Welcome to the Nexus of Ethics, Psychology, Morality, Philosophy and Health Care

Welcome to the nexus of ethics, psychology, morality, technology, health care, and philosophy
Showing posts with label Treatment Outcomes. Show all posts
Showing posts with label Treatment Outcomes. Show all posts

Thursday, August 23, 2018

Implicit Bias in Patient Care: An Endemic Blight on Quality Care

JoAnn Grif Alspach
Critical Care Nurse
August 2018 vol. 38 no. 4 12-16

Here is an excerpt:

How Implicit Bias Is Manifested

A systematic review by Hall and colleagues revealed that implicit bias is manifested in 4 key areas: patient-provider interactions, treatment decisions, treatment adherence, and patient health outcomes. How a physician communicates, including verbal cues, body language, and nonverbal behavior (physical proximity, frequency of eye contact) may manifest subconscious bias.7,10 Several investigators found evidence that providers interact more effectively with white than nonwhite patients. Bias may affect the nature and extent of diagnostic assessments and the range and scope of therapies considered. Nonwhite patients receive fewer cardiovascular interventions and kidney transplants. One meta-analysis found that 20 of 25 assumption method studies demonstrated bias either in the diagnosis, treatment recommendations, number of questions asked, or tests ordered. Women are 3 times less likely than men to receive knee arthroplasty despite comparable indications. Bias can detrimentally affect whether patients seek or return for care, follow treatment protocols, and, perhaps cumulatively, can influence outcomes of care. Numerous research studies offer evidence that implicit bias is associated with higher complication rates, greater morbidity, and higher patient mortality.

The info is here.

Friday, December 1, 2017

Selling Bad Therapy to Trauma Victims

Jonathan Shedler
Psychology Today
Originally published November 19, 2017

Here is the conclusion:

First, do no harm

Many health insurance companies discriminate against psychotherapy. Congress has passed laws mandating mental health “parity” (equal coverage for medical and mental health conditions) but health insurers circumvent them. This has led to class action lawsuits against health insurance companies, but discrimination continues.

One way that health insurers circumvent parity laws is by shunting patients to the briefest and cheapest therapies — just the kind of therapies recommended by the APA’s treatment guidelines. Another way is by making therapy so impersonal and dehumanizing that patients drop out. Health insurers do not publicly say the treatment decisions are driven by economic self-interest. They say the treatments are scientifically proven — and point to treatment guidelines like those just issued by the APA.

It’s bad enough that most Americans don’t have adequate mental health coverage, without also being gaslighted and told that inadequate therapy is the best therapy.

The APA’s ethics code begins, “Psychologists strive to benefit those with whom they work and take care to do no harm.” APA has an honorable history of fighting for patients’ access to good care and against health insurance company abuses.

Blinded by RCT ideology, APA inadvertently handed a trump card to the worst apples in the health insurance industry.

The article is here.

Tuesday, November 28, 2017

Don’t Nudge Me: The Limits of Behavioral Economics in Medicine

Aaron E. Carroll
The New York Times - The Upshot
Originally posted November 6, 2017

Here is an excerpt:

But those excited about the potential of behavioral economics should keep in mind the results of a recent study. It pulled out all the stops in trying to get patients who had a heart attack to be more compliant in taking their medication. (Patients’ adherence at such a time is surprisingly low, even though it makes a big difference in outcomes, so this is a major problem.)

Researchers randomly assigned more than 1,500 people to one of two groups. All had recently had heart attacks. One group received the usual care. The other received special electronic pill bottles that monitored patients’ use of medication. Those patients who took their drugs were entered into a lottery in which they had a 20 percent chance to receive $5 and a 1 percent chance to win $50 every day for a year.

That’s not all. The lottery group members could also sign up to have a friend or family member automatically be notified if they didn’t take their pills so that they could receive social support. They were given access to special social work resources. There was even a staff engagement adviser whose specific duty was providing close monitoring and feedback, and who would remind patients about the importance of adherence.

This was a kitchen-sink approach. It involved direct financial incentives, social support nudges, health care system resources and significant clinical management. It failed.

The article is here.

Tuesday, May 10, 2016

Cadaver study casts doubts on how zapping brain may boost mood, relieve pain

By Emily Underwood
Science
Originally posted April 20, 2016

Here is an excerpt:

Buzsáki expects a living person’s skin would shunt even more current away from the brain because it is better hydrated than a cadaver’s scalp. He agrees, however, that low levels of stimulation may have subtle effects on the brain that fall short of triggering neurons to fire. Electrical stimulation might also affect glia, brain cells that provide neurons with nutrients, oxygen, and protection from pathogens, and also can influence the brain’s electrical activity. “Further questions should be asked” about whether 1- to 2-milliamp currents affect those cells, he says.

Buzsáki, who still hopes to use such techniques to enhance memory, is more restrained than some critics. The tDCS field is “a sea of bullshit and bad science—and I say that as someone who has contributed some of the papers that have put gas in the tDCS tank,” says neuroscientist Vincent Walsh of University College London. “It really needs to be put under scrutiny like this.”

The article is here.

Editor's note:

This article represents the importance of science in the treatment of human suffering. No one wants sham interventions.

However, the stimulation interventions may work, and work effectively, in light of other models of how the brain functions. The brain creates an electromagnetic field that moves beyond the skull.  If the cadaver's brain is shut off, this finding may be irrelevant as the stimulation affects the field that moves beyond the skull.  In other words, how these stimulation procedures influence the electromagnetic field of the brain may be a better model to explain improvement.

Therefore, using dead people to nullify what happens in living people may not be the best standard to evaluate a procedure when researching brain activity.  It is a step to consider and may help develop a better working model of what actually happens with TMS.

By the way, scientists are not exactly certain how lithium or antidepressants work, either.

Thursday, February 11, 2016

An American Psychiatric Horror Story

By Todd Essig
Forbes
Originally posted January 24, 2016

Here is an excerpt:

In order to say denying care is a good thing Bennett has to denigrate the value of the care provided. He wants readers to believe weekly psychotherapy, or whatever frequency and duration a patient and therapist determine is in the patient’s best interests, has “limited potential to heal and protect.” He concludes this because, as he writes, “Objectively, there’s little evidence that the treatment relationship is as healing, powerful or anchoring as we and our patients wish it would be…”

That is such an absurd pretzel I have to resist the urge to turn on my caps lock. Of course treatment is NEVER as amazing as people wish it would be. That’s what makes them wishes and not plans. His is a meaningless statement because not gratifying wishes for transcendent change is not an outcome measure. It is an inevitability. But that’s the reason he says therapy has limited potential.

And I should point out, every (EVERY!) medical intervention has limits. Remember the old joke about the patient who gets an unequivocal yes after asking his surgeon if he’ll be able to play the piano after the life-saving operation only to say “that’s great, I can’t play now!” Well, according to Bennett that would be reason enough for an insurance company to deny coverage for the life-saving operation.

The article is here.

Tuesday, January 19, 2016

Researcher allegiance in psychotherapy outcome research: an overview of reviews

Munder T, Brütsch O, Leonhart R, Gerger H, Barth J.
Clinical Psychology Review
Volume 33, Issue 4, June 2013, Pages 501–511

Abstract

Researcher allegiance (RA) is widely discussed as a risk of bias in psychotherapy outcome research. The relevance attached to RA bias is related to meta-analyses demonstrating an association of RA with treatment effects. However, recent meta-analyses have yielded mixed results. To provide more clarity on the magnitude and robustness of the RA-outcome association this article reports on a meta-meta-analysis summarizing all available meta-analytic estimates of the RA-outcome association. Random-effects methods were used. Primary study overlap was controlled. Thirty meta-analyses were included. The mean RA-outcome association was r = .262 (p = .002, I2 = 28.98%), corresponding to a moderate effect size. The RA-outcome association was robust across several moderating variables including characteristics of treatment, population, and the type of RA assessment. Allegiance towards the RA bias hypothesis moderated the RA-outcome association. The findings of this meta-meta-analysis suggest that the RA-outcome association is substantial and robust. Implications for psychotherapy outcome research are discussed.

The entire article is here.

Thursday, November 19, 2015

With Sobering Science, Doctor Debunks 12-Step Recovery

Interview with Lance Dodes
NPR
Originally posted March 23, 2014

Here is an excerpt:

There is a large body of evidence now looking at AA success rate, and the success rate of AA is between 5 and 10 percent. Most people don't seem to know that because it's not widely publicized. ... There are some studies that have claimed to show scientifically that AA is useful. These studies are riddled with scientific errors and they say no more than what we knew to begin with, which is that AA has probably the worst success rate in all of medicine.

It's not only that AA has a 5 to 10 percent success rate; if it was successful and was neutral the rest of the time, we'd say OK. But it's harmful to the 90 percent who don't do well. And it's harmful for several important reasons. One of them is that everyone believes that AA is the right treatment. AA is never wrong, according to AA. If you fail in AA, it's you that's failed.

Monday, May 11, 2015

The Problem With Satisfied Patients

A misguided attempt to improve healthcare has led some hospitals to focus on making people happy, rather than making them well.

Alexandra Robbins
The Atlantic
Originally published April 17, 2015

Here is an excerpt:

Patient-satisfaction surveys have their place. But the potential cost of the subjective scores are leading hospitals to steer focus away from patient health, messing with the highest stakes possible: people’s lives.

The vast majority of the thirty-two-question survey, known as HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) addresses nursing care. For example, in a section about nurses, the survey asks, “During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?”

This question is misleading because it doesn’t specify whether the help was medically necessary. Patients have complained on the survey, which in previous incarnations included comments sections, about everything from “My roommate was dying all night and his breathing was very noisy” to “The hospital doesn’t have Splenda.” A nurse at the New Jersey hospital lacking Splenda said, “This somehow became the fault of the nurse and ended up being placed in her personnel file.” An Oregon critical-care nurse had to argue with a patient who believed he was being mistreated because he didn’t get enough pastrami on his sandwich (he had recently had quadruple-bypass surgery). “Many patients have unrealistic expectations for their care and their outcomes,” the nurse said.

The entire article is here.

Tuesday, July 22, 2014

The Mind Report: Psychopaths, Morality, Neuroscience and Treatment

Laurie Santos (Yale) interviews Kent Kiehl (University of New Mexico) about his new book, The Psychopath Whisperer.  They discuss neuroscience on psychopathic prisoners, morality and the brain, and treatment research.


Friday, June 13, 2014

Teaching doctors when to stop treatment

By Diane E. Meier
The Washington Post
Originally published May 19, 2014

Here is an excerpt:

For years I had tried to understand why so many of my colleagues persisted in ordering tests, procedures and treatments that seemed to provide no benefit to patients and even risked harming them. I didn’t buy the popular and cynical explanation: Physicians do this for the money. It fails to acknowledge the care and commitment that these same physicians demonstrate toward their patients. Besides, my patient’s oncologist would make no money from the neurosurgery required for the intrathecal chemotherapy procedure.

It seemed that giving more treatment was the only way the oncologist knew to express his care and commitment. To him, stopping treatment was akin to abandoning his patient. And yet the only sense in which she felt abandoned was in her oncologist’s unwillingness to talk with her about what would happen when treatment stopped working.

The entire story is here.

Tuesday, June 10, 2014

When Doctors Treat Patients Like Themselves

By Abigail Zuger
The New York Times
Originally posted May 19, 2014

Here is an excerpt:

Professional training may not remove the interpersonal chemistry that binds us to some and estranges us from others, but it can neutralize these forces somewhat, enough to enable civilized and productive dialogue among all comers. Yet until the day when we deal only in cells, organs and genes and not their human containers, we will, for better or worse, always see ourselves in some patients, our friends and relatives in others, and our patients will likewise instinctively experience doctor as mother or father, buddy or virtual stranger.

Are the ties that bind us for better, medically, or are they for worse? Is health care more effective when patient and doctor are the same — the same sex, class, race, tax bracket, sore feet and cholesterol level? Or does essential objectivity require some differences? When your doctor looks at you and sees a mirrored reflection, is that good for you, or bad?

The entire article is here.

Wednesday, May 7, 2014

15-Minute Visits Take A Toll On The Doctor-Patient Relationship

By Roni Caryn Rabin
Kaiser Health News
Originally published April 21, 2014

Here is an excerpt:

“Doctors have one eye on the patient and one eye on the clock,” said David J. Rothman, who studies the history of medicine at Columbia University’s College of Physicians and Surgeons.

By all accounts, short visits take a toll on the doctor-patient relationship, which is considered a key ingredient of good care, and may represent a missed opportunity for getting patients more actively involved in their own health. There is less of a dialogue between patient and doctor, studies show, increasing the odds patients will leave the office frustrated.

The entire story is here.

Monday, May 5, 2014

In Medical Decisions, Dread Is Worse Than Fear

Procrastination, on the other hand, may not be so bad.

By Gabriella Rosen Kellerman
The Atlantic
Originally published April 15, 2014

Here is an excerpt:

One of the solutions Rosenberg proposed was “interventions aimed at improving risk communication.” Meaning that, perhaps if healthcare providers can help patients more rationally assess the risks for now versus later, they can help them avoid unnecessary suffering. To do so, providers will have to help patients address the assumptions that enable get-it-out-of-the-way decision-making.

What, for example, is the "it" in "get-it-out-of-the-way" thinking? The pain or consequence one wishes to avoid are often moving, even unknowable, targets. In pathological anxiety states, estimations of what “it” is are part of what goes awry. Patients with phobias consistently overestimate the degree of unpleasantness of a particular exposure.

The entire article is here.

Thursday, April 24, 2014

Study confirms impact of clinician-patient relationship on health outcomes

Meta-analysis finds relationship improvement has beneficial effects similar to some common treatments

Massachusetts General Hospital Press Release
Originally released on April 9, 2014

A meta-analysis of studies that investigated measures designed to improve health professionals' interactions with patients confirms that such efforts can produce health effects just as beneficial as taking a daily aspirin to prevent heart attack. In contrast to previous such reviews, the current report from the Empathy and Relational Science Program at Massachusetts General Hospital (MGH) only included randomized, controlled trials with more reliable results than those included in earlier studies. While it has long been believed that a good patient-clinician relationship can improve health outcomes, objective evidence to support that belief has been hard to come by.

"Although the effect we found was small, this is the first analysis of the combined results of previous studies to show that relationship factors really do make a difference in patients' health outcomes," says Helen Riess, MD, director of the Empathy and Relational Science Program in the MGH Department of Psychiatry, senior author of the report in the open-access journal PLOS ONE.

The entire press release is here.

The entire article is here.


Monday, March 24, 2014

In Health Care, Choice Is Overrated

By Ezekiel J. Emanuel
The New York Times
Originally posted March 5, 2014

Here is an excerpt:

Second, we need more transparency. Insurance companies should have to publish the measures they use to select their “high performing” or “efficient” networks. This will discourage them from looking at price alone. And consumers should be able to easily find which doctors and hospitals are included in a network. The size of a plan’s network should be as transparent as its premium.

Third, we need more reliable ways of measuring the quality of networks and the doctors and hospitals within them. The N.C.Q.A. or Consumer Reports could develop a grading system, from A to F. When comparing different plans, no one should have to rely on U.S. News and World Report’s flawed rankings or hearsay from acquaintances.

The entire story is here.

Saturday, March 8, 2014

Who’s to blame for inaccurate media coverage of study of therapy for persons with schizophrenia?

By James C. Coyne
jcoynester blog
Originally published March 7, 2014
I’m in competition with literally hundreds of stories every day, political and economic stories of compelling interest…we have to almost overstate, we have to come as close as we came within the boundaries of truth to dramatic, compelling statement. A weak statement will go no place.”                                 Journalist interviewed for JA Winsten, Science and Media: The Boundaries of Truth
Hyped, misleading media coverage of a study in Lancet of CBT for persons with unmedicated schizophrenia left lots of clinicians, policymakers, and especially persons with schizophrenia and their family members confused.

Did the study actually showed that psychotherapy was as effective as medication for schizophrenia? NO!

Did the study demonstrate that persons with schizophrenia could actually forgo medication with nasty side effects and modest effectiveness and just get on with their life with the help of CBT? NO!

The entire blog post is here.

Sunday, February 2, 2014

Doctors shame women more than men about their bodies and behavior

By Rachel Feltman
Quartz
Originally published January 16, 2014

Here is an excerpt:

Both studies found that women were significantly more likely to experience these incidents than men were: In the first cohort, which was made up of university students, 26% of women reported being “shamed” by a physician, while only 15% of the men surveyed said the same. The most common topics of this shaming were sex, dental hygiene, and weight. The second study, which included a much broader age and demographic range, showed similar results: While only 38% of men reported feeling guilt or shame because of something their physician said, 53% of women could recall such behavior.

The entire article is here.

Friday, January 24, 2014

Podcast: A Conversation about Positive Ethics

In this podcast, John Gavazzi and Sam Knapp talk positive ethics.  What is different about positive ethics as compared to presentations on ethics?  We focus on how psychologists can anchor their professional conduct and decision making on overarching and foundational ethical principles. By focusing on the moral foundations of behavior, psychologists can upgrade their quality of patient care and decision making.

At the end of the podcast, the listener will be able to:

1. Describe positive ethics
2. Explain the concept of a culture of safety
3. Identity one way to apply positive ethics to daily practice




For further reading:

Sam Knapp and Leon VandeCreek: Practical Ethics for Psychologists: A Positive Approach

Click here to earn CE credits for this podcast

Listener feedback can be sent to John Gavazzi

Thursday, January 23, 2014

Evidence based medicine is broken

By Des Spence
BMJ 2014; 348 doi: http://dx.doi.org/10.1136/bmj.g22 (Published 3 January 2014)
Cite this as: BMJ 2014;348:g22

Evidence based medicine (EBM) wrong footed the drug industry for a while in the 1990s. We could fend off the army of pharmaceutical representatives because often their promotional material was devoid of evidence. But the drug industry came to realise that EBM was an opportunity rather than a threat. Research, especially when published in a prestigious journal, was worth more than thousands of sales representatives. Today EBM is a loaded gun at clinicians’ heads. “You better do as the evidence says,” it hisses, leaving no room for discretion or judgment. EBM is now the problem, fueling overdiagnosis and overtreatment.

The entire article is here.

Sunday, January 5, 2014

Doctors and empathy: Teaching Doctor Empathy

A Better NHS
Originally posted December 20, 2013

Here is an excerpt:

If at one level empathy can be demonstrated by a ‘banal social convention’ such as acknowledging my patient’s suffering, at another, empathy is inseparable from the moral obligation to care. When we say that doctors and nurses lack empathy, at one level we might actually mean that they simply lack basic courtesy and at another deeper level we mean that they don’t actually care.


Perhaps etiquette is a thinner version of empathy as ethicist Anna Smajdor, in an excellent paper about the limits of empathy in medical education and practice concludes. She suggests that we should settle for teaching this stripped down version of empathy. After all, it is clearly in short supply as any patient or health professional will testify. Kate Granger’s experiences of being a patient with cancer, led to her powerful call for healthcare professionals to introduce themselves. #hellomynameis has made a great and lasting impression.