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Funded by Foundation for Informed Medical Decision Making

Funding Years: 2007 -2008

 

The National Survey of Medical Decisions (the DECISIONS study), co-led by CBDSM investigators Mick Couper (PI) and Brian Zikmund-Fisher (co-I), is a unique effort to collect nationally representative data about when and how middle-aged and older adults manage the medical decisions they face.

The DECISIONS study consisted of a random digit dial telephone survey of 3,010 adults over the age of 40 in the United States conducted between November 2006 and May 2007.  Participants were asked a series of screening questions to identify which of 10 common medical decisions they may have discussed with their health care providers in the previous two years and then completed 2-3 question modules regarding specific decisions that were relevant to each individual. 

Its initial screening module gathered highly generalizeable data regarding the prevalence of different types of common medical decisions in the experience of older Americans.  Its dynamically-administered modules then requested detailed information regarding how and when patients discuss key medical decisions with their health care providers and whether variations in decision-making processes may have influenced patients’ medical care. 

Funded by the Foundation for Informed Medical Decision Making (FIMDM), the DECISIONS project has been a highly collaborative project that has included investigators from Institute for Social Research and FIMDM, as well as CBDSM. In addition, FIMDM-affiliated researchers from around the country are analyzing DECISIONS data to inform their research. While the initial papers from the DECISIONS dataset will be by core investigators, the study team intends to make the dataset publicly available for more widespread use sometime in 2009.

Mick Couper (PI)

Announcement of Position: Clinician Ethicist

Announcement of Position: Clinician Ethicist


Background
The Program in Clinical Ethics within the Center for Bioethics and Social Sciences in Medicine (CBSSM) represents an expansion of existing services designed to promote a culture of patient-centered excellence by developing a comprehensive set of ethics-related activities. The aims of this program are to: liaise with and provide support to the adult and pediatrics ethics committees; streamline clinical ethics consultation; assist with ethics-related policy development on a regular and proactive basis; organize and administer structured educational programs in clinical ethics; and coordinate empiric research with relevance to clinical ethics within CBSSM.


Program Organization
The Program in Clinical Ethics is co-directed by the chairs of the adult and pediatric ethics committees and consultation services, Christian J. Vercler, MD MA and Andrew G. Shuman, MD. A dedicated clinician ethicist will manage the program on a daily basis. A cadre of eight faculty ethicists will rotate on service throughout the year and work closely with the clinician ethicist. Trainees and students will rotate as well. Dedicated administrative support will be organized through CBSSM.


Position
One individual will serve as the program’s clinical ethicist. This individual will serve as the “first responder” and contact person for all ethics consults during business hours, ensure continuity with consults, and work in conjunction with faculty ethicists. The role will include arranging team/family meetings, ensuring follow-ups on all consults, and arranging additional consultations as needed for selected cases. He/she will also regularly review relevant institutional policies and attend all ethics committee meetings. Another major component of this role will be to organize and participate in educational efforts and preventative ethics rounds. This position will provide $50,000 of direct salary support annually, to be distributed and allocated in conjunction with their home department. The initial appointment will last two years and is renewable.


Qualifications
Candidates are expected to be employees or faculty at UMHS with a master’s or equivalent terminal degree in their field; any professional background is acceptable. Direct experience with clinical ethics consultation is required. Familiarity with ethics education and related clinical research would be helpful. Excellent organizational and communication skills across multidisciplinary medical fields are required. Candidates are expected to have qualifications that meet the standards outlined by The American Society for Bioethics and Humanities (ASBH) for accreditation for clinical ethics consultants.


Application Process
Candidates will be vetted, interviewed and chosen by a nomination committee. Candidates are asked to submit:

  • Curriculum vitae or resume
  • One page maximum summary of (1) education/training related to ethics consultation; (2) clinical ethics consultation experience; and (3) motivation/interest in the position
  • Letter of support from Department Chair/Division Head/Center Director or equivalent
  • Submit formal application via email to: valkahn@med.umich.edu


Timeline

  • Application is due December 11, 2015 with interviews shortly thereafter
  • Appointment will take effect January 1, 2016


Contacts

  • Co-Directors of the Program in Clinical Ethics: Christian J. Vercler, MD MA & Andrew G. Shuman, MD
  • Administrative contact: Valerie Kahn – valkahn@med.umich.edu 734 615 5371

Announcement of Position: Faculty Ethicist

Announcement of Position: Faculty Ethicist


Background
The Clinical Ethics Service within the Center for Bioethics and Social Sciences in Medicine (CBSSM) promotes a culture of patient-centered excellence by performing a comprehensive set of ethics-related activities. The aims of this service are to: liaise with and provide support to the adult and pediatric ethics committees; provide clinical ethics consultation and engage in preventative ethics endeavors; assist with ethics-related policy development on a regular and proactive basis; organize and administer structured educational programs in clinical ethics; and coordinate empiric research with relevance to clinical ethics within CBSSM.

Program Organization
The Clinical Ethics Service is led by Christian J. Vercler, MD MA and Andrew G. Shuman, MD. A dedicated clinical ethicist will manage the program on a daily basis. A cadre of faculty ethicists will rotate on service throughout the year and work closely with the clinical ethicist. Trainees and students will rotate as well. Dedicated administrative support is organized through CBSSM.


Position
The Clinical Ethics Service employs a roster of faculty ethicists who are responsible for staffing ethics consultations arising from any of the clinical venues (inpatient and outpatient; adult and pediatric) within Michigan Medicine during their time on service. They will supervise and participate in the institutional educational endeavors and preventative ethics rounds in a regular and on-going manner. Faculty ethicists will also develop and provide clinical rotations for medical students and house officers on a cohesive ethics service. Each faculty member will be expected to rotate on service for four to six weeks per year, and attend/participate in committee meetings and other events throughout the academic year (this will not necessarily require suspension of other activities when on-service). Depending on the total number appointed, each faculty ethicist will receive $15,000-$20,000 of direct salary support annually, to be distributed and allocated in conjunction with their home department. The initial appointment will last two and a half years and is renewable. Additional appointments will last two years.


Qualifications
Candidates are expected to have faculty appointments at University of Michigan and be in good academic standing; any professional background is acceptable. Candidates are expected to have qualifications that meet the standards outlined by The American Society for Bioethics and Humanities (ASBH) for accreditation for clinical ethics consultants. Direct experience with clinical ethics consultation is required. Familiarity with ethics education and related clinical research would be helpful. Excellent organizational and communication skills across multidisciplinary medical fields are required.


Application Process
Candidates will be vetted and chosen by a selection committee. Candidates are asked to submit:

  • Curriculum vitae or resume
  • One page maximum summary of (1) education/training related to ethics consultation; (2) clinical ethics consultation experience; and (3) motivation/interest in the position
  • Letter of support from Department Chair/Division Head/Center Director or equivalent
  • Submit formal application via email to: lynnam@med.umich.edu


Timeline

  • Application is due September 25, 2017
  • Appointment will take effect January 1, 2018

Contacts

  • Leaders of the Clinical Ethics Service: Christian J. Vercler, MD MA & Andrew G. Shuman, MD
  • Administrative contact: Valerie Kahn – valkahn@med.umich.edu 734 615 5371

Funded by NIH: National Cancer Institute

Funding Years: 2008-2014

Prostate cancer is a leading cause of cancer death among men, and thousands of men must make treatment decisions every year. Decision making for localized prostate cancer is especially challenging as clinical trials have shown that the standard treatment options of active surveillance, surgery and radiation are comparable in terms of survival. Thus, treatment for prostate cancer is a preference-sensitive decision, with the best choice depending in part on patient attitudes towards the risks and benefits of treatment alternatives. Therefore, ideally the treatment decision will be made with full consideration of patient preferences. As such, it is recommended that patients and their physicians discuss any preferences patients have that might be relevant to the treatment decision. This dialogue is complicated by patients’ lack of experience with sharing in these types of decisions. Additionally, physicians often use medical jargon, making it more difficult for patients to understand their diagnosis and treatment options.  Research is needed to determine the best methods for helping patients communicate their preferences to their physicians so that patient values hold considerable weight in treatment decisions.

The goals of this study are two-fold:

  • To demonstrate to patients some of the issues that might arise during their diagnosis visit that may prevent them from communicating preferences to physicians.
  • To provide solutions that would enable greater patient participation in medical decision making.

PI(s): Angela Fagerlin, PhD and Peter A. Ubel, MD

Co-I(s): John T. Wei, MD; Brian Zikmund-Fisher, PhD; Margaret Holmes-Rovner, PhD; James Tulsky, MD; Stewart Alexander, PhD

Parent grantMichigan Center for Health Communication Research II

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.

CBSSM investigators Holly Witteman, Andrea Fuhrel-Forbis, Angela Fagerlin, and Brian Zikmund-Fisher, along with CBSSM alumni Peter Ubel and Andrea Angott will give a plenary talk at the Society for Medical Decision Making's 32nd Annual Meeting in Toronto on Monday, October 25.  The talk is titled, "Colostomy is Better than Death, but a 4% Chance of Death Might Be Better Than a 4% Chance of Colostomy: Why People Make Choices Seemingly At Odds With Their Stated Preferences." 

Abstract:

Purpose: When asked for their preference between death and colostomy, most people say that they prefer colostomy. However, when given the choice of two hypothetical treatments that differ only in that one has four percent chance of colostomy while the other has four percent additional chance of death, approximately 25% of people who say that they prefer colostomy actually opt for the additional chance of death. This study examined whether probability-sensitive preference weighting may help to explain why people make these types of treatment choices that are inconsistent with their stated preferences.

Method: 1656 participants in a demographically diverse online survey were randomly assigned to indicate their preference by answering either, “If you had to choose, would you rather die, or would you rather have a colostomy?†or, “If you had to choose, would you rather have a 4% chance of dying, or would you rather have a 4% chance of having a colostomy?†They were then asked to imagine that they had been diagnosed with colon cancer and were faced with a choice between two treatments, one with an uncomplicated cure rate of 80% and a 20% death rate, and another with an uncomplicated cure rate of 80%, a 16% death rate, and a 4% rate of colostomy.

Result: Consistent with our prior research, most people whose preferences were elicited with the first question stated that they preferred colostomy (80% of participants) to death (20%), but many then made a choice inconsistent with that preference (59% chose the treatment with higher chance of colostomy; 41% chose the treatment with higher chance of death). Compared to the first group, participants whose preferences were elicited with the 4% question preferred death (31%) over colostomy (69%) more often (Chi-squared = 24.31, p<.001) and their treatment choices were more concordant with their stated preferences (64% chose the treatment with higher chance of colostomy; 36% chose the treatment with higher chance of death, Chi-squared for concordance = 36.92, p<.001).

Conclusion: Our experiment suggests that probability-sensitive preference weighting may help explain why people’s medical treatment choices are sometimes at odds with their stated preferences. These findings also suggest that preference elicitation methods may not necessarily assume independence of probability levels and preference weights.


Funded by Department of Veterans Affairs

Funding Years: 2009-2012

Because CRC-predictive genetic tests offer the potential to optimize CRC screening efforts, improving the communication and use of such tests by the millions of veterans who are screened for CRC each year could result in both improved cancer surveillance and more efficient (and potentially reduced) VA resource utilization. Our study will provide empirical data about practical risk communication methods that can be used in the future by VA clinicians to present genetic tests to veterans and about patient-level barriers which will inhibit acceptance of genetic tests that predict colorectal cancer risk within the VA patient population. By evaluating alternate methods of communicating genetic test results before such tests actually become available, we hope to identify optimal approaches that can be integrated into VA genomics initiatives from the very start.

Angela Fagerlin (PI)

It is with both sadness and joy that we announce that CBSSM Co-Director Dr. Angela Fagerlin will be assuming a new position as the inaugural Chair of

Population Health Sciences at the University of Utah. While we are very sad to see Angie leave, we congratulate her on this well-deserved opportunity and are thrilled to see her enter this new stage in her career.

Dr. Fagerlin has been with the University of Michigan for 15 years and Co-Director of CBSSM for the last 5 years. She has been an integral member of CBSSM and all its precursors—the Program for Improving Health Care Decisions and The Center for Behavioral and Decision Sciences in Medicine. Dr. Fagerlin will be greatly missed for her friendship, collegiality, mentorship, and the great science she has produced over the years.

As of January 2016, current Co-Director of CBSSM Dr. Raymond De Vries will be joined by Dr. Brian Zikmund-Fisher, who will serve as an Interim Co-Director. Dr. Zikmund-Fisher is an Associate Professor of Health Behavior and Health Education at the School of Public Health, as well as a Research Associate Professor of Internal Medicine. He has been actively involved with CBSSM and its precursors for over 13 years and has many research collaborations and mentoring relationships with CBSSM faculty, fellows, and affiliates. Dr. Zikmund-Fisher looks forward to helping to grow CBSSM's many research and educational initiatives in the future.

Give me colostomy or give me death! (Aug-06)

Click to decide between death and living with a colostomy. Which would you choose? Are you sure?

Given the choice, would you choose immediate death,or living with a colostomy (where part of your bowel is removed and you have bowel movements into a plastic pouch attached to your belly)?

  •  Immediate Death
  •  Colostomy

Think about what it would be like if you were diagnosed with colon cancer. You are given the option of choosing between two surgical treatments.The first is a surgery that could result in serious complications and the second has no chance of complications but has a higher mortality rate.

Possible outcome Surgery 1
(complicated)
Surgery 2 
(uncomplicated)
Cure without complication 80% 80%
Cure with colostomy 1%  
Cure with chronic diarrhea 1%  
Cure with intermittent bowel obstruction 1%  
Cure with wound infection 1%  
No cure (death) 16% 20%

If you had the type of colon cancer described above, which surgery do you think you would choose?

  • Surgery 1
  • Surgery 2

How do your answers compare?

In fact, past research has shown that 51% people choose the surgery with a higher death rate, even though most of them initially preferred each of the four surgical complications, including colostomy, over immediate death.

Are you saying what you really mean?

CBDSM investigators Brian Zikmund-Fisher, Angela Fagerlin, Peter Ubel, teamed up with Jennifer Amsterlaw, to see if they could reduce the number of people choosing the surgery with the higher rate of death and therefore reducing the discrepancy. A large body of past research has shown that people are notoriously averse to uncertainty. The investigators had a hunch that uncertainty could account for some of the discrepancy. Surgery 1 has a greater number of ambiguous outcomes, perhaps causing people to be averse to it. In an effort to minimize this uncertainty, the investigators laid out a series of scenarios outlining different circumstances and presentations of the two surgeries. For example the research presented some of the participants with a reframing of the surgery information, such as:

Possible outcome Surgery 1
(complicated)
Surgery 2 
(uncomplicated)
Cured without complication 80% 80%
Cured, but with one of the following complications: colostomy, chronic diarrhea, intermittent bowl obstruction, or wound infection 4%  
No cure (death) 16% 20%

The investigators believed by grouping all of the complications together that people would be more apt to chose the surgery with the lower mortality rate, because seeing a single group of undesirable outcomes, versus a list, may decrease some of the ambiguity from previous research.

Although none of the manipulations significantly reduced the percentage of participants selecting Surgery 2, the versions that yielded the lowest preference for this surgery all grouped the risk of the four possible complications into a single category, as in the example shown above.

Why these findings are important

Over the past several decades there has been a push to give patients more information so they can make decisions that are consistent with their personal preferences. On the other hand there is a growing psychological literature revealing people's tendency to make choices that are in fact inconsistent with their own preferences; this is a dilemma. Because the present research suggests that the discrepancy between value and surgery choice is extremely resilient, much research still needs to be done in order to understand what underlies the discrepancy, with the goal of eliminating it.

The research reported in this decision of the month is currently in press. Please come back to this page in the near future for a link to the article.

Read the article:

Can avoidance of complications lead to biased healthcare decisions?
Amsterlaw J, Zikmund-Fisher BJ, Fagerlin A, Ubel PA. Judgment and Decision Making 2006;1(1):64-75.

 

 

 

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