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2012 Bishop Lecture featuring Jerome Groopman, MD and Pamela Hartzband, MD

Thu, May 10, 2012 (All day)

The 2012 Bishop Lecture featured New York Times best selling authors, Jerome Groopman, MD, Dina and Raphael Recanati Professor of Medicine at Harvard Medical School, and Pamela Hartzband, MD, Assistant Professor of Medicine at Harvard Medical School. Drs. Groopman and Hartzband jointly presented the Bishop Lecture with a talk entitled, “When Experts Disagree: The Art of Medical Decision Making.” 

Drs. Groopman and Hartzband are co-authors of a 2011 book, “Your Medical Mind,” which outlines how patients can navigate health care choices when making medical decisions.  In addition to conducting research on blood development, cancer, and AIDS, Dr. Groopman writes regularly for the New Yorker, the New York Times, the Wall Street Journal, The New Republic, and the Washington Post.  A noted endocrinologist and educator, Dr. Hartzband specializes in disorders of the thyroid, adrenal, and pituitary glands, and in women’s health.  She has authored articles on the impact of electronic records, uniform practice guidelines, monetary incentives, and the Internet on the culture of clinical care.  

  • Click here for the video recording of the 2012 Bishop Lecture.

Seated: Jerome Groopman and Pamela Hartzband 

Standing from Left: Scott Kim, Susan Goold, Angela Fagerlin, Christine Bishop, Jane Bishop, and David Bishop

 

 

 

Get it out of me! (Dec-05)

A 5% chance of death or a 10% chance of death:  which would you choose?

Imagine that you have been diagnosed with a slow growing cancer. Right now, the cancer is not causing you to feel sick. For most people, the cancer will grow so slowly it will never cause them any trouble. For others, the cancer will grow to the point that it makes them sick. Untreated, five percent (5 out of 100) will die of the cancer. Your doctor tells you that you have two treatment options: watchful waiting or surgery. Watchful waiting means you will not do any treatment right away, but your doctor will follow your cancer closely and treat any symptoms that you have if it begins to spread. Although it would be too late to be cured, you would be comfortable and free of pain. There are no side effects to watchful waiting, but five percent (5 out of 100) of the people who choose this treatment will develop symptoms and die from their cancer within five years. On the other hand, the surgery would cure your cancer permanently. Following surgery you will feel more tired than usual and will experience stomach upset occasionally for the three months following your surgery. However, surgery has a ten percent (10 out of 100) risk of death during the surgery.

Imagine that both of these treatments are completely covered by your health insurance. Which would you choose?

  •  I would not take the surgery and accept the 5% chance of dying from this cancer.
  •  I would take the surgery and accept the 10% chance of dying from the surgery.

How do your answers compare?

In the real world, cancer patients sometimes choose treatments that may have devastating side effects over less invasive, yet equally or more effective, approaches. One explanation for this is that people may feel a strong need to "get the cancer out" of their bodies. Surgical removal of all potentially cancerous tissues may satisfy this desire so thoroughly that people end up ignoring important statistical information about adverse outcomes.

Making a choice not in their best interest

CBDSM investigators Angela Fagerlin, Brian Zikmund-Fisher, and Peter Ubel hypothesized that people perceive cancer diagnoses as a call to action, and more specifically, a call to get rid of the cancer through surgery, regardless of what statistical information might say to the contrary. Consequently, they predicted that when presented with hypothetical cancer diagnoses, many people would say they would pursue surgery even if such an action would decrease their chance of survival.

To explore the relative frequency of people's willingness to choose surgery when it wasn't in their best interest, the investigators designed a cancer scenario similar to the one you read on the previous page. Participants were presented either a surgery or a medication treatment that would either increase or decrease their chance of survival.

The investigators found that participants who were presented with the opportunity to rid themselves of their cancer through surgery were significantly more inclined to take action than those who were presented with the medication treatment. For example, when the treatment reduced their overall chance of survival, 65% chose the surgery, whereas only 38% chose the medication treatment. This suggests that people's treatment decisions may be based not on the effectiveness of the treatments, but rather on their beliefs about how cancer should be treated. Specifically, cancer diagnoses seem to conjure up a strong desire for active treatment. And people seem to have an intuitive belief that action should not just involve treatment, but surgical removal of the cancer.

Why these findings are important

The results of this study may resonate with many clinicians who have encountered cancer patients who seem to desire treatment for treatment's sake, or who have a preference for surgical intervention even before they learn about the pros and cons of their treatment alternatives. This study should serve to remind clinicians that patients' preference for action can be strong enough, at times, to be a bias. At a minimum, it is important for health care professionals to be aware of the potential for such biases, so they can decide whether to accept patients' preferences at face value, or try to convince patients that aggressively treating a tumor may not be in their best interests.

Read the article:

Cure me even if it kills me: Preferences for invasive cancer treatment.
Fagerlin A, Zikmund-Fisher BJ, Ubel PA. Medical Decision Making 2005;25(6):614-619.

2016 CBSSM Research Colloquium and Bishop Lecture (William Dale, MD, PhD)

Wed, April 27, 2016, 8:30am
Location: 
Founders Room, Alumni Center, 200 Fletcher St., Ann Arbor, MI

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

The CBSSM Research Colloquium featured the Bishop Lecture in Bioethics as the keynote address.  William Dale, MD, PhD presented 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.

 

The 2016 Research Colloquium Presentation Schedule:

  •     8:30 AM -- Check in & refreshments
  •     9:00 AM -- Welcome
  •     9:05 AM -- Katrina Hauschildt, MA, PhD Candidate, Department of Sociology: "Language and Communication as Professionalization Projects in Clinical Ethics Consultation"
  •     9:30 AM -- Devan Stahl, PhD, Assistant Professor of Clinical Ethics, MSU: "Is there a right not to know?"
  •     9:55 AM -- Chithra Perumalswami, MD MSc, Robert Wood Johnson Foundation/Veterans Affairs Clinical Scholar: "Insurance Status of Elderly Americans and Location of Death"
  •     10:20 AM -- Break
  •     10:35 AM -- William Dale, MD, PhD, 2016 Bishop Lecture in Bioethics: "Why Do We So Often Overtreat, Undertreat, and Mistreat Older Adults with Cancer?"
  •     12:00 PM -- Lunch
  •     12:45 PM -- Lauren B. Smith, M.D., Associate Professor, Department of Pathology/Ginny Sheffield, UM Medical Student (M3): "Special treatment for the VIP patient:  Is it ethical?  Is it dangerous?"
  •     1:10 PM -- Naomi Laventhal, MD, MA, Assistant Professor, Department of Pediatrics and Communicable Diseases: "Roman Charity Redux: The Moral Obligations of the Breastfeeding Physician"
  •     1:35 PM -- Archana Bharadwaj, Graduate Student, UM School of Public Health: "Patient understanding and satisfaction regarding the clinical use of whole genome sequencing: Findings from the MedSeq Project"
  •     2:00 PM -- Kayte Spector-Bagdady, JD, MBioethics, CBSSM Postdoctoral Research Fellow: "Direct‐to‐Consumer Biobanking"
  •     2:25 PM -- Break
  •     2:40 PM --Panel Presentation (Susan Goold, MD, MHSA, MA & colleagues) : "Community engagement in setting research priorities: Representation, Participation and Evaluation"
    • Why (and how) was CBPR supported in DECIDERS?
    • How were communities represented in DECIDERS decision making?
    • Why and how was the partnership evaluated?
    • How were the 47 focus groups engaged in setting research priorities?

Supporting information for: 2018 CBSSM Research Colloquium and Bishop Lecture (Barbara Koenig, PhD)

Parent Perceptions of Antenatal Consultation for Extreme Prematurity
Presenter: Stephanie Kukora, MD
 

Co-authors: Naomi Laventhal, MD, MA; Haresh Kirpilani, MD; Ursula Guillen, MD
 

Antenatal consultation (AC) for extreme prematurity is routine in neonatology practice, but questions remain about how best to meet the needs of expectant parents. Decision-aids have demonstrated improvement in communication of statistical outcomes, but whether they are uniformly helpful in AC, and whether provision of outcome data is essential to shared decision-making in the AC encounter remains uncertain.

To characterize the experience of parents threatened with extreme prematurity between 22 and 25 weeks gestation who received AC, identify aspects that parents perceived as favorable or unfavorable, and identify areas for improvement.

We analyzed free text responses of expectant parents enrolled in a multi-center randomized trial evaluating the use of a validated decision-aid (DA) compared to standard counseling. Qualitative thematic analysis of responses identified items valued for decision-making about delivery room resuscitation.

 201 parents were enrolled; 126 provided substantive free-text comments. 45 (36%) parents described their counseling experience positively.  31 (25%) reported a negative experience, and 23 (18%) offered suggestions for improvement.  Desire for a tailored approach was a major theme reported by many parents, with subthemes of too much or too little information, facts vs values-based counseling, and diverse learning styles.  Another major theme was shared decision-making. Subthemes included:  good or poor understanding of the decision/options; trust; parent engagement, feeling supported in decision-making.  Need for clinician sensitivity also emerged as a major theme, with subthemes of hope, thoughtful timing of AC, and identification and support of parents’ stress and emotions. 31 parents receiving AC with the DA (n=102) commented that visual depiction of the statistical information helpful.

Many parents expressed that factual information about outcomes was influential to their decisions, but some parents dislike this approach.  In addition to tailoring how and what information is communicated during AC, clinicians should be sensitive to parents’ individual needs in this context.

 

Hospice Care Quality in U.S. Nursing Homes Reported by Patients and Caregivers in Yelp Reviews

Presenter: Chithra Perumalswami, MD, MSc
 

Co-authors: Jayme Laurencelle, MD; Shawna O’Reilly, MD; Jennifer Griggs, MD, MPH; Raina Merchant, MD, MSHP
 

Background: The need to assess the quality of hospice care provided in nursing homes is a national priority. Patients and caregivers often utilize online forums such as Yelp to informally report on the experience of their healthcare episodes. These narratives are a unique data source and may provide valuable insights into the quality of care provided in U.S. nursing homes at the end of life.

Objective: To explore the content of Yelp reviews of nursing homes providing care at the end of life, specifically utilizing quality measures for palliative and hospice care determined by the National Quality Forum (NQF).

Methods: We performed a qualitative content analysis of 3421 Yelp reviews.  The reviews were double coded and the final coding scheme incorporated concepts from all of the NQF domains. Larger themes were determined by consensus.

Results: Four themes were identified: 1) staff interpersonal expertise (empathic characteristics and effective communication), 2) staff technical competence (expertise in skills, staff attention, and efficiency of response), 3) systems issues (physical facility characteristics and cleanliness), and 4) patient wellbeing (physical and emotional wellbeing, family trust and confidence in care).

Conclusion: Yelp reviews of nursing homes providing hospice identify concepts that are mostly congruent with the current NQF domains. Medicare uses the NQF domains and preferred practices in the Hospice Quality Reporting Program (HQRP) to measure and report on quality. Utilizing Yelp reviews may help to identify additional quality measures, including a more nuanced view of aspects of quality of care in nursing homes at the end of life. Future research should focus on how to make such unprompted narratives more accessible and on how to incorporate additionally identified concepts regarding quality into the HQRP.


Impact of MCI on Patient and Care Partner Preferences and Physician Decision Making for Cardiovascular Treatment

Presenters: Bailey Reale, MPH; Emilie Blair
 

Co-authors: Darin Zahuranec, MD, MS; Kenneth Langa, PhD;  Jane Forman, ScD, MHS; Bruno Giordani, PhD; Brenda Plassman, PhD; Kathleen Welsh-Bohmer, PhD; Colleen Kollman, MBA; Deborah Levine, MD, MPH
 

Background: The leading cause of death for the 5.4 million older adults with mild cognitive impairment (MCI) in the US is cardiovascular disease (CVD). Despite this, patients with pre-existing MCI may receive fewer treatments for CVD events such compared to cognitively normal patients. We conducted interviews of patients, care partners, and physicians to understand how MCI influences decision making for CVD treatments.

Methods: Qualitative study based on in-depth, semi-structured, in-person interviews with patient-care partner dyads (n=23) and physicians (n=18) using a standard guide. We used qualitative content analysis to identify unifying and recurrent themes. We gathered reflections on data suggesting neurologists recommend fewer treatments for stroke to older adults with MCI and elicited how MCI influences patient-care partner preferences for 5 common CVD treatments. We also sought to understand how a patient’s having MCI influenced physicians’ decisions to recommend these 5 CVD treatments.

Results: Most MCI patients, cognitively normal patients, and their care partners wanted all 5 stroke treatments (Table 1). Participants reported several factors affecting their decision-making for treatment (Table 1). Some participants thought that physicians might recommend fewer stroke treatments to patients with pre-existing MCI because physicians have biases about MCI patients (Table 1).

Most physicians described MCI as influencing their recommendations for CVD treatments in at least one of five ways (Table 2). Physicians reported recommending CVD treatments less to MCI patients due to their assumptions about the MCI patients and MCI itself (Table 2).

Conclusions: MCI patients have similar preferences for treatments for CVD events as do cognitively normal patients, yet physicians often recommend these treatments less often to MCI patients. We need to better understand how physician recommendations contribute to potential underuse of effective CVD treatments in MCI patients in order to improve the quality of CVD care for this large and growing population.


It’s all about Context: A Mixed-Methods Study of Institutional Review Board’s Local Context Assessment
Presenter: Adrianne Haggins, MD


Co-authors: Deneil Harney; Sacha Montas, MD, JD; Joy Black, BSN, MS; Neil Dickert, MD, PhD; Timothy Guetterman, PhD; Michael Fetters, MD; Robert Silbergleit, MD


Background: Local context assessment ostensibly allows review boards to closely consider the potential impact to study populations, the institution, and local laws and regulations.  Given the trend toward utilization of central review boards for multicenter trials, a better understanding of single institution review board assessment processes are needed.

 Objective: To explore how local context assessments in multicenter trials are made by single institution review boards.

Methods: We used a mixed methods approach to explore attitudes and perceptions of key stakeholders.  We elicited stakeholder perspectives by observing, and audiotaping IRB deliberations of trials conducted under exception from informed consent (EFIC). In-depth semi-structured interviews (n=26) and an online survey (n=80, response rate=13%) were conducted of IRB stakeholders (IRB members, central review board members, regulatory officials, etc.). Two authors independently reviewed the observations and interview transcripts to identify meaningful statements, which were grouped into codes and broader themes.  Descriptive statistics were performed on the survey results.

Results: Deliberations related to local context highlighted the importance of taking into consideration: scientific rigor, community consultation and public disclosure process, as well as local laws/regulations, weighing relative benefit vs. risk, medical standards/practices, concerns of local groups, prior experiences with investigators and within the institution.  Themes from interviews underscored the important role investigators, and IRB community members are expected to play in knowing the local population and community. Top reasons for considering local context included: knowing about community concerns, showing respect for local public, and the influence of local laws/ordinances on clinical care.

Conclusion: Local context assessment provides a mechanism to ensure research and investigators are perceptive to the concerns and impact on the broader community. A wide variety of factors are considered. To further inform central review processes, future research is needed to differentiate which factors are essential for a high-quality local context assessment.   


Does Enhancing Individual Choice and Control Promote Freedom? Challenges in Contemporary Bioethics

Bishop Lecture Keynote Presenter: Barbara Koenig, PhD
 

Over the past three decades, the discipline of bioethics has advocated for enhanced patient choice and control over a range of medical decisions, from care near the end of life to participation in clinical research. Using two current policy challenges in California—1) the advent of legally sanctioned medical aid in dying and, 2) efforts to share UC Health “big data” from the electronic health record in research with private sector partners—Professor Koenig will explore how current bioethics practices may unintentionally and ironically impede our shared goals of promoting human freedom.

 

CBSSM Seminar: Michele Gornick, PhD

Thu, January 15, 2015, 3:00pm to 4:00pm
Location: 
NCRC 16-266C

Michele Gornick, PhD

VA HSRD Fellow & CBSSM Research Investigator

Title: The public’s preferences for the return of secondary findings identified through genome sequencing: Information and deliberation make a difference

Summary: Genomic sequencing is becoming a part of clinical practice. Existing studies are limited and conclude that people would like unrestricted access to all of their genetic information. However, we do not know the extent to which respondents in these studies took into account the complex scientific and ethical issues that attend genome sequencing. In order to address this gap, we organized a deliberative democracy (DD) session to educate members of the public on genome sequencing, to engage them in dialogue about the benefits and risks of the clinical implementation of this technology, and to elicit their informed perspectives about policies governing the return of secondary findings.

BROCHER RESIDENCIES 2016 -- CALL FOR PROPOSALS

The Brocher Foundation offers visiting researchers the opportunity to come at the Brocher Centre in a peaceful park on the shores of Lake Geneva, to write a book, articles, an essay or a PhD thesis. The visiting positions are an occasion to meet other researchers from different disciplines and countries as well as experts from numerous International Organizations & Non Governmental Organizations based in Geneva, such as WHO, WTO, WIPO, UNHCR, ILO, WMA, ICRC, and others. The Brocher Foundation residencies last between 1 and 4 months.

They give researchers (PhD students to Professors) the opportunity to work at the Brocher Centre on projects on the ethical, legal and social implications for humankind of recent medical research and new technologies. Researchers can also apply with one or two other researchers to work on a collaborative project.

CHECK CONDITIONS AND APPLY ON WWW.BROCHER.CH/CALLS

CBSSM Seminar: Jodyn Platt, MPH, PhD

Thu, October 08, 2015, 3:00pm to 4:00pm
Location: 
NCRC, Building 16, Room 266C

Jodyn Platt, MPH, PhD


Research Investigator
Department of Learning Health Sciences

Terms and Conditions for Trust in Learning Health Systems

The next generation of health information technology, organized as “learning health systems,” promises efficient, engineered solutions to the well-known and enduring maladies of the existing U.S. health infrastructure: escalating costs, poor health outcomes, ineffective use of technology, sluggish research pipelines, dangerous medical error rates, and failure to implement known clinical best practices. Learning health systems would capitalize on "big data" enterprises to accelerate the production and application of knowledge in health care. However, the sharing of health information required, both within and across institutions, greatly exceeds the public’s understanding.  These initiatives are riding a precarious edge as the gap between public expectations and the realities of institutional data sharing widens at an unprecedented rate.  This presentation considers the causes and consequences of trust and mistrust of health information systems, their data sharing practices, and their policy implications. 
 

 

Bioethics Grand Rounds - Dr. Michael Jibson

Wed, August 26, 2015, 12:00pm
Location: 
Ford Auditorium

This month's grand rounds features: Michael Jibson, MD, Psychiatry Department speaking about "Psychiatry, Law, and Society: Ethical and Legal Issues in Mental Health"

Lunch provided!

Please join us for a lively discussion of medical ethics. The Bioethics Grand Rounds is co-sponsored by the Center for Bioethics and Social Sciences in Medicine, the UMHS Adult and Pediatric Medical Ethics Committee, and the Program of Society and Medicine. This educational session is open to all faculty and staff and members of the public. CME credit is available. 

To meet ACCME requirements for Faculty Planner disclosure and Presenter Disclosure to participants of CME activities at UM, please be advised that the following faculty planner(s)/co-planner(s) and presenter have no personal financial relationships relevant to the activity listed below:
Planners: 

  • Andrew Shuman, MD
  • Christian Vercler, MD

PIHCD: Kevin Kerber and Will Meurer

Thu, November 19, 2015, 2:00pm
Location: 
B004E NCRC Building 16

Dr. Kevin Kerber and Dr. Will Meurer will be presenting an implementation trial on the topic of diagnosis and treatment of benign positional vertigo in the emergency department. At this meeting, they will be discussing and seeking input regarding plans for the in-person provider training presentation. Part of the intervention is a website to educate and motivate providers. Please review the website prior to the meeting.

To access the educational website please go to www.dizztinct.com and sign up with your uniqname@med.umich.edu  email address and create a password.  After signing up, you'll receive an email with a link to click, in order to activate your account.

If you do not have a med.umich.edu email address, you can still get access by contacting Patty Johnson at johnspat@med.umich.edu

A number of CBSSM faculty spoke at the recent Michigan State Medical Society Conference on Neonatal and Pediatric Ethics on November 13-14 in Ann Arbor

  • Welcome and Opening & Closing Remarks:  Lauren B. Smith, MD, Chair, MSMS Committee on Bioethics
  • “What’s New at the Margin of Viability?”  Naomi Laventhal, MD, MA, FAAP, Assistant Professor, Pediatrics; Brandon Neonatal Intensive Care, C. S. Mott Children’s Hospital
  • “Elective Operations in Children” Christian J. Vercler, MD, MA, Clinical Assistant Professor, Plastic Surgery; Co-Chair, Pediatric & Adult Ethics Committees; and Co-Director, Clinical Ethics Program, CBSSM
  • “Harms of Newborn Screening: Fact or Fiction?” Beth A. Tarini, MD, Assistant Professor, Department of Pediatrics and Communicable Diseases

Visit this link for more information on the conference.

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