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CBSSM Seminar: Barbara Koenig, PhD

Thu, October 23, 2014, 3:00pm to 4:00pm
Location: 
NCRC 16-266C

Barbara Koenig, PhD
Professor of Medical Anthropology & Bioethics Dept. of Social & Behavioral Sciences
Institute for Health & Aging, UCSF

“Revisiting the “Race” Issue in Genomics”

Summary: Throughout the post-genomic era, efforts to categorize human populations according to geographical ancestry have been contentious. How does genetic variation map on to social categories of difference? How can researchers seeking to understand health disparities—or to interrogate diseases associated with particular genetic variants—pay attention simultaneously to race as social identity, and biological characteristic?

CBSSM Seminar: Kevin Kerber, MD

Wed, December 03, 2014, 3:00pm to 4:00pm
Location: 
NCRC 16-266C

 Kevin Kerber, MD
Associate Professor of Neurology, Medical School
Director, Dizziness Clinic

Title: Implementation of Evidence-Based Practice for Benign Paroxysmal Positional Vertigo

Summary: A wide gap exists between the evidence-base for processes to diagnose and treat Benign Paroxysmal Positional Vertigo (BPPV) and the use of these processes in real world medicine. The investigators will present their work-in-progress regarding an implementation strategy to increase the use of BPPV processes in emergency department presentations of dizziness.

Thu, September 11, 2014

Brian Zikmund-Fisher, Nicole Exe, and Holly Witteman’s study “Numeracy and Literacy Independently Predict Patients’ Ability to Identify Out-of-Range Test Results” in the Journal of Medical Internet Research was featured in Modern Healthcare and other media outlets. The articles discuss patients' understanding and informed decision making when they have direct access to lab reports and test results. In the Wall Street Journal, Dr. Zikmund-Fisher was quoted, "If we don't make it clear to patients what these numbers mean, we can't expect them to know what to do."

Thu, September 18, 2014

A new study put out by senior author Beth Tarini, MD, MS, shows that primary care doctors report challenges to incorporating genetics assessments in routine primary care. Dr. Tarini commented, "Genetics is not just about rare diseases and specialists. PCPs [Primary Care physicians] rely on genetics frequently during preventive care visits – especially when taking family histories and assessing a patient’s risk of more common, but chronic, diseases. So the fact that PCPs report many barriers to embracing and performing these tasks is concerning," The study also found that many Primary Care physicians feel as though their expertise on genetic medicine is insufficient.

Susan Dorr Goold, M.D., M.H.S.A., M.A., professor of Internal Medicine, and Health Management and Policy, was awarded a two-year, $391,000 grant from the Agency for Healthcare Research and Quality (AHRQ) to engage Michigan communities in deliberations about Medicaid priorities. Led by Goold and community partner Zachary Rowe, the project will engage communities in a priority setting exercise using the Choosing Health Plans All Together (CHAT) exercise. The award-winning CHAT tool provides structure, feedback and adaptability. It has a been used by multiple policy makers and community organizations, and a solid record of published research.

 

Valerie Kahn, MPH

Center Manager

Valerie joined CBSSM as the Center Manager in the fall of 2012 after working as a Project Manager at CBSSM since 2009. Valerie continues her work on research projects involving medical decision making and doctor-patient communication. Valerie received her MPH in Health Behavior Health Education from the University of Michigan.

 

 
Last Name: 
Kahn

Chris Krenz, BA

Research Associate

Chris Krenz joined CBSSM in the fall of 2014. He received his BA in Sociology from the University of Michigan, minoring in Philosophy. Before coming to CBSSM, Chris was located at the Institute for Social Research, working on projects concerning the health of Pacific Islanders and other minority populations.

Chris primarily works with Dr. Raymond De Vries on a study exploring factors that influence whether biobank donors provide consent for their biological material to be used in research.

Research Interests: 
Last Name: 
Krenz
Tue, January 16, 2018

CBSSM Director, Reshma Jagsi was recently interviewed for the LA Times article, "Will medicine be the next field to face a sexual harassment reckoning?" This article discusses her 2014 survey on sexual harassment and gender bias in academic medicine, as well as her recent article on the #MeToo movement as it relates to medicine in the New England Journal of Medicine.

Sorry, Doc, that doesn't fit my schedule (Feb-04)

Patients sometimes skip treatments because they just feel too busy. What should physicians do when their patients ignore their recommendations?

Imagine you are a businessperson who works long hours and you are on your way up to having a successful and lucrative career. You have a major business deal that will consume nearly all of your time over the upcoming month and your boss is relying on you to make sure the deal goes through. This is your chance to really make your mark and show your corporation that you are the kind of person that can handle deals as big as this one. Also suppose you have been smoking on and off for 25 years. You know it's a bad habit that could destroy your lungs, but you just can't quite kick it. Lately, you have been feeling tired, you have been experiencing chest pains when you are really busy at work and when you exercise, and you have had trouble breathing when climbing a flight of stairs. The chest pains are usually relieved by a little rest, but you decide it's time to get this examined by a doctor.

One day after work, you go to see Dr. Coral, who gives you a stress test and determines that you'll need an appointment for an angiogram to better evaluate your coronary arteries. Fortunately, you find one free day right before things get hectic at work, so you schedule the angiogram. Now imagine you have just had the angiogram and you are recovering in a paper gown waiting for Dr. Coral to come back with the results. Dr. Coral enters the room to speak with you and he has a serious look on his face. He says,

"I have both good and bad news for you. The angiogram shows that your 3 main coronary arteries are all severely blocked. The good news is that we caught this before you had a major heart attack."

"The bad news is that I am recommending you have triple bypass surgery as soon as possible. Your heart is working overtime, and it is just a matter of time until it gives out."

The news is shocking, but in addition to your health concerns, you also have the business deal to worry about. This deal is an opportunity to make a name for yourself, and your boss has been very vocal that he was counting on you, trusting that you'd be the one for the job. You find yourself having to weigh your work ambitions against the recommendation from Dr. Coral because if you get surgery, there is no way you'd be able to take on your current work responsibility.
 
Which of the following decisions would you be most likely to make?
 
  • I would put aside Dr. Coral's recommendation and instead take responsibility at work for the current deal. I'll wait to have surgery in about a month.
  • I would follow Dr. Coral's recommendation by having surgery immediately, even though this forfeits the current opportunity at work.

A little feedback on what you chose.

It's not that physician's don't care about your other values, but they are primarily concerned about your health, and you might not even have lived long enough to finish the business deal if you didn't have this surgery immediately. This does, however, bring up an important fact: patient's do sometimes reject their physician's medical judgment, and it can be at a great cost to their health.
 
Why should a patient be part of the decision-making process?
 
Why shouldn't Dr. Coral just tell you that you need surgery and leave no alternative? Efforts to share decision-making with patients are important because they acknowledge patients' rights to hold views, to make choices, and to take actions based on personal values and beliefs. In addition to being ethically-sound, this shared decision-making process also leads to improved patient health outcomes.
 
What can a physician do to help the patient choose surgery?
 
To answer this question, first it needs to be emphasized that in order for a patient to be able to participate in the decision-making process, the patient must be able to soundly make decisions. This sounds abstract and subjective, but it can be broken down into something a little more concrete. Decision-making capacity (DMC) is based on four guidelines:
 
The patient is able to:
 
  • understand the information about the condition and the choices available;
  • make a judgment about the information in keeping with his or her personal values and beliefs;
  • understand the potential outcomes or consequences of different choices; and
  • freely communicate his or her wishes
Based on these four elements, it is possible to see what a physician can do to help facilitate a "good" health decision. In order to make sure a patient fully understands the situation, a physician can ask him or her to state their understanding of the problem and of the treatment options. Also, a physician should use clear and unambiguous language with the patient at all times. Although a report might be quite clear from a physician's perspective, a patient might not be as clear about all the details. In the situation you were asked to imagine, Dr. Coral should tell you that you will die without this surgery and that waiting is not a safe option.
Also, there might be other factors keeping a patient from following a physician's recommendation. Again, in your hypothetical situation, your boss was putting a lot of pressure on you not to let him down. Also, this decision would potentially have an effect on your advancement at work. You might not have felt free to elect surgery even if you knew it was the only good decision for your health. By directly acknowledging and addressing a patients' concerns, physicians may facilitate a decision for the surgery.
 
In conclusion, if a physician feels that a patient is not able to fulfill one or more of the elements of DMC then his or her ability to make that decision should be brought into question and surrogate decision makers should be sought. For more serious decisions, the standards for DMC should be higher than for less important decisions or those with less significant outcome differences among the choices.
 
For more information see:

 

What is the price of life? (Aug-03)

Do you think that your life is worth more than the amount that the government usually uses as the maximum to spend to provide one year of life?

Imagine that you are a member of a government panel that is trying to decide how cost-effective a medical treatment must be in order for the government to cover the costs of the treatment. Suppose that a certain treatment could provide one additional year of life to an otherwise healthy person. What is the highest amount the government should be willing to pay per person for this treatment?

How do your answers compare?

For the past twenty years, the figure most often used as the maximum amount to spend to provide one year of life has been $50,000. This figure was originally proposed since it was the cost of a year of kidney dialysis, a lifesaving treatment that the U.S. government funds in Medicare.

Should the number be higher or lower than the current standard?

Conventional wisdom would suggest that the number be higher to take into account the inflation that has occurred in the years since the standard was developed. Current practices such as annual Pap smear screening for women with low risk for cervical cancer, which has a cost of $700,000 per year of life gained, also suggest that society is willing to pay more than the current standard for a year of life. The authors of the cited article recommend, based on current treatment practices and surveys of the general public, that the cost-effectiveness threshold should be revised to be around $200,000.

Should the number increase, decrease, or stay the same over time?

Again, it seems that the threshold amount should increase over time due to inflation. However, other factors come in to play that affect the value.

Since new technologies are emerging all the time, some of which will be deemed cost-effective, there will be more and more treatments to be offered in the future. Also, the rate of use of treatments is an important consideration, because even if a new treatment is more cost-effective than an old one, if it is used more often it will end up costing more to society overall. With more treatments becoming available and more people being given treatments, the threshold cost will probably have to decrease so that insurance companies and the government can keep up with the increasing availability and demand.

Why is this important?

Insurance companies and government health care entities face a continuing struggle when trying to determine which medical treatments to cover. Health care costs are increasing rapidly, so these groups will be facing even tougher decisions in the future. Establishing cost-effectiveness guidelines would be extremely helpful as an aid to making the decisions about treatment coverage. Evidence shows that the current threshold is probably not an accurate reflection of the desires of society or actual prescribing practices. It needs to be adjusted to become useful once again, and must be reevaluated periodically to make sure the value keeps up with trends in the health care market, rather than being left alone without question for two decades as is the current situation.

For more information see:

Ubel PA, Hirth RA, Chernew ME, Fendrick AM. What is the price of life and why doesn't it increase at the rate of inflation? Archives of Internal Medicine. 163:1637-1641, 2003.

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