Physician activity during outpatient visits and subjective workload.

We describe methods for capturing and analyzing EHR use and clinical workflow of physicians during outpatient encounters and relating activity to physicians' self-reported workload. We collected temporally-resolved activity data including audio, video, EHR activity, and eye-gaze along with post-visit assessments of workload. These data are then analyzed through a combination of manual content analysis and computational techniques to temporally align streams, providing a range of process measures of EHR usage, clinical workflow, and physician-patient communication. Data was collected from primary care and specialty clinics at the Veterans Administration San Diego Healthcare System and UCSD Health, who use Electronic Health Record (EHR) platforms, CPRS and Epic, respectively. Grouping visit activity by physician, site, specialty, and patient status enables rank-ordering activity factors by their correlation to physicians' subjective work-load as captured by NASA Task Load Index survey. We developed a coding scheme that enabled us to compare timing studies between CPRS and Epic and extract patient and visit complexity profiles. We identified similar patterns of EHR use and navigation at the 2 sites despite differences in functions, user interfaces and consequent coded representations. Both sites displayed similar proportions of EHR function use and navigation, and distribution of visit length, proportion of time physicians attended to EHRs (gaze), and subjective work-load as measured by the task load survey. We found that visit activity was highly variable across individual physicians, and the observed activity metrics ranged widely as correlates to subjective workload. We discuss implications of our study for methodology, clinical workflow and EHR redesign.

Spin propensities of octahedral complexes from density functional theory.

The fundamental balance between high- and low-spin states of transition metal systems depends on both the metal ion and the ligands surrounding it, as often visualized by the spectrochemical series. Most density functionals do not reproduce this balance, and real spin state propensities depend on orbital pairing and vibrational entropies absent in the spectrochemical series. Thus, we systematically computed the tendency toward high or low spin of "text-book" octahedral metal complexes versus ligand and metal type, using eight density functionals. Dispersion effects were generally <5 kJ/mol, favoring low-spin states. Zero-point energies favored high-spin states up to 33 kJ/mol for strong ligands, but down to a few kilojoules per mole for weak ligands. Vibrational entropy also favored high-spin states up to 40 kJ/mol, most for strong ligands. Jahn-Teller distortion in Co(II) low-spin states, particularly stable d(6) low-spin states, and entropy corrections were consistent with experiment. Entropy and zero-point energy corrections were markedly lower for Co(II) and Mn(III), viz., the differential ligand field stabilization energy, and can only be ignored for weak ligands. The data enable simple assessment of spin state propensities versus ligand and metal type and reveal, e.g., that CN(-) is consistently weaker than CO for M(II) but stronger than CO for M(III) and SCN(-) and NCS(-) change order in M(II) versus M(III) complexes. Contrary to expectation based on the spectrochemical series, Cl(-) and Br(-) are very close in spin state propensity because the pairing penalty for low spin is smaller in Br(-). Thus, for the M(II) complexes, we find a consensus order of Br(-) ∼ Cl(-) < H2O < SCN(-) < NCS(-) ∼ NH3 < CN(-) < CO, whereas for the M(III) complexes, an approximate order is Br(-) ∼ Cl(-) < H2O ∼ NCS(-) ∼ SCN(-)< NH3 < CO < CN(-).

Beliefs and perceptions of women with newly diagnosed breast cancer who refused conventional treatment in favor of alternative therapies.

PURPOSE: Although breast cancer is a highly treatable disease, some women reject conventional treatment opting for unproven "alternative therapy" that may contribute to poor health outcomes. This study sought to understand why some women make this decision and to identify messages that might lead to greater acceptance of evidence-based treatment. PATIENTS AND METHODS: This study explored treatment decision making through in-depth interviews with 60 breast cancer patients identified by their treating oncologists. Thirty refused some or all conventional treatment, opting for alternative therapies, whereas 30 accepted both conventional and alternative treatments. All completed the Beck Anxiety Inventory and the Rotter Locus of Control scale. RESULTS: Negative first experiences with "uncaring, insensitive, and unnecessarily harsh" oncologists, fear of side effects, and belief in the efficacy of alternative therapies were key factors in the decision to reject potentially life-prolonging conventional therapy. Refusers differed from controls in their perceptions of the value of conventional treatment, believing that chemotherapy and radiotherapy were riskier (p < .0073) and less beneficial (p < .0001) than did controls. Controls perceived alternative medicine alone as riskier than did refusers because its value for treating cancer is unproven (p < .0001). Refusers believed they could heal themselves naturally from cancer with simple holistic methods like raw fruits, vegetables, and supplements. CONCLUSION: According to interviewees, a compassionate approach to cancer care plus physicians who acknowledge their fears, communicate hope, educate them about their options, and allow them time to come to terms with their diagnosis before starting treatment might have led them to better treatment choices.