The Challenges in Using eHealth Decision Resources for Surrogate Decision-Making in the Intensive Care Unit.

The mortality rate in intensive care units (ICUs) is notably high, with patients often relying on surrogates for critical medical decisions due to their compromised state. This paper provides a comprehensive overview of eHealth. The challenges of applying eHealth tools, including economic disparities and information inaccuracies are addressed. This study then introduces eHealth literacy and the assessment tools to evaluate users' capability and literacy levels in using eHealth resources. A clinical scenario involving surrogate decision-making is presented. This simulated case involves a patient with a hemorrhagic stroke who has lost consciousness and requires medical procedures such as tracheostomy. However, due to the medical surrogate's lack of familiarity with eHealth devices and limited literacy in using eHealth resources, difficulties arise in assisting the patient in making medical decisions. This scenario highlights challenges related to eHealth literacy and solution strategies are proposed. In conclusion, effective ICU decision-making with eHealth tools requires a careful balance between efficiency with inclusivity. Tailoring communication strategies and providing diverse materials are essential for effective eHealth decision resources in the ICU setting. Health professionals should adopt a patient-centered approach to enhance the decision-making experience, particularly for individuals with limited eHealth literacy.

Family Members' Engagement in Symptom Communication, Assessment, and Management in the Intensive Care Unit: A Qualitative Study.

BACKGROUND: Opportunities for communication and participation in decision making are limited for critically ill patients, but family members serving as surrogates enable empowerment of these patients. OBJECTIVE: The aim of this study was to explore family members' engagement in symptom communication in the intensive care unit. METHODS: A qualitative descriptive design using fieldwork methodology with triangulation of participant observation and individual interviews was conducted. Nine mechanically ventilated patients were observed in interaction with family members and clinicians in the intensive care unit. Six of the observed patients, 6 family members, and 9 clinicians were interviewed after participant observation. Field notes and transcripts were analyzed using Braun and Clarke's method of thematic analysis. RESULTS: Family members engaged actively in symptom communication, assessment, and management, and there were barriers and facilitators to family engagement. Three main themes and 9 subthemes describing family engagement emerged: (1) intermediary role (recognize and report symptoms, provide patient information, and assist in communication), (2) independent role (provide familiarity, manage symptoms, and promote patient communication), and (3) conditions for family engagement (intensive care unit environment, relationship with the patient, and patient preferences). DISCUSSION: Family members have unique knowledge of the patient that differs from and complement the competence of the staff, and might contribute to improved symptom communication. Future research should examine how family members can contribute to symptom communication, assessment, and management.

Development of an integrated milestone assessment tool across multiple early-adopter programs for breaking bad news: a pilot project.

BACKGROUND: The transition of the Accreditation Council for Graduate Medical Education (ACGME) to milestone assessment creates opportunities for collaboration and shared assessments across graduate medical programs. Breaking bad news is an essential communication skill that is a common milestone across almost every medical specialty. The purpose of this study was to develop and pilot an integrated milestone assessment (IMA) tool for breaking bad news using ACGME milestone criteria and to compare the IMA tool with the existing SPIKES protocol. METHODS: The IMA tool was created using sub-anchors in professionalism and interpersonal communication skills that are applicable to every specialty and to the ability to break bad news. Two cases of breaking bad news, designed to be "easy" and "intermediate" in difficulty, were used to assess basic skills in breaking bad news in first-year medical residents from six residency specialties. Eight standardized patients were trained to portray the cases in sessions held in November 2013 and May 2014. Standardized patients completed an assessment checklist to evaluate each resident's performance in breaking bad news based on their use of the SPIKES protocol and IMA tool. Residents answered post-encounter questions about their training and comfort in breaking bad news. The association between SPIKES and IMA scores was investigated by simple linear regression models and Spearman rank correlations. RESULTS: There were 136 eligible medical residents: 108 (79.4%) participated in the first session and 97 (71.3%) participated in the second session, with 96 (70.6%) residents participating in both sessions. Overall, we were able to identify residents that performed at both extremes of the assessment criteria using the integrated milestone assessment (IMA) and the SPIKES protocol. Interestingly, residents rated themselves below "comfortable" on average. CONCLUSION: We developed an integrated milestone assessment (IMA) that was better than the SPIKES protocol at assessing the skill of breaking bad news. This collaborative assessment tool can be used as supplement tool in the era of milestone transformation. We aim assess our tool in other specialties and institutions, as well as assess other shared milestones across specialties.

External inspection approaches and involvement of stakeholders' views in inspection following serious incidents - a qualitative mixed methods study from the perspectives of regulatory inspectors.

OBJECTIVE: The objective was to gain knowledge about how external inspections following serious incidents are played out in a Norwegian hospital context from the perspective of the inspectors, and whether stakeholders' views are involved in the inspection. METHODS: Based on a qualitative mixed methods design, 10 government bureaucrats and inspectors situated at the National Board of Health Supervision and three County Governors in Norway, were strategically recruited, and individual semi-structured interviews were conducted. Key official government documents were selected, collected, and thematically analyzed along with the interview data. RESULTS: Our findings overall demonstrate two overarching themes: Theme (1) Perspectives on different external inspection approaches of responding and involving stakeholders in external inspection following serious incidents, Theme (2) Inspectors' internal work practices versus external expectations. Documents and all participants reported a development towards new approaches in external inspection, with more policies and regulatory attention to sensible involvement of stakeholders. Involvement and interaction with patients and informal caregivers could potentially inform the case complexity and the inspector's decision-making process. However, stakeholder involvement was sometimes complex and challenging due to e.g., difficult communication and interaction with patients and/or informal caregivers, due to resource demands and/or the inspector's lack of experience and/or relevant competence, different perceptions of the principle of sound professional practice, quality, and safety. The inspectors considered balancing the formal objectives and expectations, with the expectations of the public and different stakeholders (i.e. hospitals, patients and/or informal caregivers) a challenging part of their job. This balance was seen as an important part of the continuous development of ensuring public trust and legitimacy in external inspection processes. CONCLUSIONS AND IMPLICATIONS: Our study suggests that the regulatory system of external inspection and its available approaches of responding to a serious incident in the Norwegian setting is currently not designed to accommodate the complexity of needs from stakeholders at the levels of hospital organizations, patients, and informal caregivers altogether. Further studies should direct attention to how the wider system of accountability structures may support the internal work practices in the regulatory system, to better algin its formal objectives with expectations of the public.

Built for Advocacy.

Advocacy is a lever for positive change and is most effective and satisfying when used proactively. It is also one of nurses' superpowers and desperately needed outside health care settings, especially in the policy arenas of local, state, and federal government. Despite nurses' being the largest segment of the health care workforce, their voices are often missing from crucial conversations about access to care, health inequities, and upstream problems affecting people's health. Short of being the policy makers themselves, the best way for nurses to affect these decisions is to build and use influence with policy makers. There are concrete steps that nurses can take to grab a seat at the table.

Diversity, equity, and inclusion (DEI) in medical education: DEI at the bedside.

BACKGROUND: The ability to recognize and address bias is an important communication skill not typically addressed during training. We describe the design of an educational curriculum that aims to identify and change behavior related to diversity, equity, and inclusion (DEI). "DEI at the Bedside" uses the existing infrastructure of bedside teaching and provides a tool to normalize DEI discussions and develop skills to address bias during a neurology inpatient rotation. METHODS: As part of traditional clinical rounds, team members on an inpatient service shared experiences with DEI topics, including bias. The team developed potential responses should they encounter a similar situation in the future. We report the results of our needs assessment and curriculum development to evaluate the feasibility of incorporating a DEI educational curriculum in the neurology inpatient setting. RESULTS: Forty-two DEI experiences were recorded. Medical students were the most frequent discussants (44%). Direction of bias occurred between healthcare team members (33%), against patients (31%), and patients against healthcare team members (28%). Experiences ranged from microaggressions to explicit comments of racism, sexism, and homophobia. CONCLUSIONS: Based on needs assessment data, we developed a DEI educational curriculum for the inpatient neurology setting aimed to improve knowledge and skills related to DEI topics as well as to normalize conversation of DEI in the clinical setting. Additional study will demonstrate whether this initiative translates into measurable and sustained improvement in knowledge of how bias and disparity show up in the clinical setting and behavioral intent to discuss and address them.

Improving Adolescent Psychosocial Assessment through Standardized Patient Simulation: An Interdisciplinary Quality Improvement Initiative.

Adolescent suicide and mental illness have increased at alarming rates. Healthcare professionals report a lack of skill and confidence in obtaining adolescent histories and managing confidential care due to limited training in residency. Nursing professional development practitioners face challenges of adequately preparing interdisciplinary healthcare providers to assess, identify, and intervene at all points of contact with adolescents. To increase the confidence in clinical communication skills and clinical competency, and to increase the number of social work referrals related to modifiable risk factors for adolescent patients, a Texas pediatric tertiary care center utilized standardized patient (SP) methodology to supplement traditional clinical experiences with communication-focused education based on the Home, Education, Eating, Activities, Drugs, Sexuality, Suicidality, and Safety (HEEADSSS) interviewing. This quality improvement (QI) pilot demonstrated the benefits of utilizing standardized patient methodology in communication-focused education based on the HEEADSSS interviewing. Following the SP simulations, confidence in clinical communication skills increased by 13%, clinical competency in performing comprehensive psychosocial interviews increased by 11%, use of HEEADSSS increased by 64%, and social work referrals increased by 89%. This interdisciplinary SP interviewing simulation pilot was beneficial in improving the 36 physician and nursing residents' ability to conduct psychosocial assessments for risk factors of suicidality among adolescents.

Assessment and application of non-technical skills in robotic-assisted surgery: a systematic review.

BACKGROUND: Undeniably, robotic-assisted surgery (RAS) has become very popular in recent decades, but it has introduced challenges to the workflow of the surgical team. Non-technical skills (NTS) have received less emphasis than technical skills in training and assessment. The systematic review aimed to update the evidence on the role of NTS in robotic surgery, specifically focusing on evaluating assessment tools and their utilisation in training and surgical education in robotic surgery. METHODS: A systematic literature search of PubMed, PsycINFO, MEDLINE, and EMBASE was conducted to identify primary articles on NTS in RAS. Messick's validity framework and the Modified Medical Education Research Study Quality Instrument were utilised to evaluate the quality of the validity evidence of the abstracted articles. RESULTS: Seventeen studies were eligible for the final analysis. Communication, environmental factors, anticipation and teamwork were key NTS for RAS. Team-related factors such as ambient noise and chatter, inconveniences due to repeated requests during the procedure and constraints due to poor design of the operating room may harm patient safety during RAS. Three novel rater-based scoring systems and one sensor-based method for assessing NTS in RAS were identified. Anticipation by the team to predict and execute the next move before an explicit verbal command improved the surgeon's situational awareness. CONCLUSION: This systematic review highlighted the paucity of reporting on non-technical skills in robotic surgery with only three bespoke objective assessment tools being identified. Communication, environmental factors, anticipation, and teamwork are the key non-technical skills reported in robotic surgery, and further research is required to investigate their benefits to improve patient safety during robotic surgery.

Recommendations for the responsible use and communication of race and ethnicity in neuroimaging research.

The growing availability of large-population human biomedical datasets provides researchers with unique opportunities to conduct rigorous and impactful studies on brain and behavioral development, allowing for a more comprehensive understanding of neurodevelopment in diverse populations. However, the patterns observed in these datasets are more likely to be influenced by upstream structural inequities (that is, structural racism), which can lead to health disparities based on race, ethnicity and social class. This paper addresses the need for guidance and self-reflection in biomedical research on conceptualizing, contextualizing and communicating issues related to race and ethnicity. We provide recommendations as a starting point for researchers to rethink race and ethnicity choices in study design, model specification, statistical analysis and communication of results, implement practices to avoid the further stigmatization of historically minoritized groups, and engage in research practices that counteract existing harmful biases.

Perceived communication efficacy and unmet needs for chemotherapy-associated symptom management in patients with lung and colorectal cancer: a cross-sectional study.

BACKGROUND: Understanding cancer patients' unmet needs for chemotherapy-related symptom management will assist clinicians in developing tailored intervention programs. Little is known about the association between perceived communication efficacy and unmet care needs for symptom management in patients with lung and colorectal cancer. OBJECTIVES: To examine the unmet care needs for symptom management of patients with lung and colorectal cancer and their association with perceived communication efficacy. METHODS: A cross-sectional survey was conducted in a tertiary hospital in China from July to November 2020. A convenience sample of 203 patients with lung and colorectal cancer undergoing chemotherapy completed survey questionnaires, including the MD Anderson Symptom Inventory Scale and the Perceived Efficacy in Patient‒Physician Interactions Scale. RESULTS: Approximately 43% of participants had at least one symptom with unmet needs. Fatigue was reported as the symptom with the highest occurrence (66%), the highest demand for supportive care (36%), and the highest prevalence of unmet needs (19%). Low levels of perceived communication efficacy independently predicted participants' unmet needs for symptom management (ß=-0.13, p = 0.011). CONCLUSIONS: This study highlights the necessity of introducing clinical assessment tools and guidelines to address fatigue and other chemotherapy-induced symptoms in patients with lung and colorectal cancer. Clinical programs designed to actively engage cancer patients to voice their needs and strengthen their communication efficacy are also warranted.

Equity, diversity, and inclusion in the Multinational Association for Supportive Care in Cancer: a global membership survey.

Equity, diversity, and inclusion (EDI) are essential for healthcare organizations since they allow for the development of programs and initiatives that bring together diverse perspectives and knowledge. Global multidisciplinary organizations, such as the Multinational Association for Supportive Care in Cancer (MASCC), need to understand the perspective of their members regarding EDI to identify opportunities to enhance diversity and inclusiveness and to better meet the needs of members from different backgrounds and resources. The MASCC Health Disparities Committee designed a survey to identify issues related to disparities faced by MASCC members when providing supportive care to patients with cancer and to examine the EDI landscape within the organization. Here, we report results related to EDI initiatives within the organization. Two-hundred and eighteen MASCC members responded to the survey (response rate 10.2%). The results indicated that respondents were generally satisfied with how MASCC manages leadership, membership, and organization-related EDI issues. Opportunities for improvement noted by respondents included developing strategies to foster a more diverse membership, improving communication regarding diversity in the organization, and increasing EDI content in educational sessions and publications. The results of this survey represent the first attempt at understanding how to improve EDI within MASCC and will be utilized to guide further initiatives and programs.

Introduction of the pneumococcal conjugate vaccine in humanitarian and fragile contexts: Perspectives from stakeholders in four African countries.

Childhood pneumonia causes a significant burden of preventable child morbidity and mortality in Chad, Guinea, Somalia/Somaliland, and South Sudan. Leaders from these countries have committed to reducing this burden and are preparing to introduce the pneumococcal conjugate vaccine (PCV) into their immunization programs. To support long-term sustainability for expected PCV introductions in settings afflicted by prolonged humanitarian crises this research explores national stakeholders' perspectives on contextual factors that may influence optimal vaccine implementation. This qualitative study used purposive sampling to identify and interview stakeholders involved in vaccine decision-making. Interview transcripts were analyzed through the framework method, an approach involving charting data into pre-populated matrices. Findings from interviews with 16 key informants from government, partner organizations, and international health agencies fit within the following four overarching themes: (1) population-level vulnerabilities to pneumonia, exacerbated by climatic risks and low levels of maternal education; (2) disease burden and the interest in enhancing surveillance to monitor vaccine impact and integrate disease control efforts; (3) policy processes, including formalizing vaccine decision-making; and (4) vaccine implementation preparation, including the conduct of robust communication campaigns, training, and cold chain upgrades. This research explores perspectives from leaders in these countries which are at pivotal moments in their journeys toward introducing PCV. Widespread commitment among leaders, in addition to financial support, will facilitate vaccine introduction. Further, fostering a shared understanding among partners about context-specific determinants of program success will help build tailored implementation strategies for each country.

Codesign of health technology interventions to support best-practice perioperative care and surgical waitlist management.

OBJECTIVES: This project aimed to determine where health technology can support best-practice perioperative care for patients waiting for surgery. METHODS: An exploratory codesign process used personas and journey mapping in three interprofessional workshops to identify key challenges in perioperative care across four health districts in Sydney, Australia. Through participatory methodology, the research inquiry directly involved perioperative clinicians. In three facilitated workshops, clinician and patient participants codesigned potential digital interventions to support perioperative pathways. Workshop output was coded and thematically analysed, using design principles. RESULTS: Codesign workshops, involving 51 participants, were conducted October to November 2022. Participants designed seven patient personas, with consumer representatives confirming acceptability and diversity. Interprofessional team members and consumers mapped key clinical moments, feelings and barriers for each persona during a hypothetical perioperative journey. Six key themes were identified: 'preventative care', 'personalised care', 'integrated communication', 'shared decision-making', 'care transitions' and 'partnership'. Twenty potential solutions were proposed, with top priorities a digital dashboard and virtual care coordination. DISCUSSION: Our findings emphasise the importance of interprofessional collaboration, patient and family engagement and supporting health technology infrastructure. Through user-based codesign, participants identified potential opportunities where health technology could improve system efficiencies and enhance care quality for patients waiting for surgical procedures. The codesign approach embedded users in the development of locally-driven, contextually oriented policies to address current perioperative service challenges, such as prolonged waiting times and care fragmentation. CONCLUSION: Health technology innovation provides opportunities to improve perioperative care and integrate clinical information. Future research will prototype priority solutions for further implementation and evaluation.

Improving Cultural Humility Among Pediatric Patients With Complex Medical Needs.

It is not possible for every physician and patient to originate from the exact same circumstances. Because of this impossibility, the dynamics between the patient, caregivers, and physician are extremely important to prevent mistrust, disputes, de-emphasizing the values of others, or miscommunication. Similar to how many diverse groups exist in society so, too, are there numerous factors for influencing how medical care is provided and received. Multiple studies demonstrate the inequalities of access and quality of health care in pediatric primary care as well as increased morbidity and mortality rates. This may be even more prevailing within racial and ethnic communities, which are often underserved populations. This article presents an evaluation of cultural humility and how the awareness of differing viewpoints, values, and norms can assist and improve the medical care of pediatric patients with chronic complex conditions. [Pediatr Ann. 2024;53(3):e88-e92.].

Racial Implicit Bias and Communication Among Physicians in a Simulated Environment.

Importance: Racial implicit bias can contribute to health disparities through its negative influence on physician communication with Black patients. Interventions for physicians to address racial implicit bias in their clinical encounters are limited by a lack of high-fidelity (realistic) simulations to provide opportunities for skill development and practice. Objective: To describe the development and initial evaluation of a high-fidelity simulation of conditions under which physicians might be influenced by implicit racial bias. Design, Setting, and Participants: This cross-sectional study, performed on an online platform from March 1 to September 30, 2022, recruited a convenience sample of physician volunteers to pilot an educational simulation. Exposures: In the simulation exercise, physicians saw a 52-year-old male standardized patient (SP) (presenting as Black or White) seeking urgent care for epigastric pain, nausea, and vomiting. The case included cognitive stressors common to clinical environments, including clinical ambiguity, stress, time constraints, and interruptions. Physicians explained their diagnosis and treatment plan to the SP, wrote an assessment and management plan, completed surveys, and took the Race Implicit Association Test (IAT) and Race Medical Cooperativeness IAT. The SPs, blinded to the purpose of the study, assessed each physician's communication using skills checklists and global rating scales. Main Outcomes and Measures: Association between physicians' IAT scores and SP race with SP ratings of communication skills. Results: In 60 physicians (23 [38.3%] Asian, 4 [6.7%] Black, 23 [38.3%] White, and 10 [16.7%] other, including Latina/o/x, Middle Eastern, and multiracial; 31 [51.7%] female, 27 [45.0%] male, and 2 [3.3%] other), the interaction of physicians' Race IAT score and SP race was significant for overall communication (mean [SD] ß = -1.29 [0.41]), all subdomains of communication (mean [SD] ß = -1.17 [0.52] to -1.43 [0.59]), and overall global ratings (mean [SD] ß = -1.09 [0.39]). Black SPs rated physicians lower on communication skills for a given pro-White Race IAT score than White SPs; White SP ratings increased as physicians' pro-White bias increased. Conclusions and Relevance: In this cross-sectional study, a high-fidelity simulation calibrated with cognitive stressors common to clinical environments elicited the expected influence of racial implicit bias on physicians' communication skills. The outlined process and preliminary results can inform the development and evaluation of interventions that seek to address racial implicit bias in clinical encounters and improve physician communication with Black patients.

Fast-tracking action on the Sustainable Development Goals by enhancing national institutional arrangements.

Six years remain to achieve the Sustainable Development Goals (SDGs). Despite some progress, institutional effectiveness for SDG achievement has not been delivered at a national level. Identification and establishment of an institutional framework to operationalise the 2030 Agenda within national plans, giving science-based coordination of SDG implementation a central role, is urgently required to accelerate progress. This paper tackles this challenge. Drawing on literature analysis, it asks: 1) What are the deficiencies in institutional national arrangements that hinder SDG implementation? 2) How can existing institutional deficiencies in SDG implementation be addressed? and 3) How can institutional changes support fast-tracking of SDG implementation processes at national level? Findings show that country-specific horizontal institutional arrangements are usually advanced. However, national visions to improve mainstreaming across decision-making at different levels to enable whole-of-government and whole-of-society approaches to SDG implementation are commonly under-developed. Deficiencies are due to poor systematic engagement of scientific and technical expertise in operational day-to-day communication, as well as in the design, validation, implementation, monitoring and reporting of domestic SDG-related multi-stakeholder actions. Vertical institutional arrangements are complex, and risk resource-consuming, uncoordinated implementation. Our analyses suggest countries may benefit from establishing a national, centralised independent scientific and technical coordinating body for SDG implementation at national level, within existing science-based institutional arrangements. Such a body would not be led by governmental processes but would provide technical support to government agencies. We argue that scientific and technical skills in data and information management and quality control are central to coordinated and evidence-informed support, and could help to accelerate national SDG implementation. Such a supporting body would also enable a more joined-up approach between stakeholders working in the areas of science and technology, government and practice, improving orchestrated science-based actions and their auditing across sectors and stakeholder communities at national and sub-national levels. It would further guide actions to reduce trade-offs within national sustainable development aspirations, and would facilitate consideration of diverse values in advancing towards a durable and just transformative future. Such efforts are vital given the rapidly closing window of time for SDG achievement.

Does financial inclusion and information communication technology affect environmental degradation in oil-producing countries?

Advances in financial inclusions have contributed to economic growth and poverty alleviation, addressing environmental implications and implementing measures to mitigate climate change. Financial inclusions force advanced countries to progress their policies in a manner that does not hinder developing countries' current and future development. Consequently, this research examined the asymmetric effects of information and communication technology (ICT), financial inclusion, consumption of primary energy, employment to population ratio, and human development index on CO2 emissions in oil-producing countries (UAE, Nigeria, Russia, Saudi Arabia, Norway, Kazakhstan, Kuwait, Iraq, USA, and Canada). The study utilizes annual panel data spanning from 1990 to 2021. In addition, this study investigates the validity of the Environmental Kuznets Curve (EKC) trend on the entire sample, taking into account the effects of energy consumption and population to investigate the impact of financial inclusion on environmental degradation. The study used quantile regression, FMOLS, and FE-OLS techniques. Preliminary outcomes revealed that the data did not follow a normal distribution, emphasizing the need to use quantile regression (QR). This technique can effectively detect outliers, data non-normality, and structural changes. The outcomes from the quantile regression analysis indicate that ICT consistently reduces CO2 emissions in all quantiles (ranging from the 1st to the 9th quantile). In the same way, financial inclusion, and employment to population ratio constrains CO2 emissions across each quantile. On the other side, primary energy consumption and Human development index were found to increase CO2 emissions in each quantile (1st to 9th). The findings of this research have implications for both the academic and policy domains. By unraveling the intricate interplay between financial inclusion, ICT, and environmental degradation in oil-producing nations, the study contributes to a nuanced understanding of sustainable development challenges. Ultimately, the research aims to guide the formulation of targeted policies that leverage financial inclusion and technology to foster environmentally responsible economic growth in oil-dependent economies.

Talking in primary care (TIP): protocol for a cluster-randomised controlled trial in UK primary care to assess clinical and cost-effectiveness of communication skills e-learning for practitioners on patients' musculoskeletal pain and enablement.

INTRODUCTION: Effective communication can help optimise healthcare interactions and patient outcomes. However, few interventions have been tested clinically, subjected to cost-effectiveness analysis or are sufficiently brief and well-described for implementation in primary care. This paper presents the protocol for determining the effectiveness and cost-effectiveness of a rigorously developed brief eLearning tool, EMPathicO, among patients with and without musculoskeletal pain. METHODS AND ANALYSIS: A cluster randomised controlled trial in general practitioner (GP) surgeries in England and Wales serving patients from diverse geographic, socioeconomic and ethnic backgrounds. GP surgeries are randomised (1:1) to receive EMPathicO e-learning immediately, or at trial end. Eligible practitioners (eg, GPs, physiotherapists and nurse practitioners) are involved in managing primary care patients with musculoskeletal pain. Patient recruitment is managed by practice staff and researchers. Target recruitment is 840 adults with and 840 without musculoskeletal pain consulting face-to-face, by telephone or video. Patients complete web-based questionnaires at preconsultation baseline, 1 week and 1, 3 and 6 months later. There are two patient-reported primary outcomes: pain intensity and patient enablement. Cost-effectiveness is considered from the National Health Service and societal perspectives. Secondary and process measures include practitioner patterns of use of EMPathicO, practitioner-reported self-efficacy and intentions, patient-reported symptom severity, quality of life, satisfaction, perceptions of practitioner empathy and optimism, treatment expectancies, anxiety, depression and continuity of care. Purposive subsamples of patients, practitioners and practice staff take part in up to two qualitative, semistructured interviews. ETHICS APPROVAL AND DISSEMINATION: Approved by the South Central Hampshire B Research Ethics Committee on 1 July 2022 and the Health Research Authority and Health and Care Research Wales on 6 July 2022 (REC reference 22/SC/0145; IRAS project ID 312208). Results will be disseminated via peer-reviewed academic publications, conference presentations and patient and practitioner outlets. If successful, EMPathicO could quickly be made available at a low cost to primary care practices across the country. TRIAL REGISTRATION NUMBER: ISRCTN18010240.

A comparison of human and GPT-4 use of probabilistic phrases in a coordination game.

English speakers use probabilistic phrases such as likely to communicate information about the probability or likelihood of events. Communication is successful to the extent that the listener grasps what the speaker means to convey and, if communication is successful, individuals can potentially coordinate their actions based on shared knowledge about uncertainty. We first assessed human ability to estimate the probability and the ambiguity (imprecision) of twenty-three probabilistic phrases in a coordination game in two different contexts, investment advice and medical advice. We then had GPT-4 (OpenAI), a Large Language Model, complete the same tasks as the human participants. We found that GPT-4's estimates of probability both in the Investment and Medical Contexts were as close or closer to that of the human participants as the human participants' estimates were to one another. However, further analyses of residuals disclosed small but significant differences between human and GPT-4 performance. Human probability estimates were compressed relative to those of GPT-4. Estimates of probability for both the human participants and GPT-4 were little affected by context. We propose that evaluation methods based on coordination games provide a systematic way to assess what GPT-4 and similar programs can and cannot do.

Field based research in the era of the pandemic in resource limited settings: challenges and lessons for the future.

The coronavirus pandemic that began in December 2019, has had an unprecedented impact on the global economy, health systems and infrastructure, in addition to being responsible for significant mortality and morbidity worldwide. The "new normal" has brought along, unforeseen challenges for the scientific community, owing to obstructions in conducting field-based research in lieu of minimizing exposure through in-person contact. This has had greater ramifications for the LMICs, adding to the already existing concerns. As a response to COVID-19 related movement restrictions, public health researchers across countries had to switch to remote data collections methods. However, impediments like lack of awareness and skepticism among participants, dependence on paper-based prescriptions, dearth of digitized patient records, gaps in connectivity, reliance on smart phones, concerns with participant privacy at home and greater loss to follow-up act as hurdles to carrying out a research study virtually, especially in resource-limited settings. Promoting health literacy through science communication, ensuring digitization of health records in hospitals, and employing measures to encourage research participation among the general public are some steps to tackle barriers to remote research in the long term. COVID-19 may not be a health emergency anymore, but we are not immune to future pandemics. A more holistic approach to research by turning obstacles into opportunities will not just ensure a more comprehensive public health response in the coming time, but also bolster the existing infrastructure for a stronger healthcare system for countries.