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Is it disgusting? (May-08)

People vary in their attitudes toward physical disabilities. Give us your reactions, and we'll tell you the results of surveys of the general public--and of actual patients.

 

Strongly

disagree

Mildly

disagree

Mildly

agree

Strongly

agree

I try to avoid letting any part of my body touch the toilet seat in a public restroom, even when it appears clean.

1

2

3

4

It would make me uncomfortable to hear a couple making love in the next room of a hotel.

1

2

3

4

It would bother me tremendously to touch a dead body.

1

2

3

4

Even if I were hungry, I would not eat a bowl of my favorite soup if it had been stirred by a used-but thoroughly washed- fly-swatter

1

2

3

4

I am bothered by the odor caused by passing gas.

1

2

3

4

The smell of other persons' bowel movements disgusts me.

1

2

3

4

Consider the following

Now we'd like you to think about a specific health condition. Please read this scenario carefully so that you can answer some questions. Imagine you have a colostomy. A colostomy is an operation involving the surgical redirection of your bowels through a hole created in your gut. This hole is called a stoma. Waste passes through your intestines and out the stoma into a bag, which you must empty several times a day. If you wear relatively loose clothing, this bag won't be visible underneath your garments. Occasionally, you'll experience odors and noises caused by gas and waste passing through the stoma into the bag. There's also the chance that the colostomy bag may leak if it's allowed to fill past capacity. Although you'll be restricted from lifting very heavy objects, your daily activities won't otherwise be greatly affected by the colostomy.

To what extent does your colostomy make you feel embarrassed or socially uncomfortable?
Not at all 1       2       3       4       5       6       7       8       9        10 Very Much
 
To what extent does your colostomy make you feel stigmatized?
Not at all 1       2       3       4       5       6       7       8       9        10 Very Much
 

How do your answers compare?

Do your responses to the six questions on the disgust scale correlate with the stigmatization you expressed related to your imaginary colostomy?

In their national survey of the general public (people without colostomies), CBDSM researchers found that people who reported a higher level of disgust sensitivity responded more negatively to colostomy.

Current and former colostomy patients were also surveyed. In these groups, patients with higher disgust sensitivity had more difficulty adjusting to life with a colostomy. Specifically,colostomy patients with higher disgust sensitivity felt more stigmatized in society by their colostomy and felt more bothered by colostomy symptoms, such as leakage. Dr. Dylan Smith and his colleagues postulate that people who have a pre-existing high sensitivity to disgusting stimuli will be less likely to adjust well to life with a colostomy. Alternatively, it could be that people who adjust successfully to a colostomy do so in part by reducing their sensitivity to certain kinds of disgusting stimuli.

If future studies show that we can predict that patients with high disgust sensitivity are likely to have more difficulty adjusting to a colostomy, health-care teams can then seek ways to de-sensitize responses to bowel functioning, in order to aid patients in their adaptation to life with a colostomy. Further, many people with inflammatory bowel syndrome can choose whether or not to have a colostomy for relief of their symptoms. For these patients, a clear understanding of disgust sensitivity could be a factor in helping to make an informed choice about elective colostomy.

Certainly this research suggests that disgust plays a role in perceived and actual stigmatization of disabled patients. Previous studies of patients' adjustment to disability have focused on general responses to adversity, taking into account their social support, their coping style, or their optimism, for example. The uniqueness of this recent CBDSM study is that it considers how the specific challenges of a disability interact with a personality trait relevant to that disability: disgust sensitivity. This personality trait might also be linked to other health conditions, such as amputation or incontinence. In addition, personality traits other than disgust might affect patients' adaptation to other disabilities.

Read the article:

Sensitivity to disgust, stigma, and adjustment to life with a colostomy
Smith DM, Loewenstein G, Rozin P, Sherriff RL, Ubel PA. Journal of Research in Personality 2007;41(4):787–803.

The Disgust Scale used here is adapted from the work of Haidt J, McCauley C, Rozin P. Individual differences in sensitivity to disgust: A scale sampling seven domains of disgust elicitors. Personality and Individual Differences. 1994; 16(5): 701-713.

 

It's your call: your intuition against the experts' advice (Jan-05)

A respected national organization has released new guidelines. As a physician, would you change your patient's treatment based on these recommendations? Imagine you are a primary care physician taking care of a male patient, Sam, with mildly elevated cholesterol. He doesn't like taking pills and, fortunately, his cholesterol has been good enough that he doesn't need any pills. But now, a respected National Organization has just revised its recommendations, and are urging doctors to treat cholesterol more aggressively, even in people like this patient, who has no history of heart disease or diabetes.

What role should these new guidelines play in your decision?

The guidelines should not be a strong consideration 1       2       3       4        5  The guidelines should be a strong consideration
 
What would you recommend to your patient, Sam?
 
I would... 
 
  • ask him to take a pill.
  • urge him to take a pill.
  • give him information about cholesterol and let him decide.
  • urge him not to take a pill.
  • ask him not to take a pill.

How do your answers compare?

What were some of the things you were weighing when you made your decision? Perhaps you were wondering why the National Organization would recommend taking a pill even when a patient's cholesterol is good enough that they wouldn't necessarily need the more aggressive treatment. You might have found yourself wondering whose interests were reflected in these guidelines. Did the National Organization have some kind of investment in the pill or the pharmaceutical company that produces it? You might have had some doubts about just how much you could trust the guidelines.

Resistance to practicing "cost-effective" medicine

In the past, physicians did what was best for each individual patient in their care, without having to consider cost or having to figure out whether an HMO or accreditation board was looking over their shoulders. But now physicians are put in the awkward position of having to judge whether a particular patient will benefit enough from a specific therapy for that therapy to be cost-effective. It is not surprising that physicians disparage cost-effectiveness in health care, given that traditional medical education teaches that they should not consider the cost of medical interventions when treating individual patients.

Resistance to practicing according to Clinical Practice Guidelines

Clinical practice guidelines, like the one you read about on the previous page, offer a potentially palatable way for physicians to consider the cost-effectiveness of medical interventions. High quality guidelines are based on thorough and systematic reviews of clinical and cost-effectiveness evidence. Still, physicians are often concerned that guidelines are tainted by financial conflicts of interest. The experts who are involved in writing the guidelines are often the same individuals who interact with the pharmaceutical industry.

Why cost-effectiveness and Clinical Practice Guidelines belong together

Investigator Ellen Hummel and CBDSM investigator Peter Ubel were asked by the editors of Virtual Mentor, the online ethics forum of the American Medical Association, to comment on whether clinical practice guidelines ought to incorporate cost-effectiveness information. These investigators begin by acknowledging the resistance to practicing cost-effective medicine. At the same time, however, they argue that including cost-effectiveness information in clinical practice guidelines is an essential way to address physicians' concerns about the kinds of conflicts of interest mentioned above. If cost-effectiveness evidence is presented up-front, physicians wouldn't have as many concerns that the guielines were intended to benefit the industry while sticking the patient with a higher cost. Imagine if on the previous page the guideline had presented evidence that the new, more aggressive cholesterol treatment was still well within accepted cost-effectiveness ratios despite potential conflicts of interest. You might have then better trusted the guideline's recommendation when assessing what to tell Sam.

Including cost-effectiveness information in clinical practice guidelines will enhance the credibility of their recommendations. At the same time, evidence-based guidelines help clinicians recognize the importance of practicing cost-effective medicine with their individual patients. With the help of high quality guidelines, physicians may be encouraged by groups of peers and respected authorities to restrain themselves from pursuing rare benefits for their patients, which is especially important in a time when our current health care system increasingly demands that we become involved with the costs of medical care.

Read the article:

Cost and clinical practice guidelines: Can two wrongs make it right?
Ubel PA, Hummel EK. Virtual Mentor 2004;6:np.

PIHCD Working Group

Thu, January 08, 2015, 3:00pm to 4:00pm
Location: 
TBD

Jake Seagull will be speaking about prostate cancer shared decision making.

PIHCD: Tanner Caverly

Thu, February 12, 2015, 4:00pm
Location: 
B004E NCRC Building 16

Tanner Caverly will be presenting on a decision tool about screening for lung cancer.

PIHCD: Geoff Barnes

Thu, September 24, 2015, 2:00pm
Location: 
B003E NCRC Building 16

Geoff Barnes will present on analysis from a project about bridging anticoagulation decision making.

PIHCD: Michelle Moniz

Thu, October 22, 2015, 3:00pm
Location: 
B004E NCRC Building 16

Michelle Moniz will be presenting a Specific Aims page for an NICHD K23 application about postpartum contraceptive decision-making.

Masahito Jimbo, MD, PhD, MPH

Faculty

Masahito Jimbo is Professor of Family Medicine and Urology at the University of Michigan. Having worked as a family physician in both urban (Philadelphia) and rural (North Carolina) underserved areas, he has first-hand knowledge and experience of the challenges faced by clinicians and healthcare institutions to be successful in providing patient care that is personal, comprehensive, efficient and timely. Initially trained in basic laboratory research, having obtained his MD and PhD degrees at Keio University in Tokyo, Japan, Dr.

Last Name: 
Jimbo

Get it out of me! (Dec-05)

A 5% chance of death or a 10% chance of death:  which would you choose?

Imagine that you have been diagnosed with a slow growing cancer. Right now, the cancer is not causing you to feel sick. For most people, the cancer will grow so slowly it will never cause them any trouble. For others, the cancer will grow to the point that it makes them sick. Untreated, five percent (5 out of 100) will die of the cancer. Your doctor tells you that you have two treatment options: watchful waiting or surgery. Watchful waiting means you will not do any treatment right away, but your doctor will follow your cancer closely and treat any symptoms that you have if it begins to spread. Although it would be too late to be cured, you would be comfortable and free of pain. There are no side effects to watchful waiting, but five percent (5 out of 100) of the people who choose this treatment will develop symptoms and die from their cancer within five years. On the other hand, the surgery would cure your cancer permanently. Following surgery you will feel more tired than usual and will experience stomach upset occasionally for the three months following your surgery. However, surgery has a ten percent (10 out of 100) risk of death during the surgery.

Imagine that both of these treatments are completely covered by your health insurance. Which would you choose?

  •  I would not take the surgery and accept the 5% chance of dying from this cancer.
  •  I would take the surgery and accept the 10% chance of dying from the surgery.

How do your answers compare?

In the real world, cancer patients sometimes choose treatments that may have devastating side effects over less invasive, yet equally or more effective, approaches. One explanation for this is that people may feel a strong need to "get the cancer out" of their bodies. Surgical removal of all potentially cancerous tissues may satisfy this desire so thoroughly that people end up ignoring important statistical information about adverse outcomes.

Making a choice not in their best interest

CBDSM investigators Angela Fagerlin, Brian Zikmund-Fisher, and Peter Ubel hypothesized that people perceive cancer diagnoses as a call to action, and more specifically, a call to get rid of the cancer through surgery, regardless of what statistical information might say to the contrary. Consequently, they predicted that when presented with hypothetical cancer diagnoses, many people would say they would pursue surgery even if such an action would decrease their chance of survival.

To explore the relative frequency of people's willingness to choose surgery when it wasn't in their best interest, the investigators designed a cancer scenario similar to the one you read on the previous page. Participants were presented either a surgery or a medication treatment that would either increase or decrease their chance of survival.

The investigators found that participants who were presented with the opportunity to rid themselves of their cancer through surgery were significantly more inclined to take action than those who were presented with the medication treatment. For example, when the treatment reduced their overall chance of survival, 65% chose the surgery, whereas only 38% chose the medication treatment. This suggests that people's treatment decisions may be based not on the effectiveness of the treatments, but rather on their beliefs about how cancer should be treated. Specifically, cancer diagnoses seem to conjure up a strong desire for active treatment. And people seem to have an intuitive belief that action should not just involve treatment, but surgical removal of the cancer.

Why these findings are important

The results of this study may resonate with many clinicians who have encountered cancer patients who seem to desire treatment for treatment's sake, or who have a preference for surgical intervention even before they learn about the pros and cons of their treatment alternatives. This study should serve to remind clinicians that patients' preference for action can be strong enough, at times, to be a bias. At a minimum, it is important for health care professionals to be aware of the potential for such biases, so they can decide whether to accept patients' preferences at face value, or try to convince patients that aggressively treating a tumor may not be in their best interests.

Read the article:

Cure me even if it kills me: Preferences for invasive cancer treatment.
Fagerlin A, Zikmund-Fisher BJ, Ubel PA. Medical Decision Making 2005;25(6):614-619.

Geoff Barnes wrote a recent perspective piece and was featured in a UM Health Lab blog about anticoagulation clinic and assisting patients and providers with decision making.

Research Topics: 

PIHCD: Jacob Solomon

Wed, March 09, 2016, 2:00pm
Location: 
B004E NCRC Building 16

Jacob Solomon will be brainstorming about several ideas to study how users' ability to control decision aids affects their decision making.

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