Background
Clinician bias contributes to healthcare disparities, and the language used to describe a patient may reflect that bias. Although medical records are an integral method of communicating ...about patients, no studies have evaluated patient records as a means of transmitting bias from one clinician to another.
Objective
To assess whether stigmatizing language written in a patient medical record is associated with a subsequent physician-in-training’s attitudes towards the patient and clinical decision-making.
Design
Randomized vignette study of two chart notes employing stigmatizing versus neutral language to describe the same hypothetical patient, a 28-year-old man with sickle cell disease.
Participants
A total of 413 physicians-in-training: medical students and residents in internal and emergency medicine programs at an urban academic medical center (54% response rate).
Main Measures
Attitudes towards the hypothetical patient using the previously validated Positive Attitudes towards Sickle Cell Patients Scale (range 7–35) and pain management decisions (residents only) using two multiple-choice questions (composite range 2–7 representing intensity of pain treatment).
Key Results
Exposure to the stigmatizing language note was associated with more negative attitudes towards the patient (20.6 stigmatizing vs. 25.6 neutral,
p
< 0.001). Furthermore, reading the stigmatizing language note was associated with less aggressive management of the patient’s pain (5.56 stigmatizing vs. 6.22 neutral,
p
= 0.003).
Conclusions
Stigmatizing language used in medical records to describe patients can influence subsequent physicians-in-training in terms of their attitudes towards the patient and their medication prescribing behavior. This is an important and overlooked pathway by which bias can be propagated from one clinician to another. Attention to the language used in medical records may help to promote patient-centered care and to reduce healthcare disparities for stigmatized populations.
It has been widely demonstrated that patient education and empowerment, especially involving shared treatment decisions, improve patient outcomes in chronic medical conditions, including chronic ...kidney disease requiring kidney replacement therapies. Accordingly, regulatory agencies in the US and worldwide recommend shared decision-making for finalizing one's choice of kidney replacement therapy. It is also recognized that the US needs to substantially increase home dialysis utilization to leverage its positive impacts on patient and healthcare cost-related outcomes. This perspective highlights how the routine clinical use of the recommended practice of shared decision-making can exist in synergy with the system's goal for increased home dialysis use. It introduces a pragmatic provider checklist, The Nephrologist's Shared Decision-Making Checklist, grounded in the relevant theories of shared decision-making, and, unlike some research assessments and extant tools, is easy to understand and implement in clinical practice. This qualitative Checklist can help providers ensure that they have co-constructed an SDM experience with the patient and involved caretakers, helping them benefit from the improved outcomes associated with SDM.
This article explores how a collaboration technology called Artificial Swarm Intelligence (ASI) addresses the limitations associated with group decision making, amplifies the intelligence of human ...groups, and facilitates better business decisions. It demonstrates of how ASI has been used by businesses to harness the diverse perspectives that individual participants bring to groups and to facilitate convergence upon decisions. It advances the understanding of how artificial intelligence (AI) can be used to enhance, rather than replace, teams as they collaborate to make business decisions.
We develop a framework to investigate the foundations of an ‘entrepreneurial mindset’ — described by scholars as the ability to sense, act, and mobilize under uncertain conditions. We focus on ...metacognitive processes that enable the entrepreneur to think beyond or re-organize existing knowledge structures and heuristics, promoting adaptable cognitions in the face of novel and uncertain decision contexts. We integrate disparate streams of literature from social and cognitive psychology toward a model that specifies
entrepreneurial metacognition as situated in the entrepreneurial environment. We posit that foundations of an entrepreneurial mindset are metacognitive in nature, and subsequently detail how, and with what consequence, entrepreneurs formulate and inform “higher-order” cognitive strategies in the pursuit of entrepreneurial ends.
We conducted a preregistered close replication and extension of Studies 1, 2, and 4 in Hsee (1998). Hsee found that when evaluating choices jointly, people compare and judge the option higher on ...desirable attributes as better ("more is better"). However, when people evaluate options separately, they rely on contextual cues and reference points, sometimes resulting in evaluating the option with less as being better ("less is better"). We found support for "less is better" across all studies (N = 403; Study 1 original d = 0.70 0.24,1.15, replication d = 0.99 0.72,1.26; Study 2 original d = 0.74 0.12,1.35, replication d = 0.32 0.07,0.56; Study 4 original d = 0.97 0.43,1.50, replication d = 0.76 0.50,1.02), with weaker support for "more is better" (Study 2 original d = 0.92 0.42,1.40, replication dsub.z = 0.33 .23,.43; Study 4 original d = 0.37 0.02,0.72, replication dsub.z = 0.09 -0.05,0.23). Some results of our exploratory extensions were surprising, leading to open questions. We discuss remaining implications and directions for theory and measurement relating to economic rationality and the evaluability hypothesis. Materials/data/code: https://osf.io/9uwns/
The Soviet experience in Afghanistan provides a compelling perspective on the far-reaching hazards of military intervention. In 1985, Mikhail Gorbachev decided that a withdrawal from Afghanistan ...should occur as soon as possible. The Soviet Union's senior leadership had become aware that their strategy was unraveling, their operational and tactical methods were not working, and the sacrifices they were demanding from the Soviet people and military were unlikely to produce the forecasted results. Despite this state of affairs, operations in Afghanistan persisted and four more years passed before the Soviets finally withdrew their military forces.
In No Miracles, Michael Fenzel explains why and how that happened, as viewed from the center of the Soviet state. From that perspective, three sources of failure stand out: poor civil-military relations, repeated and rapid turnover of Soviet leadership, and the perception that Soviet global prestige and influence were inexorably tied to the success of the Afghan mission. Fenzel enumerates the series of misperceptions and misjudgments that led to the Soviet invasion of Afghanistan, tracing the hazards of their military intervention and occupation. Ultimately, he offers a cautionary tale to nation states and policymakers considering military intervention and the use of force.
Sustainable supplier selection (SSS) is an essential part of the decision-making process in sustainable supply chains. Numerous research studies have been conducted using various decision-making ...methods to attend to this research-worthy issue. This literature review presents a comprehensive SSS analysis focusing on social, economic, and environmental aspects. The present study spans five years (2018–2022) and considers 101 papers. It provides a detailed breakdown of the papers based on their dates of publication, the countries of the writers, application fields, and journals, and it categorizes them based on their approaches. In addition, this review examines the use of single- or hybrid-form methodologies in the papers reviewed. It also identifies that the TOPSIS, AHP, VIKOR, BWM, DEA, DEMATEL, and MULTIMOORA methods and their extensions are the most frequently used methods in SSS studies. It is concluded that hybrid approaches and their rough, grey, and fuzzy extensions are used to solve real-world problems. However, state-of-the-art mathematical tools, such as soft sets and their hybrid versions with fuzzy sets, have not been utilized in SSS studies. Therefore, this study inspires and encourages the use of such tools in SSS research.
We report the nationwide experience with solid organ transplant (SOT) and hematopoietic stem cell transplant (HSCT) recipients diagnosed with coronavirus disease 2019 (COVID‐19) in Spain until 13 ...July 2020. We compiled information for 778 (423 kidney, 113 HSCT, 110 liver, 69 heart, 54 lung, 8 pancreas, 1 multivisceral) recipients. Median age at diagnosis was 61 years (interquartile range IQR: 52‐70), and 66% were male. The incidence of COVID‐19 in SOT recipients was two‐fold higher compared to the Spanish general population. The median interval from transplantation was 59 months (IQR: 18‐131). Infection was hospital‐acquired in 13% of cases. No donor‐derived COVID‐19 was suspected. Most patients (89%) were admitted to the hospital. Therapies included hydroxychloroquine (84%), azithromycin (53%), protease inhibitors (37%), and interferon‐β (5%), whereas immunomodulation was based on corticosteroids (41%) and tocilizumab (21%). Adjustment of immunosuppression was performed in 85% of patients. At the time of analysis, complete follow‐up was available from 652 patients. Acute respiratory distress syndrome occurred in 35% of patients. Ultimately, 174 (27%) patients died. In univariate analysis, risk factors for death were lung transplantation (odds ratio OR: 2.5; 95% CI: 1.4‐4.6), age >60 years (OR: 3.7; 95% CI: 2.5‐5.5), and hospital‐acquired COVID‐19 (OR: 3.0; 95% CI: 1.9‐4.9).
The authors report the Spanish nationwide experience with solid organ and hematopoietic stem cell transplant recipients diagnosed with COVID‐19, revealing a higher incidence and more aggressive course of infection than in the general population.
Many factors are postulated to affect guidelines developments. We set out to identify the key determinants.
a) Web-based survey of 12 panels of 153 “voting” members who issued 2941 recommendations; ...b) qualitative analysis of 13 panels of 311 attendees (panel members, systematic review teams and observers).
Compared with “no recommendations”, when intervention's benefit outweigh harms (BH-balance), probability of issuing strong recommendations in favor of intervention was 0.22 (95%CI: 0.08 to 0.36) when certainty of evidence (CoE) was very low; 0.5 (95%CI:0.36 to 0.63) when low; 0.74 (95%CI 0.61 to 0.87) when moderate and 0.85 (95%CI:0.71 to 1.00) when high. No other postulated factor significantly affected recommendations. The findings are consistent with a J- curve model when recommendations are issued in favor but not against an intervention. Panelists often changed their judgments as a result of the meeting discussion (67% for CoE to 92% for balance between benefits and harms). The panels spent over 50% of their time debating CoE; the chairs and co-chairs dominated discussion.
CoE and BH-balance are key determinants of recommendations in favor of an intervention. Chairs and co-chairs dominate discussion. Panelists often change their judgments as a result of panel deliberation.
The left side (A) of the graph shows a theoretical model for development of guidelines recommendations according to which the probability of recommending health intervention (Rx1) is a mirror image of the probability of recommending alternative intervention (Rx2) (U-curve model). Other evidence-based health care (EBHC) and non-EBHC factors act as mediators of the interaction between certainty of evidence (CoE) and balance between benefits and harms (BH_balance). The right side (B) of the graph shows empirical assessment of the theoretical model shown on the left. The empirical evaluation points to the J-curve model as the best explanation of the process of guidelines developments. Only CoE and BH_balance are sufficient to describe the entire process; no other factors postulated in the model shown on the left were needed to explain how the panels develop guidelines recommendations - see text for details. Note that we don't consider our the results shown on the right side as the U-curve despite its resemblance to U letter because of the lack of statistical significance for the relationship of issuing recommendations for comparator- see Table 2a and text; Abbreviations: COI- conflict of interests; V&P- values and preferences; B-benefits; H-harms. Display omitted
While the historic management of food allergy includes avoidance strategies and allergic reaction treatment, oral immunotherapy (OIT) approaches have become more commonly integrated into therapeutic ...approaches. International guidelines, phase 3 trials and real‐world experience have supported the implementation of this procedure. However, OIT is an elective, rarely curative procedure with inherent risks that necessitates an increased degree of health literacy for the patients and families. Families assume the responsibility of amateur healthcare providers to ensure the daily safe administration of the allergenic food. As such, it is incumbent upon physicians to ensure that families are prepared for this role. A thorough educational and shared decision‐making approach is necessary during the counselling and consent process to adequately inform the families. Educated discussion about the efficacy and patient‐centred effectiveness, therapeutic alternatives and family goals is required to align physician and patient expectations. A frank discussion about the struggles, practical challenges, risks and contraindications can help to develop an understanding of the risk mitigation strategies employed to maintain safety. Physicians should develop a proactive approach to educate families about this, at times, burdensome procedure. This educational approach should encourage ongoing support starting prior to consent through the maintenance visits. By preparing families for their unique management role, physicians can help ensure the safe and successful integration of OIT into the therapeutic offering for the management of food allergies.
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