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1.
Am J Hosp Palliat Care ; : 1049909120923595, 2020 May 08.
Artigo em Inglês | MEDLINE | ID: mdl-32383388

RESUMO

BACKGROUND: Prior to national spread, the Department of Veterans Affairs implemented a pilot of the life-sustaining treatment decisions initiative (LSTDI) to promote proactive goals of care conversations (GoCC) with seriously ill patients, including policy and practice standards, an electronic documentation template and order set, and implementation support. AIM: To describe a 2-year pilot of the LSTDI at 4 demonstration sites. DESIGN: Prospective observational study. SETTING/PARTICIPANTS: A total of 6664 patients who had at least one GoCC. RESULTS: Descriptive statistics characterized patient demographics, goals of care, LST decisions, and risk of hospitalization or mortality among patients with at least one GoCC. Participants were on average 71.4 years old, 93.2% male, 87.1% white, and 64.7% urban; 27.3% died by the end of the pilot period. Fifteen percent lacked decision-making capacity (DMC). Nonmutually exclusive goals included to be cured (7.6%), to prolong life (34%), to improve/maintain quality of life (61.5%), to be comfortable (53%), to obtain support for family/caregiver (8.4%), to achieve life goals (2.1%), and other (10.5%). Many GoCCs resulted in a do not resuscitate (DNR) order (58.8%). Patients without DMC were more likely to have comfort-oriented goals (77.3% vs 48.8%) and a DNR (84% vs 52.6%). Chart abstraction supported content validity of GoCC documentation. CONCLUSION: The pilot demonstrated that standardizing practices for eliciting and documenting GoCCs resulted in customized documentation of goals of care and LST decisions of a large number of seriously ill patients and established the feasibility of spreading standardized practices throughout a large integrated health care system.

2.
Ann Intern Med ; 2020 Apr 24.
Artigo em Inglês | MEDLINE | ID: mdl-32330224

RESUMO

Background: The coronavirus disease 2019 pandemic has or threatens to overwhelm health care systems. Many institutions are developing ventilator triage policies. Objective: To characterize the development of ventilator triage policies and compare policy content. Design: Survey and mixed-methods content analysis. Setting: North American hospitals associated with members of the Association of Bioethics Program Directors. Participants: Program directors. Measurements: Characteristics of institutions and policies, including triage criteria and triage committee membership. Results: Sixty-seven program directors responded (response rate, 91.8%); 36 (53.7%) hospitals did not yet have a policy, and 7 (10.4%) hospitals' policies could not be shared. The 29 institutions providing policies were relatively evenly distributed among the 4 U.S. geographic regions (range, 5 to 9 policies per region). Among the 26 unique policies analyzed, 3 (11.3%) were produced by state health departments. The most frequently cited triage criteria were benefit (25 policies [96.2%]), need (14 [53.8%]), age (13 [50.0%]), conservation of resources (10 [38.5%]), and lottery (9 [34.6%]). Twenty-one (80.8%) policies use scoring systems, and 20 of these (95.2%) use a version of the Sequential Organ Failure Assessment score. Among the policies that specify the triage team's composition (23 [88.5%]), all require or recommend a physician member, 20 (87.0%) a nurse, 16 (69.6%) an ethicist, 8 (34.8%) a chaplain, and 8 (34.8%) a respiratory therapist. Thirteen (50.0% of all policies) require or recommend those making triage decisions not be involved in direct patient care, but only 2 (7.7%) require that their decisions be blinded to ethically irrelevant considerations. Limitation: The results may not be generalizable to institutions without academic bioethics programs. Conclusion: Over one half of respondents did not have ventilator triage policies. Policies have substantial heterogeneity, and many omit guidance on fair implementation.

4.
Appl Clin Inform ; 11(1): 153-159, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-32102107

RESUMO

BACKGROUND: Early electronic identification of patients at the highest risk for heart failure (HF) readmission presents a challenge. Data needed to identify HF patients are in a variety of areas in the electronic medical record (EMR) and in different formats. OBJECTIVE: The purpose of this paper is to describe the development and data validation of a HF dashboard that monitors the overall metrics of outcomes and treatments of the veteran patient population with HF and enhancing the use of guideline-directed pharmacologic therapies. METHODS: We constructed a dashboard that included several data points: care assessment need score; ejection fraction (EF); medication concordance; laboratory tests; history of HF; and specified comorbidities based on International Classification of Disease (ICD), ninth and tenth codes. Data validation testing with user test scripts was utilized to ensure output accuracy of the dashboard. Nine providers and key senior management participated in data validation. RESULTS: A total of 43 medical records were reviewed and 66 HF dashboard data discrepancies were identified during development. Discrepancies identified included: generation of multiple EF values on a few patients, missing or incorrect ICD codes, laboratory omission, incorrect medication issue dates, patients incorrectly noted as nonconcordant for medications, and incorrect dates of last cardiology appointments. Continuous integration and builds identified defects-an important process of the verification and validation of biomedical software. Data validation and technical limitations are some challenges that were encountered during dashboard development. Evaluations by testers and their focused feedback contributed to the lessons learned from the challenges. CONCLUSION: Continuous refinement with input from multiple levels of stakeholders is crucial to development of clinically useful dashboards. Extraction of all relevant information from EMRs, including the use of natural language processing, is crucial to development of dashboards that will help improve care of individual patients and populations.

5.
AJOB Empir Bioeth ; : 1-6, 2019 Oct 30.
Artigo em Inglês | MEDLINE | ID: mdl-31663810

RESUMO

Introduction: Institutions have developed professionalism policies to help guide physician social media behavior in light of professionalism lapses that have resulted in serious consequences. Prior research has gathered perspectives on online professionalism; however, the public's views remain poorly understood. Importantly, the impact of physician social media behavior on patient trust is unknown. Methods: To determine whether patients' trust might change based on their physicians' social media behavior, we conducted a cross-sectional survey across three U.S. cities (n = 491). The survey assessed patient trust using hypothetical scenarios. Results: Most respondents reported they would have less trust if their physician posted racist comments online, wrote a disrespectful patient narrative, appeared intoxicated in a photograph, or wrote profanity. Respondent age and education impacted change in trust. Conclusions: We conclude that physicians' social media behavior may affect patient trust. Better understanding of how physicians' online presence impacts their relationships with patients can help guide policy and inform educational efforts.

6.
J Gen Intern Med ; 34(7): 1334-1336, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30963441

RESUMO

Women physicians are paid less than their male peers across medical specialties and geographies. While the medical literature to date has focused on documenting the existence of a wage gap, less attention has been paid to fixing this gap. We focus on interventions around auditing, salary transparency, family leave, and childcare that can be implemented to advance gender wage parity.

7.
Am J Med ; 132(9): 1009-1010, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-30871924
8.
J Med Internet Res ; 21(1): e11507, 2019 01 17.
Artigo em Inglês | MEDLINE | ID: mdl-30664452

RESUMO

Data sharing between technology companies and academic health researchers has multiple health care, scientific, social, and business benefits. Many companies remain wary about such sharing because of unaddressed concerns about ethics, data security, logistics, and public relations. Without guidance on these issues, few companies are willing to take on the potential work and risks involved in noncommercial data sharing, and the scientific and societal potential of their data goes unrealized. In this paper, we describe the 18-month long pilot of a data-sharing program led by Crisis Text Line (CTL), a not-for-profit technology company that provides a free 24/7 text line for people in crisis. The primary goal of the data-sharing pilot was to design, develop, and implement a rigorous framework of principles and protocols for the safe and ethical sharing of user data. CTL used a stakeholder-based policy process to develop a feasible and ethical data-sharing program. The process comprised forming a data ethics committee; identifying policy challenges and solutions; announcing the program and generating interest; and revising the policy and launching the program. Once the pilot was complete, CTL examined how well the program ran and compared it with other potential program models before putting in place the program that was most suitable for its organizational needs. By drawing on CTL's experiences, we have created a 3-step set of guidelines for other organizations that wish to develop their own data-sharing program with academic researchers. The guidelines explain how to (1) determine the value and suitability of the data and organization for creating a data-sharing program; (2) decide on an appropriate data sharing and collaboration model; and (3) develop protocols and technical solutions for safe and ethical data sharing and the best organizational structure for implementing the program. An internal evaluation determined that the pilot satisfied CTL's goals of sharing scientific data and protecting client confidentiality. The policy development process also yielded key principles and protocols regarding the ethical challenges involved in data sharing that can be applied by other organizations. Finally, CTL's internal review of the pilot program developed a number of alternative models for sharing data that will suit a range of organizations with different priorities and capabilities. In implementing and studying this pilot program, CTL aimed both to optimize its own future data-sharing programs and to inform similar decisions made by others. Open data programs are both important and feasible to establish. With careful planning and appropriate resources, data sharing between big data companies and academic researchers can advance their shared mission to benefit society and improve lives.


Assuntos
Segurança Computacional/normas , Intervenção na Crise/métodos , Coleta de Dados/normas , Disseminação de Informação/métodos , Privacidade/psicologia , Humanos , Projetos Piloto
12.
Ann Intern Med ; 168(9): 651-657, 2018 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-29582076

RESUMO

This American College of Physicians position paper aims to inform ethical decision making surrounding participation in short-term global health clinical care experiences. Although the positions are primarily intended for practicing physicians, they may apply to other health care professionals and should inform how institutions, organizations, and others structure short-term global health experiences. The primary goal of short-term global health clinical care experiences is to improve the health and well-being of the individuals and communities where they occur. In addition, potential benefits for participants in global health include increased awareness of global health issues, new medical knowledge, enhanced physical diagnosis skills when practicing in low-technology settings, improved language skills, enhanced cultural sensitivity, a greater capacity for clinical problem solving, and an improved sense of self-satisfaction or professional satisfaction. However, these activities involve several ethical challenges. Addressing these challenges is critical to protecting patient welfare in all geographic locales, promoting fair and equitable care globally, and maintaining trust in the profession. This paper describes 5 core positions that focus on ethics and the clinical care context and provides case scenarios to illustrate them.


Assuntos
Tomada de Decisão Clínica/ética , Assistência à Saúde/ética , Saúde Global/ética , Competência Clínica , Assistência à Saúde Culturalmente Competente/ética , Ética Médica , Humanos , Relações Interprofissionais , Satisfação no Emprego , Profissionalismo
13.
Ann Intern Med ; 168(7): 506-508, 2018 04 03.
Artigo em Inglês | MEDLINE | ID: mdl-29482210

RESUMO

Much of what is formally taught in medicine is about the knowledge, skills, and behaviors required of a physician, including how to express compassion and respect for patients at the bedside. What is learned, however, includes not only admirable qualities but also behaviors and qualities that are inconsistent with ethics and professionalism. Positive role models may reinforce the character and values the profession seeks to cultivate; negative ones directly contradict classroom lessons and expectations of patients, society, and medical educators. These positive and negative lessons, which are embedded in organizational structure and culture, are the hidden curricula conveyed in medical schools, residency programs, hospitals, and clinics. This position paper from the American College of Physicians focuses on ethics, professionalism, and the hidden curriculum. It provides strategies for revealing what is hidden to foster the development of reflective and resilient lifelong learners who embody professionalism and clinicians who are, and are perceived as, positive role models. Making the hidden visible and the implicit explicit helps to create a culture reflecting medicine's core values.


Assuntos
Currículo , Educação Médica , Ética Médica/educação , Profissionalismo/educação , Humanos , Cultura Organizacional , Inovação Organizacional , Competência Profissional , Faculdades de Medicina/organização & administração , Sociedades Médicas , Estados Unidos
14.
Genet Med ; 20(5): 545-553, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-28858330

RESUMO

PurposeThe Clinical Sequencing Exploratory Research (CSER) Consortium encompasses nine National Institutes of Health-funded U-award projects investigating translation of genomic sequencing into clinical care. Previous literature has distinguished norms and rules governing research versus clinical care. This is the first study to explore how genomics investigators describe and navigate the research-clinical interface.MethodsA CSER working group developed a 22-item survey. All nine U-award projects participated. Descriptive data were tabulated and qualitative analysis of text responses identified themes and characterizations of the research-clinical interface.ResultsSurvey responses described how studies approached the research-clinical interface, including in consent practices, recording results, and using a research versus clinical laboratory. Responses revealed four characterizations of the interface: clear separation between research and clinical care, interdigitation of the two with steps to maintain separation, a dynamic interface, and merging of the two. All survey respondents utilized at least two different characterizations. Although research has traditionally been differentiated from clinical care, respondents pointed to factors blurring the distinction and strategies to differentiate the domains.ConclusionThese results illustrate the difficulty in applying the traditional bifurcation of research versus clinical care to translational models of clinical research, including in genomics. Our results suggest new directions for ethics and oversight.


Assuntos
Pesquisa Biomédica , Genômica , Pesquisa Médica Translacional , Pesquisa Biomédica/métodos , Pesquisa Biomédica/organização & administração , Revelação , Registros Eletrônicos de Saúde , Genômica/métodos , Genômica/organização & administração , Pessoal de Saúde , Humanos , Consentimento Livre e Esclarecido , National Institutes of Health (U.S.) , Inquéritos e Questionários , Pesquisa Médica Translacional/métodos , Pesquisa Médica Translacional/organização & administração , Estados Unidos
15.
AMA J Ethics ; 19(12): 1186-1192, 2017 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-29278344

RESUMO

As climate change progresses, we humans might have to inhabit a world for which we are increasingly maladapted. If we were able to identify genes that directly influence our ability to thrive in a changing climate, would it be ethically justifiable to edit the human genome to enhance our ability to adapt to this new environment? Should we use gene editing not only to prevent significant disease but also to enhance our ability to function in the world? Here I suggest a "4-S framework" for analyzing the justifiability of gene editing that includes these considerations: (1) safety, (2) significance of harm to be averted, (3) succeeding generations, and (4) social consequences.


Assuntos
Adaptação Biológica , Mudança Climática , Edição de Genes/ética , Melhoramento Genético/ética , Genoma Humano , Meio Ambiente , Características da Família , Humanos , Princípios Morais , Saúde Pública , Medição de Risco , Segurança , Responsabilidade Social
16.
J Gen Intern Med ; 32(11): 1186-1192, 2017 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-28717899

RESUMO

BACKGROUND: Financial ties between physicians and the pharmaceutical and medical device industry are common, but little is known about how patient trust is affected by these ties. OBJECTIVE: The purpose of this study was to evaluate how viewing online public disclosure of industry payments affects patients' trust ratings for physicians, the medical profession, and the pharmaceutical and medical device industry. DESIGN: This was a randomized experimental evaluation. PARTICIPANTS: There were 278 English-speaking participants over age 18 who had seen a healthcare provider in the previous 12 months who took part in the study. INTERVENTIONS: Participants searched for physicians on an online disclosure database, viewed payments from industry to the physicians, and assigned trust ratings. Participants were randomized to view physicians who received no payment ($0), low payment ($250-300), or high payment (>$13,000) from industry, or to a control arm in which they did not view the disclosure website. They also were asked to search for and then rate trust in their own physician. MAIN MEASURES: Primary outcomes were trust in individual physician, medical profession, and industry. These scales measure trust as a composite of honesty, fidelity, competence, and global trust. KEY RESULTS: Compared to physicians who received no payments, physicians who received payments over $13,000 received lower ratings for honesty [mean (SD): 3.36 (0.86) vs. 2.75 (0.95), p < 0.001] and fidelity [3.19 (0.65) vs. 2.89 (0.68), p = 0.01]. Among the 7.9% of participants who found their own physician on the website, ratings for honesty and fidelity decreased as the industry payment to the physician increased (honesty: Spearman's ρ = -0.52, p = 0.02; fidelity: Spearman's ρ = -0.55, p = 0.01). Viewing the disclosure website did not affect trust ratings for the medical profession or industry. CONCLUSIONS: Disclosure of industry payments to physicians affected perceptions of individual physician honesty and fidelity, but not perceptions of competence. Disclosure did not affect trust ratings for the medical profession or the pharmaceutical and medical device industry. ClinicalTrials.gov identifier: NCT02179632 ( https://clinicaltrials.gov/ct2/show/NCT02179632 ).


Assuntos
Revelação/ética , Indústria Farmacêutica/ética , Relações Médico-Paciente/ética , Médicos/ética , Confiança , Adulto , Conflito de Interesses , Revelação/normas , Indústria Farmacêutica/normas , Feminino , Humanos , Internet/ética , Internet/normas , Masculino , Pessoa de Meia-Idade , Médicos/normas , Projetos Piloto , Adulto Jovem
18.
Oncologist ; 22(7): 860-863, 2017 07.
Artigo em Inglês | MEDLINE | ID: mdl-28408620

RESUMO

Oncofertility is a unique, multidisciplinary field that serves to bridge the gap between available fertility resources and the special reproductive needs of cancer patients. Oncofertility is a growing field due to the increasing number of survivors, development of new oncologic therapies, extension of duration of therapies, and development and refinement of reproductive therapies. While the technologies and demand for services expand, clinicians need to be appropriately prepared for dealing with various clinical scenarios that may require ethical deliberation. Three real cases are presented in which the patient wishes to pursue reproductive assistance, but her decision is met with hesitance or uncertainty by her care team. Discussion of these clinical scenarios highlights ethical implications of oncofertility practice and serves to highlight the need for the establishment of multidisciplinary care teams and guidelines to support both clinicians and patients. IMPLICATIONS FOR PRACTICE: The growing field of oncofertility is ripe for conflict between patient autonomy and medical values due to the nature of cancer and associated threat on an individual's health and survival, as well as the personal significance of childbearing. Cases are presented and ethical implications are discussed to further explore the inherent difficulties in oncofertility practice and guide clinicians in similar situations. Developing guidelines and establishing multidisciplinary teams to facilitate oncofertility discussions and care, as well as training of clinical team members, may improve patient safety, well-being, and satisfaction within the context of fertility decision making, care, and outcomes.


Assuntos
Preservação da Fertilidade/ética , Recuperação de Oócitos/efeitos adversos , Autonomia Pessoal , Complicações Neoplásicas na Gravidez , Adulto , Neoplasias da Mama , Criopreservação/métodos , Transferência Embrionária/ética , Feminino , Preservação da Fertilidade/métodos , Humanos , Recuperação de Oócitos/ética , Recuperação de Oócitos/métodos , Oócitos/fisiologia , Gravidez , Adulto Jovem
19.
BMJ Qual Saf ; 26(11): 869-880, 2017 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-28442609

RESUMO

BACKGROUND: Open communication between healthcare professionals about care concerns, also known as 'speaking up', is essential to patient safety. OBJECTIVE: Compare interns' and residents' experiences, attitudes and factors associated with speaking up about traditional versus professionalism-related safety threats. DESIGN: Anonymous, cross-sectional survey. SETTING: Six US academic medical centres, 2013-2014. PARTICIPANTS: 1800 medical and surgical interns and residents (47% responded). MEASUREMENTS: Attitudes about, barriers and facilitators for, and self-reported experience with speaking up. Likelihood of speaking up and the potential for patient harm in two vignettes. Safety Attitude Questionnaire (SAQ) teamwork and safety scales; and Speaking Up Climate for Patient Safety (SUC-Safe) and Speaking Up Climate for Professionalism (SUC-Prof) scales. RESULTS: Respondents more commonly observed unprofessional behaviour (75%, 628/837) than traditional safety threats (49%, 410/837); p<0.001, but reported speaking up about unprofessional behaviour less commonly (46%, 287/628 vs 71%, 291/410; p<0.001). Respondents more commonly reported fear of conflict as a barrier to speaking up about unprofessional behaviour compared with traditional safety threats (58%, 482/837 vs 42%, 348/837; p<0.001). Respondents were also less likely to speak up to an attending physician in the professionalism vignette than the traditional safety vignette, even when they perceived high potential patient harm (20%, 49/251 vs 71%, 179/251; p<0.001). Positive perceptions of SAQ teamwork climate and SUC-Safe were independently associated with speaking up in the traditional safety vignette (OR 1.90, 99% CI 1.36 to 2.66 and 1.46, 1.02 to 2.09, respectively), while only a positive perception of SUC-Prof was associated with speaking up in the professionalism vignette (1.76, 1.23 to 2.50). CONCLUSIONS: Interns and residents commonly observed unprofessional behaviour yet were less likely to speak up about it compared with traditional safety threats even when they perceived high potential patient harm. Measuring SUC-Safe, and particularly SUC-Prof, may fill an existing gap in safety culture assessment.


Assuntos
Atitude do Pessoal de Saúde , Coragem , Internato e Residência , Segurança do Paciente , Má Conduta Profissional/psicologia , Centros Médicos Acadêmicos , Comunicação , Estudos Transversais , Feminino , Humanos , Masculino , Profissionalismo , Gestão da Segurança , Estados Unidos
20.
J Gen Intern Med ; 32(7): 767-774, 2017 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-28265803

RESUMO

BACKGROUND: The Physician Payments Sunshine Act, part of the Affordable Care Act, requires pharmaceutical and medical device firms to report payments they make to physicians and, through its Open Payments program, makes this information publicly available. OBJECTIVE: To establish estimates of the exposure of the American patient population to physicians who accept industry payments, to compare these population-based estimates to physician-based estimates of industry contact, and to investigate Americans' awareness of industry payments. DESIGN: Cross-sectional survey conducted in late September and early October 2014, with data linkage of respondents' physicians to Open Payments data. PARTICIPANTS: A total of 3542 adults drawn from a large, nationally representative household panel. MAIN MEASURES: Respondents' contact with physicians reported in Open Payments to have received industry payments; respondents' awareness that physicians receive payments from industry and that payment information is publicly available; respondents' knowledge of whether their own physician received industry payments. KEY RESULTS: Among the 1987 respondents who could be matched to a specific physician, 65% saw a physician who had received an industry payment during the previous 12 months. This population-based estimate of exposure to industry contact is much higher than physician-based estimates from the same period, which indicate that 41% of physicians received an industry payment. Across the six most frequently visited specialties, patient contact with physicians who had received an industry payment ranged from 60 to 85%; the percentage of physicians with industry contact in these specialties was much lower (35-56%). Only 12% of survey respondents knew that payment information was publicly available, and only 5% knew whether their own doctor had received payments. CONCLUSIONS: Patients' contact with physicians who receive industry payments is more prevalent than physician-based measures of industry contact would suggest. Very few Americans know whether their own doctor has received industry payments or are aware that payment information is publicly available.


Assuntos
Conscientização , Indústria Farmacêutica/normas , Patient Protection and Affordable Care Act/normas , Relações Médico-Paciente , Setor Público/normas , Inquéritos e Questionários , Adulto , Estudos Transversais , Indústria Farmacêutica/economia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Patient Protection and Affordable Care Act/economia , Setor Público/economia , Adulto Jovem
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