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A new $13.6 million program award from the National Cancer Institute awarded to a national team of researchers centered at the U-M Comprehensive Cancer Center will examine how patients make treatment decisions, how doctors make treatment recommendations and how to improve the process for better outcomes.
Steven J Katz, MD, MPH, Co-Director of the Socio-Behavioral Program at the UM Comprehensive Cancer Center is theprincipal investigator on this new program grant.
Several CBSSM-affiliated faculty are involved with this project: Sarah Hawley, PhD, MPH and Jennifer Griggs, MD, MPH are program lead investigators,and Angela Fagerlin, PhD (CBSSM Co-Director) and Reshma Jagsi, MD, PhD are also investigators on this grant. Click here for more information.
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.
- Don't know
How do your answers compare?
In a recent study published in the journal Medical Decision Making, CBSSM investigators Brian Zikmund-Fisher, Mick 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.
PI(s): Geoffrey Barnes, James Froehlich
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
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
- 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
Funded by the National Institutes of Health
Funding years: 2011-2015
Colorectal cancer has a major impact on Americans, yet its screening rate remains suboptimal. This study aims to improve colorectal cancer screening rate by using an innovative and interactive decision aid that helps patients choose among colorectal cancer screening options. The study will also elucidate how patients and physicians discuss colorectal cancer screening options. for more information visit NIH Reporter.
PI: Masahito Jimbo
Co-I: Sarah Hawley
Dr. Sarah T. Hawley is a Professor in the Division of General Medicine at the University of Michigan and a Research Investigator at the Ann Arbor VA Center of Excellence in Health Services Research & Development. She holds a PhD in health services research from the University of North Carolina and an MPH from Yale University Department of Public Health. Her primary research is in decision making related to cancer prevention and control, particularly among racial/ethnic minority and underserved populations.
Roi Livne, PhD
Assistant Professor, Sociology
Title: “The New Economy of Dying: Palliative Care, Morality, and Finance in the Age of Excess”
Abstract: This talk argues that over the past 40 years, a new economy has emerged around end-of-life care: one seeking to control, cap, and limit both spending and treatment near the end of life. Built around the expertise of Hospice and Palliative Care, this economy draws on the moral conviction that near the end of life, less treatment (and consequently, less spending) is better. Based on a historical analysis and ethnographic fieldwork in three California hospitals, Livne examines the interactive work that palliative care clinicians do with severely ill patients and their families, trying to facilitate their voluntary consent to pursue less life-sustaining and life-prolonging treatments.