0.54%]). Little evidence was available on other outcomes. Limitation: Many studies were small, of short duration, and limited to white persons with type 1 diabetes mellitus. Conclusion: Continuous subcutaneous insulin infusion and MDI have similar effects on glycemic control and hypoglycemia, except CSII has a favorable effect on glycemic control in adults with type 1 diabetes mellitus. For glycemic control, rt-CGM is superior to SMBG and sensor-augmented insulin pumps are superior to MDI and SMBG without increasing the risk for hypoglycemia.
During the Coronavirus (COVID-19) pandemic, in-person interpreters have been deemed “nonessential... more During the Coronavirus (COVID-19) pandemic, in-person interpreters have been deemed “nonessential,” and thus eliminated to minimize viral exposure and conserve personal protective equipment. Considering alarming patterns of interpreter underuse, we evaluate how substitution for remote modalities (telephone or video) may exacerbate existing inequalities for patients with limited English proficiency. The inherent intimacy, dynamic physicality, and cultural nuances of labor and delivery pose unique communication challenges. Using clinical scenarios, we illustrate the vital role interpreters have in providing accessible obstetric care. We argue that eliminating in-person interpreters in this setting is not justified by COVID-related harms given the potential to exacerbate underlying health disparities.
In the light of US Central Intelligence Agency guidelines that limited routine care of detainees ... more In the light of US Central Intelligence Agency guidelines that limited routine care of detainees to promote torture, Zackary Berger and colleagues call for sanctions against health professionals who cooperate
e21558 Background: Patient-physician communication is important to cancer care. The National Coal... more e21558 Background: Patient-physician communication is important to cancer care. The National Coalition for Cancer Survivorship developed the Know Yourself Tool, a 2-page form, to improve patients’ understanding of goals of care and clinicians’ understanding of patients’ priorities/expectations. We assessed the Tool’s use and usefulness. Methods: This mixed-methods study at an academic cancer center recruited 1 medical, 1 radiation, and 1 surgical oncologist for each of 5 cancer types: breast, lung, gastrointestinal, genitourinary, head & neck. For each clinician (n = 15), we recruited 2 control patients to observe usual care (n = 30) and then 4 intervention patients who were provided the Tool (n = 60); eligible patients were at a decision point in their care. Data were collected for the decision making visit via patient and physician post-visit surveys analyzed descriptively and visit recordings/transcripts to analyze: 1) option presentation 2) patient preference assessment 3) share...
Background: Little is known about how hospitalized patients share decisions with physicians. Meth... more Background: Little is known about how hospitalized patients share decisions with physicians. Methods: We conducted an observational study of patient-doctor communication on an inpatient medicine service among 18 hospitalized patients and 9 physicians. A research assistant (RA) approached newly hospitalized patients and their physicians before morning rounds and obtained consent. The RA audio recorded morning rounds, and then separately interviewed both patient and physician. Coding was done using integrated analysis. Results: Most patients were white (61%) and half were female. Most physicians were male (66%) and of Southeast Asian descent (66%). All physicians explained the plan of care to the patients; most believed that their patient understood. However, many patients did not. Physicians rarely asked the patient for their opinion. In all those cases, the decision had been made previously by the doctors. No decisions were made with the patient. Patients sometimes disagreed. Conclusions: Shared decision-making may not be the norm in hospital care. Although physicians do explain treatment plans, many hospitalized patients do not understand enough to share in decisions. When patients do assert their opinion, it can result in conflict. Practice implications: Some hospitalized patients are interested in discussing treatment. Improving hospital communication can foster patient autonomy.
3. Borradaile KE, Sherman S, Vander Veur SS, et al. Snacking in children: the role of urban corne... more 3. Borradaile KE, Sherman S, Vander Veur SS, et al. Snacking in children: the role of urban corner stores. Pediatrics. 2009; 124 (5): 1293-1298. 4. Lucan SC, Karpyn A, Sherman S. Storing empty calories and chronic disease risk: snack-food products, nutritive content, and manufacturers in Philadelphia corner stores. J Urban Health. 2010; 87 (3): 394-409. 5. The White House, Office of the First Lady. First Lady Michelle Obama announces nationwide commitments to provide millions of people access to healthy, affordable food in ...
Patient centred diagnosis: sharing diagnostic decisions with patients in clinical practice Shared... more Patient centred diagnosis: sharing diagnostic decisions with patients in clinical practice Shared decision making for diagnostic decisions is understudied and differs from treatment decision making. Zackary D Berger and colleagues discuss how uncertainty and stakes should shape the conversation
As the COVID-19 pandemic worsens in the United States [1], colleges that have invited students ba... more As the COVID-19 pandemic worsens in the United States [1], colleges that have invited students back for the fall are finalizing mitigation plans to lessen the spread of SARS-CoV-2. Even though students have largely been away from campuses over the summer, several outbreaks associated with colleges have already occurred [2], foreshadowing the scale of infection that could result from hundreds of thousands of students returning to college towns and cities. While many institutions have released return-to-campus plans designed to reduce viral spread and to rapidly identify outbreaks should they occur, in many cases communications by college administrators have been opaque. To contribute to an evaluation of university preparedness for the COVID-19 pandemic, we assessed a crucial element: COVID-19 on-campus testing. We examined testing plans at more than 500 colleges and universities throughout the US, and collated statistics, as well as narratives from publicly facing websites. We discov...
Medicine is not merely a job that requires technical expertise, but a profession concerned with m... more Medicine is not merely a job that requires technical expertise, but a profession concerned with making the best decisions and recommendations with reference to, and in consultation with, the patient. This means that the skill set required for healthcare professionals in order to provide good care is a combination of scientific knowledge, technical aptitude, and affective qualities or virtues such as compassion and empathy.
Introduction: Management of cancer is often characterized by difficult decisions. The National Co... more Introduction: Management of cancer is often characterized by difficult decisions. The National Coalition for Cancer Survivorship (NCCS) has developed the "Know Yourself" tool, a question prompt list (QPL) to enable patients to participate in these decisions. Methods: We investigated the feasibility of using the NCCS tool by oncologists and their patients with cancer in a before-and-after pilot study at a tertiary medical center. We also measured patient reported decision preparedness, anxiety, satisfaction with care, trust in physician, discussion of care with their primary care physician (PCP), and general state of health, and solicited feedback from clinicians and patients on use of the form. Results: Ninety patients and fifteen clinicians participated. Most patients reported the Tool was easy to use (91%) and would recommend it to others (73%) however fewer reported discussing the Tool at the visit (31%) or felt that it improved the quality of care (45%) or communication with the oncologist (56%). Clinicians reported Tool use in only 16 of 60 visits (27%); in these visits the Tool was helpful in identifying areas of concern (74%), guiding the clinical interaction (67%), promoting communication (62%), identifying areas of need (70%), and improving quality of care (71%). Decision preparedness, trust in physicians, uncertainty about care, anxiety, patient satisfaction and discussion of care with the PCP was unchanged with Tool use compared to non-use. Conclusions: The Know Yourself tool had poor uptake but was favorably received among both patients and clinicians who used it. These findings suggest some patients could benefit from QPLs. Future work should test how implementation strategies might achieve greater use.
We discuss the role of prior authorization (PA) in supporting patient-centered care (PCC) by dire... more We discuss the role of prior authorization (PA) in supporting patient-centered care (PCC) by directing health system resources and thus the ability to better meet the needs of individual patients. We begin with an account of PCC as a standard that should be aimed for in patient care. In order to achieve widespread PCC, appropriate resource management is essential in a healthcare system. This brings us to PA, and we present an idealized view of PA in order to argue how at its best, it can contribute to the provision of PCC. PA is a means of cost saving and as such it has mixed success. The example of the US demonstrates how implementation of PA has increased health inequalities whereas best practice has the potential to reduce them. In contrast, systems of universal coverage, like those in Europe, may use the cost savings of PA to better address individuals' care and PCC. The conclusion we offer therefore is an optimistic one, pointing towards areas of supportive overlap between PCC and PA where usually the incongruities are most evident.
Patient-centered communication is essential because of the 5 E's: ethics, effectiveness, efficien... more Patient-centered communication is essential because of the 5 E's: ethics, effectiveness, efficiency, emotions, and equity.
Agenda
0-3min
Introduction; ascertainment of learners' needs
4-15min
Ranking risk; discussing de... more Agenda
0-3min Introduction; ascertainment of learners' needs 4-15min Ranking risk; discussing definitions of risk 16-20min Introduction to concepts of risk, risk perception, and risk psychology 21-30min Small-group role play (patient, provider, observer) regarding risk communication 31-41min Analysis of small group role play, group decision on effective methods, evidence of effective methods 41-45min Goal-setting for improvement of risk communication or perception
Learning objectives Define risk and understand its importance to general internal medicine Understand that many people (me included) find this difficult Understand four common factors in risk perception: innumeracy, hueristics, motivation, and emotion Understand how these factors influence patients' ranking of risks Learn techniques to improve risk communication
Epistemology and the doctor-patient relationship
Introduction: Patients and doctors think diffe... more Epistemology and the doctor-patient relationship
Introduction: Patients and doctors think differently about illness. This is party related to differences in the ways in which they define, accumulatee, and process knowledge. Understanding their differing epistemologies can improve patient-provider communication and patient safety.
Methods: Physicians use a variety of epistemologies to further and justify their practice, some of which involve non-scientific forms of knowledge. If healthcare workers evaluate their own epistemologies, this can make explicit the judgments they use professionally and personally.
Results: Directed questioning of themselves and colleagues involving classification of statements into categories of knowledge can inform this evaluation. By the same token, patients make use of non-scientific epistemologies to create and organize knowledge. Finding points of contact between these worldviews (for example, which statements of value and ethics can be agreed upon by doctors and patients) can clarify differences of opinion.
Conclusions: We can better understand patients' and doctors' actions by modeling the epistemology involved. For example, patients' nonadherence to medical treatment, according to this approach, is not predominantly a lack of understanding, or a worldview different from their doctors', but as a reaction to the state of affairs they are facing. Understanding epistemological differences can improve quality and patient safety.
If physician and patient do not agree on why the patient is in the hospital, what are the chances... more If physician and patient do not agree on why the patient is in the hospital, what are the chances things will go well?
Patients and doctors think differently about illness and the body. This has often been understood as a phenomenon of (mis)communication. Communication is an important contributor to satisfaction with care. Failed communication is linked to dissatisfaction with healthcare providers, lack of adherence, ignorance of the diagnoses and treatment plan, lower desire for a quick recovery, and poor outcomes. Conversely, in multiple settings, patient education improves outcomes after patient discharge.
However, the difference in approach between patients and providers is even more basic. Patients and providers think about, process, and understand knowledge (especially medical knowledge) in different ways, and without addressing this fact, our understanding of the patient-provider interaction is bound to be incomplete. While there is a highly developed literature on this processing of and approach to knowledge - known as epistemology - in philosophy and the social sciences, with some recent work relating to evidence based medicine, its application to doctor-patient communication has been limited. This brief report of a hypothesis-generating pilot study suggests a road map to research epistemological differences between providers and patients in the hospital setting, as an answer to the question, "What do patients know about the reason for their admission and their providers' treatment plans?"
Concordance (agreement by doctor and patient on aspects of the medical visit) can be understood as a proxy for knowledge. Not assessing concordance may be a missed opportunity for improving patient satisfaction, systems of care, and clinical outcomes. Concordance is clinically important: if patients are not aware of their physicians' reason for admitting them to the hospital, adherence, safety, and end-of-life discussions may suffer. Moreover, understanding concordance is necessary to improve healthcare systems if we wish EMRs to reflect basic aspects of the inpatient visit, e.g., the reason for admission.
In order to estimate the concordance on reason for hospitalization between patient report and medical chart, and to generate hypotheses concerning characteristics related to discordance, we conducted a pilot study among inpatients in Bellevue Hospital in New York.
Uploads
Papers by Zackary Berger
0-3min
Introduction; ascertainment of learners' needs
4-15min
Ranking risk; discussing definitions of risk
16-20min
Introduction to concepts of risk, risk perception, and risk psychology
21-30min
Small-group role play (patient, provider, observer) regarding risk communication
31-41min
Analysis of small group role play, group decision on effective methods, evidence of effective methods
41-45min
Goal-setting for improvement of risk communication or perception
Learning objectives
Define risk and understand its importance to general internal medicine
Understand that many people (me included) find this difficult
Understand four common factors in risk perception: innumeracy, hueristics, motivation, and emotion
Understand how these factors influence patients' ranking of risks
Learn techniques to improve risk communication
Introduction: Patients and doctors think differently about illness. This is party related to differences in the ways in which they define, accumulatee, and process knowledge. Understanding their differing epistemologies can improve patient-provider communication and patient safety.
Methods: Physicians use a variety of epistemologies to further and justify their practice, some of which involve non-scientific forms of knowledge. If healthcare workers evaluate their own epistemologies, this can make explicit the judgments they use professionally and personally.
Results: Directed questioning of themselves and colleagues involving classification of statements into categories of knowledge can inform this evaluation. By the same token, patients make use of non-scientific epistemologies to create and organize knowledge. Finding points of contact between these worldviews (for example, which statements of value and ethics can be agreed upon by doctors and patients) can clarify differences of opinion.
Conclusions: We can better understand patients' and doctors' actions by modeling the epistemology involved. For example, patients' nonadherence to medical treatment, according to this approach, is not predominantly a lack of understanding, or a worldview different from their doctors', but as a reaction to the state of affairs they are facing. Understanding epistemological differences can improve quality and patient safety.
Patients and doctors think differently about illness and the body. This has often been understood as a phenomenon of (mis)communication. Communication is an important contributor to satisfaction with care. Failed communication is linked to dissatisfaction with healthcare providers, lack of adherence, ignorance of the diagnoses and treatment plan, lower desire for a quick recovery, and poor outcomes. Conversely, in multiple settings, patient education improves outcomes after patient discharge.
However, the difference in approach between patients and providers is even more basic. Patients and providers think about, process, and understand knowledge (especially medical knowledge) in different ways, and without addressing this fact, our understanding of the patient-provider interaction is bound to be incomplete. While there is a highly developed literature on this processing of and approach to knowledge - known as epistemology - in philosophy and the social sciences, with some recent work relating to evidence based medicine, its application to doctor-patient communication has been limited. This brief report of a hypothesis-generating pilot study suggests a road map to research epistemological differences between providers and patients in the hospital setting, as an answer to the question, "What do patients know about the reason for their admission and their providers' treatment plans?"
Concordance (agreement by doctor and patient on aspects of the medical visit) can be understood as a proxy for knowledge. Not assessing concordance may be a missed opportunity for improving patient satisfaction, systems of care, and clinical outcomes. Concordance is clinically important: if patients are not aware of their physicians' reason for admitting them to the hospital, adherence, safety, and end-of-life discussions may suffer. Moreover, understanding concordance is necessary to improve healthcare systems if we wish EMRs to reflect basic aspects of the inpatient visit, e.g., the reason for admission.
In order to estimate the concordance on reason for hospitalization between patient report and medical chart, and to generate hypotheses concerning characteristics related to discordance, we conducted a pilot study among inpatients in Bellevue Hospital in New York.