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About Us

About CBSSM

The Center for Bioethics and Social Sciences in Medicine (CBSSM) is supported by the University of Michigan Medical School Dean's Office, the Office of Clinical Affairs, and the Department of Internal Medicine. CBSSM is directed by Dr. Reshma Jagsi, MD, DPhil. CBSSM was established in July 2010 at the University of Michigan Medical School through the merger of the Bioethics Program with the Center for Behavioral and Decision Sciences in Medicine (CBDSM).

Mission

The mission of CBSSM is to be the premier intellectual gathering place of clinicians, social scientists, bioethicists, and all others interested in improving individual and societal health through scholarship and service.

CBSSM is a multidisciplinary unit integrating bioethics with key social science disciplines. CBSSM acts as a "home" for anyone interested in applying empirical social science methods to improve health. The primary research interests of CBSSM faculty focus on five overarching themes:

  • Clinical and research ethics
  • Health communication and decision-making
  • Medicine and society
  • Health, justice and community
  • Genomics, health and society

CBSSM attracts scholars from across departmental and disciplinary boundaries and in so doing, provides fertile ground for new synergies.  Our team includes:

  • Social and cognitive psychologists
  • Behavioral economists
  • Clinicians from many specialties
  • Bioethicists
  • Decision scientists
  • Survey methodologists
  • Sociologists
  • Public health researchers

Currently, CBSSM is housed in the North Campus Research Complex in Ann Arbor. Faculty investigators, project managers, and research associates are supported by a core administrative and financial staff. CBSSM gives considerable attention to training the next generation of interdisciplinary scholars, offering support to junior investigators who can collaborate with seasoned researchers in an umbrella organization.

 

Funded by the NIH

The overarching goal of our research is to improve opioid analgesic safety and efficacy by optimizing opioid risk recognition, informed analgesic decision-making, and drug storage/disposal behaviors among parents of youth who are prescribed these agents for home use. With this proposal, we aim to demonstrate that our Scenario-Tailored Opioid Messaging Program (STOMP?) will: 1) Improve parents' opioid risk understanding and their analgesic decision-making; 2) Enhance parents' analgesic self-efficacy, analgesic use, storage behaviors and their children's pain outcomes, and 3) To demonstrate that the STOMP? plus provision of a method to get rid of left-over medications will effectively nudge parents to safely dispose of left-over opioid analgesics. For more info: http://grantome.com/grant/NIH/R01-DA044245-01A1

PI: Terri Lewis-Voepel

CBSSM Co-Is: Brian Zikmund-Fisher & Alan Tait

Funded by Patient-Centered Outcomes Research Institute (PCORI).

Funding Years: 2013-2017

The birth of a child with a disorder of sex development (DSD) is stressful for parents and members of the healthcare team. The "right" decisions about gender assignment (is it a boy? a girl?) and the best course of action (e.g., should there be surgery? what kind? when?) are not obvious. While there have been large advances in diagnostic assessments like genetic and endocrine testing, the tests do not always show what caused the DSD. And, even when the tests do reveal an explanation for the DSD, knowing what happened genetically or hormonally does not usually lead to a single "correct" treatment plan. Instead, it is likely that there are different acceptable treatment options - and parents will need to make decisions based, in part, on their personal preferences, values, and cultural background. Adding more stress to the situation is knowledge that many of the decisions that need to be made by parents early in a child's life are irreversible and exert life-long consequences for the child and the family.

To support parents becoming actively involved in making such decisions, and to reduce the likelihood of future worry and regret about decisions that have been made, the investigators will create a decision support tool (DST). The DST will help educate families about typical and atypical sex development of the body, the process by which DSD are diagnosed (especially how to interpret genetic test results), and possible relationships between diagnostic/genetic testing, decisions about care, and known consequences of those decisions on their child and entire family. The DST will be used by parents of young children together with their child's health care provider.

The investigators will bring together a network of researchers, health care providers, representatives of patient support and advocacy organizations, and parents of children with DSD to share their experiences. Participants of this network will be involved at each stage of creating the DST, revising it, and putting it into practice. At the end of this project, the investigators will have a fully formed and tested DST that will be available for parents to use with their child's health care team as they are first learning their child may have a DSD.

PI(s): David Sandberg

Co-I(s): Edward Goldman, Catherine Keegan, Beth Tarini, Beverly Yashar

 

Funded by the Department of Veterans Affairs.

Funding Years: 2012-2013.

Diabetes is a complex, chronic disease encompassing many domains of treatment. VHA and others have created diabetes guidelines to help support providers and patients in making choices about optimal treatment approaches. However, most guidelines are broad in nature, and offer relatively little guidance on how to personalize care in order to maximize treatment benefits, minimize the intensity and negative effects of treatment, and best align with individual treatment preferences. 

We will test the effectiveness of a personalized decision support program. Our long term goals are:

  • To test and implement a decision support program, including decision coaching supported by an interactive, personalized decision support tool, in clinical practice via our Patient-Aligned Care Team (PACT) laboratory.
  • To assess the impact of personalized decision support on patient-centeredness, patient satisfaction, and the effectiveness of risk communication and treatment decision making.

We propose an interventional study to examine the effectiveness of personalized decision support. The intervention will consist of two key components: a decision coach  and a personalized diabetes decision support tool. The decision support tool has mostly been developed via AHRQ and local pilot funding mechanisms, and is informed by personalized estimation of treatment benefits for blood glucose, blood pressure, and lipid treatment based on extensive modeling work done by our investigative team. The personalized benefit information is communicated through graphical risk communication methods (pictographs).  

PI(s): Angela Fagerlin 

Should this patient get a liver transplant? (Nov-08)

There aren't enough donor organs to go around for patients who need aliver transplant. This sometimes forces doctors to make tough choices.If you were the doctor, how would you decide in the following scenario?  There aren't enough donor organs to go around for patients who need a liver transplant. This sometimes forces doctors to make tough choices. If you were the doctor, how would you decide in the following scenario?Suppose there is a person who develops acute liver failure (ALF). While waiting for a liver transplant, this person gets sicker and sicker. When an organ is finally available, the chance that this person will survive WITH a transplant is only 42% at five years after the transplant. Since the average survival for most patients who receive a liver transplant is 75% at five years, the doctor wonders if it would be better to save the liver for someone else. Two possible ethical principles may guide the doctor in making this decision. 

Using the principle of URGENCY, the doctor would give the first available organ to the sickest patient on the transplant waiting list, the ALF patient, because she/he is otherwise likely to die within a few days.

Using the principle of UTILITARIANISM, the doctor would try to maximize the quality and quantity of life of all the people on the transplant list. Let's say there are 25 other patients currently on the waiting list, and transplanting the ALF patient increases their risk of death by 2% each, for a cumulative harm of 50%. Since this harm of 50% is more than the benefit to the ALF patient (42%), the liver should be saved for someone else on the list.

A third possibility is for the doctor to weigh both URGENCY and UTILITARIANISM in making a decision about a transplant.

If you were the ALF patient's doctor, what would you base your decision about a transplant on?
 
  • URGENCY (sickest patient on the list gets preference)
  • UTILITARIANISM (maximize benefit for the entire waiting list)
  • A combination of URGENCY and UTILITARIANISM

How do your answers compare?

There's no absolutely right or wrong answer in this case—the choice depends on which of several competing ethical principles or which combination of principles you follow. In choosing a combination of URGENCY and UTILITARIANISM, you've decided to try to balance the needs of the sickest patient with the needs of all the people on the transplant waiting list.

CBDSM researcher Michael Volk, MD, is the lead author on a recent article that tackles difficult decisions like this one. Volk and his colleagues examined a method to incorporate competing ethical principles in a decision analysis of liver transplantation for a patient with ALF. Currently, liver transplantation in the United States is determined by the principle of “sickest first," with patients at highest risk for death on the waiting list receiving first priority. In other words, the principle of URGENCY is paramount. However, most experts agree that, given the limited supply of organs, there should be a cutoff for posttransplant survival below which transplantation is no longer justified.

Where does society draw this line? And what framework can we use for ethical guidance?

Decision analysis of resource allocation would utilize the principle of UTILITARIANISM, to maximize the broad social benefit. But surveys of the general public have shown that most people prefer to temper utilitarianism with other considerations, such as equal opportunity, racial equity, and personal responsibility. Another factor that might be considered is the principle of fair chances. This is the idea that patients who have not had a chance at a liver transplant should receive priority over those who have already had once chance at a transplant.

Volk constructed a mathematical model (Markov model) to test the use of competing ethical principles. First he compared the benefit of transplantation for a patient with ALF to the harm caused to other patients on the waiting list, to determine the lowest acceptable five-year survival rate for the transplanted ALF patient. He found that giving a liver to the ALF patient resulted in harms to the others on the waiting list that cumulatively outweighed the benefit of transplantation for the ALF patient. That is, using UTILITARIANISM as the sole guiding ethical principle gave a clear threshold for the transplant decision: if the ALF patient did not have a five-year survival rate of at least 48%, she/he should not receive a transplant under this principle.

But UTILITARIANISM is not always the sole guiding ethical principle. When Volk adjusted the model to incorporate UTILITARIANISM, URGENCY, and other ethical principles such as fair chances, he got different thresholds. Depending on the combination of ethical principles used, Volk and his colleagues have shown that the threshold for an acceptable posttransplant survival at five years for the ALF patient would range from 25% to 56%.

The authors of this study conclude:

"Our model is an improvement over clinical judgment for several reasons. First, the complexity of the various competing risks makes clinical decision making challenging without some form of quantitative synthesis such as decision analysis. Second, a systematic approach helps ensure that all patients are treated equally. Most important, this study provides moral guidance for physicians who must simultaneously act as patient advocates and as stewards of scarce societal resources."

Volk ML, Lok ASF, Ubel PA, Vijan S, Beyond utilitarianism: A method for analyzing competing ethical principles in a decision analysis of liver transplantation, Med Decis Making 2008;28, 763-772.

Online: http://mdm.sagepub.com/cgi/content/abstract/28/5/763

More information:

Beyond utilitarianism: A method for analyzing competing ethical principles in a decision analysis of liver transplantation.
Volk M, Lok AS, Ubel PA, Vijan S. Medical Decision Making 2008;28(5):763-772.

 

Thu, February 01, 2018

Breast cancer patients face complex decisions about their treatment. Sarah Hawley, Reshma Jagsi, and colleagues developed an interactive online tool to help patients understand their treatment options. In a study published in the Journal of Clinical Oncology, they found that patients using the interactive tool had higher knowledge and felt more informed about options and felt better prepared to make a treatment choice.

Funded by NIH - Department of Health and Human Services

Funding Years: 2012-2017

Treatments for cancer impose substantial burden and morbidity but net survival benefit of different strategies is often small and virtually always uncertain. Thus, clinicians may do more harm than good if treatment is too aggressive. There are a number of management strategies for breast cancer aimed at reducing unnecessary morbidity and burden on patients with favorable disease. A key barrier to advancing these initiatives is the need for a better understanding of the challenges of individualizing cancer care. The goal of this program is to improve population health by helping clinicians and their patients address the challenges of individualizing treatment of breast cancer for patients with favorable prognosis. Objective 1: To examine the challenges of individualizing treatment for women with breast cancer. Two projects will each undertake an observational study of patients newly diagnosed with breast cancer (including their attending clinicians) who were reported to the SEER registries of Georgia and New Jersey during an 18 month period to examine patient and clinician factors associated with key evaluative tests, treatments, and patient appraisal of decision quality. Project 1 will focus on challenges for surgeons and their patients with regard to locoregional therapy. Project 2 will focus on challenges for medical oncologists and their patients with regard to systemic therapy. Objective 2: To improve treatment decision quality. Project 3 will perform a randomized controlled trial of a practice based online decision tool for patients newly diagnosed with breast cancer in the Detroit and Atlanta SEER regions intended to improve decision quality. Objective 3: To accelerate the dissemination of SEER-based research findings by implementing and evaluating a tailored online portal aimed at all surgeons and medical oncologists who treated the patient samples in P1 and P2 to evaluate whether our research findings can more directly and promptly inform clinicians knowledge and attitudes about individualizing treatment. Objective 4: To advance methods in SEER population translational research focused on quality of cancer care. We propose four shared resource cores that will support program project activities, advance innovative methods in oncology population sciences, and advance team mission and long-term strategic planning.

PI(s): Steven Katz

Co-I(s): Lawrence An, Michael Elliott, Angela Fagerlin, Sarah Hawley, Timothy Hofer, Reshma Jagsi, Nancy Janz, Yun Li, Kenneth Resnicow, Jeremy Taylor, Christopher Friese

Sarah Hawley, PhD, MPH

Faculty

Dr. Sarah T. Hawley is a Professor in the Division of General Medicine at the University of Michigan and a Research Investigator at the Ann Arbor VA Center of Excellence in Health Services Research & Development. She holds a PhD in health services research from the University of North Carolina and an MPH from Yale University Department of Public Health. Her primary research is in decision making related to cancer prevention and control, particularly among racial/ethnic minority and underserved populations.

Last Name: 
Hawley
Press Coverage: 

Parents' decision-making about medicating infants (Jul-13)

Imagine that you are the parent of a 1-month-old infant. Your infant spits up a lot. Often there is so much spit-up that you are amazed that there is anything left in your infant’s stomach.  After spitting-up, your infant cries a lot. The crying and spitting seems especially bad after eating. But sometimes it seems like she is uncomfortable most of the time. It seems like there is nothing that you can do to stop the crying or to soothe your infant. You are worried that an infant who is this uncomfortable, and that spits up this much, might not be healthy. So, you decided to take your infant to the doctor to be checked.

After listening to your story and examining your infant, your doctor says, “You infant has something called GERD, or Gastroesophageal Reflux Disease. GERD happens when infants have a weak valve at the entrance to their stomach and, as a result, food and acid from the stomach can travel back up toward the infant’s mouth. When this happens, the infant may spit-up, and the acid in the spit-up may make her uncomfortable, and cause her to cry. Some doctors prescribe a medication that is often used to treat infants with GERD. Most infants grow out of GERD on their own, but medication is an option if you want it. However, studies have shown that this medicine probably doesn’t do anything to help improve symptoms in babies with GERD. This is the same medication that is taken by adults who have bothersome heartburn. This medication is generally considered safe for infants, and rarely causes serious side effects. I’ll give you this prescription and leave it up to you to decide whether or not you want to give it to your infant.”

Funded by American Cancer Society.

Funding Years: 2014-2017.

The study will examine how informal decision supporters (e.g., partners, family, and friends) contribute decisions about surgery, radiation, and chemotherapy treatment, and how these roles may vary by race and ethnicity. The project will utilize existing resources from the Cancer Surveillance and Outcomes Research Team's (CanSORT) Program Project Grant "The Challenge of Individualizing Treatments for Patients with Breast Cancer," a $13 million award received from NCI in 2012.

PI(s): Sarah Hawley

Co-I(s): Jennifer Griggs, Nancy Janz, Steven Katz, Yun Li

 

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