The scientific productions in Iranian biomedical ethics: A combined study of bibliometrics and social network analysis.

This study aims at increasing our understanding of the research activities of Iranian researchers and institutions in the field of biomedical ethics from 1995 to 2015. A combination of bibliometrics and social network analysis was used to examine the bibliographic data of 580 documents published on Iranian biomedical ethics in Web of Science and Scopus databases to investigate the publication trend, scientific impact, subject keywords network, and social network analysis indicators for international and cross-institutional co-authorship networks. The results showed that the publication of documents has had a consistent and increasing growth and that the citation trend has grown along with it. The analysis of thematic clusters by keyword co-occurrence network shows that Iranian biomedical ethics research has dealt with various topics and that has introduced different research directions. Researchers from 28 countries were identified in the international collaboration network. The main partners of Iranian researchers were from the US (17.8%) and the UK (9.2%). However, there is a tendency to develop and complete cooperation with researchers from different countries. The cross-institutional collaboration network comprises of 63 institutes, of which Tehran University of Medical Sciences (38%), Shahid Beheshti University of Medical Sciences (11%) and Shiraz University of Medical Sciences (7%) have the largest share in publishing documents. The superiority of the first two universities based on centralization indicators in the cross-institutional collaboration network has caused the exchange of cross-network knowledge between and via these players. The network density indicator shows that almost half of the co-authorship links within the international collaboration network and 8% of the co-authorship links within the cross-institutional collaboration network have been implemented and that these networks are not very coherent.

Cost-consciousness among Iranian internal medicine residents.

Background: Study aimed at assessing residents' cost awareness and their attitude about health care costs.Methods: Internal medicine residents at teaching hospitals of Tehran University of Medical Sciences were surveyed during August-December 2016 using a researcher-made questionnaire comprising attitude statements and cost estimation of diagnostic and treatment items.Results: Eighty-nine residents completed the survey (response rate = 56.6%). The results indicate that less than one quarter (23.69%) of cost estimates were in the range of correct answers. The mean (SD) for correct estimation of medications (out of 8 scores), lab tests (out of 20 scores), and total (out of 35 scores) were 1.25 (0.96), 4.92 (0.27), and 7.97 (0.34), respectively. An analysis of variance showed that the level of residency was positively correlated with residents' correct cost estimation (F (3, 77)=9.98, p = 0.029). There was a significant positive correlation between age of residents with the correct estimate of medication prices (p = 0.018, r = 0.261).Conclusions: The internal medicine residents of Tehran University of Medical Sciences have poor knowledge of health care costs, including medications, diagnostic tests, and hospitalization costs. The results of this study explain the necessity of developing a training program for the transfer of cost information to physicians.

Patient privacy: Awareness and attitudes of Iran University of Medical Sciences medical students.

Background: Respecting patients' privacy is an essential professional responsibility for physicians and other health team members. In this regard, this study investigates medical students' knowledge and attitude about confidentiality and disclosure of patients' information. Methods: In this cross-sectional study, 160 medical students of Iran University of Medical Sciences participated who were selected using stratified random sampling. Data were gathered using a valid and reliable self-report questionnaire. Student's knowledge and attitude toward medical confidentiality were assessed using self-administered and researcher-made questionnaires. Cronbach's alpha coefficients for knowledge and attitude levels were 79.7 and 82.2, respectively. Results: The average of medical students' responses to knowledge and attitude questions were 56.6% (9.6/ 17) and 55.3% (9.4 out of 17), respectively. On average, females had an acceptable attitude about 57.5% of the questions, whereas this was 50.9% for males. On average, females had an acceptable knowledge about 59.5% of the questions, whereas this was 50.6% for males. Therefore, female's attitudes and knowledge were more correct than their male counterparts (p<0.001). Conclusion: The low level of knowledge and attitude of medical students towards medical confidentiality indicates that revision of Iranian medical education curriculum to reinforce attention and knowledge of medical students on this issue to render appropriate care to patients is a necessity. Medical students' knowledge and attitude towards patient's confidentiality rights is not fulfilling.

From whom do physicians obtain consent for surgery?

OBJECTIVE: To evaluate the knowledge and performance of surgical residents regarding the person from whom informed consent should be taken for surgery and from whom the consent is taken in practice. MATERIALS AND METHODS: This study was done in 2013. The population of this study was all residents of urology, surgery, orthopaedic surgery and gynaecology of Tehran and Iran University of Medical Sciences. The study tool was a self-administered questionnaire, containing questions on their knowledge and performance regarding informed consent acquisition from patients with different conditions in terms of age, sex, marital status and their capacity to make treatment decisions. RESULTS: A total of 213 residents participated in the study (response rate=51.9%). The mean score of the participants' knowledge was 72.95 out of 100. There was no significant correlation between the residents' knowledge and performance. Regarding a competent married male patient, 98.2% of the residents knew that the person's consent was enough, but only 63.6% obtained informed consent only from the patient. These percentages were 69% and 19.7% for a competent married female patient, respectively. For a competent single male patient, 90.9% of the residents were aware that the patient's consent was enough, while only 40% of the residents obtained informed consent only from the patient. These percentages were 65.3% and 16% for a competent single female patient, respectively. CONCLUSION: Despite the residents' average knowledge of patient autonomy, this right is not observed for female patients, and their treatment is subject to consent acquisition from other family members.

Do ethical considerations influence any in HTA reports? A review of reports.

BACKGROUND: Dealing with ethical considerations is a major component of Health Technology Assessment (HTA) definitions. OBJECTIVES: Present study aimed to explore and describe the manner of ethical analyses in HTA reports and the effects it had on HTA-related decision making around the world. METHODS: By considering the contextual milieu of reports and searching for ethical themes and subjects in HTA full reports, a descriptive analysis of HTA reports' contents and related processes was conducted. The review focused on all English HTA reports issued in a year. All ethical aspects, criteria, approaches, and also decision- making related ethical issues were described and summarized in retrieved reports. The inclusion of ethical aspects in final decision-making criteria of HTA reports was also considered. RESULTS: Eighty-nine HTA reports issued in one year were included in this review and analyzed for ethical considerations. There was no trace of any ethical issues in 60.7% of retrieved HTA reports. Dimensions of equity in resource distribution, stakeholder engagement, social values, essence and nature of technology, and ethical issues about the method of assessment for decision making, and physician-patient relationship were raised and discussed in 38.2%, 3.4%, 3.4%, 3.4%, 34.8% and 3.4% of reports respectively. Those issues were also included in 44.1, 5.9, 2.9, 2.9, 0 and 2.9% of final reports, respectively. In overall, only in 16 cases (17.9%) of all 89 reports, ethical issues were included in HTA decision-making orientations. CONCLUSION: This review shows that ethical issues are occasionally raised and discussed in HTA reports. More importantly, the inclusion of ethical concerns as a decision criterion in HTAs is few and insufficient.

Design of formative assessment model for professional behavior using stages of change theory.

Background: Professionalism is a core competency of physicians. This study was conducted to design a model for formative assessment of professional commitment in medical students according to stages of change theory. Methods: In this qualitative study, data were collected through literature review & focus group interviews in the Tehran University of Medical Sciences in 2013 and analyzed using content analysis approach. Results: Review of the literature and results of focus group interviews led to design a formative assessment model of professional commitment in three phases, including pre-contemplation, contemplation, and readiness for behavior change that each one has interventional and assessment components. In the second phase of the study, experts' opinion collected in two main categories: the educational environment (factors related to students, students' assessment and educational program); and administrative problems (factors related to subcultures, policymakers or managers and budget). Moreover, there was a section of recommendations for each category related to curriculum, professors, students, assessments, making culture, the staff and reinforcing administrative factors. Conclusion: This type of framework analysis made it possible to develop a conceptual model that could be effective on forming the professional commitment and behavioral change in medical students.

Estimating the prevalence of illicit drug use among students using the crosswise model.

OBJECTIVE: The aim of our study is to compare the prevalence of illicit drug use estimated through a technique referred to as the "crosswise model" (CM) with the results from conventional direct questioning (DQ). METHOD: About 1,500 students from Tehran University of Medical Sciences 2009-2010 were first interviewed by DQ and, then three months later, by the CM. RESULT: The CM yielded significantly higher estimates than DQ for lifetime prevalence of use of any illicit drug (CM = 20.2%,DQ = 3.0%, p < .001) and for lifetime prevalence of use of opium or its residue (CM = 13.6%, DQ = 1.0%, p < .001). Also, for use of any illicit drug in the last month and use of opium or its residue in the last month, the CM yielded higher point estimates than DQ, although these differences were not significant (any drug: CM = 1.5%, DQ = 0.2%, p = .66; opium: CM = 3.8%, DQ = 0.0%, p = .21). CONCLUSION: Our findings suggest that the CM is a fruitful data collection method for sensitive topics such as substance abuse.

Public preferences for donor kidney allocation: a study in Iran.

INTRODUCTION: Fair allocation of donor organs is essential to maintain public trust in a public healthcare system. A study of the public's views and opinions of this could clarify non-medical prioritization criteria. We report our survey of public opinion of criteria for donor kidney allocation. METHODS: This was a cross-sectional study using random digit dialing to phone interview 706 Tehran residents. Patient scenarios were presented to determine interviewee opinions on nine recipient criteria: probability for survival, previous transplant history, time on the waiting list, age, an individual's role in developing their kidney failure, gender, marital status, social status, and financial situation. Each scenario introduced two patients and interviewees then chose the better candidate for transplantation. RESULTS: More than 50% of the participants chose length of waiting time, a patient's role in causing their disease, age, and survival time after transplantation as important allograft allocation criteria. CONCLUSION: This study disclosed other criteria in addition to the likelihood for successful transplantation-the patient's role in the development of their disease and patient age-which should be prioritization considerations.

Academic disintegrity among medical students: a randomised response technique study.

OBJECTIVES: Medical students, as tomorrow's doctors, are responsible for their patients' health; cheating may affect their academic knowledge and clinical skills. The main purpose of this study was to investigate the frequency of and attitudes towards academic disintegrity among medical students at Tehran University of Medical Sciences (TUMS). METHODS: Anonymous questionnaires including questions about various types of academic disintegrity were distributed among medical students during the clerkship and internship phases of the curriculum. Randomised response technique (RRT) was used to maintain the responders' privacy. Because the study design guaranteed the confidentiality of respondents, the TUMS Institutional Review Board declared that formal ethical approval was not required. RESULTS: A total of 124 students were enrolled in this study, of whom 63 were in the clerkship phase and 61 were in the internship phase. Of these respondents, 29% (n = 36) were male. The most frequently reported type of academic disintegrity was found to be 'impersonating an absent student in a class' (93%) and the least frequent to be 'legitimising absences by using bribes' (5%). Only a small number of interns considered 'buying hospital shifts', 'selling hospital shifts', 'impersonating an absent student' and 'helping others to cheat in examinations' as representing academic disintegrity. Approximately one third of participants stated that the RRT increased their confidence in anonymity and 90% of students found the use of RRT not difficult. CONCLUSIONS: Academic integrity is widely disrespected in different ways among medical students. Effective policies and interventions are required to control these misbehaviours in future doctors in order to optimise medical practice. Almost all respondents found it not difficult to use the RRT; the technique proved to be an effective and easily applied method of eliciting truthful responses to sensitive questions and represents an alternative to conventional anonymising techniques.

Educational content of professional ethics in postgraduate dental education.

PURPOSE: Inclusion of proper educational content with respect to professional ethics in dental curricula is an important step to achieve objectives of ethics education especially in postgraduate programs when the time and opportunities for explicit instruction of ethics are limited. This study aimed to find and discuss the topics of ethics and professionalism for dental postgraduate programs. METHODS: A modified Delphi survey of experts' opinions with three rounds was conducted to establish a consensus on the need to teach professional ethics topics. The topics were identified through a literature review and according to the opinion of the experts. Items scored as highly important by over 80% of the participants in each round of the survey were considered educational needs. RESULTS: A total of 154 ethical issues were identified and classified into 29 topical categories to design the initial questionnaire. A consensus was developed on 24 ethics and professionalism topics for inclusion in the professional ethics curriculum for all dental postgraduate programs. CONCLUSIONS: Based on the results of this study, the same educational content in professional ethics is needed for all dental residency programs in all specialties. Most of the topics on which experts reached a consensus to be included in the ethics educational content were related to ethical and professional standards of conduct.

Public opinion of organ donation: a survey in Iran.

INTRODUCTION: The objective of this study was to assess the views of Tehran citizens in regard to donating their organs in case of brain death. METHODS: In this cross-sectional study, conducted between February 2009 and November 2010, two interviewers contacted 1379 people through random digit dialing for phone interviews. Phone calls were made between 6 and 9 pmon a workday, and those reaching companies or organizations were excluded. The interviewee was selected randomly from among the household members, and those 18 yr and older were included in the study. RESULTS: Of the 1379 people eligible for entering the study, 706 consented to have the interview (response rate = 51%). Among the respondents, 84.6% were willing to donate. Of these, 94.6% were willing to complete a donor card as well, but only 10.7% of them already had one. CONCLUSION: There should be simple processes for the public to declare their decision about organ donation in case of brain death. People should be encouraged to communicate their wishes with others so that family members can decide about their organ donation more easily.

Medical error disclosure: the gap between attitude and practice.

BACKGROUND: This study aims to evaluate the attending surgeons' and residents' attitudes towards error disclosure and factors that can potentially affect these tendencies in major academic hospitals affiliated with Tehran University of Medical Sciences (TUMS). METHODS AND MATERIAL: In a cross-sectional study, self-administered questionnaires were delivered to all attending surgeons and second to fourth year surgical residents of TUMS during October and November 2009. The questionnaire contained two clinical scenarios and questions regarding physicians' attitudes towards disclosing medical error and their actual practice in the case of their last error. Of the 63 distributed questionnaires, 53 (84.1%) were completed and returned. RESULTS: Participants were less likely to disclose minor (39.6%; 21/53) than major (49.1%; 29/53) medical errors. Participants believed that their most important concerns for not disclosing errors were fear of a malpractice lawsuit (71.7%, n=38), losing patients' trust (62.3%, n=33), and emotional reactions of the patients and their relatives (56.6%, n=30). Although most physicians indicated they would disclose errors in minor and major scenarios, only 16.7% (n=8) had disclosed their last medical errors to their patients, two of which had resulted in patients taking legal action. CONCLUSION: There was an obvious gap between surgeons' intentions and actual practices concerning disclosure of medical error. Education in medical error management to professionally support error disclosure might help reduce the gap.

Factors associated with reporting nursing errors in Iran: a qualitative study.

BACKGROUND: Reporting the professional errors for improving patient safety is considered essential not only in hospitals, but also in ambulatory care centers. Unfortunately, a great number of nurses, similar to most clinicians, do not report their errors. Therefore, the present study aimed to clarify the factors associated with reporting the nursing errors through the experiences of clinical nurses and nursing managers. METHODS: A total of 115 nurses working in the hospitals and specialized clinics affiliated to Tehran and Shiraz Universities of Medical Sciences, Iran participated in this qualitative study. The study data were collected through a semi-structured group discussion conducted in 17 sessions and analyzed by inductive content analysis approach. RESULTS: The main categories emerged in this study were: a) general approaches of the nurses towards errors, b) barriers in reporting the nursing errors, and c) motivators in error reporting. CONCLUSION: Error reporting provides extremely valuable information for preventing future errors and improving the patient safety. Overall, regarding motivators and barriers in reporting the nursing errors, it is necessary to enact regulations in which the ways of reporting the error and its constituent elements, such as the notion of the error, are clearly identified.

Developing a professional guideline for the use of cyberspace by health-care professionals in Iran: a mixed methods study.

The present study aimed to compile and develop a professional guideline for health-care providers in Iran regarding cyberspace usage. This was a mixed-methods study, conducted in three phases. In the first phase, the principles of ethics in cyberspace were collected through a review of the literature and available documents, and were then subjected to content analysis. In the second phase, the views of experts on medical ethics, virtual education, information technology and medical education, as well as clinical sciences experts and representatives of medical students and graduates were evaluated using the focus group method. In the third phase, the draft was evaluated by various stakeholders. Finally, after receiving the comments, the necessary modifications were applied to the guideline. The professional guideline for the use of cyberspace by health-care professionals comprised 30 codes in 5 domains, including the general regulations domain, care and treatment, research, education, and personal development. This guideline presents the various ways professionalism can be maintained in cyberspace interactions. Adherence to the principles of professionalism in cyberspace is required to protect and preserve the public trust in health-care professionals.

Challenges of the Medical Ethics PhD curriculum in Iran: A qualitative study.

Background: Bioethics is the foundation of medical practices, and can be applied in the different levels of medicine. In Iran, Medical Ethics started to be taught in the form of PhD course in Tehran University of Medical Sciences (TUMS) in 2007. Although many aspects of this plan are successfully implemented, some deficits also are frequently pointed out by many professors and students. The purpose of this study was to recognize the deficits and weaknesses of the current curriculum. Methods: This study was a qualitative descriptive type which was conducted based on semi-structured deep interview with open questions. The sample population of this research was composed of faculty members in Medical Ethics department of TUMS, students and graduates of PhD in Medical Ethics and also, the experts who worked on codification of the initial curriculum. Results: Overall, eleven individuals were interviewed. In general, "Practical application", "Feeling the Need", "Professional Doctorate", "Human Sciences", "Paramedical", "Possible", "Impossible", "Defining the Discipline Nature", "Student Attraction", "Professor", "Training", "Evaluation Procedure", "Student Admission", "Educational Content", "Teaching Method", :Student Evaluation", and "Course Management" were the main themes. Conclusion: With regard to the deficiencies in Medical Ethics training and also, the problems identified through interviews, it seems that a great deal of problems are possible to solve if Medical Ethics is considered an interdisciplinary field instead a monodisciplinary one. One of the main purposes in interdisciplinary fields is investigating, analyzing and introducing measures for issues and problems that cannot be known and solved by a single discipline.

Patients' perspectives of the substitute decision maker: who makes better decisions?

INTRODUCTION: Substitute decision making on behalf of incapable patients is based on the ethical principle of 'respect for autonomy'. This study was conducted to assess patients' wishes and preferences in terms of a substitute decision maker and determinants of such preferences. METHODS: The authors conducted a cross-sectional study and selected samples randomly from patients presenting at Farabi Eye Hospital clinics who were 18 years of age or older. Questionnaires were completed through interviews. RESULTS: 200 patients between the ages of 18 and 83 years were interviewed. About 52% (N=105) were men and 73% (N=77) were married. Among married patients, the spouse was chosen as the substitute decision maker in only 51% of cases. Single men preferred their father first in 36% (N=9) of cases, while single girls chose their father in 5.6% (N=1) of cases and their most prevalent choice was other unmentioned people (33.3%, N=6). Most patients (93.5%) wished to be asked about their substitute decision maker when hospitalised. CONCLUSION: The results of this study show that the people we usually consult for decisions concerning patient treatment are significantly different from the patients' preferred substitute decision makers. The authors suggest patients be allowed to choose their substitute decision maker while conscious.

Are we proper role models for students? Interns' perception of faculty and residents' professional behaviour.

AIM: This study was conducted to assess interns' level of exposure to different aspects of professional attitude and behaviour among faculty and residents. METHODS: In this descriptive study, 218 interns in surgery and internal medicine wards at four teaching hospitals of Tehran University of Medical Sciences were enrolled during the first semester of the 2007/2008 academic year. Each intern completed one questionnaire for faculty and one for residents in their ward. RESULTS: The questionnaire was completed by 150 students (68.8%) for faculty and by 139 students (63.7%) for residents. In terms of overall aspects of professionalism, the mean (±SD) score on observing professionalism was 52.9±10 and 49.26±7.9 points out of 70 for faculty and residents, respectively. Students agreed that responsibility was observed better than other aspects of professionalism (119/150 (79.3%) and 115/139 (82.8%) students stated it was often or always observed by faculty and residents, respectively). In both groups, commitment to honour and integrity and excellence was less compared with other areas. CONCLUSION: Medical faculty and residents should be more aware of their behaviour and attitudes in practice, especially their interaction with colleagues so that students' professional behaviour can be improved.

Priority Setting of Ventilators in the COVID-19 Pandemic from the Public's Perspective.

Background: Ventilator allocation plan for a public health crisis should be developed through recognizing the values of society and engaging the general public. This study was conducted to assess the Iranian citizens' attitude about some principles and criteria for allocation of ventilators in the current COVID-19 epidemic.Materials and Methods: An electronic self-administered questionnaire was publicly distributed through social networks of Telegram and WhatsApp to perform this cross-sectional study. The questionnaire consisted of 11 statements about the selection and prioritization of patients for the use of a ventilator.Results: 1262 persons, including 767 citizens and 495 health care providers participated in this study. More than 95% of participants agreed upon the necessity to avoid discrimination and avoid prioritization according to patients' gender, economic and political status. While 40.9% of citizens and 49.6% of healthcare workers believed that a ventilator can be disconnected from a patient with a poor prognosis to help another patient who has a better prognosis (P-value = 0.13), 34.3% of people and 29.6% of healthcare workers believed that the earlier admitted patients have the right to receive the device even if the likeliness of his/her survival is less than the next patient (P-value = 0.009).Conclusions: Maximizing health benefits as a measure of ventilator allocation in the pandemic of COVID-19 is an accepted criterion. Meanwhile, periodic evaluation of patients and disconnecting the device from a patient that no longer benefits from ICU services requires its scientific and ethical basis to be brought in public discourse.

Medical students' perception of professionalism climate in clinical settings.

Medical professionalism has a crucial role in educating medical students. The role of professionalism in the clinical environment is therefore an important factor in medical education. This study attempts to evaluate the opinions of medical students in the teaching hospitals of Tehran University of Medical Sciences (TUMS) about the professionalism environment in this university. A sample of 165 students filled out the Persian translation of UMKC-SOM (Climate of Professionalism Survey) questionnaire. This instrument evaluates students' perspectives on the degree of adherence to professionalism by faculty, residents and other students. The results of the study revealed that the total score of professionalism climate was 53.9 for faculty, 42.09 for residents, and 50.76 for students and the difference between these three groups was statistically significant (p-value < 0.01). Results of further analysis through post-hoc tests for multiple comparisons among the groups revealed that the students found their fellow students and faculty more professional than residents. The study also showed that the medical ethics course had no impact on perceptions observations (p-values > 0.05). The study results also revealed that the students found their fellow students and faculty more professional than residents. This finding demonstrates the importance of teaching professionalism to residents since they serve as role models for students. Further multicenter studies are needed to improve the professionalism climate in the medical teaching environment.

Developing a comprehensive tool to assess professional attitude among physicians and medical students.

It appears that up until now, no comprehensive tool has been developed to assess medical students' attitudes toward the different dimensions of professionalism. The present study aimed to develop a comprehensive quantitative tool to evaluate medical students' attitudes toward professionalism. This study consisted of two phases: The first phase was item generation and questionnaire design based on literature review and a qualitative survey. The qualitative data were extracted from 49 semi-structured individual interviews and one focus group discussion. In the second phase, the questionnaire was developed and its face, content, and structure validity and reliability were evaluated. To measure the construct validity of the questionnaire, a cross-sectional study was conducted on 354 medical students at different academic levels at Isfahan University of Medical Sciences. The final questionnaire was loaded on five factors. The factors accounted for 43.5% of the total variance. Moreover, Cronbach's alpha was 0.84 for the total scale, and the interclass correlation coefficient was 0.77 for the test-retest reliability. The 17-item questionnaire measuring medical students' professional attitude had acceptable validity and reliability and can be adopted in other studies on physicians' and medical students' professional attitudes.