The evolution of uncertainty in second opinions about prostate cancer treatment.

BACKGROUND: People who have cancer increasingly seek second opinions. Yet, we know little about what motivates patients to seek them and how beneficial they are. Uncertainty-experienced by patients or communicated by physician and patient-may be crucial throughout the second opinion process. OBJECTIVE: This study sought to investigate (1) how uncertainty influences men with prostate cancer to seek second opinions and (2) how second opinions may affect these patients' sense of uncertainty and subsequent experiences with their care. METHODS: A qualitative study using semi-structured interviews was performed. Men with localized or advanced prostate cancer (n=23) were interviewed by telephone about their motivations and experiences with seeking second opinions and the uncertainties they experienced. Analysis was performed using the constant comparative method. RESULTS: Patients sought second opinions because they were uncertain about receiving too little or biased information, experienced insufficient support in coming to a treatment decision, or because physicians expressed different levels of uncertainty than they did ("unshared uncertainty"). Uncertainty was reduced by the second opinion process for most patients, whereas for others, it increased or was sustained. This evolution depended on the way uncertainty was addressed during the second opinion consultation. CONCLUSIONS: Second opinions may be a useful tool for some but not all patients. They should be used judiciously and not be viewed as a solution for current limitations to health-care organization. An important yet challenging task for physicians is to focus less on information per se and more on how to assist patients manage irreducible uncertainty.

Physicians' perceptions of the value of prognostic models: the benefits and risks of prognostic confidence.

BACKGROUND: The communication of prognosis in end-of-life (EOL) care is a challenging task that is limited by prognostic uncertainty and physicians' lack of confidence in their prognostic estimates. Clinical prediction models (CPMs) are increasingly common evidence-based tools that may mitigate these problems and facilitate the communication and use of prognostic information in EOL care; however, little is known about physicians' perceptions of the value of these tools. OBJECTIVE: To explore physicians' perceptions of the value of CPMs in EOL care. DESIGN: Qualitative study using semi-structured individual interviews which were analysed using a constant comparative method. SETTING AND PARTICIPANTS: Convenience sample of 17 attending physicians representing five different medical specialties at a single large tertiary care medical centre. RESULTS: Physicians perceived CPMs as having three main benefits in EOL care: (i) enhancing their prognostic confidence; (ii) increasing their prognostic authority; and (iii) enabling patient persuasion in circumstances of low prognostic and therapeutic uncertainty. However, physicians also perceived CPMs as having potential risks, which include producing emotional distress in patients and promoting prognostic overconfidence in EOL care. DISCUSSION AND CONCLUSIONS: Physicians perceive CPMs as a potentially valuable means of increasing their prognostic confidence, communication and explicit use of prognostic information in EOL care. However, physicians' perceptions of CPMs also indicate a need to establish broad and consistent implementation processes to engage patients in shared decision making in EOL care, to effectively communicate uncertainty in prognostic information and to help both patients and physicians manage uncertainty in EOL care decisions.

Understanding the Effect of Bias on the Experience of Women Surgeons: A Qualitative Study.

BACKGROUND: Exploring the lived experiences of surgeons is necessary to understand the changing culture of surgery and the unique challenges of being a woman in surgery. Surgeons have significant experiences and observations best discovered through qualitative study. The purpose of this study is to identify the similarities and differences between the experiences of men and women surgeons after initiation of mandatory microaggression training. STUDY DESIGN: Qualitative semi-structured interviews with female and male surgeons and residents were done following a year-long series of training sessions on the detrimental effects of microaggression. Participants were selected using a convenience sampling method. MAXQDA coding software (Verbi) was used to evaluate interview transcripts with thematic analysis. RESULTS: Nineteen surgeons and surgical residents were interviewed. The participants were of equal gender identification, with the majority being attending surgeons. Multiple themes highlighted similarities and differences between male and female participants. Differences were noted in identification of a sensitive personality, family planning considerations, and experiences of bias. Similarities were related to the personality traits required to be successful in surgery, the sacrifice inherent to a surgical career, and the war rhetoric used to describe the comradery of residency. CONCLUSION: The challenges and rewards of surgery are similar for women and men, but women have additional stressors, including gender-based bias, microaggression, and family planning. These stressors take up energy, decreasing the mental space available for additional roles and affecting the work environment. Microaggression education can incite necessary discussions of bias and provide women with an opportunity to reflect on and share their experiences.

Tolerance of uncertainty: Conceptual analysis, integrative model, and implications for healthcare.

RATIONALE: Uncertainty tolerance (UT) is an important, well-studied phenomenon in health care and many other important domains of life, yet its conceptualization and measurement by researchers in various disciplines have varied substantially and its essential nature remains unclear. OBJECTIVE: The objectives of this study were to: 1) analyze the meaning and logical coherence of UT as conceptualized by developers of UT measures, and 2) develop an integrative conceptual model to guide future empirical research regarding the nature, causes, and effects of UT. METHODS: A narrative review and conceptual analysis of 18 existing measures of Uncertainty and Ambiguity Tolerance was conducted, focusing on how measure developers in various fields have defined both the "uncertainty" and "tolerance" components of UT-both explicitly through their writings and implicitly through the items constituting their measures. RESULTS: Both explicit and implicit conceptual definitions of uncertainty and tolerance vary substantially and are often poorly and inconsistently specified. A logically coherent, unified understanding or theoretical model of UT is lacking. To address these gaps, we propose a new integrative definition and multidimensional conceptual model that construes UT as the set of negative and positive psychological responses-cognitive, emotional, and behavioral-provoked by the conscious awareness of ignorance about particular aspects of the world. This model synthesizes insights from various disciplines and provides an organizing framework for future research. We discuss how this model can facilitate further empirical and theoretical research to better measure and understand the nature, determinants, and outcomes of UT in health care and other domains of life. CONCLUSION: Uncertainty tolerance is an important and complex phenomenon requiring more precise and consistent definition. An integrative definition and conceptual model, intended as a tentative and flexible point of departure for future research, adds needed breadth, specificity, and precision to efforts to conceptualize and measure UT.

Implementation of a cancer prevention program for working class, multiethnic populations.

BACKGROUND: This paper describes the implementation of the Healthy Directions-Health Centers intervention and examines the characteristics of participants associated with completion of intervention activities. Healthy Directions-Health Centers was designed to address social contextual factors relevant to cancer prevention interventions for working class, multi-ethnic populations. METHODS: Ten community health centers were paired and randomly assigned to intervention or control. Patients who resided in low income, multi-ethnic neighborhoods were approached for participation. This study targeted fruit and vegetable consumption, red meat consumption, multi-vitamin intake, and physical activity. The intervention components consisted of: (1) a brief study endorsement from a clinician; (2) an in-person counseling session with a health advisor; (3) four follow-up telephone counseling sessions; and (4) multiple distributions of tailored materials. RESULTS: Among the 1,088 intervention group participants, 978 participants (90%) completed at least five out of six intervention activities. Participants who missed clinical appointments were less likely to complete all components of the intervention. Participant characteristics that predicted receipt of clinician endorsement differed from characteristics that predicted completion of health advisor activities. Low acculturation did not present a barrier to delivery of the intervention once the participant was enrolled. CONCLUSIONS: Collection and reporting on process evaluation results can help explain variations in program implementation.