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Michele Heisler, MD, MPA

Faculty

Michele Heisler, MD, MPA, is Professor of Internal Medicine at the University of Michigan Medical School, Professor, School of Public Health, and Research Scientist at the Ann Arbor VA's Center for Clinical Research Management. Dr. Heisler's clinical interest is chronic disease, with a focus on diabetes. Her research centers on patient self-management of chronic illnesses, patient-doctor relations and disparities in processes and outcomes in chronic illnesses.

Last Name: 
Heisler

Announcement of Position: Faculty Ethicist

Announcement of Position: Faculty Ethicist


Background
The Clinical Ethics Service within the Center for Bioethics and Social Sciences in Medicine (CBSSM) promotes a culture of patient-centered excellence by performing a comprehensive set of ethics-related activities. The aims of this service are to: liaise with and provide support to the adult and pediatric ethics committees; provide clinical ethics consultation and engage in preventative ethics endeavors; 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 Clinical Ethics Service is led by Christian J. Vercler, MD MA and Andrew G. Shuman, MD. A dedicated clinical ethicist will manage the program on a daily basis. A cadre of faculty ethicists will rotate on service throughout the year and work closely with the clinical ethicist. Trainees and students will rotate as well. Dedicated administrative support is organized through CBSSM.


Position
The Clinical Ethics Service employs a roster of faculty ethicists who are responsible for staffing ethics consultations arising from any of the clinical venues (inpatient and outpatient; adult and pediatric) within Michigan Medicine during their time on service. They will supervise and participate in the institutional educational endeavors and preventative ethics rounds in a regular and on-going manner. Faculty ethicists will also develop and provide clinical rotations for medical students and house officers on a cohesive ethics service. Each faculty member will be expected to rotate on service for four to six weeks per year, and attend/participate in committee meetings and other events throughout the academic year (this will not necessarily require suspension of other activities when on-service). Depending on the total number appointed, each faculty ethicist will receive $15,000-$20,000 of direct salary support annually, to be distributed and allocated in conjunction with their home department. The initial appointment will last two and a half years and is renewable. Additional appointments will last two years.


Qualifications
Candidates are expected to have faculty appointments at University of Michigan and be in good academic standing; any professional background is acceptable. 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. 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.


Application Process
Candidates will be vetted and chosen by a selection 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: lynnam@med.umich.edu


Timeline

  • Application is due September 25, 2017
  • Appointment will take effect January 1, 2018

Contacts

  • Leaders of the Clinical Ethics Service: Christian J. Vercler, MD MA & Andrew G. Shuman, MD
  • Administrative contact: Valerie Kahn – valkahn@med.umich.edu 734 615 5371

Bioethics Grand Rounds

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:

Funded by: NIH

Funding Years: 2016-2021

 

There is a fundamental gap in understanding how Mild Cognitive Impairment (MCI) influences treatment and Decision Making for serious illnesses, like Cardiovascular disease (CVD), in older patients. Poor understanding of Clinical Decision Making is a critical barrier to the design of interventions to improve the quality and outcomes of CVD care of in older patients with MCI. The long-term goal of this research is to develop, test, and disseminate interventions aimed to improve the quality and outcomes of CVD care and to reduce CVD-related disability in older Americans with MCI. The objective of this application is to determine the extent to which people with MCI are receiving sub-standard care for the two most common CVD events, Acute myocardial infarction (AMI) and acute ischemic stroke, increasing the chance of mortality and morbidity in a population with otherwise good quality of life, and to determine how MCI influences patient preferences and physician recommendations for treatment. AMI and acute ischemic stroke are excellent models of serious, acute illnesses with a wide range of effective therapies for acute management, Rehabilitation, and secondary prevention. Our central hypothesis is that older Adults with MCI are undertreated for CVD because patients and physicians overestimate their risk of dementia and underestimate their risk of CVD. This hypothesis has been formulated on the basis of preliminary data from the applicants' pilot research. The rationale for the proposed research is that understanding how patient preferences and physician recommendations contribute to underuse of CVD treatments in patients with MCI has the potential to translate into targeted interventions aimed to improve the quality and outcomes of care, resulting in new and innovative approaches to the treatment of CVD and other serious, acute illnesses in Adults with MCI. Guided by strong preliminary data, this hypothesis will be tested by pursuing two specific aims: 1) Compare AMI and stroke treatments between MCI patients and cognitively normal patients and explore differences in Clinical outcomes associated with treatment differences; and 2) Determine the influence of MCI on patient and surrogate preferences and physician recommendations for AMI and stroke treatment. Under the first aim, a health services research approach- shown to be feasible in the applicants' hands-will be used to quantify the extent and outcomes of treatment differences for AMI and acute ischemic stroke in older patients with MCI. Under the second aim, a multi-center, mixed-methods approach and a national physician survey, which also has been proven as feasible in the applicants' hands, will be used to determine the influence of MCI on patient preferences and physician recommendations for AMI and stroke treatment. This research proposal is innovative because it represents a new and substantially different way of addressing the important public health problem of enhancing the health of older Adults by determining the extent and causes of underuse of effective CVD treatments in those with MCI. The proposed research is significant because it is expected to vertically advance and expand understanding of how MCI influences treatment and Decision Making for AMI and ischemic stroke in older patients. Ultimately, such knowledge has the potential to inform the development of targeted interventions that will help to improve the quality and outcomes of CVD care and to reduce CVD-related disability in older Americans.

PI: Deborah Levine

CO(s): Darin Zahuranec, Lewis Morgenstern & Ken Langa

Pediatric Ethics Committee

The Michigan Medicine Committee advisory groups are appointed by the Hospital's Office of Clinical Affairs. They review ethical or moral questions that may come up during a pediatrics patient's care. The consultants facilitate communication among patients, their families and the treatment team to assist everyone in making appropriate choices when difficult decisions need to be made. The Committee's goal is to help everyone decide the right thing to do. The Michigan Medicine Ethics Committee is a sub-committee of the Executive Committee on Clinical Affairs as determined by the Medical Staff Bylaws. 

About Us


The committee is available for consultation to family members, patients, staff, and health care providers. The committee may help you and your child’s medical team clarify facts, examine ethical issues, and assist in the resolution of disagreements about your child’s care. The committee includes people with additional training in medical ethics, doctors, nurses, social workers, a lawyer, a chaplain, an administrator, and members of the community
The University of Michigan has a Pediatric Ethics Committee because the best medical care requires not only medical skill but good moral judgment. The Committee’s main purpose is to offer help and guidance on moral and ethical questions, such as:

  • Should treatment be started or stopped?
  • How much should a child be told about his or her disease?
  • Is the promise of treatment worth the suffering it may cause?
  • What is the best thing to do when we must face the end of life?
  • What happens when a meeting with the Ethics Committee is requested?

The consultants on call review the patient's medical situation and treatment options. In addition, concerns and feelings of the patient, family members, and the health care team are discussed. Members of the committee may visit with patients, families and medical personnel to discuss these concerns.

Ethics Committee members discuss the information which has been gathered. The Ethics Committee makes suggestions about the best course of action. Often there are a number of options available in the course of a patient's care. Final decisions are made by the patient, family and the health care team.

The Pediatric Ethics Committee meets on the first Tuesday of the month from 12-1:30pm at University Hospital in dining rooms C&D. If you would like to attend as a guest, please contact Amy Lynn @ lynnam@med.umich.edu

Request a Consult

Monday-Friday
8:00 a.m. - 5:00 p.m. Call 734-615-1379
After normal business hours, please call 936-6267 and ask for the clinical ethicist on call to be paged.

Resources

Financial Assistance

Withdrawal and Withholding of Medical Treatment

Committee Bylaws

 

For upcoming Bioethics Grand Rounds see Events

 

Adult Ethics Committee

The Michigan Medicine Committee advisory groups are appointed by the Hospital's Office of Clinical Affairs. They review ethical or moral questions that may come up during an adult patient's care. The consultants facilitate communication among adult patients, their families and the treatment team to assist everyone in making appropriate choices when difficult decisions need to be made. The Committee's goal is to help everyone decide the right thing to do. The Michigan Medicine Adult Ethics Committee is a sub-committee of the Executive Committee on Clinical Affairs as determined by the Medical Staff Bylaws.

About Us

Sometimes patients, families and staff have very difficult choices and ethical questions they need to talk about. Discussions with the Ethics Committee can be helpful and reassuring when a difficult choice must be made (for example, questions on end-of-life care, or issues of confidentiality). The goal of the Committee is to facilitate communication among adult patients, their families and the treatment team to assist everyone in making appropriate choices, as well as to assist Michigan Medicine in complying with ethical regulatory standards, when difficult decisions need to be made. The Committee provides consultation to the treatment team, patients and families on ethical, moral or philosophical problems and issues encountered in the course of managing inpatient and outpatient care.

Committee members include physicians, residents, nurses and social workers, as well as medical students, an attorney/compliance officer, a chaplain, a medical ethics professor and members from the community.

The Adult Ethics Committee meets on the third Tuesday of the month, form 12-1:30pm, at University Hospital in dining room D, if you would like to attend as a guest, please contact Amy Lynn @ lynnam@med.umich.edu

What happens when a meeting with the Ethics Committee is requested?

The consultants on call review the patient's medical situation and treatment options. In addition, concerns and feelings of the patient, family members, and the health care team are discussed. Members of the committee may visit with patients, families and medical personnel to discuss these concerns.

Ethics Committee members discuss the information which has been gathered. The Ethics Committee makes suggestions about the best course of action. Often there are a number of options available in the course of a patient's care. Final decisions are made by the patient, family and the health care team.

Request a Consult

Monday-Friday
8:00 a.m. - 5:00 p.m. Call 734-615-1379
After normal business hours, please call 936-6267 and ask for the clinical ethicist on call to be paged.

Resources

Financial Assistance

Withdrawal and Withholding of Medical Treatments

Advance Directives

Committee Bylaws

 

For upcoming Bioethics Grand Rounds see Events

CBSSM Colloquium 2016-- call for abstracts

2016 CBSSM Research Colloquium – University of Michigan

 

Call for Abstracts

 

The Center for Bioethics and Social Sciences in Medicine (CBSSM) Research Colloquium will be held Wednesday, April 27, 2016 at the Founders Room, Alumni Center, 200 Fletcher Street, Ann Arbor, MI 48109.

The CBSSM Research Colloquium will feature the Bishop Lecture in Bioethics as the keynote address.  This year CBSSM is delighted to announce that William Dale, MD, PhD will present the Bishop Lecture with a talk entitled: "Why Do We So Often Overtreat, Undertreat, and Mistreat Older Adults with Cancer?"

William Dale, MD, PhD is Associate Professor of Medicine and Chief, Section of Geriatrics & Palliative Medicine & Director, SOCARE Clinic at the University of Chicago. A geriatrician with a doctorate in health policy and extensive experience in oncology, Dr. Dale has devoted his career to the care of older adults with cancer -- particularly prostate cancer. Dr. Dale has a special interest in the identification and treatment of vulnerable older patients who have complex medical conditions, including cancer. He is actively researching the interactions of cancer therapies with changes associated with aging.
 

 

Abstract submissions are welcome from all disciplines both within UM, as well as other institutions. CBSSM is an interdisciplinary center focusing on bioethics and social sciences in medicine. Our research program areas of interest include:

  • Clinical and Research Ethics - committed to empirical research in ethics (what some have called empirical ethics) by providing an evidence base for informed policy and practice.
  • Health Communication and Decision Making – using techniques from basic and applied research, determines the best practices for communicating health information to patients.
  • Medicine and Society - examines the way health care and bioethics are influenced by social structures and cultural ideas.
  • Health, Justice, and Community - aims to improve knowledge, understanding and practice in resource allocation and distributive justice, ethics of health policy (public and private) and community engagement, with the overarching goal of improving health equity.
  • Genomics, Health, and Society - examines the ethical, social and behavioral implications of advances in genomics.

For more information about our program areas: http://cbssm.med.umich.edu/


Submission Details: (Form is below)

  • Abstracts should contain a title, followed by the names and designations of all contributing authors and the contact details of the corresponding author.
  • Abstracts are to be a maximum of 300 words in length (exclusive of title and author information).
  • Presentations should last no more than 20 minutes, with an additional 5 minutes for questions.  The total time allotted is therefore 25 minutes per presentation. 
  • Abstracts should be submitted on the attached Abstract Submission form.  Submit abstracts via email to Kerry Ryan, kryanz@med.umich.edu. If you have questions about the abstract, please contact CBSSM at 734-615-8377 or email Kerry Ryan.
  • Deadline for abstract submission is Friday, March 11, 2016.
  • Notification:  Applicants will be notified by Friday, March 25, 2016.


Tentative Schedule for the Colloquium:


9:00-10:30 Presentations
10:45-12:00 Bishop Lecture:  William Dale, MD, PhD
12:00-1:15 Lunch
1:15-4:30 Presentations

Click here for Abstract Submission Form.

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

CBSSM Seminar: Scott L. Greer, Ph.D.

Wed, September 12, 2018, 3:00pm
Location: 
NCRC, Building 10, Room G065

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.

 

 

How much will chemotherapy really help you? (Dec-08)

After breast cancer surgery, additional treatments such as chemotherapy can reduce the risk of cancer coming back. But do women understand how much (or little) benefit chemotherapy provides? Imagine that you're a woman who has recently been diagnosed with breast cancer and then had the cancerous breast tumor surgically removed. While you're at an appointment about 3 weeks after your surgery, your doctor says the following to you:

"Sometimes cancer cells remain after surgery and start to grow again. To try to prevent your cancer from growing again, you should consider having some additional treatment.

"One of our test results shows that you have a type of cancer that is estrogen receptive (ER) positive. This means that your cancer needs the hormone estrogen in order to grow.

"Because you have an ER-positive tumor, you should have hormonal therapy to block estrogen and make it harder for any remaining cancer cells to grow. Hormonal therapy is usually in pill form. It does not cause hair loss or fatigue and generally has very few short-term side effects. You'll start to take hormonal therapy after all other treatments are finished and continue to take it for at least 5 years.

"Although it's clear that you should have hormonal therapy, you'll still need to make a choice about chemotherapy treatments. You could decide to have additional chemotherapy treatments for several months before starting the hormonal therapy. Sometimes, adding chemotherapy can make a big difference in decreasing the risk of dying from cancer. Other times, there's almost no benefit from adding chemotherapy.

"If you decide to have chemotherapy, you'll have 2 to 4 months of fatigue, nausea, hair loss, and other side effects. You'll also face a small risk (less than 1% or less than 1 in 100) of getting a serious infection, a bleeding problem, heart failure, or leukemia. Only you can decide if the benefit of adding chemotherapy to hormonal therapy is worth the risks and side effects."

Next, your doctor shows you a graph that may help you to decide about chemotherapy.

Your doctor says, "The graph below may help you decide if the risk reduction you would get from adding chemotherapy is worth the side effects and risks that the chemotherapy would cause.

  • The green part shows the chance that you'll be alive in 10 years.
  • The red part shows the chance that you'll die because of cancer.
  • The blue part shows the chance that you'll die from other causes.
  • The yellow part shows how much your chance of being alive in 10 years would increase if you add a therapy.
"Remember, given your situation, I think you should definitely take hormonal therapy. What you need to decide is whether to take both chemotherapy and hormonal therapy."
 
In interpreting this graph, imagine that there are two groups of 100 women each. All of these women have the same type of cancer as your hypothetical cancer.
  • The first group all decides to take hormonal therapy only.
  • The second group all decides to take both chemotherapy and hormonal therapy

How many fewer women will die from cancer in the second group, as compared with the first group?

Your doctor continues, "Now, here is another graph that shows the same information in a different way. As before,

  • The green part shows the chance that you'll be alive in 10 years.
  • The red part shows the chance that you'll die because of cancer.
  • The blue part shows the chance that you'll die from other causes.
  • The yellow part shows how much your chance of being alive in 10 years would increase if you add a therapy.
Now we asked you to consider the following question:
How many fewer women will die from cancer in the second group, as compared with the first group?
Do you want to change your answer?
 

About the study

Many participants who saw this graph in a study conducted by CBDSM researchers had similar problems. However, when study participants saw GRAPH B (with the two pictographs), many more were able to correctly calculate the difference.

The CBDSM study compared tools intended to help cancer patients make informed decisions about additional therapies (also called "adjuvant" therapies). The 4 horizontal stacked bars were taken from an online tool called "Adjuvant!" that is often used by physicians to explain risk to cancer patients. The researchers compared comprehension of risk statistics from horizontal bars and from a pictograph format.

They found that study participants who viewed a 2-option pictograph version (GRAPH B in this Decision of the Month) were more accurate in reporting the risk reduction achievable from adding chemotherapy to hormonal therapy for the hypothetical cancer scenario. With GRAPH B, 77% of participants could identify that 2 fewer women out of 100 would die from cancer with both chemotherapy and hormonal therapy. With the 4 horizontal bars (GRAPH A), only 51% of participants could make this calculation. Participants who saw GRAPH B were also much faster at answering this question than participants who saw GRAPH A.
In addition, participants in this study strongly preferred the format of the pictograph you saw (GRAPH B) to the bar graphs you saw (GRAPH A).
The researchers comment:
"While decision support tools such as Adjuvant! use graphical displays to communicate the mortality risks that patients face with different adjuvant therapy options, our research shows that women had difficulty interpreting the 4-option horizontal bar graph format currently used by Adjuvant!. Two simple changes, displaying only risk information related to treatment options that included hormonal therapy...and using pictographs instead of horizontal bars, resulted in significant improvements in both comprehension accuracy and speed of use in our demographically diverse sample....The results...support the concept that simpler information displays can make it easier for decision makers to implement optimal decision strategies. Specifically, focusing patients' attention on those treatment options currently under consideration while removing information related to options which have been already eliminated from consideration (for medically appropriate reasons) may be particularly beneficial. In the context of adjuvant therapy decisions, such an approach would imply that clinicians should discuss the decision in two stages: A first stage in which hormonal therapy is considered and a second stage in which the incremental benefit of chemotherapy is evaluated...Adjuvant! and other online risk calculators enable oncologists and patients to receive individually tailored estimates of mortality and recurrence risks, information that is essential to informed decision making about adjuvant therapy questions. Yet, the full potential of these modeling applications cannot be realized if users misinterpret the statistics provided."
 
Read the article:
Zikmund-Fisher BJ, Fagerlin A, Ubel PA. Cancer 2008;113(12):3382-3390.

 

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