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Brian Zikmund-Fisher, PhD, a CBSSM investigator and Director of the CBSSM Internet Survey lab, is the principal investigator on an Investigator Initiated Research award from the Foundation for Informed Medical Decision Making that began in October 2008.  The grant, entitled "Learning by Doing: Improving Risk Communication Through Active Processing of Interactive Pictographs," will fund the development and testing of of Flash-based interactive risk graphics that research participants or patients can use to visually demonstrate how likely they believe some event is to occur. Dr. Zikmund-Fisher hopes that people who create risk graphics themselves will have a better intuitive understanding of risk than people who just view static images. Co-investigators on the award include Angela Fagerlin, Peter A. Ubel, and Amanda Dillard.

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.

Fri, December 09, 2016

Kenneth Langa's national study, published in JAMA Internal Medicine, was cited in a New York Times article discussing US dementia trends. Despite concern that dementia rates were increasing, Langa found that it is actually decreasing. He found that population brain health seemed to improve between 2000 and 2012 and that increasing educational attainment and better control of cardiovascular risk factors may have contributed to the improvement. However, the full set of social, behavioral, and medical factors contributing to the improvement is still uncertain.

Research Topics: 

The novelty of risk and vaccination intentions (May-12)

It's 2009.  Early in the year, a 9-year-old girl from California became the first person with a confirmed case of H1N1 ("swine") influenza in the United States.  Shortly thereafter, the U.S. declared a public health emergency and the World Health Organization declared a phase 6 pandemic (the highest level possible).  By September 2009 a vaccination was developed and was available within a month.

You've been following the news about the H1N1 influenza as developments have unfolded throughout the year, and you feel some concern.  You have been wondering about the risk of coming down with the H1N1 flu yourself and have been thinking about whether you should be vaccinated. 

Funded by Veterans Affairs Health Services Research & Development CDA-2

Funding Years: 2014-2015


Despite the availability of evidence-based strategies to prevent type 2 diabetes mellitus (T2DM), engagement in these strategies is low among at-risk Veterans. A key opportunity to engage at-risk Veterans in interventions to prevent T2DM is when they are informed they have prediabetes. It remains unclear how VHA communications to patients diagnosed with prediabetes could be optimized to improve their engagement in evidence-based preventive strategies.

  • Aim 1: To describe at-risk Veterans' current engagement in behaviors to prevent T2DM and the mediators of this engagement.
  • Aim 2: To examine the effects of receipt of a prediabetes diagnosis on at-risk Veterans' weight and engagement in behaviors to prevent T2DM.
  • Aim 3: To identify the effects of 4 strategies from behavioral economics and health psychology on weight, HbA1c, and engagement in behaviors to prevent T2DM among Veterans with prediabetes.

To accomplish Aim 1, we will survey 189 non-diabetic Veterans with risk factors for T2DM about their engagement in behaviors to prevent T2DM and mediators of this engagement such as risk perception, motivation, and awareness of and preferences for preventive strategies. To accomplish Aim 2, we will conduct a pilot randomized trial among the same 189 non-diabetic Veterans from Project 1 in which we will randomly assign 126 of these Veterans to undergo screening for T2DM using a hemoglobin A1c (HbA1c) test. The 63 Veterans who we project will have HbA1c values in the prediabetes range will receive that diagnosis and preventive recommendations from their PACT provider via brief standardized counseling. All 189 Veterans will have their weight tracked over the next year and will be surveyed immediately after the screening and brief counseling process, at 3 months, and at 1 year. Then we will compare changes in weight, engagement in behaviors to prevent T2DM, and mediators of this engagement between the 63 Veterans who we project will have prediabetes and the 63 Veterans who were not screened. Among the 63 Veterans with prediabetes, we will conduct 20 semi-structured interviews to gain insights into the effects of this diagnosis and brief counseling. To accomplish Aim 3, we will conduct a fractional factorial design experiment to evaluate the effectiveness of 4 innovative strategies from behavioral economics and health psychology in promoting weight loss, decreasing HbA1c, and increasing engagement in behaviors to prevent T2DM among 144 Veterans who are identified as having prediabetes through an HbA1c test. We will conduct qualitative evaluations of the acceptability of these strategies to patients.

PI(s): Jeffrey Kullgren

Medical Students

Systematizing the Teaching of Medical Ethics in the Undergraduate Medical Years

Medical students at the University of Michigan encounter ethical issues throughout their four years of training.  Some are obvious – decisions at the end of life, the allocation of scarce of medical resources, challenges to patient autonomy – others are less obvious – relationships between medical residents and medical students, problems with the “hidden curriculum,” and systemic discrimination in the provision of care.  Our goal is to make students aware of the variety of ethical problems in medical care and to equip them to respond to these problems in a wise and responsible manner.

To that end, our curriculum efforts focus on extending the existing curriculum and on making the medical ethics curriculum for undergraduate medical students at UM more systematic and explicit. Because we want students to become well-versed in thinking through ethical dilemmas before they encounter them in their clinical work we weave ethics into the curriculum throughout the 4 years of their undergraduate training. We use the expertise of our CBSSM faculty to create novel curricular components that incorporate our empirical work in bioethics with our particular expertise in decision science.

Increasing Opportunities for Ethics Teaching in the Clerkship Years

Discussions During Required Clinical Rotations

We facilitate regular ethics discussions for medical students at the end of their required clinical rotations in Obstetrics and Gynecology (in the third year) and Emergency Medicine (in the fourth year). To facilitate these discussions, students prepare short essays on ethical dilemmas encountered in these clerkships.  Students are given a summary of all the issues that came up that rotation, which is used as a starting point for a discussion facilitated by a clinical faculty member trained in ethics. In addition, the Internal Medicine subinternship (an option for fourth year students) includes an ethics discussion at the end of the rotation.

These discussions allow medical students to bring up concerns with ethical dilemmas in a safe environment, teach the students about approaches to ethics, and embed training in ethical decision-making in clinical practice. This is often the first time students learn about the role of the hospital ethics committee and how they can contact them if desired.

     “That was unexpectedly awesome!"  

-- Medical student after Ob/Gyn ethics discussion

 

Advanced Medical Therapeutics Ethics Module

All fourth year medical students are required to take an online Advanced Medical Therapeutics course. As part of the course, we created an ethics module that includes multiple cases that present ethical dilemmas.  Each case includes pre-recorded videos of faculty discussing the ethical aspects of the case and interactive components requiring students to choose possible solutions to the problem, after which they receive explanations of the pros and cons of their choice.

Medical Ethics Path of Excellence

CBSSM faculty work closely with the medical school to strengthen the medical ethics curriculum for Michigan medical students.  Our goal is to make students aware of the broad range of  ethical challenges facing 21st century medicine – challenges in clinical care, medical research and the design of health care delivery. Most recently, a team of CBSSM faculty developed the Medical Ethics Pathway of Excellence, an opportunity for students to receive mentored training in ethics throughout their four years of medical school.

Overview of Medical Ethics Pathway to Excellence:

  • Introduced in September 2013, the first 10 students were accepted in 2014. Twelve students joined in 2015.
  • Students apply to the Ethics Path of Excellence at the end of February during their M1 year, and continue their studies through their M4 year. Students in the POE learn to:
    • Identify ethical issues in the organization and delivery of health care
    • Implement tools and strategies to address ethical issues
    • Continue their professional education and development of the skills required for leadership
  • Highlights:
    • Before applying to the Ethics Path of Excellence, students have the opportunity to attend fourteen interactive lunchtime lectures that review various aspects of ethics in a healthcare setting. Applicants must attend a minimum of five of these lectures.
    • Students who want to serve on ethics committees and/or include ethics as part of an academic career are provided with specialized training.
    • All students participate in an individualized, independent study, culminating in a capstone project in the M4 year. Often this work includes field work at CBSSM.

Beginning in 2015, the Path of Excellence has been responsible for administering the core ethics curriculum for all of the M1 students. The Ethics Path of Excellence will continue to be a co-curricular activity until 2017 when all students will be required to choose one of the paths offered in the medical school.

“We really want to educate people to be the ethics committee consultants of the future. I think it's pretty unique to have the option of pursuing this extracurricular program because essentially it teaches you leadership skills and how to be a self-directed learner. These are skills you'll really need when you become faculty. Students can take their interest in ethics and pursue it further.”             
Lauren Smith, M.D., Associate Professor of Pathology

Lauren Smith is the Director of the Path of Excellence. Andrew Barnosky, Christian Vercler, Ed Goldman, Kathryn Moseley, Janice Firn, Sacha Montas, and Raymond De Vries are core faculty members.

Start Seeing Ethics Lunch Discussions

As part of the Medical Ethics Path of Excellence, we offer lunch time discussions of cutting-edge topics in ethics. The content of these discussions includes topics such as conscientious objection, mandatory vs. optional vaccinations, patient centered care and shared decision making.  We have also used these discussions to hold mock ethics committee meetings with discussion of a specific case. Facilitators provide a relaxed atmosphere in which students can feel comfortable asking questions and voicing opinions.

 

"It is exciting to see medical students engage with the ethical issues that arise in the clinic and the classroom.  With encouragement from us they are beginning to see that there is more to medical ethics than just the well-known issues at the beginning and end of life.  While these ethical issues are important, there are also moral consequences associated with the mundane aspects of being a student and working with patients." Raymond De Vries, PhD, Director, Ethics Education Initiative

 

CBSSM Seminar: Jacob Solomon, PhD

Thu, November 19, 2015, 3:00pm to 4:00pm
Location: 
NCRC, Building 16, Room 266C

Jacob Solomon, PhD


CBSSM Postodoctoral Fellow

Title:

Designing the information cockpit: The impact of customizable algorithms on computer-supported decision making

Abstract:

Intelligent systems that provide decision support necessitate interaction between a human decision maker and powerful yet complex and often opaque algorithms. I will discuss my research on end-user control of these algorithms and show that designing highly customizable decision aids can make it difficult for decision makers to identify when the system is giving poor advice.

MD vs. WebMD: The Internet in Medical Decisions (Dec-10)

With just a simple search term and a click of the mouse, a person can find a large amount of health information on the Internet. What role does the Internet play in how patients make medical decisions? Does using the Internet as a source for information to help patients make informed decisions vary by health condition? Does the Internet substitute for detailed discussions with a health care provider?

Consider the following:

Imagine that you recently visited your health care provider for an annual physical examination. During the exam your doctor told you that you are at the age where you should start thinking about getting a screening test for colon cancer. In this conversation your health care provider explained some of the reasons why you should get screened. At the end of the visit, you had more information about screening tests for colon cancer but had not yet decided whether or not you wanted to get tested.

As you think about how you would make a decision about whether or not to get screened for colon cancer:
 
How important is your health care provider as a source of information about screening tests for colon cancer?
Not at all important (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) Extremely important
 
Would you use, or have someone else use for you, the Internet to find information on screening tests for colon cancer?
 
  • Yes
  • No
  • Don't know
How important is the Internet as a source of information screening tests for colon cancer?
Not at all important (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) Extremely important
 
 
 

How do your answers compare?

In a recent study published in the journal Medical Decision Making, CBSSM investigators Brian Zikmund-FisherMick Couper, and Angela Fagerlin examined Internet use and perceived importance of different sources of information by patients making specific medical decisions.

In this study, US adults aged 40 years and older were asked about how they got information about 9 common medical decisions, including decisions about common prescription medication (for high blood pressure, cholesterol, and depression), cancer-screening tests (for colorectal, breast, and prostate cancer), and elective surgeries (for lower back pain, cataracts, and knee/hip replacement). In addition, they study compared participants' ratings of the Internet as a source of information with their ratings of other sources, such as their health care provider.

So, how did your responses compare to the average adult in this study's population?

Results from this study showed that most patients did not use the Internet to make specific medical decisions like the ones you considered. On average, about 26% of participants made use of the Internet for information to make decisions about colon cancer screening tests and about 47% used it to inform a decision about lower back pain surgery.

Among participants who chose to use the Internet for finding information about specific medical decisions, data show that Internet use varies significantly across different types of medical decisions. Internet users were more likely to use the Internet for information related to elective surgery (36%), such as lower back pain surgery, and prescription medication (32%) than for cancer-screening decisions (22%), such as colon cancer screening.

Another element of this study looked at participants' ratings of different information sources. You are unlike other participants in this study in that you did not consistently rate health care providers as the most important source for information about colon cancer screening and lower back pain surgery. The CBSSM study found that, for both Internet users and nonusers, health care providers were rated highest as a source for information for all 9 decisions studied. Among Internet users, however, the Internet was rated as their 2nd-most important source of information.

The researchers found that Internet use to inform specific medical decisions varied by age ranging from 38% for those aged 40 to 49 years to 14% for those aged 70 years or older. Approximately 33% of 50 to 59 year olds used the Internet to make these medical decisions and 24% for those in the 60 to 69 year age category. This result is consistent with previous research on the demographics of Internet use.

The study authors concluded that the Internet has an impact on people's access to health care information; however, "the data suggest that access is not the same as use, and use for one medical decision does not imply use for all health decisions." In other words, people use the Internet differently depending on the context. The authors end by stating, "Clinicians, health educators, and health policy makers need to be aware that we remain a long way away from having Internet-based information sources universally used by patients to improve and support the process of medical decision making."

For the full text of this article:

Couper M, Singer E, Levin CA, Fowler F, Fagerlin A, Zikmund-Fisher BJ. Use of the internet and ratings of information sources for medical decisions: Results from the DECISIONS survey. Medical Decision Making 2010;30:106S-114S.

 

Funded by Patient-Centered Outcomes Research Institute (PCORI)

Funding Years: 2014 - 2018

Obesity is increasingly considered among the most important public health problems of our times. Bariatric surgery is arguably the only treatment that has proven effective in producing long-term weight loss for patients with morbid obesity. Bariatric surgery also results in resolution of obesity related comorbid conditions, improvements in quality of life, and increased survival.

There are currently four different bariatric surgical procedures in use: adjustable gastric banding, gastric bypass, sleeve gastrectomy, and duodenal switch. Bariatric surgery is considered a highly preference sensitive medical issue. Existing decision aids in bariatric surgery are limited in that they provide information about the average comparative risks and benefits of the treatment options, but do not provide customized estimates of the risks and benefits of the different procedures for individual patients. As a result of these draw-backs, decision aids are not frequently used in making treatment decisions in bariatric surgery.

Our proposal is highly innovative in that our decision support tool integrates data from a large clinical registry with individual patient data to provide patients with real-time, customized, accurate information regarding the risks and benefits of the treatment options to better inform decision making. This tool will be continuously updated to ensure that the data on risks and benefits that it provides are accurate and current. Our tool also provides information about other attributes of the treatment options that bariatric surgery patients and other relevant stakeholders feel are important for patients to consider in deciding whether and what type of bariatric surgery to have.

The proposed research promotes shared medical decision making for patients who are considering bariatric surgery for the treatment of morbid obesity. If our intervention proves effective, it will result in improved decision quality and outcomes of care for patients. It may also result in improved efficiency of care to the extent that it serves to augment or guide communication between the patient and physician to promote shared medical decision-making.

PI(s): Nancy Birkmeyer/Amir Ghaferi

Co-I(s): Lawrence An, Mousumi Banerjee, Angela Fagerlin, Sarah Hawley, Edward Norton, Lisa Prosser

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

 

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