Knowledge, Wisdom, and Service: The Meaning and Teaching of Professionalism in Medicine

Papers presented for the Center for the Study of Ethics in Society Western Michigan University. Presented September 29, 2011

Physicians’ Experiences and Opinions Regarding Strategies to Improve Care for Minority Patients

Objective: To assess the views and experiences of a select group of physicians interested in minority health issues regarding promising strategies to improve minority care. Methods: Physicians were asked to respond to a 17-item survey assessing the level of agreement, frequency of implementation of and interest in learning more about 7 promising strategies for alleviating disparities. Results: Most physicians (75-95%) agreed that the 7 proposed strategies could be useful to improve the quality of care provided to minority patients, but only 40-66% of physicians had implemented the strategies sometimes or often in their practices. Between 22 and 29% of physicians were interested in learning more about 6 of the 7 strategies, preferably by CME, seminars and newsletters. Conclusion: Physicians concerned with minority health issues agree that commonly suggested strategies for eliminating racial and ethnic disparities in health care could be useful, but have difficulty implementing such approaches

Variance in Patient Access to Support Persons by Race/Ethnicity and Language Preference: An Analysis of Patient Survey Data

Regulatory and accreditation organizations have advocated open visitation policies and allowance of support persons of patients’ choosing, but it is unknown if support is allowed equitably. Data from hospitalized patients were analyzed to determine access to support persons, stratified by patient-reported race/ethnicity, language, sex, age, and education. A multivariate regression model was constructed using race and language, controlling for site and patient sex, education and age. Additionally, sites’ policies explicitly allowing support persons were correlated to reports of allowance of support persons. Among 1,196 respondents, 17% reported not being allowed a support person or being unsure. African American patients had 2.4 times greater odds of reporting non-allowance of support than their white counterparts, while speakers of a language other than English or Spanish had 3.9 times greater odds. There were no significant differences noted between sites with a policy allowing patient support persons and those with no policy or one in development. Most patients report being allowed a support person, but African Americans and those speaking a language other than English or Spanish have greater odds of reporting not being allowed a support person. Reliable methods of informing all patients of this right are needed

Uncertainty, Scarcity and Transparency: Public Health Ethics and Risk Communication in a Pandemic

Communicating public health guidance is key to mitigating risk during disasters and outbreaks, and ethical guidance on communication emphasizes being fully transparent. Yet, communication during the pandemic has sometimes been fraught, due in part to practical and conceptual challenges around being transparent. A particular challenge has arisen when there was both evolving scientific knowledge on COVID-19 and reticence to acknowledge that resource scarcity concerns were influencing public health recommendations. This essay uses the example of communicating public health guidance on masking in the United States to illustrate ethical challenges of developing and conveying public health guidance under twin conditions of uncertainty and resource scarcity. Such situations require balancing two key principles in public health ethics: the precautionary principle and harm reduction. Transparency remains a bedrock value to guide risk communication, but optimizing transparency requires consideration of additional ethical values in developing and implementing risk communication strategies

Real-Time Electronic Health Record Mortality Prediction During the COVID-19 Pandemic: A Prospective Cohort Study

Background: The SARS-CoV-2 virus has infected millions of people, overwhelming critical care resources in some regions. Many plans for rationing critical care resources during crises are based on the Sequential Organ Failure Assessment (SOFA) score. The COVID-19 pandemic created an emergent need to develop and validate a novel electronic health record (EHR)-computable tool to predict mortality. Research Questions: To rapidly develop, validate, and implement a novel real-time mortality score for the COVID-19 pandemic that improves upon SOFA. Study Design and Methods: We conducted a prospective cohort study of a regional health system with 12 hospitals in Colorado between March 2020 and July 2020. All patients >14 years old hospitalized during the study period without a do not resuscitate order were included. Patients were stratified by the diagnosis of COVID-19. From this cohort, we developed and validated a model using stacked generalization to predict mortality using data widely available in the EHR by combining five previously validated scores and additional novel variables reported to be associated with COVID-19-specific mortality. We compared the area under the receiver operator curve (AUROC) for the new model to the SOFA score and the Charlson Comorbidity Index. Results: We prospectively analyzed 27,296 encounters, of which 1,358 (5.0%) were positive for SARS-CoV-2, 4,494 (16.5%) included intensive care unit (ICU)-level care, 1,480 (5.4%) included invasive mechanical ventilation, and 717 (2.6%) ended in death. The Charlson Comorbidity Index and SOFA scores predicted overall mortality with an AUROC of 0.72 and 0.90, respectively. Our novel score predicted overall mortality with AUROC 0.94. In the subset of patients with COVID-19, we predicted mortality with AUROC 0.90, whereas SOFA had AUROC of 0.85. Interpretation: We developed and validated an accurate, in-hospital mortality prediction score in a live EHR for automatic and continuous calculation using a novel model, that improved upon SOFA. Study Question: Can we improve upon the SOFA score for real-time mortality prediction during the COVID-19 pandemic by leveraging electronic health record (EHR) data? Results: We rapidly developed and implemented a novel yet SOFA-anchored mortality model across 12 hospitals and conducted a prospective cohort study of 27,296 adult hospitalizations, 1,358 (5.0%) of which were positive for SARS-CoV-2. The Charlson Comorbidity Index and SOFA scores predicted all-cause mortality with AUROCs of 0.72 and 0.90, respectively. Our novel score predicted mortality with AUROC 0.94. Interpretation: A novel EHR-based mortality score can be rapidly implemented to better predict patient outcomes during an evolving pandemic

Attitudes toward cost-conscious care among U.S. physicians and medical students: analysis of national cross-sectional survey data by age and stage of training

Abstract Background The success of initiatives intended to increase the value of health care depends, in part, on the degree to which cost-conscious care is endorsed by current and future physicians. This study aimed to first analyze attitudes of U.S. physicians by age and then compare the attitudes of physicians and medical students. Methods A paper survey was mailed in mid-2012 to 3897 practicing physicians randomly selected from the American Medical Association Masterfile. An electronic survey was sent in early 2015 to all 5,992 students at 10 U.S. medical schools. Survey items measured attitudes toward cost-conscious care and perceived responsibility for reducing healthcare costs. Physician responses were first compared across age groups (30–40 years, 41–50 years, 51–60 years, and > 60 years) and then compared to student responses using Chi square tests and logistic regression analyses (controlling for sex). Results A total of 2,556 physicians (65%) and 3395 students (57%) responded. Physician attitudes generally did not differ by age, but differed significantly from those of students. Specifically, students were more likely than physicians to agree that cost to society should be important in treatment decisions (p < 0.001) and that physicians should sometimes deny beneficial but costly services (p < 0.001). Students were less likely to agree that it is unfair to ask physicians to be cost-conscious while prioritizing patient welfare (p < 0.001). Compared to physicians, students assigned more responsibility for reducing healthcare costs to hospitals and health systems (p < 0.001) and less responsibility to lawyers (p < 0.001) and patients (p < 0.001). Nearly all significant differences persisted after controlling for sex and when only the youngest physicians were compared to students. Conclusions Physician attitudes toward cost-conscious care are similar across age groups. However, physician attitudes differ significantly from medical students, even among the youngest physicians most proximate to students in age. Medical student responses suggest they are more accepting of cost-conscious care than physicians and attribute more responsibility for reducing costs to organizations and systems rather than individuals. This may be due to the combined effects of generational differences, new medical school curricula, students’ relative inexperience providing cost-conscious care within complex healthcare systems, and the rapidly evolving U.S. healthcare system.https://deepblue.lib.umich.edu/bitstream/2027.42/146517/1/12909_2018_Article_1388.pd