Involving patients in decisions about preventive medication : A focus group study

Original article can be found at: http://www.pccj.eu/ Copyright Sherborne Gibbs Ltd. [reproduced here with permission of publishers]Background: Patients may have unrealistic expectations of preventive treatment and frequently do not take long-term medication. Involvement of the patient in the decision to start such medication may improve this, but enabling an informed decision is notoriously difficult. Aims: To explore patients' perceptions of preventive medication, the desire for informed choice and how this could best be achieved. Method: Purposive sampling was used to select patients registered with one of two general practices in South England. Audio recording, transcription and computer-assisted textual analysis were conducted for focus group discussions. Results: This was a small study, but the majority of focus group participants who had been prescribed a preventive medication said they received very little or no information about benefits and disadvantages when it was started. Some felt that doctors did not want to share information. Older participants thought that choice was over-rated, trusted their doctor to recommend appropriate medication and did not necessarily wish to be involved in the decision. Younger participants wanted to be more involved. However, even those who expressed little interest in involvement felt that personalised information compared with population norms comparing individuals to the 'average person' would be helpful. Written information specific to the individual and on how the medication or lifestyle changes might affect them was considered welcome. Conclusions: Doctors need to be sensitive to patients' preferences for involvement in the decision-making process and for the way information on risk is shared. Providing written information specific to the individual patient is likely to facilitate shared decisions about preventive medication.Peer reviewedFinal Published versio

Another argument for values-based medicine

There is a contemporary dialectic concerning the status of evidence-based medicine, criticising it for being ‘scientistic’, epistemologically inconsistent, rigid and dismissive of non-numerical sources of knowledge. A host of alternative frameworks has been proposed, including values-based medicine, narrative medicine, patient-centered care and personcentered medicine. Person-centered medicine is amongst the most persuasive and well-argued models. Miles and Mezzich [1] have argued in a major article that person-centered medicine employs theories of personhood to elaborate and justify its epistemology and praxis. At the same time, they claim that person-centered medicine is an ‘emergent’ concept that needs no base or foundation to justify it. We believe, however, that without some foundational values to underpin the status claimed for personhood, the arguments for person-centered medicine are incomplete. We therefore propose a set of foundational values – survival, security and flourishing – that underpin individual and social functioning transculturally. While these values are the same in all cultures, their expressions differ from culture to culture. Importantly, our notion of values is only modestly foundational. Modest foundationalism recognises that foundational propositions are only ‘warrantable assertions’ that may very well change in time and place. Foundational values in this sense are pragmatic and heuristic in kind and not normative. We enter a plea for their recognition in the form of the values-based medicine we describe. Keywords Evidence-based medicine, medical epistemology, modest foundationalism, person-centered medicine, values-based medicin

Another argument for values-based medicine

There is a contemporary dialectic concerning the status of evidence-based medicine, criticising it for being ‘scientistic’, epistemologically inconsistent, rigid and dismissive of non-numerical sources of knowledge. A host of alternative frameworks has been proposed, including values-based medicine, narrative medicine, patient-centered care and personcentered medicine. Person-centered medicine is amongst the most persuasive and well-argued models. Miles and Mezzich [1] have argued in a major article that person-centered medicine employs theories of personhood to elaborate and justify its epistemology and praxis. At the same time, they claim that person-centered medicine is an ‘emergent’ concept that needs no base or foundation to justify it. We believe, however, that without some foundational values to underpin the status claimed for personhood, the arguments for person-centered medicine are incomplete. We therefore propose a set of foundational values – survival, security and flourishing – that underpin individual and social functioning transculturally. While these values are the same in all cultures, their expressions differ from culture to culture. Importantly, our notion of values is only modestly foundational. Modest foundationalism recognises that foundational propositions are only ‘warrantable assertions’ that may very well change in time and place. Foundational values in this sense are pragmatic and heuristic in kind and not normative. We enter a plea for their recognition in the form of the values-based medicine we describe. Keywords Evidence-based medicine, medical epistemology, modest foundationalism, person-centered medicine, values-based medicin

Values as ‘modest foundations’ for medicine

Medicine and healthcare have been around for thousands of years, but we seldom ask why they are so important. It seems self-evident that we should seek relief of suffering from some institution in the society in which we live and equally selfevident that each society should provide healthcare for its people at some level. Yet when we inquire further, we are driven to seek foundational answers to iterative questions, seeking answers at deeper and deeper levels. Ultimately, it seems best to accept the Humean refuge [1] and finish with some such statement as "Humans are like that" or "Societies can't function in any other way". These Humean questions suggest that survival, security and flourishing are endpoints for such an inquiry and that medical (and many other) systems are built on these implicit foundations. The ways in which societies build relevant systems (such as medicine, welfare, law, transport, housing and so on) will differ strikingly, but common ground will still exist at the foundational level. Acknowledging a commonality of foundations does not commit one either to a conservative normativity, nor to a loose relativism. Increasing activity at the level of the International Court of Justice makes clear that there is a possibility of consensus for judging the validity of the interpretations and enactments of foundational values in any society. The ideals of the American Declaration of Independence — life, liberty and the pursuit of happiness — are principles very similar to the foundational values of survival, security and flourishing. Person-centered medicine is inescapably based on theories of the person and must therefore be able to offer an account of what personhood is. Values underpin the philosophy and practice of medicine, including person-centered medicine, because they are foundations of personhood, as well as foundations of the societies in which each person lives. Keywords: Discourse, evidence-based medicine, foundationalism, medical epistemology, narrative-based medicine, person-centered medicine, reform, values-based medicinen/

Making decisions in the mechanistic, probabilistic and scientific domains of medicine: a qualitative study of medical practitioners

Rationale, aims and objectives: To find out how medical practitioners perceive the processes of decision-making in the context of the individual patient and to examine the importance of decision- making in the development and identity of medical practitioners throughout their clinical lives and to suggest how these perceptions might influence medical pedagogy. Method:A qualitative study of medical practitioners of varying ages and specialties, using loosely structured biographical interviews that were read to determine the different ways in which decisions were constructed and recalled and the impact these decisions were felt to have onboth the decision-maker and othersfor whom the decision was salient. Results: Personal decisions about career choice were important because they shaped the life of the practitioner and made a significant impact on those around them. Professional decisions were made in the domains of the mechanistic and probabilistic scientific world of medicine and in the domain of human relationships, emotions and suffering. There was often a tension between the different domains and the context of the life-world often modified decisions that might logically have been determined by evidence-based medicine and its bio-knowledge. Conclusions: Decisions had a strong effect on the development of identity within the field of practice. Individuals came to see themselves as doctors who made certain kinds of decisions of immediate relevance to the individual patient. Teaching medical students and graduates how to apply evidence to their decisions and how to use formal computational decision aids may well have a useful place in pedagogy, but the impact of decision-making on the lives of doctors and their individual patients deserves at least equal emphasis. Keywords Bio-knowledge, decisions, identity, life-world, personal developmen

Testing the assumptions of linear prediction analysis in normal vowels

This paper develops an improved surrogate data test to show experimental evidence, for all the simple vowels of US English, for both male and female speakers, that Gaussian linear prediction analysis, a ubiquitous technique in current speech technologies, cannot be used to extract all the dynamical structure of real speech time series. The test provides robust evidence undermining the validity of these linear techniques, supporting the assumptions of either dynamical nonlinearity and/or non-Gaussianity common to more recent, complex, efforts at dynamical modelling speech time series. However, an additional finding is that the classical assumptions cannot be ruled out entirely, and plausible evidence is given to explain the success of the linear Gaussian theory as a weak approximation to the true, nonlinear/non-Gaussian dynamics. This supports the use of appropriate hybrid linear/nonlinear/non-Gaussian modelling. With a calibrated calculation of statistic and particular choice of experimental protocol, some of the known systematic problems of the method of surrogate data testing are circumvented to obtain results to support the conclusions to a high level of significance

Supporting Self-management Among Young People With Acne Vulgaris Through a Web-Based Behavioral Intervention: Development and Feasibility Randomized Controlled Trial

Background: Acne is a common skin condition that is most prevalent in young people. It can have a substantial impact on the quality of life, which can be minimized with the appropriate use of topical treatments. Nonadherence to topical treatments for acne is common and often leads to treatment failure. Objective: The aim of this study is to develop a web-based behavioral intervention to support the self-management of acne and to assess the feasibility of recruitment, retention, and engagement of users with the intervention. Methods: The intervention was developed iteratively using the LifeGuide software and following the person-based approach for intervention development. The target behavior was appropriate use of topical treatments. Barriers and facilitators identified from the qualitative research and evidence from the wider literature were used to identify techniques to improve and promote their use. Young people with acne aged 14-25 years who had received treatment for acne in the past 6 months were invited to participate through mail-out from primary care practices in the South of England in a parallel, unblinded randomized trial. Participants were automatically randomized using a computer-generated algorithm to usual care or to usual care plus access to the web-based intervention. Usage data was collected, and a series of questionnaires, including the primary outcome measure for skin-specific quality of life (Skindex-16), were collected at baseline and at the 4- and 6-week follow-ups. Results: A total of 1193 participants were invited, and 53 young people with acne were randomized to usual care (27/53, 51%) or usual care plus intervention (26/53, 49%). The response rate for the primary outcome measure (Skindex-16) was 87% at 4 weeks, 6 weeks, and at both time points. The estimate of mean scores between groups (with 95% CI) using linear regression showed a trend in the direction of benefit for the web-based intervention group in the primary outcome measure (Skindex-16) and secondary measures (Patient Health Questionnaire-4 and the Problematic Experiences of Therapy Scale). Intervention usage data showed high uptake of the core module in the usual care plus web-based intervention group, with 88% (23/26) of participants completing the module. Uptake of the optional modules was low, with less than half visiting each (myth-busting quiz: 27%; living with spots or acne: 42%; oral antibiotics: 19%; what are spots or acne: 27%; other treatments: 27%; talking to your general practitioner: 12%). Conclusions: This study demonstrated the feasibility of delivering a trial of a web-based intervention to support self-management in young people with acne. Additional work is needed before a full definitive trial, including enhancing engagement with the intervention, recruitment, and follow-up rates

Electro-optically tunable microring resonators in lithium niobate

Optical microresonators have recently attracted a growing attention in the photonics community. Their applications range from quantum electro-dynamics to sensors and filtering devices for optical telecommunication systems, where they are likely to become an essential building block. The integration of nonlinear and electro-optical properties in the resonators represents a very stimulating challenge, as it would incorporate new and more advanced functionality. Lithium niobate is an excellent candidate material, being an established choice for electro-optic and nonlinear optical applications. Here we report on the first realization of optical microring resonators in submicrometric thin films of lithium niobate. The high index contrast films are produced by an improved crystal ion slicing and bonding technique using benzocyclobutene. The rings have radius R=100 um and their transmission spectrum has been tuned using the electro-optic effect. These results open new perspectives for the use of lithium niobate in chip-scale integrated optical devices and nonlinear optical microcavities.Comment: 15 pages, 8 figure