Qualitative analysis of how patients decide that they want risk-reducing mastectomy, and the implications for surgeons in responding to emotionally-motivated patient requests

Objective Contemporary approaches to medical decision-making advise that clinicians should respect patients’ decisions. However, patients’ decisions are often shaped by heuristics, such as being guided by emotion, rather than by objective risk and benefit. Risk-reducing mastectomy (RRM) decisions focus this dilemma sharply. RRM reduces breast cancer (BC) risk, but is invasive and can have iatrogenic consequences. Previous evidence suggests that emotion guides patients’ decision-making about RRM. We interviewed patients to better understand how they made decisions about RRM, using findings to consider how clinicians could ethically respond to their decisions. Methods Qualitative face-to-face interviews with 34 patients listed for RRM surgery and two who had decided against RRM. Results Patients generally did not use objective risk estimates or, indeed, consider risks and benefits of RRM. Instead emotions guided their decisions: they chose RRM because they feared BC and wanted to do ‘all they could’ to prevent it. Most therefore perceived RRM to be the ‘obvious’ option and made the decision easily. However, many recounted extensive post-decisional deliberation, generally directed towards justifying the original decision. A few patients deliberated before the decision because fears of surgery counterbalanced those of BC. Conclusion Patients seeking RRM were motivated by fear of BC, and the need to avoid potential regret for not doing all they could to prevent it. We suggest that choices such as that for RRM, which are made emotionally, can be respected as autonomous decisions, provided patients have considered risks and benefits. Drawing on psychological theory about how people do make decisions, as well as normative views of how they should, we propose that practitioners can guide consideration of risks and benefits even, where necessary, after patients have opted for surgery. This model of practice could be extended to other medical decisions that are influenced by patients’ emotions

Psychological Typhoon Eye in the 2008 Wenchuan Earthquake

BACKGROUND: On May 12, 2008, an earthquake measuring 8.0 on the Richter scale jolted Wenchuan, China, leading to 69,227 deaths and 374,643 injured, with 17,923 listed as missing as of Sept. 25, 2008, and shook the whole nation. We assessed the devastating effects on people's post-earthquake concern about safety and health. METHODOLOGY/PRINCIPAL FINDINGS: From June 4 to July 15, 2008, we surveyed a convenience sample of 2,262 adults on their post-earthquake concern about safety and health. Residents in non-devastated areas (Fujian and Hunan Provinces, and Beijing) and devastated areas (Sichuan and Gansu Provinces) responded to a questionnaire of 5 questions regarding safety measures, epidemic disease, medical workers, psychological workers, and medication. The ANOVAs showed a significant effect of residential devastation level on the estimated number of safety measures needed, the estimated probability of the outbreak of an epidemic, and the estimated number of medical and psychological workers needed (Ps<0.001). The post-earthquake concern decreased significantly as the level of residential devastation increased. Because of the similarity with the meteorological phenomenon of the eye of a typhoon, we dubbed these findings a "Psychological Typhoon Eye": the closer to the center of the devastated areas, the less the concern about safety and health a resident felt. CONCLUSIONS/SIGNIFICANCE: Contrary to common perception and ripple effect that the impact of an unfortunate event decays gradually as ripples spread outward from a center, a "Psychological Typhoon Eye" effect was observed where the post-earthquake concern was at its lowest level in the extremely devastated areas. The resultant findings may have implications for Chinese governmental strategies for putting "psychological comfort" into effect

Public health, conflict and human rights: toward a collaborative research agenda

Although epidemiology is increasingly contributing to policy debates on issues of conflict and human rights, its potential is still underutilized. As a result, this article calls for greater collaboration between public health researchers, conflict analysts and human rights monitors, with special emphasis on retrospective, population-based surveys. The article surveys relevant recent public health research, explains why collaboration is useful, and outlines possible future research scenarios, including those pertaining to the indirect and long-term consequences of conflict; human rights and security in conflict prone areas; and the link between human rights, conflict, and International Humanitarian Law

Organizing risk: organization and management theory for the risk society

Risk has become a crucial part of organizing, affecting a wide range of organizations in all sectors. We identify, review and integrate diverse literatures relevant to organizing risk, building on an existing framework that describes how risk is organized in three ‘modes’ – prospectively, in real-time, and retrospectively. We then identify three critical issues in the existing literature: its fragmented nature; its neglect of the tensions associated with each of the modes; and its tendency to assume that the meaning of an object in relation to risk is singular and stable. We provide a series of new insights with regard to each of these issues. First, we develop the concept of a risk cycle that shows how organizations engage with all three modes and transition between them over time. Second, we explain why the tensions have been largely ignored and show how studies using a risk work perspective can provide further insights into them. Third, we develop the concept of risk translation to highlight the ways in the meanings of risks can be transformed and to identify the political consequences of such translations. We conclude the paper with a research agenda to elaborate these insights and ideas further

Effect of the COVID-19 pandemic on surgery for indeterminate thyroid nodules (THYCOVID): a retrospective, international, multicentre, cross-sectional study

Background Since its outbreak in early 2020, the COVID-19 pandemic has diverted resources from non-urgent and elective procedures, leading to diagnosis and treatment delays, with an increased number of neoplasms at advanced stages worldwide. The aims of this study were to quantify the reduction in surgical activity for indeterminate thyroid nodules during the COVID-19 pandemic; and to evaluate whether delays in surgery led to an increased occurrence of aggressive tumours.Methods In this retrospective, international, cross-sectional study, centres were invited to participate in June 22, 2022; each centre joining the study was asked to provide data from medical records on all surgical thyroidectomies consecutively performed from Jan 1, 2019, to Dec 31, 2021. Patients with indeterminate thyroid nodules were divided into three groups according to when they underwent surgery: from Jan 1, 2019, to Feb 29, 2020 (global prepandemic phase), from March 1, 2020, to May 31, 2021 (pandemic escalation phase), and from June 1 to Dec 31, 2021 (pandemic decrease phase). The main outcomes were, for each phase, the number of surgeries for indeterminate thyroid nodules, and in patients with a postoperative diagnosis of thyroid cancers, the occurrence of tumours larger than 10 mm, extrathyroidal extension, lymph node metastases, vascular invasion, distant metastases, and tumours at high risk of structural disease recurrence. Univariate analysis was used to compare the probability of aggressive thyroid features between the first and third study phases. The study was registered on ClinicalTrials.gov, NCT05178186.Findings Data from 157 centres (n=49 countries) on 87 467 patients who underwent surgery for benign and malignant thyroid disease were collected, of whom 22 974 patients (18 052 [78 center dot 6%] female patients and 4922 [21 center dot 4%] male patients) received surgery for indeterminate thyroid nodules. We observed a significant reduction in surgery for indeterminate thyroid nodules during the pandemic escalation phase (median monthly surgeries per centre, 1 center dot 4 [IQR 0 center dot 6-3 center dot 4]) compared with the prepandemic phase (2 center dot 0 [0 center dot 9-3 center dot 7]; p&lt;0 center dot 0001) and pandemic decrease phase (2 center dot 3 [1 center dot 0-5 center dot 0]; p&lt;0 center dot 0001). Compared with the prepandemic phase, in the pandemic decrease phase we observed an increased occurrence of thyroid tumours larger than 10 mm (2554 [69 center dot 0%] of 3704 vs 1515 [71 center dot 5%] of 2119; OR 1 center dot 1 [95% CI 1 center dot 0-1 center dot 3]; p=0 center dot 042), lymph node metastases (343 [9 center dot 3%] vs 264 [12 center dot 5%]; OR 1 center dot 4 [1 center dot 2-1 center dot 7]; p=0 center dot 0001), and tumours at high risk of structural disease recurrence (203 [5 center dot 7%] of 3584 vs 155 [7 center dot 7%] of 2006; OR 1 center dot 4 [1 center dot 1-1 center dot 7]; p=0 center dot 0039).Interpretation Our study suggests that the reduction in surgical activity for indeterminate thyroid nodules during the COVID-19 pandemic period could have led to an increased occurrence of aggressive thyroid tumours. However, other compelling hypotheses, including increased selection of patients with aggressive malignancies during this period, should be considered. We suggest that surgery for indeterminate thyroid nodules should no longer be postponed even in future instances of pandemic escalation.Funding None.Copyright (c) 2023 Published by Elsevier Ltd. All rights reserved

Impediments to effective altruism: the role of subjective preferences in charitable giving

Charity could do the most good if every dollar donated went to causes that produced the greatest welfare gains. In line with this proposition, the “Effective Altruism” movement seeks to provide individuals with information regarding the effectiveness of charities in hopes that they will donate to organizations that maximize the social return of their donation. This paper investigates the extent to which presenting effectiveness information leads people to choose more effective charities. We find that even when effectiveness information is made easily comparable across options, it has a limited impact on choice. Specifically, people frequently choose less effective charity options when those options represent more subjectively preferred causes. In contrast to making a personal donation decision, outcome metrics are used to a much greater extent when choosing financial investments and when allocating aid resources as an agent of an organization. Implications for Effective Altruism are discussed

Impacts of adaptation and responsibility framings on attitudes towards climate change mitigation

It is likely that climate change communications and media coverage will increasingly stress the importance of adaptation, yet little is known about whether or how this may affect attitudes towards mitigation. Despite concerns that communicating adaptation could undermine public support for mitigation, previous research has found it can have the opposite effect by increasing risk salience. It is also unclear whether people respond differently to information about mitigation and adaptation depending on whether action is framed as an individual or government responsibility. Using an experimental design, this study sought to examine how public attitudes towards mitigation are influenced by varying climate change messages, and how this might interact with prior attitudes to climate change. UK-based participants (N = 800) read one of four texts in a 2 × 2 design comparing adaptation versus mitigation information and personal versus governmental action. No main effect was found for adaptation versus mitigation framing, nor for individual action versus government policy, but we did observe a series of interaction effects with prior attitudes to climate change. Mitigation and adaptation information affected participants’ responses differently depending on their pre-existing levels of concern about climate change, suggesting that mitigation framings may be more engaging for those with high levels of concern, whereas adaptation framings may be more engaging for low-concern individuals. Government mitigation action appears to engender particularly polarised attitudes according to prior concern. Implications for climate change communications are considered