Dr. Lesly Dossett MD, MPH is Assistant Professor of Surgery in the Division of Surgical Oncology at the University of Michigan. Dr. Dossett is an Honors Program and Summa Cum Laude graduate of Western Kentucky University. She earned her medical degree at Vanderbilt University School of Medicine in 2003, attending on a United States Navy Health Professions Scholarship. She completed general surgery residency at Vanderbilt University Medical Center in 2010, where she served as Administrative Chief Resident.
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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.
CBSSM’s Clinical Ethics Service sponsors the monthly Bioethics Grand Rounds, focusing on ethical issues arising in health care and medicine. This educational session is open to Michigan Medicine faculty and staff and CME credit is available.
Link to previous Bioethics Grand Rounds:
- Andrew Shuman, Edward Goldman, & Christian Vercler -- "Futility Revisited: UMHS Policy on Non-Beneficial Treatments" (Dec. 2016)
- Meredith Walton -- "The Ethical Principles Underlying Two Methods of Organ Donation" (Jan. 2017)
- Devan Stahl, PhD -- "Responding to Hopes for a Miracle" (Feb. 2017)
- Autumn Fiester, PhD -- "The Difficult Patient Reconceived" (March 2017)
- Scott Grant, MD, MBE -- "Dealing with Complications and Poor Outcomes and Surgical Futility" (May 2017)
- Anna Kirkland, JD, PhD -- "The Vaccine Injury Compensation Court and Its Critics" (June 2017)
- Susan Goold, MD, MHSA, MA, FACP -- "Trust me, I'm an Accountable Care Organization" (July 2017)
- Nicholson Price, JD, PhD -- "Black-Box Medicine" (Sept. 2017)
- Reshma Jagsi, MD, DPhil -- "Ethical Issues Related to Fundraising from Grateful Patients" (Oct. 2017)
- Lauren Smith, MD -- "Ethical Issues in Tranfusion Medicine" (Nov. 2017)
- Janice Firn, PhD, MSW & Tom O'Neil, MD -- "Professionalism, Ethical Obligations, and the Moral Imperative of Self-Care" (Dec. 2017)
- Marschall S. Runge, MD, PhD; Reshma Jagsi, MD, DPhil; David J. Brown, MD (Panel Discussion) -- "Examining the Ethics of Victors Care" (Feb. 2018)
- Katelyn Bennett, MD -- "Social Media and the 'Medutainment' Phenomenon" (March 2018)
- Andrew Shuman, MD -- "Ethical and Practical Approaches to Drug Shortages" (April 2018)
- Naomi Laventhal, MD -- "Pediatric Care Before Birth: Complex Perinatal Care Coordination and Decision-Making at Michigan Medicine" (May 2018)
Out with the old drugs and in with the new! How is your doctor prescribing for you?
Imagine that you are a physician and your patient is a 55-year-old white male with high blood pressure. He has no other medical problems, is on no medications, and has completed a 1-year program of diet and exercise to control his condition, but his blood pressure remains elevated at 170/105 (140/90 is the definition of high blood pressure).
As his physician, you have to decide on a medication to prescribe him in order to lower his blood pressure. You have the following options to choose from:
Diuretics: Diuretics are medications that lower blood pressure by getting rid of excess fluid in your body, making it easier for your heart to pump. They were first introduced in the 1950s.
Beta-blockers: Beta-blockers are medications that lower blood pressure by helping the heart to relax and pump more effectively, and by also reducing heart rate. They were first introduced in the 1960s.
ACE inhibitors: Angiotensin converting enzyme (ACE) inhibitors are medications that lower blood pressure by widening blood vessels and increasing blood flow. They were first introduced in 1981.
- A diuretic
- A beta-blocker
- An ACE inhibitor
- A calcium channel blocker
How do you compare to the physicians surveyed?
Of the physicians surveyed, 18% chose the same medication as you did. 38% chose an ACE inhibitor, 29% chose a beta-blocker, and 11% chose a calcium channel blocker. Most physicians chose an ACE inhibitor, a newer type of medication, rather than beta-blockers or diuretics, which are older types of medication.
Why is this important? When asked how they made their decision, the majority of physicians believed that diuretics were less effective and that beta-blockers were less likely to be tolerated by a patient's body than the other medications. However, a number of important studies have shown that beta-blockers and diuretics are as effective at lowering blood pressure as newer medications like ACE inhibitors and calcium channel blockers. Studies have also shown that beta-blockers and diuretics are equally or even better tolerated than the newer types of medications. Yet, the use of beta-blockers and diuretics has declined steadily in the past 15 years in favor of the newer and more expensive types of medications.
Why do physicians believe these things when the studies say otherwise?
The answer to this question is not fully known. One possibility is that physicians may be prescribing newer medications because these are the medications actively promoted by pharmaceutical companies. By providing free samples of the newer medications for physicians to give to patients, these companies may be influencing which medications physicians actually decide to prescribe. To test this possibility, after physicians had decided between diuretics, beta-blockers, ACE inhibitors, and calcium channel blockers, they were asked if they ever provide their patients with free medication samples from these companies to treat their high blood pressure. It was found that physicians who used free samples were more likely to believe that ACE inhibitors are more effective. This isn't proof that physicians are influenced by pharmaceutical companies when prescribing medication for high blood pressure, but it does urge us to seriously consider if physicians may need to be re-educated about the effectiveness and tolerability of beta-blockers and diuretics.
For more information see:
A longer life may result from the amount of social support present in your life, but is the longevity due to giving or receiving that support?
Imagine that in your busy schedule each week, you typically at least have Wednesday and Saturday nights free as time to spend however you want. Recently, however, one of your close friends had her car break down and now she is wondering whether you would be willing to drive her to and from a yoga class on Wednesday nights for the next three weeks while the car is in the shop. She told you that the class is only about a 15 minute drive each way. She said that you shouldn't feel pressured, and she just thought she'd ask if you had the time to help her out.
- Yes, I'd take the time to help her out.
- No, I'd keep my Wednesday nights free.
Giving vs. receiving: effects on mortality
A research team of investigators at the U of M Institute for Social Research teamed up with CBDSM investigator, Dylan Smith, to conduct a study investigating whether giving or receiving help affects longevity. The researchers noted that receiving social support is likely to be correlated with other aspects of close relationships, including the extent to which individuals give to one another. Based on this, they hypothesized that some of the benefits of social contact, sometimes attributed to receiving support from others, may instead be due to the act of giving support to others.
Using a sample of 423 married couples from the Detroit area, the investigators conducted face-to-face interviews over an 11-month period. The interviews assessed the amount of instrumental support respondents had given to and received from neighbors, friends, and relatives, as well as the amount of emotional support they had given to and received from their spouse. Instrumental support included things like helping with transportation, errands, and child care, whereas emotional support involved having open discussions with a spouse and feeling emotionally supported. Mortality was monitored over a 5-year period by checking daily obituaries and monthly death record tapes provided by the State of Michigan. To control for the possibility that any beneficial effects of giving support are due to a type of mental or physical robustness that underlies both giving and mortality risk, the investigators also measured a variety of demographic, health, and individual difference variables, including social contact and dependence on the spouse.
The investigators found that those who reported giving support to others had a reduced risk of mortality. This was true for both instrumental supoprt given to neighbors, friends, and relatives, and for emotional support given to a spouse. They also found that the relationship between receiving social support and mortality depended on other factors. Specifically, receiving emotional support appeared to reduce the risk of mortality when dependence on spouse, but not giving emotional support, was controlled. Receiving instrumental support from others actually increased the risk of mortality when giving support, but not dependence on spouse, was controlled.
What can we make of these findings?
It appears from these results that the benefits of social contact are mostly associated with giving rather than receiving. Measures that assess receiving alone may be imprecise, producing different results as a function of dependence and giving support.
Given the correlational nature of this study, it is not possible to determine conclusively that giving support accounts for the social benefit traditionally associated with receiving support. Nevertheless, the results of the present study should be considered a strong argument for the inclusion of measures of giving support in future studies of social support, and perhaps more importantly, researchers should be cautious of assuming that the benefits of social contact reside in receiving support.
It's true that when helping others out, you might have to give up some of your own time, but based on the above findings, it looks like in the long run you may end up ultimately gaining more time.
Read the article:
Providing social support may be more beneficial than receiving it: results from a prospective study of mortality.
Brown S, Nesse RM, Vinokur AD, Smith DM. Psychological Science 2003;14:320-327.
Scott L. Greer, Ph.D.
Professor, Health Management and Policy, Global Public Health, and Political Science
Physician Autonomy in Neonatology from 1979-2016: The Forces of Law, Ethics, Technology, and Families
Charley Willison, University of Michigan
Michael Rozier, St. Louis University
Scott L. Greer, University of Michigan
Joel Howell, University of Michigan
Renee Anspach, University of Michigan
Ann Greer, University of Wisconsin-Milwaukee
Neonatology as a field has pushed the boundary of which lives can be saved, now making it possible for babies to survive even if they are born ten earlier than than Patrick Kennedy, whose treatment in 1963 marked a surge into public consciousness for the field. Neonatologists are therefore positioned on frontiers of both medical advance and legal, ethical, and social debates.
Like other medical specialists, neonatologists face competing pressures. They must balance what can be done for their patients against what should be done for their patients. Evolving technology constantly changes what can be done, which means providers regularly reconsider what should be done. Because the neonatologist’s patient is always silent about her or his wishes, providers must give heed to the interests voiced by other interested parties. First among these are their patients’ caregivers, usually parents. Neonatologists also face pressure from colleagues both within neonatology and in other specialties. Additionally, hospital administration also shapes provider choices, especially related to matters of finance and public relations. Neonatologists must also navigate social forces, especially in law and ethics, that can be particularly challenging in the United States, where any question related to reproduction can quickly become a social controversy far beyond a single practitioner’s control.
Our study attempts to answer the following question: Over the past several decades, how have neonatologists negotiated these complex pressures when making life-and-death decisions? To put it more personally, in a field where providers must often choose between the lesser of many poor options, how do neonatologists arrive at decisions that they can live with? To answer these questions, we draw upon existing scholarship in the history of neonatology9,10 as well as several waves of interviews with physicians that took place over the course of nearly four decades. Our approach is to explore changes that limit the professional autonomy of neonatologists by comparing the findings of interview data collected since 1979 with the better-known technological, organizational, and legal or ethical developments surrounding neonatologists. Neonatologists created a new area of medicine by rescuing children who had previously died, but thereby exposed themselves to pressures from parents to the law.