Evidence-based medicine (EBM) is arguably the most important contemporary initiative committed to reshaping biomedical reason and practice. The move to establish scientific research as a fundamental ...ground of medical decision making has met with an enthusiastic reception within academic medicine, but has also generated considerable controversy. EBM and the broader forms of evidence-based decision making it has occasioned raise provocative questions about the relation of scientific knowledge to social action across a variety of domains. Social science inquiry about EBM has not yet reached the scale one might expect, given the breadth and significance of the phenomenon. This paper contributes reflections, critique and analysis aimed at helping to build a more robust social science investigation of EBM. The paper begins with a “diagnostics” of the existing social science literature on EBM, emphasizing the possibilities and limitations of its two central organizing analytic perspectives: political economy and humanism. We further explore emerging trends in the literature including a turn to original empirical investigation and the embrace of “newer” theoretical resources such as postmodern critique. We argue for the need to move the social inquiry of EBM beyond concerns about rationalization and the potential erasure of the patient and, to this end, suggest new avenues of exploration. The latter include analysis of clinical epidemiology and clinical reason as the discursive preconditions of EBM, the role of the patient as a site for the production of evidence, and the textually mediated character of EBM.
Background
Palliative systematic treatment offers uncertain and often limited benefits, and the burden can be high. Hence, treatment decisions require shared decision making (SDM). This trial ...examined the independent and combined effect of an oncologist training and a patient communication aid on SDM.
Methods
In this multicenter randomized controlled trial with four parallel arms (2016–2018), oncologists (n = 31) were randomized to receive SDM communication skills training or not. The training consisted of a reader, two group sessions, a booster session, and a consultation room tool (10 hours). Patients (n = 194) with advanced cancer were randomized to receive a patient communication aid or not. The aid consisted of education on SDM, a question prompt list, and a value clarification exercise. The primary outcome was observed SDM as rated by blinded observers from audio‐recorded consultations. Secondary outcomes included patient‐reported SDM, patient and oncologist satisfaction, patients’ decisional conflict, patient quality of life 3 months after consultation, consultation duration, and the decision made.
Results
The oncologist training had a large positive effect on observed SDM (Cohen's d = 1.12) and on patient‐reported SDM (d = 0.73). The patient communication aid did not improve SDM. The combination of interventions did not add to the effect of training oncologists only. The interventions affected neither patient nor oncologist satisfaction with the consultation nor patients’ decisional conflict, quality of life, consultation duration, or the decision made.
Conclusion
Training medical oncologists in SDM about palliative systemic treatment improves both observed and patient‐reported SDM. A patient communication aid does not. The incorporation of skills training in (continuing) educational programs for medical oncologists is likely to stimulate the widely advocated uptake of shared decision making in clinical practice. Trial registration. Netherlands Trial Registry NTR 5489.
Implications for Practice
Treatment for advanced cancer offers uncertain and often small benefits, and the burden can be high. Hence, treatment decisions require shared decision making (SDM). SDM is increasingly advocated for ethical reasons and for its beneficial effect on patient outcomes. Few initiatives to stimulate SDM are evaluated in robust designs. This randomized controlled trial shows that training medical oncologists improves both observed and patient‐reported SDM in clinical encounters (n = 194). A preconsultation communication aid for patients did not add to the effect of training oncologists. SDM training effectively changes oncologists’ practice and should be implemented in (continuing) educational programs.
Decisions about treatment for advanced cancer require shared decision making, involving both physician and patient. This trial examined the independent and combined effect of oncologist training and a patient communication aid on shared decision making about palliative chemotherapy.
The employment of ultrathin Li metal electrodes with matched capacity with current cathodes and improved electrochemical stripping/plating behaviors plays a key role in the realization of ...high‐energy‐density batteries. However, their fabrication remains challenging using regular cold rolling processing due to inferior processibility of metallic Li. Herein, a facile molten metal doctor‐blade casting approach is explored to fabricate uniform metallic Li layers with thickness ranging from 10 to 50 µm on regular battery Cu current collectors with a lithiophilic Sn interphase layer. The enhanced surface wettability between Li and the spontaneously formed Li–Sn alloy helps to realize uniform spreading, and formation of an ultrathin and uniform metallic Li layer. The existence of the Li–Sn alloy in the bulk of metallic Li electrode helps to reduce the nucleation barrier and improve the electrochemical performance of the Li metal. With a cathode areal capacity of 2.8 mA h cm−2 the LiCoO2||Li/Li–Sn full cell shows improved capacity retention from 58% to 77% after 100 cycles at a lower Negative/Positive ratio of 2/1, offering a high energy density of 662.4 W h kg−1. The enhanced electrochemical performance of the as‐fabricated ultrathin Li metal electrode with high energy density opens up a promising pathway for realizing next‐generation high‐energy‐density batteries.
Ultrathin Li/Li–Sn electrodes (10–50 µm) with uniform distributed Li–Sn alloy particles are readily fabricated on lithiophilic Cu/Sn current collectors through a simple doctor‐blading casting method. The resultant Li/Li–Sn electrodes with controlled areal capacities demonstrate high energy density and superior electrochemical performance in carbonate‐based electrolytes.
Today the doctor-patient relationship typically takes place in a face-to-face setting. However, with the advent of artificial intelligence (AI) systems, two further interaction scenarios are ...possible: an AI system supports the doctor’s decision regarding diagnosis and/or treatment while interacting with the patient, or an AI system could even substitute the doctor and hence a patient interacts with a chatbot (i.e., a machine) alone. Against this background, we report on an online experiment in which we analyzed data from N = 1,183 people. The data was collected in German-speaking countries (Germany, Austria, Switzerland). The participants were asked to imagine they had been suffering from medical conditions of unknown origin for some time and that they were therefore visiting a health center to seek advice from a doctor. We developed descriptions of patient-doctor interactions (referred to as vignettes), thereby manipulating the patient’s interaction partner: (i) human doctor, (ii) human doctor with an AI system, and (iii) an AI system only (i.e., chatbot). Furthermore, we manipulated medical discipline: (i) cardiology, (ii) orthopedics, (iii) dermatology, and (iv) psychiatry. Based on this 3 × 4 experimental within-subjects design, our results indicate that people prefer a human doctor, followed by a human doctor with an AI system, and an AI system alone came in last place. Specifically, based on these 12 hypothetical interaction situations, we found a significant main effect of a patient’s interaction partner on trust, distrust, perceived privacy invasion, information disclosure, treatment adherence, and satisfaction. Moreover, perceptions of trust, distrust, and privacy invasion predicted information disclosure, treatment adherence, and satisfaction as a function of interaction partner and medical discipline. We found that the situation in psychiatry is different from the other three disciplines. Specifically, the six outcome variables differed strongly between psychiatry and the three other disciplines in the “human doctor with an AI system” condition, while this effect was not that strong in the other conditions (human doctor, chatbot). These findings have important implications for the use of AI in medical care and in the interaction between patients and their doctors.
The aim of this study was to analyse with sequence analysis physician–patient dialogue surrounding patients’ expression of emotional cues. Two samples, sample 1 consisting of 36 cancer patient ...consultations conducted by four oncologists, and sample 2 consisting 79 consultations of haematology patients conducted by nine specialists, were audiotaped and coded with the Roter Interaction Analysis System (RIAS). Sequence analysis by means of a generalized sequential querier (GSEQ) was applied to the coded data. Lag sequential analysis (analysed using RIAS categories) showed that certain behaviours of physicians corresponded with patients’ expressions of concern. Physicians in both samples used silence and minimal encouragers before patient concern. The oncologists also used optimistic and affirming responses. The most common physician responses to patients’ concern were minimal encouragers or affirming and optimistic responses. Sequence analysis based on RIAS coding appears to be a promising method for the study of doctor–patient dialogue and should be utilized more in studies of the communication process in medical consultations.
Background: Being a doctor is physically and mentally challenging but immensely satisfying, as it is one of the most sought-after professions in India. Every year, about 20 lakh candidates appear for ...the National Eligibility and Entrance Test, commonly known as the NEET examination, of whom only 80,000 (4%) can secure a seat in a medical college (about 43,000 in government colleges and 37,000 in private institutions). Through a mailed questionnaire, we compared why our students became doctors in India and how they differed from their compatriots in Western countries. Aims: Was the motivation to become a doctor not altruistic but more influenced by financial rewards and social status, and did it change over the years? Was there a difference in the ambitions of those who regretted taking medicine as a career? Materials and Methods: We prepared a questionnaire using Google Forms and sent it through WhatsApp and email to 1000 doctors who had completed their final MBBS examination, including a 1-year compulsory internship, and were working in India as residents, medical officers, consultants in public or private hospitals or running their establishments. The results we received automatically over the Google Forms were analysed. Results: Out of 1000 questionnaires sent to doctors all over India, we received 265 responses. ‘Self-interest/passion for the profession, to relieve suffering’, ‘financial security’ and ‘prestige associated with the profession’ were the most common motivating factors. Seventy-one respondents (26.8%) regretted taking medicine as a career, and they were especially those candidates who joined medicine due to their ‘parent’s wishes’ ( P = 0.009), ‘as a means to go abroad’ ( P = 0.03) and ‘not sure’ ( P < 0.001). Out of those who regretted choosing medicine as a career, only eight wanted to change to a non-medical job. Conclusions: India, a developing country with the world’s largest population, grapples with healthcare challenges. Medical students, often burdened by family expectations, struggle with intrinsic motivation. To address this, we can implement strategies such as lifestyle adjustments, mentorship improvements and granting more autonomy. In addition, compulsory internships can guide students towards their desired career paths.
This paper describes general practitioners’ (GPs) experiences of detecting and managing alcohol and alcohol-related problems in consultations. We undertook qualitative research in two phases in the ...North-East of England. Initially, qualitative interviews with 29 GPs explored their everyday work with patients with alcohol-related issues. We then undertook group interviews—two with GPs and one with a primary care team—where they discussed and challenged findings of the interviews. The GPs reported routinely discussing alcohol with patients with a range of alcohol-related problems. GPs believed that this work is important, but felt that until patients were willing to accept that their alcohol consumption was problematic they could achieve very little. They tentatively introduced alcohol as a potential problem, re-introduced the topic periodically, and then waited until the patient decided to change their behaviour. They were aware that they could identify and manage more patients. A lack of time and having to work with the multiple problems that patients brought to consultations were the main factors that stopped GPs managing more risky drinkers. Centrally, we compared the results of our study with Thom, B., & Tellez, C. (1986). A difficult business—Detecting and managing alcohol-problems in general-practice.
British Journal of Addiction, 81, 405–418 seminal study that was undertaken 20 years ago. We show how the intellectual, moral, emotional and practical difficulties that GPs currently face are quite similar to those faced by GPs from 20 years ago. As the definition of what could constitute abnormal alcohol consumption has expanded, so the range of consultations that they may have to negotiate these difficulties in has also expanded.
Abstract Objective To review research on emotional communication in medical interviews regarding predictors, physiological correlates and effects of clinicians’ responses to patients’ cues and ...concerns and individual differences among patients. Methods A selective review of research literature on emotional communication in medical interviews was conducted. Results Four questions regarding emotional communication were explored: What factors predict how clinicians respond to emotional cues and concerns? What happens in the brain and the body of both patients and clinicians during emotional talk? Are there individual differences in patients’ responses to emotional talk in medical interviews? Do clinicians’ responses to emotion affect health outcome? Conclusion Building on evidence reviewed, research on predictors of clinician responses, physiological correlates of behavior, individual differences and effects on outcome should be further pursued. Practice implications In communication skills training programs, better understanding of the phenomena described could have implications for training clinicians to handle emotions in clinical interviews.
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