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The Privileged Choices (Jan-08)

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.

Scenario 1

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?

  • Yes
  • No

Scenario 2

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?

  • Yes 
  • No

Scenario 3

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?

  • Yes 
  • No

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.

What's in a Name? A Pregnancy Scenario (Nov-07)

Tell us how you'd respond to the results of a blood test for fetal chromosomal problems. And find out how your response compares with that of participants in a national survey.

Consider the following

Imagine that you are four months pregnant. You and your partner have talked with your doctor about prenatal screening tests for your fetus. Based on your family history and personal medical history, your doctor has told you that you're at low risk (2 in 1000) of having a fetus with chromosomal problems. Chromosomal problems include such conditions as Down Syndrome. In talking further with your doctor, you decide to have a routine blood test for chromosomal problems in your fetus. This test will help to give you a better estimate of the chance that your fetus would have a chromosomal problem.

Your doctor tells you that the results of this blood test have come back "abnormal." She clarifies that the blood test showed that your risk of fetal chromosomal problems is about 5 in 1000, which is higher than the number she had told you before the test. She next asks if you are interested in amniocentesis, a medical procedure in which a small amount of amniotic fluid is extracted from the amniotic sac surrounding the fetus. This procedure can tell you for sure whether or not the fetus has chromosomal problems. However, amniocentesis has its own risks. Your doctor explains that the risk of miscarriage as a result of amniocentesis may be as high as 5 in 1000.

In these circumstances would you be interested in having an amniocentesis performed?
  • Definitely No
  • Probably No
  • Probably Yes
  • Definitely Yes

How do your answers compare?

Many women decide to go ahead and have amniocentesis. There are two things in this scenario that could influence women's decisions about amniocentesis. First, the doctor described the test as "abnormal", a label that may increase worry about the possibility that the fetus would have a chromosomal problem. Second, the risk estimate of 5 in 1000 was higher than the original estimate of 2 in 1000, which also may increase concern.

CBDSM researchers, led by Brian Zikmund-Fisher, wanted to know how much influence labels such as "abnormal", "normal", "positive", or "negative" might have on people's decisions in situations like the one described above. To test this, they gave one group of women a scenario just like the one you read. In this scenario, the test results were described as either "abnormal" or "positive" before the risk estimate of 5 in 1000 was given. A second group of women read the same scenario, but in their scenario, the doctor presented only the numeric risk estimate, without any label.

Women whose test results were introduced using a qualitative label ("positive/abnormal") were significantly more worried - and significantly more likely to choose to have amniocentesis - than women who were told only the numeric risk estimate, without any label. Note that all of the women in this survey were told that they had the same final risk: 5 in 1000. The decision of the women in each group should have been the same, but adding that one qualitative label significantly changed what the women in the study decided to do.

Interestingly, the CBDSM researchers also found a reverse effect when test results were introduced with the labels "negative" or "normal." These labels tended to make women less worried and less likely to have amniocentesis than women in a comparison group. Again, these results show that adding a one-sentence introduction with a qualitative label could significantly change people's decisions.

Read the article:

Does labeling prenatal screening test results as negative or positive affect a woman's responses?
Zikmund-Fisher BJ, Fagerlin A, Keeton K, Ubel PA. American Journal of Obstetrics and Gynecology 2007;197(5):528.e1-528.e6.

Wed, March 01, 2017

Interim co-director, Brian Zikmund-Fisher, as well as former co-director, Angela Fagerlin, were recently featured in the Wall Street Journal article, "How to Get Patients to Take More Control of Their Medical Decisions."

Funded by the Department of Veterans Affairs

Funding Years: 2007-2012

Prostate cancer is the second leading cause of cancer related death among men in the United States, and accounts for 29% of all cancers diagnosed in men. Furthermore, approximately one in six men will be diagnosed with prostate cancer in their lifetime. Thus, 17% of male Veterans will be asked to make a decision about the treatment of their prostate cancer. The burden of this disease is further magnified when one considers that most patients will live for years following their diagnosis and with any adverse effects of therapy. Given that there have been no clinical trials showing that any prostate cancer treatment produces an increased likelihood of survival; men are asked to actively participate in treatment decisions. Previous research has revealed that men are often uninformed about their prostate cancer, particularly African American men and men with lower educational attainment. Thus, it is critical to develop and test decision aids that can help all men (especially men with low literacy skills) make an informed decision. The goal of the study was to compare the impact of a plain language decision aid (DA) to a conventional DA on prostate cancer patients’ decision making experience and communication with their physician.

PI(s): Angela Fagerlin, PhD and Peter A. Ubel, MD

Co-I(s): Khaled Hafez, MD; Bruce Ling, MD; Jeffrey Gingrich, MD; Sara Knight, PhD; Phillip Walther, MD; Margaret Holmes-Rovner, PhD; James Tulsky, MD; Stewart Alexander, PhD


 


 


 

 

Journeys in Genetics: Ethical, Legal, and Social Implications

Tue, September 27, 2016, 3:00pm
Location: 
2610 SPH I

Journeys in Genetics: Ethical, Legal, and Social Implications
with Toby Citrin, J.D. and Scott Roberts, Ph.D.


September 27, 2016
3:00 - 4:00 p.m.
2610 SPH I
1415 Washington Heights
Ann Arbor, MI 48109-2029


Sponsored by Certificate Program in Public Health Genetics 20th Anniversary Seminar Series


"Journeys in Genetics" is an interactive series of seminars that will highlight the unique personal and professional paths that the Certificate Program in Public Health Genetics (CPHG) faculty members have traversed throughout their careers in the field of public health genetics. In this seminar, Professor Citrin will describe a phone call from Detroit's Mayor in 1970, a request from Francis Collins in the early '90s, creation of the Center for Public Health and Community Genomics in 2001, and projects engaging minority communities in learning about genetics and helping to shape policies to guide the field. Professor Roberts will discuss his research program on how individuals appraise and respond to personal genetic information in contexts including genetic susceptibility testing for Alzheimer's disease, cancer genomics, and direct-to-consumer genetic testing.

Funded by Patient Centered Outcomes Research Institute.

Funding Years: 2012-2014.

While substantial progress has occurred recognizing community expertise in research, and involving communities in decisions about research aims and methods, community influence on research priorities remains limited. Building on experience with developing, testing and using the award-winning CHAT (Choosing Healthplans All Together) tool, and propelled by a current project that is developing and evaluating a tool to engage minority and underserved communities in setting priorities for clinical and translational research, we plan to develop and test a method to engage the public and patients in deliberations about patient-centered outcomes research (PCOR) priorities. The proposed study expands public input on research priorities beyond the limited settings of advisory boards and disease advocates in which much public engagement currently functions and contribute to a more just and equitable system of PCOR. Importantly, by evaluating the tool this project will also add to the body of knowledge about methods, processes and outcomes of community engagement. For more information, visit PCORI.

PI(s): Susan Goold

Co-I(s): Lawrence An, Ray De Vries, Jennifer Griggs,  Myra Kim

 

Liver Transplant Organ Quality Decision Aid: Would you consider a less than perfect liver? (Jan-16)

Imagine that you are a patient with end-stage liver disease and you are currently on the liver transplant waiting list.

Available donor livers are limited and vary in quality. Donor characteristics such as age and cause of death can make a difference between a 20% and a 40% rate of liver transplant (graft) failure by 3-years post-transplant.

Now imagine that you and your doctor are discussing the risks and benefits of a liver transplant and whether you might consider a “less than perfect” liver (with a higher risk for graft failure).  To help you in your decision making, you are provided with a decision aid to help you to consider the level of risk you would be willing to accept from a donated liver.

On the following page, consider an image representing your (pretend!) risk of dying or becoming too sick for a liver transplant within the next 3-months if you don’t get a transplant.

Medical Students

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

Discussions During Required Clinical Rotations

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
  • Highlights:
    • 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

 

CBSSM Seminar: Darin Zahuranec, MD

Wed, January 20, 2016, 3:00pm to 4:00pm
Location: 
NCRC, Building 16, Room 266C

Darin Zahuranec, MD


Assistant Professor, Neurology

Title:  Improving decisions on life-sustaining treatments after stroke

Abstract:  Individuals with acute stroke face the sudden onset of new deficits, along with a need to make many decisions about medical treatments with impact on the potential for survival and long-term disability. This talk will review the challenges in decision-making after acute stroke and discuss possible solutions for the future.

 

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)

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