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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

Bioethics Grand Rounds: Janice Firn, MSW; Andrew Shuman, MD; Christian Vercler, MD

Wed, January 27, 2016, 12:00pm
Location: 
UH Ford Amphitheater & Lobby

"Implementation of the Program in Clinical Ethics"

Janice Firn, MSW; Andrew Shuman, MD; Christian Vercler, MD

Abstract: The Program in Clinical Ethics within the Center for Bioethics and Social Sciences in Medicine represents an expansion of existing services designed to promote a culture of patient-centered excellence by developing a comprehensive set of ethics-related activities at UMHS. We will introduce and outline the projects and services available to all members of the UMHS Community.

Sacha Montas, JD, MD

Faculty

Dr. Montas is a Clinical Lecturer in the Department of Emergency Medicine. Dr. Montas holds a law and medical degrees from the University of Michigan and a Master of Bioethics from the University of Pennsylvania. He has been a member of the University of Michigan Adult Ethics Committee since 2009. His research interest is in the intersection of Law and Medicine, and Bioethics, with a focus on the influence of the legal system and legal norms on patient-physician communication and decision making.

Last Name: 
Montas

H. Myra Kim, ScD

Faculty

H. Myra Kim is a Research Scientist at the Center for Statistical Consultation and Research and and Adjunct Professor at the Department of Biostatistics. She received her Sc.D. in Biostatistics from Harvard University in 1995 and worked at Brown University as an Assistant Professor from 1995 to 1997. She has worked at UM since 1997 and has collaborated with various researchers from around the UM community as well as from other universities.

Research Interests: 
Last Name: 
Kim

Funded by Department of Health and Human Services - National Institutes of Health Subcontracts

Funding Years: 2014.

Promoting physical activity and decreasing sedentary behavior are key goals in the fight against cancers; physical activity is associated with lower risk of several cancers [1-10], and lower overall morbidity and mortality [11-26]. Thus, theory-driven initiatives to change these behaviors are essential [1-10, 26-40]. PQ#3 highlights the necessity for new perspectives on the interplay of cognitive and emotional factors in promoting behavior change. Current theories, which focus primarily on predictors derived from self-report measures, do not fully predict behavior change. For example, recent meta-analyses suggest that on average, variables from the Theory of Planned Behavior account for ~27% of the variance in behavior change [41, 42]. This limits our ability to design optimally effective interventions [43], and invites new methods that may explain additional variance. Our team has shown that neural activation in response to health messages in hypothesized neural regions of interest can double the explained variance in behavior change, above and beyond self-reports of attitudes, intentions, and self-efficacy [44, 45]. We now propose a next leap, inspired by PQ3, to identify how cognitive and affective processes interact in the brain to influence and predict behavior change. Our core hypothesis is that the balance of neural activity in regions associated with self-related processing versus defensive counterarguing is key in producing health behavior change, and that self-affirmation (an innovative approach, relatively new to the health behavior area [46]) can alter this balance. Self-affirmation theory [47] posits that people are motivated to maintain a sense of self-worth, and that threats to self-worth will be met with resistance, often i the form of counterarguing. One common threat to self-worth occurs when people are confronted with self-relevant health messages (e.g. encouraging less sedentary behavior in overweight, sedentary adults). This phenomenon speaks to a classic and problematic paradox: those at highest risk are likely to be most defensive and least open to altering cancer risk behaviors [48]. A substantial, and surprisingly impressive, body of evidence demonstrates that affirmation of core-values (self-affirmation priming) preceding messages can reduce resistance and increase intervention effectiveness [46, 49-53]. Uncovering neural mechanisms of such affirmation effects [46], has transformative potential for intervention design and selection. To test our conceptual assumptions and core hypothesis we will: (1) Identify neural signals associated with processing health messages as self-relevant versus counterarguing; (2) Test whether self-affirmation alters the balance of these signals; (3) Use these neural signals to predict physical activity behavior change, above and beyond what is predicted by self-report measures alone. Our approach is innovative methodologically (using fMRI to understand and predict behavior change), and conceptually (self-affirmation may dramatically increase intervention effectiveness). Benchmarks will include objectively measured decreases in sedentary behavior in affirmed vs. control subjects (using accelerometers), and increases in predictive capacity afforded by neuroimaging methods, compared to self-report alone.

PI(s): Thad Polk

Co-I(s): Lawrence An, Sonya Dal Sin, Kenneth Resnicow, Victor Strecher

Funded by National Institutes of Health.

Funding Years: 2014-2019.

Randomized controlled trial (RCT) results diffuse into clinical practice slowly - the average time from trial completion to widespread adoption of a new treatment is nearly 20 years. These delays result in suboptimal treatment for patients with neurological diseases. In light of these delays and the enormous societal value of NINDS clinical trials findings, NINDS has recognized the need to accelerate implementation by promoting research to translate trial findings into routine care (T2 translational research). This application seeks to optimize translation of NINDS trials by personalizing clinical trial results ad addressing barriers to translation for clinicians and policy-makers. Using translational research methods, we can move from one-size-fits-all evidence-based medicine towards personalized medicine by estimating treatment benefit for individual patients. Other translational methods can evaluate and address stakeholder concerns that hinder translation. Because clinicians are often skeptical of trial results, changing practice requires convincing them not only that a treatment works in an RCT or that it works in academic medical centers, but that it will work for their patients. Similarly, if policy-makers and payers can be convinced that a new treatment is a good value (e.g., a favorable cost-benefit ratio), they can use their considerable influence on the healthcare delivery system to facilitate translation. Specifically, we will use translational research methods to address three important issues essential to improving trial translation: 1. estimating individual-level outcomes using multivariable outcome prediction 2. Estimating the impact of real world circumstances on outcomes using simulation analyses and 3. Cost effectiveness analysis. Results from these analyses can influence clinicians and policy-makers directly or through the use of tools, such as websites and mobile applications. This proposal has two key objectives. First, we will adapt translational research methods to clinical trials by addressing essential translation-relevant questions for the Carotid Revascularization Endarterectomy versus Stenting (CREST) trial. Second, we will develop a model to concurrently perform similar translational analyses in the Neurology Emergency Treatment Trials (NETT) network. These objectives will be addressed through 3 specific aims: 1. to estimate the expected net benefit of carotid endarterectomy (CEA) vs. carotid artery stenting (CAS) for individual patients in the CREST trial using refined multivariable outcome prediction methods. 2. To estimate the impact of personalized decision-making and real world circumstances (e.g., differing complication rates) on the net benefit of CAS vs. CEA for real world patients using simulation analyses. 3. To assess the feasibility of performing concurrent translational and cost analyses in NETT trials by evaluating a process implementation model in newly initiated and recently completed NETT trials. Dr. Burke has a unique background as a vascular neurologist with training in Translational research methodology through the highly regarded Robert Wood Johnson Clinical Scholars Program. In this proposal, Dr. Burke will develop the additional expertise in clinical trials, multivariable outcome prediction, simulation analyses and cost analyses to become a leader and independently-funded investigator in neurological translational research working to develop a new generation of NETT trials better designed to effectively inform real world clinical practice and improve patient outcomes. This proposal capitalizes on unique environmental strengths at the University of Michigan. Most importantly, Dr. Burke will be supported by an outstanding multi- disciplinary mentorship team including Dr. William Barsan the NETT Clinical Coordinating Center (CCC) principal investigator and a research leader in the emergency treatment of neurological diseases, Dr. Rodney Hayward a Professor of Internal Medicine and a pioneer in translational research and Dr. Lewis Morgenstern, a leader in neurological translational research. All three mentors have excellent track records in mentoring junior faculty and transitioning junior faculty to independence. In addition, Dr. Burke will have te opportunity to participate in a unique hands-on clinical trials immersion through the NETT to gain experience in clinical trial design, management and implementation. Finally, the University of Michigan has recently built the largest academic Translational Research center in the United States (the Institute for Health Policy and Innovation) which will support the advanced statistical methods required for this proposal.

PI(s): James Burke

Jeffrey Kullgren, MS, MD, MPH

Faculty

Dr. Jeff Kullgren is a Research Scientist in the Center for Clinical Management Research at the VA Ann Arbor Healthcare System and an Assistant Professor in the Department of Internal Medicine at the University of Michigan Medical School and Institute for Healthcare Policy and Innovation.  Dr.

Last Name: 
Kullgren

Brian Zikmund-Fisher, PhD, is the featured guest editor for a special supplement to Medical Decision Making's September/October 2010 issue, highlighting the DECISIONS study, a nationwide survey of adults in the US regarding common medical decisions.  Lead author on the main paper of the supplement, Zikmund-Fisher and co-authors (including CBSSM faculty Angela Fagerlin, PhD and Mick Couper, PhD) describe the DECISIONS study, a telephone interview of a nationally representative sample of 3010 adults age 40 and over faced with making a medical decision in the past two years.  Researchers defined medical decisions as the patient having initiated medications, been screened, or had surgery within the past 2 years or having discussed these actions with a health care provider during the same interval.  Key findings from the study:

Although patients frequently receive information about the benefits of a procedure or medication, they don't always learn about the disadvantages.

Healthcare providers don't always ask patients what they want to do.

Most patients don't use the Internet to help them make common medical decisions; healthcare professionals remain the most important source of information.

Patients often don't know as much as they think they do.  Many patients feel well informed even when they don't know key facts that would help them make a better decision.

African-Americans and Hispanics were less knowledgeable than other patients about medications to treat high cholesterol.  In addition, they were more likely to say their doctor made decisions about cholesterol medications for them.

Most patients think they are more likely to get cancer than they really are, and tend to view cancer screenings as more accurate than they are.

Men and women think about cancer risks differently.  Women are more active participants in cancer screening decisions regardless of their perception of risk, whereas men tended to get involved only if they felt at higher risk.

The ethics of resuscitation (Sep-11)

Traditional ethical teaching suggests that a physician's assessment of a patient's best interest should guide the decision of whether to administer emergency life-sustaining therapy, absent guidance by the patient or family members.  In pediatric medicine, physicians may insist on life-saving therapy if they believe it is in a child's best interest to receive it, even if the parents seek to refuse it.  It is unclear exactly how physicians make such assessments, however, and whether/how these assessments influence decision-making in critical situations.  Consider the following scenario:

CBSSM Working Group Meeting- Leslie Skolarus, MD

Tue, April 10, 2018, 4:00pm
Location: 
NCRC bldg 16 266C

Acute stroke treatments are highly effective and very timesensitive (ie. Time is brain).  One barrierto timely treatment is tpa discussion induced delay/refusals. Based onqualitative data from a safety net hospital we think this is due to: 1) lowhealth literacy of the patient population and 2) physician framing of theconversation that may overemphasize the risks. We are seeking to build patientand provider guides to expedite the discussion.

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