Joseph joined CBSSM as a Research Area Specialist in November 2017. As a project manager, he coordinates the daily operations of Dr. Jeffrey Kullgren’s project “Provider, Patient, and Health System Effects of Provider Commitments to Choose Wisely,” a grant funded research project using novel approaches to reduce the overuse of low-value services in healthcare.
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The Woll Family Speaker Series on Health, Spirituality and Religion
We are excited to be hosting a debate on Conscience Protection on Friday March 9th from 12-1 as part of the UMMS Program on Health, Spirituality and Religion. Please save the date! CME Credit provided (see below).
Point: Healthcare professionals are "obligated to provide, perform, and refer patients for interventions according to the standards of the profession.” NEJM, 2017
Counterpoint: Healthcare professionals have the right to opt out of performing or referring for procedures they view as objectionable in accord with their religious or personal values.
Join Dr. Naomi Laventhal and Dr. Ashley Fernandes in this academic discussion as part of the University of Michigan Program on Health, Spirituality and Religion.
Professionalism, Ethical Obligations, and the Moral Imperative of Self-Care
Healthcare providers are inevitably called to participate in and bear witness to emotionally challenging cases. Combined with time constraints, competing responsibilities, the urgent nature of these cases, healthcare providers risk burnout. The consequences of burnout have been shown to be increased staff turnover, substandard patient outcomes and increased likelihood for errors. As part of competent clinical practice, healthcare providers must not only attend to the needs of the patient and family but also themselves. However, a tension exists between making enough time for patients and taking enough time for oneself. But, engaging in self-care activities can help address clinician distress; this practice is essential for remaining compassionate, providing competent patient care services, and avoiding harm. Healthcare providers, therefore, have an ethical duty to engage in personal self-care. This presentation makes a case for why self-care is a key component of competent clinical practice. Several ways in which a lack of self-care can undermine professional competence, thus risking burnout and poor patient outcomes, are discussed. Strategies for recognizing and addressing burnout are also reviewed.
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)
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.
Funded by National Institutes of Health
Funding Years: 2015-2020
Deaf American Sign Language (ASL) users are nearly seven times more likely to have inadequate health literacy when compared with their hearing peers. This population is the non-English speaking minority group at greatest risk for miscommunication in health care settings. Health literacy mechanisms for deaf individuals remain poorly understood, thereby limiting interventions to address health literacy disparities and their impact on health care. It is unclear how differences in attitudes, knowledge, and skills related to health information affect health literacy in deaf populations and how they may contribute to ongoing health inequities. The two primary objectives of this proposal are: 1) to elucidate the role of information marginalization on health literacy in Deaf American Sign Language (ASL) users and 2) to better understand the mechanisms of health literacy in this population so as to identify viable targets for future health literacy intervention development. This proposal is responsive to PAR-10-133's request for studies that assess mechanisms underlying health literacy, including roles of cognition, culture, language fluency, and information-seeking and interpretation ability in the deaf population and, how these may differ from the hearing population. To meet the study objectives, we will employ an explanatory sequential mixed methods design using extensive quantitative data collection procedures, namely, cross-sectional surveys and measures that will identify predictors and moderators of health literacy with 450 deaf and 450 hearing subjects across three geographically diverse sites. These results will inform the subsequent qualitative assessment that will help explain the quantitative results, and elucidate how and why deaf individuals access and understand health information. We will incorporate cutting edge technology to assess health information-seeking and interpretation patterns in this population, in addition to using a variety of validated and ASL-accessible instruments to assess health literacy and other constructs related to health literacy. The diverse team, consisting of both leading deaf and hearing researchers, provides a unique insight into how health information is distributed and disseminated visually. This approach has the potential to generate rich data on how to formulate health information and health literacy interventions for individuals with hearing loss.
PI(s): Michael McKee
Co-I(s): Lorraine Buis, Michael Fetters, Ananda Sen
Dorene S. Markel, M.S., M.H.S.A
Director, The Brehm Center
Assistant Research Scientist, Department of Learning Health Systems
Funded by: NIH
Funding Years: 2016-2020
In the past 30 years, the Incidence of thyroid cancer has tripled. The majority of the rise in thyroid cancer incidence is attributed to an increase in low-risk, well-differentiated thyroid cancer, a disease that has a 10-year mortality close to zero. Our previous work suggests that patients with low-risk thyroid cancer are at risk for overtreatment, defined as the use of Surgical and medical interventions in the absence of a clear survival benefit. The overtreatment of thyroid cancer has inherent costs, both to patient health and to society. The reason for the intensive management and potential overtreatment of low-risk thyroid cancer remains unclear. By using SEER-linked patient and physician Surveys, we plan to understand the Treatment decision making in low-risk thyroid cancer. We hypothesize that knowledge and attitudes influence decision making. Specifically, we anticipate that lack of knowledge of risks of death, recurrence and Treatment complications is associated with Treatment that is more intensive. in addition, we postulate that a general preference for active treatment will also be associated with more intensive cancer Treatment. Although both patient and physician perceptions of Treatment need (i.e., knowledge and attitudes) likely contribute to Treatment intensity, we anticipate that the primary driver will be physicians, even after controlling for their patients' perceptions. This study will serve as the foundation for future Intervention studies. By identifying the specific role of physician and patient knowledge and attitudes toward thyroid cancer Treatment, we will be able to create tailored educational interventions to personalize Surgical and medical care for thyroid cancer patients, thus minimizing overtreatment and its inherent risks and costs. As the rising Incidence, low mortality, and pattern of intensive Treatment make thyroid cancer arguably the best cancer model for overtreatment, this proposed study will also serve as a model to understand overtreatment in other malignancies.
PI: Megan Haymart
CO(s): Brian J. Zikmund-Fisher, PhD & Sarah Hawley, PhD. MPH
What's the difference between opting in and opting out of an activity? Who decides if people will be put automatically into one category or another? Click this interactive decision to learn how default options work.
Imagine that you're a US Senator and that you serve on the Senate's Committee on Health, Education, Labor, and Pensions. The Infectious Diseases Society of America has come before your committee because they believe that too many health care workers are getting sick with influenza ("flu") each year and infecting others. As a result, your Senate committee is now considering a new bill that would require that all health care workers get annual influenza vaccinations ("flu shots") unless the worker specifically refuses this vaccination in writing.
Do you think you would support this bill for mandatory flu shots for health care workers?
Imagine that you're the human resources director at a mid-sized company that's initiating an employee retirement plan. Management is concerned that many employees are not saving enough for retirement. They're considering a policy that would automatically deduct retirement contributions from all employees' wages unless the employee fills out and submits a form requesting exemption from the automatic deductions.
Do you think a policy of automatic retirement deductions is reasonable for your company to follow?
Organ transplants save many lives each year, but there are always too many deserving patients and too few organs available. To try to improve the number of organs available for donation, the state legislature in your state is considering a new policy that all people who die under certain well-defined circumstances will have their organs donated to others. The system would start in three years, after an information campaign. People who do not want to have their organs donated would be given the opportunity to sign a refusal of organ donation when they renewed their drivers' licenses or state ID cards, which expire every three years. Citizens without either of these cards could also sign the refusal at any drivers' license office in the state. This is a policy similar to ones already in place in some European countries.
Does this seem like an appropriate policy to you?
How do your answers compare?
For many decisions in life, people encounter default options-that is, events or conditions that will be set in place if they don't actively choose an alternative. Some default options have clear benefits and are relatively straightforward to implement, such as having drug prescriptions default to "generic" unless the physician checks the "brand necessary" box. Others are more controversial, such as the automatic organ donation issue that you made a decision about.
Default options can strongly influence human behavior. For example, employees are much more likely to participate in a retirement plan if they're automatically enrolled (and must ask to be removed, or opt out) than if they must actively opt in to the plan. Researchers have found a number of reasons for this influence of default options, including people's aversion to change.
But default options can seem coercive also. So, an Institute of Medicine committee recently recommended against making organ donation automatic in the US. One reason was the committee's concern that Americans might not fully understand that they could opt out of donation or exactly how they could do so.
The policy scenarios presented to you here have been excerpted from a 2007 article in the New England Journal of Medicine titled "Harnessing the Power of Default Options to Improve Health Care," by Scott D. Halpern, MD, PhD, Peter A. Ubel, MD, and David A. Asch, MD, MBA. Dr. Ubel is the Director of the Center for Behavioral and Decision Sciences in Medicine.
This article provides guidance for policy-makers in setting default options, specifically in health care. Generally, default options in health care are intended to promote the use of interventions that improve care, reduce the use of interventions that put patients at risk, or serve broader societal agendas, such as cost containment.
In this NEJM article, the researchers argue that default options are often unavoidable-otherwise, how would an emergency-room physician decide on care for an uninsured patient? Many default options already exist but are hidden. Without either returning to an era of paternalism in medicine or adopting a laissez-faire approach, the authors present ways to use default options wisely but actively, based on clear findings in the medical literature.
Some examples of default policies that may improve health care quality:
- routine HIV testing of all patients unless they opt out.
- removal of urinary catheters in hospital patients after 72 hours unless a nurse or doctor documents why the catheter should be retained.
- routine ventilation of all newly intubated patients with lung-protective settings unless or until other settings are ordered.
Drs. Halpern, Ubel, and Asch conclude, "Enacting policy changes by manipulating default options carries no more risk than ignoring such options that were previously set passively, and it offers far greater opportunities for benefit."
Read the article:
Harnessing the power of default options to improve health care.
Halpern SD, Ubel PA, Asch DA. New England Journal of Medicine 2007;357:1340-1344.
CBSSM is soliciting applications from qualified individuals for 1-2 postdoctoral research fellow positions for the 2018-2019 academic year.
The mission of CBSSM is to be the premier intellectual gathering place of clinicians, social scientists, bioethicists, and all others interested in improving individual and societal health through scholarship and service.
Bioethics Post-Doctoral Research Fellow
Active projects in bioethics at CBSSM currently include the ethical, legal, and social implications of genomic medicine, human subjects research ethics, empirical research with relevance to clinical ethics, global bioethics, gender equity, reproductive justice, deliberative democratic methods in bioethics, resource allocation, ethical issues associated with learning health systems, and the sociology of medical ethics/bioethics, among others. Candidates' area of focus must be in bioethics, although their backgrounds may be in social or natural sciences, humanities, medicine, or law.
Decision Sciences Post-Doctoral Research Fellow
This fellowship focuses on understanding and improving the health care communication and decisions made by both patients and providers. Past postdoctoral fellows have included scholars whose research in health care communication and decision making has been approached using theories drawn from social cognition, motivation and emotion, risk communication, human factors, ethics, and economics.
Postdoctoral fellows are expected to collaborate on established projects and are encouraged to conduct independent research with an emphasis on study inception, manuscript writing, and applying for grants. CBSSM’s resources and collaborative support enable fellows to build their own research programs.
Please see: http://cbssm.med.umich.edu/training-mentoring/post-doctoral-fellowship for more details about these fellowship opportunities.