The Opioid Epidemic and Faith-Based Responses in Southern Appalachia, USA: An Exploration of Factors for Successful Cross-Sector Collaboration.

This study aimed to identify factors for successful cross-sector collaboration with faith-based responses to the opioid epidemic in southern Appalachia. In-depth interviews were conducted with representatives from organizations responding to the opioid epidemic (N = 25) and persons who have experienced opioid dependency (N = 11). Stakeholders perceived that collaboration is hindered by stigma, poor communication, and conflicting medical and spiritual approaches to opioid dependency. Collaborations are facilitated by cultivating compassion and trust, sharing information along relational lines, and discerning shared commitments while respecting different approaches. The study concludes with theoretical and practical implications for both religious leaders and potential cross-sector collaborators.

The Power of Proximity: Toward an Ethic of Accompaniment in Surgical Care.

Although the field of surgical ethics focuses primarily on informed consent, surgical decision-making, and research ethics, some surgeons have started to consider ethical questions regarding justice and solidarity with poor and minoritized populations. To date, those calling for social justice in surgical care have emphasized increased diversity within the ranks of the surgical profession. This article, in contrast, foregrounds the agency of those most affected by injustice by bringing to bear an ethic of accompaniment. The ethic of accompaniment is born from a theological tradition that has motivated work to improve health outcomes in those at the margins through its emphasis on listening, solidarity against systemic drivers of disease, and proximity to individuals and communities. Through a review of surgical ethics and exploration of a central patient case, we argue for applying an ethic of accompaniment to the care of surgical patients and their communities.

The NERSH Questionnaire and Pool of Data from 12 Countries: Development and Description.

Modern healthcare research has only in recent years investigated the impact of health care workers' religious and other values on medical practice, interaction with patients, and ethically complex decision making. So far, only limited international data exist on the way such values vary across different countries. We therefore established the NERSH International Collaboration on Values in Medicine with datasets on physician religious characteristics and values based on the same questionnaire. The present article provides (a) an overview of the development of the original and optimized questionnaire, (b) an overview of the content of the NERSH data pool at this stage and (c) a brief review of insights gained from articles published with the questionnaire. The pool at this stage consists of data from 17 studies from research units in 12 different countries representing six continents with responses from more than 6000 health professionals. The joint data pool suggests that there are large differences in religious and other moral values across nations and cultures, and that these values contribute to the observed differences in health professionals' clinical practices-across nations and cultures!

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.

Conscience and the Way of Medicine.

Disputes about conscientious refusals reflect, at root, two rival accounts of what medicine is for and what physicians reasonably profess. On what we call the "provider of services model," a practitioner of medicine is professionally obligated to provide interventions that patients request so long as the interventions are legal, feasible, and are consistent with well-being as the patient perceives it. On what we call the "Way of Medicine," by contrast, a practitioner of medicine is professionally obligated to seek the patient's health, objectively construed, and to refuse requests for interventions that contradict that profession. These two accounts coexist amicably so long as what patients want is for their practitioners to use their best judgment to pursue the patient's health. But conscientious refusals expose the fact that the two accounts are ultimately irreconcilable. As such, the medical profession faces a choice: either suppress conscientious refusals, and so reify the provider of services model and demoralize medicine, or recover the Way of Medicine, and so allow physicians to refuse requests for any intervention that is not unequivocally required by the physician's profession to preserve and restore the patient's health.

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.

Intensive Care Clinicians' Views on the Role of Chaplains.

There is evidence that addressing the religious and spiritual needs of patients has positive effects on patient satisfaction and health care utilization. However, in the intensive care unit (ICU), chaplains are often consulted only at the very end of life, thereby leaving patients' spiritual needs unmet. This study looked at the views of 219 ICU clinicians on the role of chaplains. We found that all clinicians find chaplains helpful when a patient is dying or when the chaplain brings up religious or spiritual topics. Physicians find chaplains less helpful in other clinical scenarios such as challenging family meetings or when patients are recovering. Nurses are more likely to consult chaplains for a difficult family meeting or when patients are recovering from critical illness. Communication between clinicians and chaplains, both directly and indirectly through electronic health record notes, remains infrequent, highlighting the need for interventions aimed at improving multidisciplinary spiritual care.

Addressing religion and spirituality in the intensive care unit: A survey of clinicians.

OBJECTIVE: Studies have shown that when religious and spiritual concerns are addressed by the medical team, patients are more satisfied with their care and have lower healthcare costs. However, little is known about how intensive care unit (ICU) clinicians address these concerns. The objective of this study was to determine how ICU clinicians address the religious and spiritual needs of patients and families. METHOD: We performed a cross-sectional survey study of ICU physicians, nurses, and advance practice providers (APPs) to understand their attitudes and beliefs about addressing the religious and spiritual needs of ICU patients and families. Each question was designed on a 4- to 5-point Likert scale. A total of 219 surveys were collected over a 4-month period. RESULT: A majority of clinicians agreed that it is their responsibility to address the religious/spiritual needs of patients. A total of 79% of attendings, 74% of fellows, 89% of nurses, and 83% of APPs agreed with this statement. ICU clinicians also feel comfortable talking to patients about their religious/spiritual concerns. In practice, few clinicians frequently address religious/spiritual concerns. Only 14% of attendings, 3% of fellows, 26% of nurses, and 17% of APPs say they frequently ask patients about their religious/spiritual needs. SIGNIFICANCE OF RESULTS: This study shows that ICU clinicians see it as their role to address the religious and spiritual needs of their patients, and report feeling comfortable talking about these issues. Despite this, a minority of clinicians regularly address religious and spiritual needs in clinical practice. This highlights a potential deficit in comprehensive critical care as outlined by many national guidelines.

"Just do your job": technology, bureaucracy, and the eclipse of conscience in contemporary medicine.

Market metaphors have come to dominate discourse on medical practice. In this essay, we revisit Peter Berger and colleagues' analysis of modernization in their book The Homeless Mind and place that analysis in conversation with Max Weber's 1917 lecture "Science as a Vocation" to argue that the rise of market metaphors betokens the carry-over to medical practice of various features from the institutions of technological production and bureaucratic administration. We refer to this carry-over as the product presumption. The product presumption foregrounds accidental features of medicine while hiding its essential features. It thereby confounds the public understanding of medicine and impedes the professional achievement of the excellences most central to medical practice. In demonstrating this pattern, we focus on a recent article, "Physicians, Not Conscripts-Conscientious Objection in Health Care," in which Ronit Stahl and Ezekiel Emanuel decry conscientious refusals by medical practitioners. We demonstrate that Stahl and Emanuel's argument depends on the product presumption, ignoring and undermining central features of good medicine. We conclude by encouraging conscientious resistance to the product presumption and the language it engenders.

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.

Palliative sedation: clinical context and ethical questions.

Practitioners of palliative medicine frequently encounter patients suffering distress caused by uncontrolled pain or other symptoms. To relieve such distress, palliative medicine clinicians often use measures that result in sedation of the patient. Often such sedation is experienced as a loss by patients and their family members, but sometimes such sedation is sought as the desired outcome. Peace is wanted. Comfort is needed. Sedation appears to bring both. Yet to be sedated is to be cut off existentially from human experience, to be made incapable of engaging self-consciously in any human action. To that extent, it seems that to lose consciousness is to lose something of real value. In this paper, I describe how sedation and the question of intentionally bringing about sedation arise in the care of patients with advanced illness, and I propose heuristics to guide physicians, including Christian physicians, who seek to relieve suffering without contradicting their profession to heal.

What Should Physicians and Chaplains Do When a Patient Believes God Wants Him to Suffer?

When physicians encounter a patient who gives religious reasons for wanting to suffer, physicians should maintain their commitment to the patient's health while making room for religiously informed understandings of suffering and respecting the patient's authority to refuse medically indicated interventions. Respecting the patient can include challenging the patient's reasoning, and physicians can decline to participate in interventions that they believe contradict their professional commitments. Chaplains likewise should both support and possibly respectfully challenge a patient in instances that involve desire to suffer for religious reasons, and physicians should draw on chaplains' expertise in these situations to attend to the patient's spiritual concerns. Finally, conversations involving spiritual and existential suffering might include members of the patient's religious community when the patient is open to this option.

Role Models' Influence on Specialty Choice for Residency Training: A National Longitudinal Study.

BACKGROUND: Role models in medical school may influence students' residency specialty choice. OBJECTIVE: We examined whether medical students who reported clinical exposure to a role model during medical school would have an increased likelihood of selecting the role model's specialty for their residencies. METHODS: We conducted a 5-year prospective, national longitudinal study (2011-2016) of medical students from 24 US allopathic medical schools, starting from the middle of their third year. The primary outcome measure was type of residency specialty choice 4 years after graduation. Main predictors were the clinical specialty of a student's most admired physician and the relative importance of 7 potentially influential factors for specialty choice in the fourth year of medical school. RESULTS: From 919 eligible participants, 564 (61%) responded to the first survey; 474 of the respondents (84%) completed the follow-up survey. We excluded 29 participants who were not in their fourth year by the time of the follow-up survey. Of the follow-up respondents, 427 (96%) had specialty data 4 years after graduation. In our multivariate models, exposure to an admired generalist physician prior to medical school (odds ratio [OR] = 2.21, 95% confidence interval [CI] 1.03-4.73) and during medical school (OR = 2.62, 95% CI 1.69-4.05) had the strongest odds with respect to training in a generalist residency 4 years after graduation. Role model exposure also predicted specialty choice among those training in surgical and radiology, ophthalmology, anesthesiology, and dermatology (ROAD) specialties. CONCLUSIONS: Personal exposure to role models in medical school is an important predictor of residency training in that role model's specialty.