Making clinical decisions when the stakes are high and the evidence unclear.
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ABSTRACT:
SUBMITTER: Hu W
PROVIDER: S-EPMC521583 | biostudies-literature | 2004 Oct
REPOSITORIES: biostudies-literature
Publications
Making clinical decisions when the stakes are high and the evidence unclear.
Hu Wendy W Kemp Andrew A Kerridge Ian I
BMJ (Clinical research ed.) 20041001 7470
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Project description:To explore high-stakes surgical decision making from the perspective of seniors and surgeons.A majority of older chronically ill patients would decline a low-risk procedure if the outcome was severe functional impairment. However, 25% of Medicare beneficiaries have surgery in their last 3 months of life, which may be inconsistent with their preferences. How patients make decisions to have surgery may contribute to this problem of unwanted care.We convened 4 focus groups at senior centers and 2 groups of surgeons in Madison and Milwaukee, Wisconsin, where we showed a video about a decision regarding a choice between surgery and palliative care. We used qualitative content analysis to identify themes about communication and explanatory models for end-of-life treatment decisions.Seniors (n = 37) and surgeons (n = 17) agreed that maximizing quality of life should guide treatment decisions for older patients. However, when faced with an acute choice between surgery and palliative care, seniors viewed this either as a choice between life and death or a decision about how to die. Although surgeons agreed that very frail patients should not have surgery, they held conflicting views about presenting treatment options.Seniors and surgeons highly value quality of life, but this notion is difficult to incorporate in acute surgical decisions. Some seniors use these values to consider a choice between surgery and palliative care, whereas others view this as a simple choice between life and death. Surgeons acknowledge challenges framing decisions and describe a clinical momentum that promotes surgical intervention.
| S-EPMC4492901 | biostudies-literature
Project description:ImportanceAlthough many older adults prefer to avoid burdensome interventions with limited ability to preserve their functional status, aggressive treatments, including surgery, are common near the end of life. Shared decision making is critical to achieve value-concordant treatment decisions and minimize unwanted care. However, communication in the acute inpatient setting is challenging.ObjectiveTo evaluate the proof of concept of an intervention to teach surgeons to use the Best Case/Worst Case framework as a strategy to change surgeon communication and promote shared decision making during high-stakes surgical decisions.Design, setting, and participantsOur prospective pre-post study was conducted from June 2014 to August 2015, and data were analyzed using a mixed methods approach. The data were drawn from decision-making conversations between 32 older inpatients with an acute nonemergent surgical problem, 30 family members, and 25 surgeons at 1 tertiary care hospital in Madison, Wisconsin.InterventionsA 2-hour training session to teach each study-enrolled surgeon to use the Best Case/Worst Case communication framework.Main outcomes and measuresWe scored conversation transcripts using OPTION 5, an observer measure of shared decision making, and used qualitative content analysis to characterize patterns in conversation structure, description of outcomes, and deliberation over treatment alternatives.ResultsThe study participants were patients aged 68 to 95 years (n = 32), 44% of whom had 5 or more comorbid conditions; family members of patients (n = 30); and surgeons (n = 17). The median OPTION 5 score improved from 41 preintervention (interquartile range, 26-66) to 74 after Best Case/Worst Case training (interquartile range, 60-81). Before training, surgeons described the patient's problem in conjunction with an operative solution, directed deliberation over options, listed discrete procedural risks, and did not integrate preferences into a treatment recommendation. After training, surgeons using Best Case/Worst Case clearly presented a choice between treatments, described a range of postoperative trajectories including functional decline, and involved patients and families in deliberation.Conclusions and relevanceUsing the Best Case/Worst Case framework changed surgeon communication by shifting the focus of decision-making conversations from an isolated surgical problem to a discussion about treatment alternatives and outcomes. This intervention can help surgeons structure challenging conversations to promote shared decision making in the acute setting.
| S-EPMC5479749 | biostudies-literature
Project description:UnlabelledA recent trial in rheumatoid arthritis found an inexpensive, but infrequently used, combination of therapies is neither inferior nor less safe than an expensive biologic drug. If the trial had been conducted over 10 years ago, arguably 100's of millions of dollars since spent on biologics could have been released to other, more effective treatments. Given the ever increasing number of trials proposed, this commentary uses the trial as an example to challenge payers and research funders to make smarter investments in clinical research to save potential future costs.Trial registrationNCT00405275 , registered 29 November 2006.
| S-EPMC4693420 | biostudies-literature
Project description:BackgroundIncorporating emerging knowledge into Emergency Medical Service (EMS) competency assessments is critical to reflect current evidence-based out-of-hospital care. However, a standardized approach is needed to incorporate new evidence into EMS competency assessments because of the rapid pace of knowledge generation.ObjectiveThe objective was to develop a framework to evaluate and integrate new source material into EMS competency assessments.MethodsThe National Registry of Emergency Medical Technicians (National Registry) and the Prehospital Guidelines Consortium (PGC) convened a panel of experts. A Delphi method, consisting of virtual meetings and electronic surveys, was used to develop a Table of Evidence matrix that defines sources of EMS evidence. In Round One, participants listed all potential sources of evidence available to inform EMS education. In Round Two, participants categorized these sources into: (a) levels of evidence quality; and (b) type of source material. In Round Three, the panel revised a proposed Table of Evidence. Finally, in Round Four, participants provided recommendations on how each source should be incorporated into competency assessments depending on type and quality. Descriptive statistics were calculated with qualitative analyses conducted by two independent reviewers and a third arbitrator.ResultsIn Round One, 24 sources of evidence were identified. In Round Two, these were classified into high- (n = 4), medium- (n = 15), and low-quality (n = 5) of evidence, followed by categorization by purpose into providing recommendations (n = 10), primary research (n = 7), and educational content (n = 7). In Round Three, the Table of Evidence was revised based on participant feedback. In Round Four, the panel developed a tiered system of evidence integration from immediate incorporation of high-quality sources to more stringent requirements for lower-quality sources.ConclusionThe Table of Evidence provides a framework for the rapid and standardized incorporation of new source material into EMS competency assessments. Future goals are to evaluate the application of the Table of Evidence framework in initial and continued competency assessments.
| S-EPMC10267721 | biostudies-literature
Project description:Background & need for innovationObjective Structured Clinical Examinations (OSCEs) are commonly employed to assess clinical skills. While several existing tools address components of clinical reasoning, including the Assessment of Reasoning Tool, none are calibrated for competency-based assessment of medical students (UME) in an OSCE setting.Goal of innovationWe sought to create a clinical reasoning assessment for use in a high-stakes, summative medical student OSCE.Steps taken for development and implementation of innovationA minimum-competency OSCE was administered to medical students following their required clinical clerkships. We developed a tool to assess clinical reasoning of medical students at the conclusion of their required clinical clerkships and deployed it during a minimum-competency OSCE exam given at that time. The highest level of the modified tool represented minimum acceptable performance for examinees.Evaluation of innovationThe scores and analyses provided evidence to support the use of this tool. Examinees' performance on clinical reasoning tasks was comparable with their overall performance on the OSCE. The sub-scores for clinical reasoning accurately distinguished successful examinees from those who did not meet the minimum performance level, providing support for the use of the tool in this high stakes setting.Critical reflectionThis tool was found to be useful and defensible to assess medical students' clinical reasoning. Expanded evidence for generalizability of the tool and its utility in other settings will need to be garnered through multi-center implementation and study.
| S-EPMC11639687 | biostudies-literature
Project description:Objective: Giving information and providing advice on diagnostic tests is one of the tasks physicians must carry out personally. To do so, they must evaluate the evidence and integrate their findings into everyday practice. Clinical decisions should be based on evidence. How well current medical education prepares for such evidence-based clinical decision-making is largely unclear. Therefore, it was examined how confident medical students are in clinical decision-making based on evidence using epidemiological data. It was examined whether the decision-making confidence increases the higher the semester. Further questions were whether scientifically active medical students show higher decision-making confidence and whether the representation of figures as pictograms rather than tables positively influences the decision-making confidence.Methods: An online survey of the medical students of the Friedrich-Alexander-University Erlangen-Nürnberg was carried out. Respondents were presented with three clinical decision-making situations in random order for evaluation in the form of screening scenarios. In each case, the decision-making confidence also had to be specified. The scenarios contained only epidemiological data on existing screening tests. For each scenario, the numbers were presented as a table or a pictogram in a random fashion. In order to avoid false confidence resulting from preconceived opinions neither the illnesses nor the screening tests were mentioned by name.Results: Answers from 171 students were evaluated. Decision-making confidence in dealing with the numbers does not increase in higher semesters (rPearson=0.018, p=0.41). Scientific work is not associated with a higher decision-making confidence (t(169)=-1.26, p=0.11, d=-0.19). Presentation as a pictogram leads to a higher decision-making confidence compared to tables (Pictogram: M=2.33, SD=1.07, Table with numbers: M=2.64, SD=1.11, t(511)=3.21, p<0.01, d=0.28).Conclusions: Medical students from higher semesters show no higher decision-making confidence compared to medical students from lower semesters. Curricular events and scientific work, such as a doctoral thesis, do not seem to strengthen the required skills sufficiently. If evidence is presented in the form of pictograms, this seems to improve student confidence in decision-making.
| S-EPMC6905364 | biostudies-literature
Project description:ObjectiveTo assess whether training provided to an inexperienced clinician just before performing a high stakes procedure can improve procedural care quality, measuring the first attempt success rate of trainees performing infant orotracheal intubation.DesignRandomized clinical trial.SettingSingle center, quaternary children's hospital in Boston, MA, USA.ParticipantsA non-crossover, prospective, parallel group, non-blinded, trial design was used. Volunteer trainees comprised pediatric anesthesia fellows, residents, and student registered nurse anesthetists from 10 regional training programs during their pediatric anesthesiology rotation. Trainees were block randomized by training roles. Inclusion criteria were trainees intubating infants aged ≤12 months with an American Society of Anesthesiology physical status classification of I-III. Exclusion criteria were trainees intubating infants with cyanotic congenital heart disease, known or suspected difficult or critical airways, pre-existing abnormal baseline oxygen saturation <96% on room air, endotracheal or tracheostomy tubes in situ, emergency cases, or covid-19 infection.InterventionsTrainee treatment group received preoperative just-in-time expert intubation coaching on a manikin within one hour of infant intubation; control group carried out standard practice (receiving unstructured intraoperative instruction by attending pediatric anesthesiologists).Main outcome measuresPrimary outcome was the first attempt success rate of intraoperative infant intubation. Modified intention-to-treat analysis used generalized estimating equations to account for multiple intubations per trainee participant. Secondary outcomes were complication rates, cognitive load of intubation, and competency metrics.Results250 trainees were assessed for eligibility; 78 were excluded, 172 were randomized, and 153 were subsequently analyzed. Between 1 August 2020 and 30 April 2022, 153 trainees (83 control, 70 treatment) did 515 intubations (283 control, 232 treatment). In modified intention-to-treat analysis, first attempt success was 91.4% (212/232) in the trainee treatment group and 81.6% (231/283) in the control group (odds ratio 2.42 (95% confidence interval 1.45 to 4.04), P=0.001). Secondary outcomes favored the intervention, showing significance for decreased cognitive load and improved competency. Complications were lower for the intervention than for the control group but the difference was not significant.ConclusionsJust-in-time training among inexperienced clinicians led to increased first attempt success of infant intubation. Integration of a just-in-time approach into airway management could improve patient safety, and these findings could help to improve high stakes procedures more broadly. Randomized evaluation in other settings is warranted.Trial registrationClinicalTrials.gov NCT04472195.
| S-EPMC11648086 | biostudies-literature
Project description:Cheating reduces the signaling value of examinations. It also shifts the focus of teachers and students away from learning. Combating widespread cheating is difficult as students, teachers, and bureaucrats all benefit from high reported grades. We evaluate the impact of computer-based testing (CBT), an at-scale policy implemented by the Indonesian government to reduce widespread cheating in the national examinations. Exploiting the phased roll-out of the program from 2015 to 2019, we find that test scores declined dramatically, by 0.5 standard deviations, after the introduction of CBT. Schools with response patterns that indicated cheating prior to CBT adoption experienced a steeper decline. The effect is similar between schools with and without access to a computer lab, indicating that the reduction in the opportunity to cheat is the main reason for the test score decline. In districts with high adoption of CBT, schools that still used paper-based exams cheated less and scored lower, indicating spillovers of CBT. The results highlight the potential role of technology in improving the effectiveness in efforts to overcome collusive behavior in the education sector.
| S-EPMC11216028 | biostudies-literature
Project description:ObjectiveTo clarify the concept of best interests, setting out how they should be ascertained and used to make healthcare decisions for patients who lack the mental capacity to make decisions.ContextThe legal framework is the Mental Capacity Act (MCA) 2005, which applies to England and Wales.TheoryUnless there is a valid and applicable Advance Decision, an appointed decision-maker needs to decide for those without capacity. This may be someone appointed by the patient through a Lasting Power of Attorney, or a Deputy appointed by the court. Otherwise the decision-maker is usually the responsible clinician. Different approaches exist to surrogate decision-making cross-nationally. In England and Wales, decision-making is governed by the MCA 2005, which uses a person-centred, flexible best interests (substituted interests) approach.ObservationsThe MCA is often not followed in healthcare settings, despite widespread mandatory training. The possible reasons include its focus on single decisions, when multiple decisions are made daily, the potential time involved and lack of clarity about who is the responsible decision-maker.SolutionOne solution is to decide a strategic policy to cover more significant (usually health-related) decisions and to separate these from day-to-day relational decisions covering care and activities. Once persistent lack of capacity is confirmed, an early meeting should be arranged with family and friends, to start a process of sharing information about the patient's medical condition and their values, wishes, feelings and beliefs with a view to making timely treatment decisions in the patient's best interests.
| S-EPMC6745603 | biostudies-literature
Project description:How do people decide which action to take? This question is best answered using Game Theory, which has proposed a series of decision-making mechanisms that people potentially use. In network simulations, wherein games are repeated and pay-off differences can be observed, those mechanisms often rely on imitation of successful behaviour. Surprisingly, little to no evidence has been provided about whether people actually imitate more successful opponents when altering their actions in that context. By comparing two experimental treatments wherein participants play the iterated Prisoner's Dilemma game in a lattice, we aim to answer whether more successful actions are imitated. While in the first treatment, participants have the possibility to use pay-off differences in making their decision, the second treatment hinders such imitation as no information about the gains is provided. If imitation of the more successful plays a role then there should be a difference in how players switch from cooperation to defection between both treatments. Although, cooperation and pay-off levels do not appear to be significantly different between both treatments, detailed analysis shows that there are behavioural differences: when confronted with a more successful co-player, the focal player will imitate her behaviour as the switching is related to the experienced pay-off inequality.
| S-EPMC7428279 | biostudies-literature