Medicine and Health Sciences Commons^™

Beneath The Surface: Discovering The Unvoiced Concerns Of Older Adults With Type 2 Diabetes Mellitus, Jennifer Tjia, Jane Givens, Jason Karlawish, A. Okoli-Umeweni, Frances Barg

Jason Karlawish

Emerging clinical guidelines recommend shared decision making to individualize drug regimens for older adults with Type 2 diabetes mellitus. While the current health education campaign for diabetes in the United States recommends physician-initiated medication-related discussions about adherence and side effects, little emphasis is placed on soliciting patient concerns. This study's aim was to explore the concerns of older adults with diabetes about the complexity of their drug regimens and to determine whether they discussed medication-related concerns with their physician. Twenty-two patients with Type 2 diabetes age 65 years and older who used five or more medications were selected from an …

The Impact On Patient Trust Of Legalising Physician Aid In Dying, Mark Hall, Felicia Trachtenberg, Elizabeth Dugan

Elizabeth Dugan

OBJECTIVE: Little empirical evidence exists to support either side of the ongoing debate over whether legalising physician aid in dying would undermine patient trust. DESIGN: A random national sample of 1117 US adults were asked about their level of agreement with a statement that they would trust their doctor less if "euthanasia were legal [and] doctors were allowed to help patients die". RESULTS: There was disagreement by 58% of the participants, and agreement by only 20% that legalising euthanasia would cause them to trust their personal physician less. The remainder were neutral. These attitudes were the same in men and …

Prevalence Of Sexual Abuse Among Women Seeking Gynecologic Care In Germany, Ursula Peschers, Janice Du Mont, Katharina Jundt, Mona Pfurtner, Elizabeth Dugan, Gunther Kindermann

Elizabeth Dugan

OBJECTIVE: To estimate the prevalence of sexual abuse among patients seen for gynecologic care in Germany. METHODS: A short anonymous questionnaire was distributed to 1157 women attending a gynecologic outpatient clinic at a large urban teaching hospital. Data collected using the questionnaire included patient characteristics, sexual abuse history, and screening practices. Women who reported that they had been abused were asked if they had ever discussed the issue with their gynecologist. RESULTS: A total of 1075 questionnaires were returned, for a response rate of 92.9%. Almost half (n = 479 [44.6%]) of the women surveyed reported that they had been …

Medicare Beneficiaries And Free Prescription Drug Samples: A National Survey., Jennifer Tjia, Becky Briesacher, Stephen Soumerai, Marsha Pierre-Jacques, Fang Zhang, Dennis Ross-Degnan, Jerry Gurwitz

Jennifer Tjia

BACKGROUND: New policies regulating physician/pharmaceutical company relationships propose to eliminate access to free prescription drug samples. Little is known about the prevalence of patient activity in requesting or receiving free prescription drug samples, or the characteristics of patients who access drug samples. OBJECTIVE: To determine the prevalence of free sample access and to examine demographic, clinical, and insurance characteristics of Medicare beneficiaries who access free samples. DESIGN: Cross-sectional study. PARTICIPANTS: A national sample of 13,847 Medicare beneficiaries participating in the fall 2004 Medicare Current Beneficiary Survey. MEASUREMENTS AND MAIN RESULTS: Prevalence of free prescription drug sample access (self-reported request for …

Beneath The Surface: Discovering The Unvoiced Concerns Of Older Adults With Type 2 Diabetes Mellitus, Jennifer Tjia, Jane Givens, Jason Karlawish, A. Okoli-Umeweni, Frances Barg

Jennifer Tjia

Emerging clinical guidelines recommend shared decision making to individualize drug regimens for older adults with Type 2 diabetes mellitus. While the current health education campaign for diabetes in the United States recommends physician-initiated medication-related discussions about adherence and side effects, little emphasis is placed on soliciting patient concerns. This study's aim was to explore the concerns of older adults with diabetes about the complexity of their drug regimens and to determine whether they discussed medication-related concerns with their physician. Twenty-two patients with Type 2 diabetes age 65 years and older who used five or more medications were selected from an …

Development Of Abbreviated Measures To Assess Patient Trust In A Physician, A Health Insurer, And The Medical Profession, Elizabeth Dugan, Felicia Trachtenberg, Mark Hall

Elizabeth Dugan

BACKGROUND: Despite the recent proliferation in research on patient trust, it is seldom a primary outcome, and is often a peripheral area of interest. The length of our original scales to measure trust may limit their use because of the practical needs to minimize both respondent burden and research cost. The objective of this study was to develop three abbreviated scales to measure trust in: (1) a physician, (2) a health insurer, and (3) the medical profession. METHODS: Data from two samples were used. The first was a telephone survey of English-speaking adults in the United States (N = 1117) …

Patient Education About Anticoagulant Medication: Is Narrative Evidence Or Statistical Evidence More Effective?, Kathleen Mazor, Joann Baril, Elizabeth Dugan, Frederick Spencer, Pamela Burgwinkle, Jerry Gurwitz

Elizabeth Dugan

OBJECTIVE: To determine the relative impact of incorporating narrative evidence, statistical evidence or both into patient education about warfarin, a widely used oral anticoagulant medication.

METHODS: 600 patients receiving anticoagulant therapy were randomly assigned to view one of three versions of a video depicting a physician-patient encounter where anticoagulation treatment was discussed, or usual care (no video). The videos differed in whether the physician used narrative evidence (patient anecdotes), statistical evidence, or both to highlight key information. 317 patients completed both the baseline and post-test questionnaires. Questions assessed knowledge, beliefs and adherence to medication and laboratory monitoring regimens.

RESULTS: All …

The Anatomy Of The Professional Lapse: Bridging The Gap Between Traditional Frameworks And Students' Perceptions, Shiphra Ginsburg, Glenn Regehr, David Stern, Lorelei Lingard

Lorelei Lingard

PURPOSE: To support students' developing professionalism, it is necessary to understand the professional challenges and dilemmas they perceive in the clinical setting. This study systematically documented and catalogued students' reports of professional lapses. METHOD: Six focus groups were conducted with senior medical students (n = 29) at three universities. Using a grounded-theory approach, three researchers analyzed the students' reports of specific lapses in professionalism for recurrent themes. The resulting coding structure was applied using NVivo qualitative data analysis software. RESULTS: A total of 120 pages of text yielded 48 specific incidents of professional lapses, which were analyzed by three researchers …

Basing The Evaluation Of Professionalism On Observable Behaviors: A Cautionary Tale, Shiphra Ginsburg, Glenn Regehr, Lorelei Lingard

Lorelei Lingard

PROBLEM STATEMENT AND BACKGROUND: The evaluation of professionalism often relies on the observation and interpretation of students' behaviors; however, little research is available regarding faculty's interpretations of these behaviors.

METHOD: Interviews were conducted with 30 faculty, who were asked to respond to five videotaped scenarios in which students are placed in professionally challenging situations. Behaviors were catalogued by person and by scenario.

RESULTS: There was little agreement between faculty about what students should and should not do in each scenario. Abstracted principles (e.g., honesty, altruism) were defined and applied inconsistently, both between and within individual faculty. There was no apparent …

'Is That Normal?' Pre-Clerkship Students' Approaches To Professional Dilemmas, Shiphra Ginsburg, Lorelei Lingard

Lorelei Lingard

OBJECTIVES: Context has been recognised as a key variable in studies of medical student professionalism, yet the effect of students' stage of training has not been well explored, despite growing recognition that medical students begin to form their professional ethos from their earliest medical school experiences. The purpose of this study, which builds on previous research involving clinical clerks, was to explore the decision-making processes of pre-clerkship medical students in the face of standardised professional dilemmas.

METHODS: Structured interviews were conducted with 30 pre-clerkship (Years 1 and 2) medical students at one institution. During the interviews, students were asked to …

Ethical Challenges In Icu Research, Charles Weijer

Charles Weijer

No abstract provided.

When Can Physicians Say “No” To Families And Patients?, Charles Weijer

Charles Weijer

No abstract provided.

Providing Research Results To Participants: Attitudes And Needs Of Adolescents And Parents Of Children With Cancer, Conrad Fernandez, Jun Gao, Caron Strahlendorf, Albert Moghrabi, Rebecca Pentz, Raymond Barfield, Justin Baker, Darcy Santor, Charles Weijer, Eric Kodish

Charles Weijer

PURPOSE: There is an increasing demand for researchers to provide research results to participants. Our aim was to define an appropriate process for this, based on needs and attitudes of participants.

METHODS: A multicenter survey in five sites in the United States and Canada was offered to parents of children with cancer and adolescents with cancer. Respondents indicated their preferred mode of communication of research results with respect to implications; timing, provider, and content of the results; reasons for and against providing results; and barriers to providing results.

RESULTS: Four hundred nine parents (including 19 of deceased children) and 86 …

Care Of An Unresponsive Patient With A Poor Prognosis, Arthur Slutsky, Leonard Hudson, Nancy Dubler, Charles Weijer, Mark Tonelli

Charles Weijer

No abstract provided.

The Rhetoric Of Patient Voice: Reported Talk With Patients In Referral And Consultation Letters, Marlee Spafford, Catherine Schryer, Lorelei Lingard

Lorelei Lingard

Referral and consultation letters are written to enable the exchange of patient information and facilitate the trajectory of patients through the healthcare system. Yet, these letters, written about yet apart from patients, also sustain and constrain professional relationships and influence attitudes towards patients. We analysed 35 optometry referral letters and 35 corresponding ophthalmology consultation letters for reported 'patient voice' coded as 'experience' or 'agenda' and we interviewed 15 letter writers (eight optometry students, six optometrists, and one community ophthalmologist). There were 80 instances of reported 'patient voice' in 35 letters. The majority (68%) of the instances occurred in referral letters, …

Trust-Based Obligations Of The State And Physician-Researchers To Patient-Subjects, Paul Miller, Charles Weijer

Charles Weijer

When may a physician enroll a patient in clinical research? An adequate answer to this question requires clarification of trust-based obligations of the state and the physician-researcher respectively to the patient-subject. The state relies on the voluntarism of patient-subjects to advance the public interest in science. Accordingly, it is obligated to protect the agent-neutral interests of patient-subjects through promulgating standards that secure these interests. Component analysis is the only comprehensive and systematic specification of regulatory standards for benefit-harm evaluation by research ethics committees (RECs). Clinical equipoise, a standard in component analysis, ensures the treatment arms of a randomised control trial …

The Balm Of Gilead: Is The Provision Of Treatment To Those Who Seroconvert In Hiv Prevention Trials A Matter Of Moral Obligation Or Moral Negotiation?, Charles Weijer, Guy Leblanc

Charles Weijer

Must treatment be provided to subjects who acquire HIV during the course of a prevention study? An analysis of ethical foundation, regulation, and recent argumentation provides no basis for the obligation. We outline an alternative approach to the problem based on moral negotiation.

Fiduciary Obligation In Clinical Research, Paul Miller, Charles Weijer

Charles Weijer

Heated debate surrounds the question whether the relationship between physician-researcher and patient-subject is governed by a duty of care. Miller and Weijer argue that fiduciary law provides a strong legal foundation for this duty, and for articulating the terms of the relationship between physician-researcher and patient-subject.

A Death In The Family: Reflections On The Terri Schiavo Case, Charles Weijer

Charles Weijer

No abstract provided.

Will The Real Charles Fried Please Stand Up?, Paul Miller, Charles Weijer

Charles Weijer

In response to the preceding commentary by Jerry Menikoff in this issue of the Journal, the authors argue that Fried's central concern is not that randomized clinical trials (RCTs) are conducted without consent, but rather that various aspects of the design and conduct of RCTs are in tension with physicians' duties of personal care to their patients. Although Fried does argue that the existence of equipoise cannot justify failure to obtain consent from research subjects, informed consent by itself does not supplant ill subjects' rights to personalized judgment and care embodied in Fried's equipoise.

Importance Of Informed Consent In Offering To Return Research Results To Research Participants, Conrad Fernandez, Eric Kodish, Charles Weijer

Charles Weijer

No abstract provided.

Rehabilitating Equipoise, Paul Miller, Charles Weijer

Charles Weijer

When may a physician legitimately offer enrollment in a randomized clinical trial (RCT) to her patient? Two answers to this question have had a profound impact on the research ethics literature. Equipoise, as originated by Charles Fried, which we term Fried's equipoise (FE), stipulates that a physician may offer trial enrollment to her patient only when the physician is genuinely uncertain as to the preferred treatment. Clinical equipoise (CE), originated by Benjamin Freedman, requires that there exist a state of honest, professional disagreement in the community of expert practitioners as to the preferred treatment. FE and CE are widely understood …

Disclosure Of The Right Of Research Participants To Receive Research Results: An Analysis Of Consent Forms In The Children's Oncology Group, Conrad Fernandez, Eric Kodish, Shaureen Taweel, Susan Shurin, Charles Weijer

Charles Weijer

BACKGROUND: The offer of return of research results to study participants has many potential benefits. The current study examined the offer of return of research results by analyzing consent forms from 2 acute lymphoblastic leukemia studies of the 235 institutional members of the Children's Oncology Group.

METHODS: Institutional review board (IRB)-approved consent forms from 2 standard-risk acute lymphoblastic leukemia studies (Children's Cancer Group [CCG] 1991 and Pediatric Oncology Group [POG] 9407) were analyzed independently by 2 reviewers.

RESULTS: The authors received replies from 202 of the 235 institutions that were contacted (85%). One hundred eighty-one institutions had CCG 1991 (n …

Should Physicians Accept Gifts From Their Patients? No: Gifts Debase The True Value Of Care, Charles Weijer

Charles Weijer

No abstract provided.

Hospital Policy On Appropriate Use Of Life-Sustaining Treatment, Peter Singer, Geoff Barker, Kerry Bowman, Christine Harrison, Philip Kernerman, Judy Kopelow, Neil Lazar, Charles Weijer, Stephen Workman

Charles Weijer

OBJECTIVE: To describe the issues faced, and how they were addressed, by the University of Toronto Critical Care Medicine Program/Joint Centre for Bioethics Task Force on Appropriate Use of Life-Sustaining Treatment. The clinical problem addressed by the Task Force was dealing with requests by patients or substitute decision makers for life-sustaining treatment that their healthcare providers believe is inappropriate.

DESIGN: Case study.

SETTING: The University of Toronto Joint Centre for Bioethics/Critical Care Medicine Program Task Force on Appropriate Use of Life-Sustaining Treatment.

PARTICIPANTS: The 24-member Task Force included physician and nursing leaders from five critical care units, bioethicists, a legal …

An Historical Take On The Physician's Charter, Nuala Kenny, Charles Weijer

Charles Weijer

No abstract provided.

Voting Ourselves Rights: A Critique Of The Canadian Medical Association Charter For Physicians, Nuala Kenny, Charles Weijer, Francoise Baylis

Charles Weijer

No abstract provided.

Getting Doctors To Listen: Ethics And Outcomes Data In Context, Charles Weijer

Charles Weijer

No abstract provided.

Medical Futility: Physicians, Not Patients, Call The Shots, Charles Weijer

Charles Weijer

No abstract provided.

Cpr For Patients In A Persistent Vegetative State?, Charles Weijer

Charles Weijer

No abstract provided.