The role of conversation in health care interventions: enabling sensemaking and learning

<p>Abstract</p> <p>Background</p> <p>Those attempting to implement changes in health care settings often find that intervention efforts do not progress as expected. Unexpected outcomes are often attributed to variation and/or error in implementation processes. We argue that some unanticipated variation in intervention outcomes arises because unexpected conversations emerge during intervention attempts. The purpose of this paper is to discuss the role of conversation in shaping interventions and to explain why conversation is important in intervention efforts in health care organizations. We draw on literature from sociolinguistics and complex adaptive systems theory to create an interpretive framework and develop our theory. We use insights from a fourteen-year program of research, including both descriptive and intervention studies undertaken to understand and assist primary care practices in making sustainable changes. We enfold these literatures and these insights to articulate a common failure of overlooking the role of conversation in intervention success, and to develop a theoretical argument for the importance of paying attention to the role of conversation in health care interventions.</p> <p>Discussion</p> <p>Conversation between organizational members plays an important role in the success of interventions aimed at improving health care delivery. Conversation can facilitate intervention success because interventions often rely on new sensemaking and learning, and these are accomplished through conversation. Conversely, conversation can block the success of an intervention by inhibiting sensemaking and learning. Furthermore, the existing relationship contexts of an organization can influence these conversational possibilities. We argue that the likelihood of intervention success will increase if the role of conversation is considered in the intervention process.</p> <p>Summary</p> <p>The generation of productive conversation should be considered as one of the foundations of intervention efforts. We suggest that intervention facilitators consider the following actions as strategies for reducing the barriers that conversation can present and for using conversation to leverage improvement change: evaluate existing conversation and relationship systems, look for and leverage unexpected conversation, create time and space where conversation can unfold, use conversation to help people manage uncertainty, use conversation to help reorganize relationships, and build social interaction competence.</p

What you know can influence what you are going to know (especially for older adults)

Stimuli related to an individual's knowledge/experience are often more memorable than abstract stimuli, particularly for older adults. This has been found when material that is congruent with knowledge is contrasted with material that is incongruent with knowledge, but there is little research on a possible graded effect of congruency. The present study manipulated the degree of congruency of study material with participants’ knowledge. Young and older participants associated two famous names to nonfamous faces, where the similarity between the nonfamous faces and the real famous individuals varied. These associations were incrementally easier to remember as the name-face combinations became more congruent with prior knowledge, demonstrating a graded congruency effect, as opposed to an effect based simply on the presence or absence of associations to prior knowledge. Older adults tended to show greater susceptibility to the effect than young adults, with a significant age difference for extreme stimuli, in line with previous literature showing that schematic support in memory tasks particularly benefits older adults

Rethinking Serious Games Design in the Age of COVID-19: Setting the Focus on Wicked Problems

We live in a complex world, in which our existence is defined by forces that we cannot fully comprehend, predict, nor control. This is the world of wicked problems, of which the situation triggered by the COVID-19 pandemic is a notable example. Wicked problems are complex scenarios defined by the interplay of multiple environmental, social and economic factors. They are everchanging, and largely unpredictable and uncontrollable. As a consequence, wicked problems cannot be definitively solved through traditional problem-solving approaches. Instead, they should be iteratively managed, recognizing and valuing our connectedness with each other and the environment, and engaging in joint thinking and action to identify and pursue the common good. Serious games can be key to foster wicked problem management abilities. To this end, they should engage players in collective activities set in contexts simulating real-world wicked problem scenarios. These should require the continuous interpretation of changing circumstances to identify and pursue shared goals, promoting the development of knowledge, attitudes and skill sets relevant to tackle real-world situations. In this paper we outline the nature, implications and challenges of wicked problems, highlighting why games should be leveraged to foster wicked problem management abilities. Then, we propose a theory-based framework to support the design of games for this purpose

Outcome and quality of life after aorto-bifemoral bypass surgery

<p>Abstract</p> <p>Background</p> <p>Aorto-bifemoral bypass (AFB) is commonly performed to treat aorto-iliac disease and a durable long-term outcome is achieved. Most studies documenting beneficial outcomes after AFB have been limited to mortality and morbidity rates, costs and length of hospital stay (LOS). Few studies have examined the dependency of patients and how their perception of their own health changes after surgery. The aim of the present study was to evaluate outcome after AFB and to study its determinants.</p> <p>Methods</p> <p>This retrospective study was carried out in the multidisciplinary Post-Anaesthesia Care Unit (PACU) with five intensive care beds. Out of 1597 intensive care patients admitted to the PACU, 75 were submitted to infrarenal AFB and admitted to these intensive care unit (ICU) beds over 2 years. Preoperative characteristics and outcome were evaluated by comparing occlusive disease with aneurysmatic disease patients. Six months after discharge, the patients were contacted to complete a Short Form-36 questionnaire (SF-36) and to have their dependency in Activities of Daily Living (ADL) evaluated. Patient's characteristics and postoperative follow-up data were compared using Mann-Whitney U test, t test for independent groups, chi-square or Fisher's exact test. Patient preoperative characteristics were evaluated for associations with mortality using a multiple logistic regression analysis.</p> <p>Results</p> <p>The mortality rate was 12% at six months. Multivariate analysis identified congestive heart disease and APACHE II as independent determinants for mortality. Patients submitted to AFB for occlusive disease had worse SF-36 scores in role physical and general health perception. Patients submitted to AFB had worse SF-36 scores for all domains than a comparable urban population and had similar scores to other PACU patients. Sixty-six percent and 23% of patients were dependent in at least one activity in instrumental and personal ADL, respectively, but 64% reported having better general health.</p> <p>Conclusion</p> <p>This study shows that congestive heart disease and APACHE II were risk factors for mortality after AFB surgery. Survivors who have undergone AFB perceive an improved quality of life although they are more dependent in ADL tasks and have worse scores in almost all SF-36 than the population to which they belong.</p

Lessons learned in developing family medicine residency training programs in Japan

BACKGROUND: While family medicine is not well established as a discipline in Japan, a growing number of Japanese medical schools and training hospitals have recently started sougoushinryoubu (general medicine departments). Some of these departments are incorporating a family medicine approach to residency training. We sought to learn from family medicine pioneers of these programs lessons for developing residency training. METHODS: This qualitative project utilized a long interview research design. Questions focused on four topics: 1) circumstances when becoming chair/faculty member; 2) approach to starting the program; 3) how Western ideas of family medicine were incorporated; and 4) future directions. We analyzed the data using immersion/crystallization to identify recurring themes. From the transcribed data, we selected representative quotations to illustrate them. We verified the findings by emailing the participants and obtaining feedback. RESULTS: Participants included: five chairpersons, two program directors, and three faculty members. We identified five lessons: 1) few people understand the basic concepts of family medicine; 2) developing a core curriculum is difficult; 3) start with undergraduates; 4) emphasize clinical skills; and 5) train in the community. CONCLUSION: While organizational change is difficult, the identified lessons suggest issues that merit consideration when developing a family medicine training program. Lessons from complexity science could inform application of these insights in other countries and settings newly developing residency training

The Toxic Effects of Cigarette Additives. Philip Morris' Project Mix Reconsidered: An Analysis of Documents Released through Litigation

Stanton Glantz and colleagues analyzed previously secret tobacco industry documents and peer-reviewed published results of Philip Morris' Project MIX about research on cigarette additives, and show that this research on the use of cigarette additives cannot be taken at face value

Analysis of a viral metagenomic library from 200 m depth in Monterey Bay, California constructed by direct shotgun cloning

<p>Abstract</p> <p>Background</p> <p>Viruses have a profound influence on both the ecology and evolution of marine plankton, but the genetic diversity of viral assemblages, particularly those in deeper ocean waters, remains poorly described. Here we report on the construction and analysis of a viral metagenome prepared from below the euphotic zone in a temperate, eutrophic bay of coastal California.</p> <p>Methods</p> <p>We purified viruses from approximately one cubic meter of seawater collected from 200m depth in Monterey Bay, CA. DNA was extracted from the virus fraction, sheared, and cloned with no prior amplification into a plasmid vector and propagated in <it>E. coli </it>to produce the MBv200m library. Random clones were sequenced by the Sanger method. Sequences were assembled then compared to sequences in GenBank and to other viral metagenomic libraries using BLAST analyses.</p> <p>Results</p> <p>Only 26% of the 881 sequences remaining after assembly had significant (E ≤ 0.001) BLAST hits to sequences in the GenBank nr database, with most being matches to bacteria (15%) and viruses (8%). When BLAST analysis included environmental sequences, 74% of sequences in the MBv200m library had a significant match. Most of these hits (70%) were to microbial metagenome sequences and only 0.7% were to sequences from viral metagenomes. Of the 121 sequences with a significant hit to a known virus, 94% matched bacteriophages (Families <it>Podo</it>-, <it>Sipho</it>-, and <it>Myoviridae</it>) and 6% matched viruses of eukaryotes in the Family <it>Phycodnaviridae </it>(5 sequences) or the Mimivirus (2 sequences). The largest percentages of hits to viral genes of known function were to those involved in DNA modification (25%) or structural genes (17%). Based on reciprocal BLAST analyses, the MBv200m library appeared to be most similar to viral metagenomes from two other bays and least similar to a viral metagenome from the Arctic Ocean.</p> <p>Conclusions</p> <p>Direct cloning of DNA from diverse marine viruses was feasible and resulted in a distribution of virus types and functional genes at depth that differed in detail, but were broadly similar to those found in surface marine waters. Targeted viral analyses are useful for identifying those components of the greater marine metagenome that circulate in the subcellular size fraction.</p