Should Pediatric Patients Be Prioritized When Rationing Life-Saving Treatments During COVID-19 Pandemic.

Coronavirus disease 2019 can lead to respiratory failure. Some patients require extracorporeal membrane oxygenation support. During the current pandemic, health care resources in some cities have been overwhelmed, and doctors have faced complex decisions about resource allocation. We present a case in which a pediatric hospital caring for both children and adults seeks to establish guidelines for the use of extracorporeal membrane oxygenation if there are not enough resources to treat every patient. Experts in critical care, end-of-life care, bioethics, and health policy discuss if age should guide rationing decisions.

How Should Physicians Respond to Patient Requests for Religious Concordance?

In which ways and in which circumstances should institutions and individual physicians facilitate patient-physician religious concordance when requested by a patient? This question suggests not only uncertainty about the relevance of particular traits to physicians' professional roles but also that medical practice can be construed as primarily bureaucratic and technological. This construal is misleading. Using the metaphor of shared language, this article contends that patient-physician concordance is always a question of degree and that greater concordance can, in certain circumstances, help to obtain important goals of medicine.

Taking societal cost into clinical consideration: U.S. physicians' views.

BACKGROUND: Recent campaigns (e.g., the American Board of Internal Medicine Foundation's Choosing Wisely) reflect the increasing role that physicians are expected to have in stewarding health care resources. We examine whether physicians believe they should pay attention to societal costs or refuse requests for costly interventions with little chance of patient benefit. METHODS: We conducted a secondary analysis of data from a 2010 national survey of 2016 U.S. physicians sampled from the AMA Physician Masterfile. Criterion measures were agreement or disagreement with two survey items related to costs of care. We also examined whether physicians' practice and religious characteristics were associated with their responses. RESULTS: The adjusted response rate was 62% (1156/1878). Forty-seven percent of physicians agreed that physicians "should not consider the societal cost of medical care when caring for individual patients," whereas 69% agreed that physicians "should refuse requests from patients or their families for costly interventions that have little chance of benefitting the patient." Physicians in specialties that care for patients at the end of life were more supportive of refusing such costly interventions. We did not find consistent associations between physicians' religiosity and their responses to these items, though those least supportive of taking into account societal cost were disproportionately from Christian affiliations. CONCLUSION: Physicians were nearly evenly divided regarding whether they should help control societal costs when caring for individual patients, but a strong majority agreed that physicians should refuse costly interventions that have little chance of benefit.

A National Longitudinal Survey of Medical Students' Intentions to Practice Among the Underserved.

PURPOSE: To explore students' intentions to practice in medically underserved areas. METHOD: In January 2011, 960 third-year medical students from 24 MD-granting U.S. medical schools were invited to participate in a survey on their intention to practice in a medically underserved area. A follow-up survey was sent to participants in September 2011. Covariates included student demographics, medical school characteristics, environmental exposures, work experiences, sense of calling, and religious characteristics. RESULTS: Adjusted response rates were 564/919 (61.4%, first survey) and 474/564 (84.0%, follow-up survey). Among fourth-year medical students, an estimated 34.3% had an intention to practice among the underserved. In multivariate logistic regression modeling, predictors for intentions to practice among the underserved included growing up in an underserved setting (odds ratio [OR] range: 2.96-4.81), very strong sense of calling (OR range: 1.86-3.89), and high medical school social mission score (in fourth year: OR = 2.34 [95% confidence interval (CI), 1.31-4.21]). International experience was associated with favorable change of mind in the fourth year (OR = 2.86 [95% CI, 1.13-7.24]). High intrinsic religiosity was associated with intentions to practice primary care in underserved settings (in fourth year: OR = 2.29 [95% CI = 1.13-4.64]). CONCLUSIONS: Growing up in medically underserved settings, work experience in religiously affiliated organizations, very strong sense of calling, and high medical school social mission score were associated with intentions to practice in underserved areas. Lack of formative educational experiences may dissuade students from considering underserved practice.

Physician Perspectives on Long-Term Relationships and Friendships with Patients: A National Assessment.

OBJECTIVES: Shifts in the healthcare environment have introduced challenges to the long-term continuity of the doctor-patient relationship. This study examines whether certain demographic or religious characteristics of physicians are associated with maintaining long-term relationships (LTRs) and/or friendships with their patients and describes physicians' opinions regarding the influence of such patient relationships on health outcomes. METHODS: In 2011, survey responses were obtained from 1289 US physicians from various specialties. Physicians answered 8 items that assessed their opinions regarding their friendships, sense of meaningfulness, and experience in LTRs. The χ2 test was used to examine bivariate associations between each demographic characteristic and physician responses to the importance of LTRs. The survey included 2 questions about the duration of physician practice and the number of patients seen in a typical week, 4 questions about perceived meaningfulness and friendship in the doctor-patient relationship, and 2 questions about the doctor-patient relationship setting. RESULTS: The adjusted survey response rate was 69% (1289/1863), 43% of physicians indicated that many or most of their patient relationships are LTRs, and 13.7% indicated they consider many or most of their patients to be friends. Just fewer than half of physicians (45.1%) perceive LTRs to have a great impact on clinical outcomes, 64.8% believe that LTRs contribute to patient trust, and 52.2% believe that LTRs are more likely to cause a patient to follow a physician's medical recommendations. CONCLUSIONS: This study presents a representative picture of US physicians' perceptions regarding relationships with patients. Physicians generally perceive LTRs to have a positive impact on patients' clinical outcomes, although the majority of physicians report they have few or no such relationships.

Quality of Life and Recommendations for Further Care.

OBJECTIVES: Physician recommendations for further medical treatment or palliative treatment only at the end of life may influence patient decisions. Little is known about the patient characteristics that affect physician-assessed quality of life or how such assessments are related to subsequent recommendations. DESIGN, SETTING, AND SUBJECTS: A 2010 mailed survey of practicing U.S. physicians (1,156/1,878 or 62% of eligible physicians responded). MEASUREMENTS AND MAIN RESULTS: Measures included an end of life vignette with five experimentally varied patient characteristics: setting, alimentation, pain, cognition, and communication. Physicians rated vignette patient quality of life on a scale from 0 to 100 and indicated whether they would recommend continuing full medical treatment or palliative treatment only. Cognitive deficits and alimentation had the greatest impacts on recommendations for further care, but pain and communication were also significant (all p < 0.001). Physicians who recommended continuing full medical treatment rated quality of life three times higher than those recommending palliative treatment only (40.41 vs 12.19; p < 0.01). Religious physicians were more likely to assess quality of life higher and to recommend full medical treatment. CONCLUSIONS: Physician judgments about quality of life are highly correlated with recommendations for further care. Patients and family members might consider these biases when negotiating medical decisions.

An official American Thoracic Society policy statement: managing conscientious objections in intensive care medicine.

RATIONALE: Intensive care unit (ICU) clinicians sometimes have a conscientious objection (CO) to providing or disclosing information about a legal, professionally accepted, and otherwise available medical service. There is little guidance about how to manage COs in ICUs. OBJECTIVES: To provide clinicians, hospital administrators, and policymakers with recommendations for managing COs in the critical care setting. METHODS: This policy statement was developed by a multidisciplinary expert committee using an iterative process with a diverse working group representing adult medicine, pediatrics, nursing, patient advocacy, bioethics, philosophy, and law. MAIN RESULTS: The policy recommendations are based on the dual goals of protecting patients' access to medical services and protecting the moral integrity of clinicians. Conceptually, accommodating COs should be considered a "shield" to protect individual clinicians' moral integrity rather than as a "sword" to impose clinicians' judgments on patients. The committee recommends that: (1) COs in ICUs be managed through institutional mechanisms, (2) institutions accommodate COs, provided doing so will not impede a patient's or surrogate's timely access to medical services or information or create excessive hardships for other clinicians or the institution, (3) a clinician's CO to providing potentially inappropriate or futile medical services should not be considered sufficient justification to forgo the treatment against the objections of the patient or surrogate, and (4) institutions promote open moral dialogue and foster a culture that respects diverse values in the critical care setting. CONCLUSIONS: This American Thoracic Society statement provides guidance for clinicians, hospital administrators, and policymakers to address clinicians' COs in the critical care setting.

Patterns of user disclosure of complementary and alternative medicine (CAM) use.

OBJECTIVE: To investigate patterns of complementary and alternative medicine (CAM) use disclosure across medical and sociobehavioral factors and to provide a model that takes into account factors in explaining those patterns. SUBJECTS: A total of 21,849 CAM use episodes from 7347 respondents in the 2007 US National Health Interview Survey which involves the latest survey on CAM use. RESEARCH DESIGN: Respondents were a representative sample of US national population. Logistic hierarchical linear models specify how characteristics of users and their CAM use episodes influence user disclosure behaviors. RESULTS: At the individual level, users were more likely to disclose CAM use to health care professionals when they had health problems and when they were insured. At the episode level, CAM use episodes were more likely to be disclosed when they were intended to treat a specific medical condition and recommended by a health professional. Disclosure rates were high among most susceptible users (ie, sick people intending to treat specific conditions with CAM) and among the biologically based CAM modalities (eg, herbal supplements) that are most likely to produce adverse interactions with conventional biomedical treatments. CONCLUSIONS: User disclosure was affected not only by users' demographic and socioeconomic characteristics but also by episode-specific factors. Efforts to improve provider-user communication of CAM use should consider the varying effects of these factors.

The moral psychology of rationing among physicians: the role of harm and fairness intuitions in physician objections to cost-effectiveness and cost-containment.

INTRODUCTION: Physicians vary in their moral judgments about health care costs. Social intuitionism posits that moral judgments arise from gut instincts, called "moral foundations." The objective of this study was to determine if "harm" and "fairness" intuitions can explain physicians' judgments about cost-containment in U.S. health care and using cost-effectiveness data in practice, as well as the relative importance of those intuitions compared to "purity", "authority" and "ingroup" in cost-related judgments. METHODS: We mailed an 8-page survey to a random sample of 2000 practicing U.S. physicians. The survey included the MFQ30 and items assessing agreement/disagreement with cost-containment and degree of objection to using cost-effectiveness data to guide care. We used t-tests for pairwise subscale mean comparisons and logistic regression to assess associations with agreement with cost-containment and objection to using cost-effectiveness analysis to guide care. RESULTS: 1032 of 1895 physicians (54%) responded. Most (67%) supported cost-containment, while 54% expressed a strong or moderate objection to the use of cost-effectiveness data in clinical decisions. Physicians who strongly objected to the use of cost-effectiveness data had similar scores in all five of the foundations (all p-values > 0.05). Agreement with cost-containment was associated with higher mean "harm" (3.6) and "fairness" (3.5) intuitions compared to "in-group" (2.8), "authority" (3.0), and "purity" (2.4) (p < 0.05). In multivariate models adjusted for age, sex, region, and specialty, both "harm" and "fairness" were significantly associated with judgments about cost-containment (OR = 1.2 [1.0-1.5]; OR = 1.7 [1.4-2.1], respectively) but were not associated with degree of objection to cost-effectiveness (OR = 1.2 [1.0-1.4]; OR = 0.9 [0.7-1.0]). CONCLUSIONS: Moral intuitions shed light on variation in physician judgments about cost issues in health care.

"Righteous minds" in health care: measurement and explanatory value of social intuitionism in accounting for the moral judgments in a sample of U.S. physicians.

The broad diversity in physicians' judgments on controversial health care topics may reflect differences in religious characteristics, political ideologies, and moral intuitions. We tested an existing measure of moral intuitions in a new population (U.S. physicians) to assess its validity and to determine whether physicians' moral intuitions correlate with their views on controversial health care topics as well as other known predictors of these intuitions such as political affiliation and religiosity. In 2009, we mailed an 8-page questionnaire to a random sample of 2000 practicing U.S. physicians from all specialties. The survey included the Moral Foundations Questionnaire (MFQ30), along with questions on physicians' judgments about controversial health care topics including abortion and euthanasia (no moral objection, some moral objection, strong moral objection). A total of 1032 of 1895 (54%) physicians responded. Physicians' overall mean moral foundations scores were 3.5 for harm, 3.3 for fairness, 2.8 for loyalty, 3.2 for authority, and 2.7 for sanctity on a 0-5 scale. Increasing levels of religious service attendance, having a more conservative political ideology, and higher sanctity scores remained the greatest positive predictors of respondents objecting to abortion (ß = 0.12, 0.23, 0.14, respectively, each p<0.001) as well as euthanasia (ß = 0.08, 0.17, and 0.17, respectively, each p<0.001), even after adjusting for demographics. Higher authority scores were also significantly negatively associated with objection to abortion (ß = -0.12, p<0.01), but not euthanasia. These data suggest that the relative importance physicians place on the different categories of moral intuitions may predict differences in physicians' judgments about morally controversial topics and may interrelate with ideology and religiosity. Further examination of the diversity in physicians' moral intuitions may prove illustrative in describing and addressing moral differences that arise in medical practice.

Substituted judgment in principle and practice: a national physician survey.

OBJECTIVE: To describe the extent to which US physicians endorse substituted judgments in principle or accommodate them in practice. PATIENTS AND METHODS: We surveyed a stratified, random sample of 2016 physicians by mail from June 25, 2010, to September 3, 2010. Primary outcome measures were agreement with 2 in-principle statements about substituted judgment and, after an experimental vignette that varied the basis used by a patient's surrogate to refuse life-saving treatment, responses indicating how appropriate it would be to overrule the surrogate's decision. RESULTS: Our response rate was 62% (1156 of 1875 respondents). When there is a conflict between what a surrogate believes a patient would have wanted (substituted judgment) and what the surrogate believes is in the patient's best interest, 4 of 5 physicians (78%) agreed that the surrogate should base their decision on substituted judgment. Yet we also found that 2 of 5 physicians (40%) agree that surrogates should make decisions they believe are in the patient's best interest, even if those seem to contradict the patient's prior wishes. In the experimental vignette, physicians were much more likely to oppose overruling a surrogate's refusal of life-sustaining medical treatment when that refusal was made on the basis of substituted judgment compared with when the refusal was made on the basis of the patient's best interest (50% vs 20%; odds ratio, 4.2; 95% CI, 2.7-6.3). Responses to the in-principle items about substituted judgment were not consistently associated with responses to the experimental vignette. CONCLUSION: US physicians largely agree, in principle, that surrogates should prioritize what the patient would have wanted over what they believe is in the patient's best interest, although many physicians are ambivalent in cases in which the 2 norms conflict. Even physicians who reject the principle of substituted judgment tend to treat substituted judgment as the preferred norm for surrogate decision making when responding to a clinical vignette.

Religion and disparities: considering the influences of Islam on the health of American Muslims.

Both theory and data suggest that religions shape the way individuals interpret and seek help for their illnesses. Yet, health disparities research has rarely examined the influence of a shared religion on the health of individuals from distinct minority communities. In this paper, we focus on Islam and American Muslims to outline the ways in which a shared religion may impact the health of a racially, ethnically, and socioeconomically diverse minority community. We use Kleinman's "cultural construction of clinical reality" as a theoretical framework to interpret the extant literature on American Muslim health. We then propose a research agenda that would extend current disparities research to include measures of religiosity, particularly among populations that share a minority religious affiliation. The research we propose would provide a fuller understanding of the relationships between religion and health among Muslim Americans and other minority communities and would thereby undergird efforts to reduce unwarranted health disparities.

An assessment of US physicians' training in religion, spirituality, and medicine.

This study examined US physicians' training in religion and medicine and its association with addressing religious and spiritual issues in clinical encounters. Reports of receiving training were higher for highly spiritual physicians, psychiatrists, and physicians with high numbers of critically ill patients. Discussing religion or spirituality with patients was associated with having received training through a book or CME literature or during Grand Rounds, through one's religious tradition and from other unspecified sources but not with having received such training in medical school.

Attention to inpatients' religious and spiritual concerns: predictors and association with patient satisfaction.

BACKGROUND: Little is known about how often patients desire and experience discussions with hospital personnel regarding R/S (religion and spirituality) or what effects such discussions have on patient satisfaction. OBJECTIVE, DESIGN AND PARTICIPANTS: We examined data from the University of Chicago Hospitalist Study, which gathers sociodemographic and clinical information from all consenting general internal medicine patients at the University of Chicago Medical Center. MAIN MEASURES: Primary outcomes were whether or not patients desired to have their religious or spiritual concerns addressed while hospitalized, whether or not anyone talked to them about religious and spiritual issues, and which member of the health care team spoke with them about these issues. Primary predictors were patients' ratings of their religious attendance, their efforts to carry their religious beliefs over into other dealings in life, and their spirituality. KEY RESULTS: Forty-one percent of inpatients desired a discussion of R/S concerns while hospitalized, but only half of those reported having such a discussion. Overall, 32% of inpatients reported having a discussion of their R/S concerns. Religious patients and those experiencing more severe pain were more likely both to desire and to have discussions of spiritual concerns. Patients who had discussions of R/S concerns were more likely to rate their care at the highest level on four different measures of patient satisfaction, regardless of whether or not they said they had desired such a discussion (odds ratios 1.4-2.2, 95% confidence intervals 1.1-3.0). CONCLUSIONS: These data suggest that many more inpatients desire conversations about R/S than have them. Health care professionals might improve patients' overall experience with being hospitalized and patient satisfaction by addressing this unmet patient need.

Obstetrician-gynecologist physicians' beliefs about emergency contraception: a national survey.

BACKGROUND: Although emergency contraception (EC) is available without a prescription, women still rely on doctors' advice about its safety and effectiveness. Yet little is known about doctors' beliefs and practices in this area. STUDY DESIGN: We surveyed 1800 US obstetrician-gynecologists. Criterion variables were doctors' beliefs about EC's effects on pregnancy rates, and patients' sexual practices. We also asked which women are offered EC. Predictors were demographic, clinical and religious characteristics. RESULTS: Response rate was 66% (1154/1760). Most (89%) believe EC access lowers unintended pregnancy rates. Some believe women use other contraceptives less (27%), initiate sex at younger ages (12%) and have more sexual partners (15%). Half of physicians offer EC to all women (51%), while others offer it never (6%) or only after sexual assault (6%). Physicians critical of EC, males and religious physicians were more likely to offer it never or only after sexual assault (odds ratios 2.1-12). CONCLUSION: Gender, religion and divergent beliefs about EC's effects shape physicians' beliefs and practices.

Do religious physicians disproportionately care for the underserved?

PURPOSE: Religious traditions call their members to care for the poor and marginalized, yet no study has examined whether physicians' religious characteristics are associated with practice among the underserved. This study examines whether physicians' self-reported religious characteristics and sense of calling in their work are associated with practice among the underserved. METHODS: This study entailed a cross-sectional survey by mail of a stratified random sample of 2,000 practicing US physicians from all specialties. RESULTS: The response rate was 63%. Twenty-six percent of US physicians reported that their patient populations are considered underserved. Physicians who were more likely to report practice among the underserved included those who were highly spiritual (multivariate odds ratio [OR] = 1.7; 95% confidence interval [CI], 1.1-2.7], those who strongly agreed that their religious beliefs influenced their practice of medicine (OR = 1.6; 95% CI, 1.1-2.5), and those who strongly agreed that the family in which they were raised emphasized service to the poor (OR = 1.7; 95% CI, 1.0-2.7). Physicians who were more religious in general, as measured by intrinsic religiosity or frequency of attendance at religious services, were much more likely to conceive of the practice of medicine as a calling but not more likely to report practice among the underserved. CONCLUSIONS: Physicians who are more religious do not appear to disproportionately care for the underserved.

Following the call: how providers make sense of their decisions to work in faith-based and secular urban community health centers.

We interviewed 49 health care providers from 6 faith-based and 4 secular community health centers (CHCs) to explore the ways they relate their religious commitments to practice among the underserved. Interviews were transcribed, coded, and analyzed for emergent themes through an iterative process of textual analysis. Providers in faith-based CHCs explained the decision to work in underserved settings as a response to a religious calling to medicine as a means of ministry, and by reference to particular benefits and freedoms of working with colleagues who share an explicitly faith-informed vision for care of the underserved. Most providers from secular CHCs explained their motivations in less religious terms by reference to intrinsic rewards such as "making a difference" for the underserved. Providers from both settings emphasized the frustrations and difficulties of meeting overwhelming demands with inadequate resources. In light of prior literature regarding work orientation, our findings suggest that CHCs may provide distinctive opportunities for intrinsically motivated providers to craft their work into a calling, where a calling is understood as a deeply felt motivation for work that goes beyond the satisfaction of the worker's material and social needs. Faith-based CHCs appear to provide a context that is attractive to some minority of providers who desire to enact a religious calling to ministry through the practice of medicine. Future studies are needed to test these hypotheses using quantitative methods and broader representative sampling.