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Abstract: Medical decision-making for frail geriatric trauma patients is complex, especially toward the end of life. The goal of this paper is to review aspects of end-of-life decision-making, such as frailty, cognitive impairment, quality of life, goals of care, and palliative care. Additionally, we make recommendations for composing a patient-tailored treatment plan. In doing so, we seek to initiate the much-needed discussion regarding end-of-life care for frail geriatric patients. [ABSTRACT FROM AUTHOR]

Health care systems can go beyond advance care planning to create mechanisms for eliciting and documenting the goals of care and life-sustaining treatment decisions of patients with serious life-limiting illnesses. These systems can help ensure that patients receive care that is consistent with their values and preferences. We describe a case in which even though a patient with a serious illness had completed an advance directive and had discussed preferences with family, clinicians failed to identify the patient's authentic preferences for life-sustaining treatment. We offer a stepwise framework for communication with seriously ill patients and describe a systems approach to transforming the process of eliciting, documenting, and honoring patients' life-sustaining treatment preferences in the U. S. Veterans Health Administration. [ABSTRACT FROM AUTHOR]

This American College of Physicians position paper aims to inform ethical decision making surrounding participation in short term global health clinical care experiences. Although the positions are primarily intended for practicing physicians, they may apply to other health care professionals and should inform how institutions, organizations, and others structure short-term global health experiences. The primary goal of short-term global health clinical care experiences is to improve the health and well-being of the individuals and communities where they occur. In addition, potential benefits for participants in global health include increased awareness of global health issues, new medical knowledge, enhanced physical diagnosis skills when practicing in low technology settings, improved language skills, enhanced cultural sensitivity, a greater capacity for clinical problem solving, and an improved sense of self-satisfaction or professional satisfaction. However, these activities involve several ethical challenges. Addressing these challenges is critical to protecting patient welfare in all geographic locales, promoting fair and equitable care globally, and maintaining trust in the profession. This paper describes 5 core positions that focus on ethics and the clinical care context and provides case scenarios to illustrate them. [ABSTRACT FROM AUTHOR]

Much of what is formally taught in medicine is about the knowledge, skills, and behaviors required of a physician, including how to express compassion and respect for patients at the bedside. What is learned, however, includes not only admirable qualities but also behaviors and qualities that are inconsistent with ethics and professionalism. Positive role models may reinforce the character and values the profession seeks to cultivate; negative ones directly contradict classroom lessons and expectations of patients, society, and medical educators. These positive and negative lessons, which are embedded in organizational structure and culture, are the hidden curricula conveyed in medical schools, residency programs, hospitals, and clinics. This position paper from the American College of Physicians focuses on ethics, professionalism, and the hidden curriculum. It provides strategies for revealing what is hidden to foster the development of reflective and resilient lifelong learners who embody professionalism and clinicians who are, and are perceived as, positive role models. Making the hidden visible and the implicit explicit helps to create a culture reflecting medicine's core values. [ABSTRACT FROM AUTHOR]

This American College of Physicians position paper aims to inform ethical decision making surrounding participation in short-term global health clinical care experiences. Although the positions are primarily intended for practicing physicians, they may apply to other health care professionals and should inform how institutions, organizations, and others structure short-term global health experiences. The primary goal of short-term global health clinical care experiences is to improve the health and well-being of the individuals and communities where they occur. In addition, potential benefits for participants in global health include increased awareness of global health issues, new medical knowledge, enhanced physical diagnosis skills when practicing in low-technology settings, improved language skills, enhanced cultural sensitivity, a greater capacity for clinical problem solving, and an improved sense of self-satisfaction or professional satisfaction. However, these activities involve several ethical challenges. Addressing these challenges is critical to protecting patient welfare in all geographic locales, promoting fair and equitable care globally, and maintaining trust in the profession. This paper describes 5 core positions that focus on ethics and the clinical care context and provides case scenarios to illustrate them. [ABSTRACT FROM AUTHOR]

As climate change progresses, we humans might have to inhabit a world for which we are increasingly maladapted. If we were able to identify genes that directly influence our ability to thrive in a changing climate, would it be ethically justifiable to edit the human genome to enhance our ability to adapt to this new environment? Should we use gene editing not only to prevent significant disease but also to enhance our ability to function in the world? Here I suggest a "4-S framework" for analyzing the justifiability of gene editing that includes these considerations: (1) safety, (2) significance of harm to be averted, (3) succeeding generations, and (4) social consequences. [ABSTRACT FROM AUTHOR]

This American College of Physicians position paper aims to inform ethical decision making for the integration of precision medicine and genetic testing into clinical care. Although the positions are primarily intended for practicing physicians, they may apply to other health care professionals and can also inform how health care systems, professional schools, and residency programs integrate genomics into educational and clinical settings. Addressing the challenges of precision medicine and genetic testing will guide ethical and responsible implementation to improve health outcomes. [ABSTRACT FROM AUTHOR]

Women physicians are paid less than their male peers across medical specialties and geographies. While the medical literature to date has focused on documenting the existence of a wage gap, less attention has been paid to fixing this gap. We focus on interventions around auditing, salary transparency, family leave, and childcare that can be implemented to advance gender wage parity. [ABSTRACT FROM AUTHOR]

When a patient is disruptive, abusive, or persistently non-adherent, healthcare professionals are ethically justified in terminating the patient-physician relationship.[13], [14] Similarly, as long as a patient is not in need of acute care, healthcare professionals are ethically justified in refusing to provide in-person care to patients who refuse to wear a face covering. We also provide guidance for how clinicians can respond to patients who refuse to wear a mask, encouraging patient engagement and offering the alternative of care through telehealth. When patients' behavior poses a risk to healthcare workers and other patients, clinicians are justified in restricting the provision of care. [Extracted from the article]

Background: The “hidden curriculum” and role models for responding to medical errors might play a central role in influencing residents' attitudes about disclosure. We sought to compare surgical and nonsurgical residents' exposure to role modeling for responding to medical errors and their attitudes about error disclosure. Study Design: We conducted a cross-sectional, electronic survey of surgical and nonsurgical residents at 2 large academic medical centers. The questionnaire asked respondents about personal experience with medical errors; training for responding to errors; frequency of exposure to role modeling related to disclosure; and attitudes about disclosure. Descriptive statistics were used to describe frequencies. Chi-square and Fisher's exact test were used to compare proportions between surgical and nonsurgical trainees. Results: The response rate was 58% (253 of 435). Surgical residents reported more frequently observing a colleague be treated harshly (eg, humiliated or verbally abused) for an error than nonsurgical residents (sometimes or often, 39% [26 of 66] vs 20% [37 of 187]; p = 0.002). Surgical residents were more likely than nonsurgical residents to believe they would be treated harshly by others if they acknowledged making a medical error (35% [23 of 66] vs 12% [23 of 187]; p < 0.001) and believe they have to compromise their own values when dealing with medical errors at their institution (11% [7 of 66] vs 2% [4 of 187]; p = 0.008). Surgical residents were less likely than nonsurgical residents to feel free to express concerns to other members of the team about medical errors in patient care (70% [46 of 66] vs 83% [115 of 187]; p = 0.02). Conclusions: The punitive response to error by senior members of the health care team might be an impediment to the transparent disclosure of errors among residents that might disproportionally affect surgical training programs. [Copyright &y& Elsevier]

The article compares the effect of a video depiction with that of a verbal description of a patient with advanced dementia for individuals selecting level of medical care at 7 primary care clinics at 2 U.S. medical centers. Results reveal that watching the video changed preferences for care, transcending apparent differences in preferences associated with race/ethnicity and educational level. Using video plus improved verbal communication may result in more informed advance care planning.

Abstract: Purpose: To identify the frequency and type of iatrogenic medical events requiring admission to an intensive care unit. To assess the consequences of iatrogenic medical events for patients and institutions. To assess the prevalence of disclosure of iatrogenic medical events to patients, surrogates, and institutions. Methods: The project on Care Improvement for the Critically Ill enrolled 5727 patients to 8 intensive care units at 4 Boston teaching hospitals. To determine the nature, consequences, and disclosure of iatrogenic medical events, we did a retrospective chart review on all patients whose admission to an intensive care unit was precipitated by an iatrogenic event. Results: Sixty-six patients (1.2 %) were identified by an intensive care unit’s clinical team as having an iatrogenic medical event as the primary reason for admission to the unit. The majority (29, or 45%) of iatrogenic medical events were secondary to technical error, but a high percentage (21, or 33%) was due to iatrogenic drug events. Twenty-two (34%) cases were assessed by the investigators to have been preventable. In 60 (94%) cases there was no documentation in the patient’s chart of communication to the patient regarding the reason for admission to the intensive care unit. In 11 (17%) cases there was documentation of a discussion with the surrogate about the reason for admission to the unit. In only 3 (5%) cases was there documentation that the patient or surrogate was informed that an iatrogenic medical event was the reason for admission to the intensive care unit. Incident reports or malpractice claims were filed in only 4 (6 %) cases. Conclusion: The frequency of iatrogenic medical events resulting in admission to intensive care units is lower than previous studies have reported. Iatrogenic drug events continue to be an important source of error. A considerable percentage of iatrogenic events may be preventable. Health care professionals rarely document disclosure of iatrogenic events to patients and surrogates. [Copyright &y& Elsevier]

Background: The familial implications of genetic information can lead to a conflict between a physician's duties to maintain patient confidentiality and to inform at-risk relatives about susceptibility to genetic diseases. As genes are discovered that can identify patients at risk of adverse outcomes, this conflict has become the subject of discussion and debate.Methods: We performed a one-time telephone survey of a population-based sample of 200 Jewish women to assess knowledge and attitudes about genetic testing. Attitudes toward sharing genetic test results with family members were evaluated using three hypothetical scenarios that described an easily preventable disease, a disease (breast cancer) in which the only option for prevention was prophylactic mastectomies, and a nonpreventable disease.Results: Nearly all respondents believed that a patient should inform at-risk family members when the disease was preventable (100% and 97% in the relevant scenarios), compared with only 85% who felt a duty to inform at-risk family members about a nonpreventable disease (P <0.001). The proportions of respondents who believed that physicians should seek out and inform at-risk family members against a patient's wishes was much lower: only 18% of respondents to the easily preventable disease scenario, 22% of respondents to the breast cancer scenario, and 16% of respondents to the nonpreventable disease scenario.Conclusions: Most women surveyed believed that genetic information should be shared within families, unless it violated a patient's wishes. These sorts of opinions should be considered in the debate over the confidentiality of genetic information. [ABSTRACT FROM AUTHOR]

The article discusses a draft guidance issued by the U.S. Food and Drug Administration (FDA) to regulate in vitro diagnostic tests conducted outside of a living body to diagnose diseases. Topics include safety issues associated with laboratory-developed tests for rare diseases, developed by individual laboratories, the Clinical Laboratory Improvement Amendments Act, and the analytical and clinical validity required for premarket approval of in vitro diagnostics by the FDA.

: Lisa Lehmann and colleagues discuss how “grateful patient” programs that solicit donations from wealthy individuals who receive care may be problematic for physicians and propose policies that mitigate these risks. Please see later in the article for the Editors' Summary [ABSTRACT FROM AUTHOR]

The authors propose a system that would remove physicians from direct involvement in the self-directed dying process. They describe some of the efforts and movements toward greater social and legal acceptance of the process. They also highlight findings of a survey of relatives of terminally ill patients in Oregon which reflect the perspective that some terminally ill patients wish to exercise their autonomy for their death. They discuss six primary objections to legalizing assisted dying.

Objectives: For decades, researchers in anthropology and archaeology have used teeth, including exfoliated primary teeth, as fossil records of people's physical life experiences. Recently, researchers in psychiatry, epidemiology, environmental health and other fields have recognized the potential for teeth to serve as biomarkers of other early‐life experiences, including trauma exposure and other types of psychosocial stress, which are potent determinants of later mental and physical health problems. Despite the emerging appreciation and value of teeth as biospecimens, little is understood about cultural beliefs and practices surrounding exfoliated teeth. If known, such insights could inform culturally appropriate practices for paediatric dental care and improve protocols for the ethical acquisition of teeth as biospecimens in research studies. To address this gap, a qualitative systematic review was performed to summarize the variety of traditions performed worldwide for disposing of primary exfoliated teeth. Methods: PubMed, Google Scholar, AnthroSource, Anthropological Literature, EHRAF World Cultures and Anthropology Plus were searched with a systematic search strategy to identify articles published from inception through December 2, 2021. Citations of relevant papers were also forward and backward searched. Results: There were 3289 articles that met the initial inclusion criteria, of which 37 were included after individual screening and applying exclusion criteria. Thematic analysis was used to identify 74 distinct traditions related to the disposal of exfoliated teeth, which were organized into seven general themes: (1) giving teeth to a tooth fairy, (2) giving teeth to mouse figures, (3) throwing teeth, (4) hiding/keeping teeth, (5) burying teeth, (6) giving teeth to animals and (7) eating the tooth. Conclusions: The results of this study elucidate the diversity within—yet universality of—exfoliated tooth disposal traditions and underscore the importance of tooth exfoliation as a major milestone during child development. Special attention must be paid to these traditions and related ethical concerns when designing research protocols related to their collection. With a greater understanding of beliefs and practices related to exfoliated teeth, researchers will be better equipped to engage children and families in studies that include analyses of exfoliated teeth, collect teeth as biospecimens, and broaden the use of teeth in research. [ABSTRACT FROM AUTHOR]

This study examines the distribution of payments within and across specialties and the medical products associated with the largest total payments. [ABSTRACT FROM AUTHOR]

Background: The Department of Veterans Affairs (VA) healthcare system routinely screens Veterans for food insecurity, housing instability, and intimate partner violence, but does not systematically screen for other health-related social needs (HRSNs). Objectives: To (1) develop a process for systematically identifying and addressing Veterans' HRSNs, (2) determine reported prevalence of HRSNs, and (3) assess the acceptability of HRSN screening among Veterans. Design: "Assessing Circumstances and Offering Resources for Needs" (ACORN) is a Veteran-tailored HRSN screening and referral quality improvement initiative. Veterans were screened via electronic tablet for nine HRSNs (food, housing, utilities, transportation, legal needs, social isolation, interpersonal violence, employment, and education) and provided geographically tailored resource guides for identified needs. Two-week follow-up interviews with a purposive sample of Veterans explored screening experiences. Participants: Convenience sample of Veterans presenting for primary care at a VA urban women's health clinic and suburban community-based outpatient clinic (October 2019–May 2020). Main Measures: Primary outcomes included prevalence of HRSNs, Veteran-reported acceptability of screening, and use of resources guides. Data were analyzed using descriptive statistics, chi-square tests, and rapid qualitative analysis. Key Results: Of 268 Veterans screened, 50% reported one or more HRSNs. Social isolation was endorsed most frequently (29%), followed by educational needs (19%), interpersonal violence (12%), housing instability (9%), and utility concerns (7%). One in five Veterans reported at least one form of material hardship. In follow-up interviews (n = 15), Veterans found screening acceptable and felt VA should continue screening. No Veterans interviewed had contacted recommended resources at two-week follow-up, although several planned to use resource guides in the future. Conclusion: In a VA HRSN screening and referral program, Veterans frequently reported HRSNs, felt screening was important, and thought VA should continue to screen for these needs. Screening for HRSNs is a critical step towards connecting patients with services, identifying gaps in service delivery, and informing future resource allocation. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Medicare's requirement for research participation as a condition of coverage: is it ethical?" by S. D. Pearson, F. G. Miller and E. J. Emanuel in a previous issue.

Objectives Psychiatric comorbidities such as mood, anxiety and adjustment disorders are common among individuals seeking lung transplantation. The objective of this study is to describe the association between these disorders and length of initial hospitalization and number of hospitalizations in the first year following transplantation. Methods This was a retrospective cohort study of all lung transplantation patients between January 1, 2008 and July 1, 2014 at a large academic center. We evaluated whether pretransplantation mood, anxiety or adjustment disorders were associated with length and number of hospitalizations after transplant, adjusting for age, sex, native disease, forced expiratory volume in 1 s prior to transplantation, wait list time and lung allocation score. Results There were 185 patients who underwent transplantation during the 7.5-year study period of whom 125 (67.6%) had a mood, anxiety or adjustment disorder. Patients with an adjustment disorder had decreased length of initial hospitalization [ B coefficient =−5.76; 95% confidence interval (CI)=−11.40 to − 0.13; P = .04]. Patients with anxiety disorders had an increased number of hospitalizations in the first year following transplantation (rate ratio = 1.41; 95% CI = 1.06–1.88; P = .02). There was no association between mood disorders and length or number of hospitalizations. Mood, adjustment and anxiety disorders were not associated with time to initial rehospitalization. Conclusions Among the three most common pretransplantation psychiatric disorders, only anxiety disorders are associated with increased hospitalization in the first year following lung transplant. Interventions designed to better control pretransplantation and posttransplantation anxiety may be associated with less frequent hospitalization. [ABSTRACT FROM AUTHOR]

A response by Lisa Soleymani Lehmann, Frederick L. Brancati, and Adrian S. Dobs to letters to the editor about their article "The effect of bedside case presentations on patients' perceptions of their medical care" in the April 17, 1997 issue is presented.

Importance: Selecting effective antidepressants for the treatment of major depressive disorder (MDD) is an imprecise practice, with remission rates of about 30% at the initial treatment.Objective: To determine whether pharmacogenomic testing affects antidepressant medication selection and whether such testing leads to better clinical outcomes.Design, Setting, and Participants: A pragmatic, randomized clinical trial that compared treatment guided by pharmacogenomic testing vs usual care. Participants included 676 clinicians and 1944 patients. Participants were enrolled from 22 Department of Veterans Affairs medical centers from July 2017 through February 2021, with follow-up ending November 2021. Eligible patients were those with MDD who were initiating or switching treatment with a single antidepressant. Exclusion criteria included an active substance use disorder, mania, psychosis, or concurrent treatment with a specified list of medications.Interventions: Results from a commercial pharmacogenomic test were given to clinicians in the pharmacogenomic-guided group (n = 966). The comparison group received usual care and access to pharmacogenomic results after 24 weeks (n = 978).Main Outcomes and Measures: The co-primary outcomes were the proportion of prescriptions with a predicted drug-gene interaction written in the 30 days after randomization and remission of depressive symptoms as measured by the Patient Health Questionnaire-9 (PHQ-9) (remission was defined as PHQ-9 ≤ 5). Remission was analyzed as a repeated measure across 24 weeks by blinded raters.Results: Among 1944 patients who were randomized (mean age, 48 years; 491 women [25%]), 1541 (79%) completed the 24-week assessment. The estimated risks for receiving an antidepressant with none, moderate, and substantial drug-gene interactions for the pharmacogenomic-guided group were 59.3%, 30.0%, and 10.7% compared with 25.7%, 54.6%, and 19.7% in the usual care group. The pharmacogenomic-guided group was more likely to receive a medication with a lower potential drug-gene interaction for no drug-gene vs moderate/substantial interaction (odds ratio [OR], 4.32 [95% CI, 3.47 to 5.39]; P < .001) and no/moderate vs substantial interaction (OR, 2.08 [95% CI, 1.52 to 2.84]; P = .005) (P < .001 for overall comparison). Remission rates over 24 weeks were higher among patients whose care was guided by pharmacogenomic testing than those in usual care (OR, 1.28 [95% CI, 1.05 to 1.57]; P = .02; risk difference, 2.8% [95% CI, 0.6% to 5.1%]) but were not significantly higher at week 24 when 130 patients in the pharmacogenomic-guided group and 126 patients in the usual care group were in remission (estimated risk difference, 1.5% [95% CI, -2.4% to 5.3%]; P = .45).Conclusions and Relevance: Among patients with MDD, provision of pharmacogenomic testing for drug-gene interactions reduced prescription of medications with predicted drug-gene interactions compared with usual care. Provision of test results had small nonpersistent effects on symptom remission.Trial Registration: ClinicalTrials.gov Identifier: NCT03170362. [ABSTRACT FROM AUTHOR]

METHODS We used Google's COVID-19 Vaccination Access dataset, powered by Google Maps Directions API, which identified "vaccine deserts" as areas within which a known vaccination site could not be reached within a 15-min drive.[5] All currently known vaccination sites were identified by VaccineFinder, a web-based tool containing all known vaccine providers, and Google data. B Bivariate choropleth map showing concentration of places of worship within vaccine deserts compared to healthcare sites within vaccine deserts. [Extracted from the article]

Importance: Quality measures of palliative and end-of-life care relevant to patients with advanced cancer have been developed, but few are in routine use. It is unclear which of these measures are most important for providing patient- and family-centered care and have high potential for improving quality of care. Objective: To prioritize process quality measures for assessing delivery of patient- and family-centered palliative and end-of-life cancer care in US Veterans Affairs (VA) health care facilities. Design, Setting, Participants: A panel of 10 palliative and cancer care expert stakeholders (7 physicians, 2 nurses, 1 social worker) rated process quality measure concepts before and after a 1-day meeting. Measures: Panelists rated 64 measure concepts on a nine-point scale on: (1) importance to providing patient- and family-centered care, and (2) potential for quality improvement (QI). Panelists also nominated five highest priority measure concepts ("top 5") on each attribute. Results: Panelists rated most measure concepts (54 premeeting, 56 post-meeting) as highly important to patient- and family-centered care (median rating ≥7). Considerably fewer (17 premeeting, 22 post-meeting) were rated as having high potential for QI. Measure concepts having postpanel median ratings ≥7 and nominated by one or more panelists as "top 5" on either attribute comprised a shortlist of 20 measure concepts. Conclusions: A panel of expert stakeholders helped prioritize 64 measure concepts into a shortlist of 20. Half of the shortlisted measures were related to communication about patient preferences and decision making, and half were related to symptom assessment and treatment. [ABSTRACT FROM AUTHOR]

Goals-of-care conversations (GoCCs) to elicit patients' values regarding end-of-life care, including life-sustaining treatment, are a hallmark of high-quality, patient-centered care.[1] Ideally, GoCCs are proactive, held in outpatient settings before clinical deterioration; unfortunately, patients' first GoCCs are often delayed until hospitalization ("just-in-time").[1] The COVID-19 pandemic heightened the importance of proactive GoCCs, which can improve both patient-centered and population-level outcomes when life-sustaining treatment resources may be limited.[1]-[3] It is unknown whether hospitals effectively and rapidly mobilized resources in response to calls to increase proactive GoCCs,[2], [3] or if they struggled to do so amidst competing demands during early COVID surges. We calculated rate ratios (COVID versus pre-COVID) and used single-variable linear regression models to assess associations between facility-level characteristics and rate ratios. No facility-level characteristics were significantly associated with change from pre-COVID to COVID documented GoCC rates. [Extracted from the article]

Context: The Veterans Health Administration (VA) National Center for Ethics in Healthcare implemented the Life-Sustaining Treatment Decisions Initiative, including policy and practice standards, clinician communication training, a documentation template, and central implementation support to foster advance care planning via goals-of-care conversations for seriously ill veterans in 2014, spreading nationally to other Veterans Health Affairs (VA) sites in 2017.Objectives: Our goal was to describe the range of early implementation experiences among the pilot sites, and compare them with spread sites that implemented LSTDI about two years later, identifying cross-site best practices and pitfalls.Methods: We conducted semistructured interviews with 32 key stakeholders from 12 sites to identify cross-site best practices and pitfalls related to implementation.Results: Three primary implementation themes emerged: organizational readiness for transformation, importance of champions, and time and resources needed to achieve implementation. Each theme's barriers and facilitators highlighted variability in success based on complexity in terms of vertical hierarchy and horizontal cross-role/cross-clinic relationships.Conclusion: Learning health care systems need multilevel interdisciplinary implementation approaches to support communication about serious illness, from broad-based system-level training and education to build communication skills, to focusing on characteristics of successful individual champions who listen to critics and are tenacious in addressing concerns. [ABSTRACT FROM AUTHOR]

The authors reflect on the issue of performance of elective surgical procedures despite sleep deprivation. They point out that a continuity-of-care argument will not rationalize such practice. Based on research, there is an 83 percent increase in the risk of complications in surgery due to sleep deprivation and sleep disorders. They encourage hospitals to prohibit the practice and ensure priority rescheduling of the canceled surgery.

Background: The coronavirus disease 2019 pandemic has or threatens to overwhelm health care systems. Many institutions are developing ventilator triage policies.Objective: To characterize the development of ventilator triage policies and compare policy content.Design: Survey and mixed-methods content analysis.Setting: North American hospitals associated with members of the Association of Bioethics Program Directors.Participants: Program directors.Measurements: Characteristics of institutions and policies, including triage criteria and triage committee membership.Results: Sixty-seven program directors responded (response rate, 91.8%); 36 (53.7%) hospitals did not yet have a policy, and 7 (10.4%) hospitals' policies could not be shared. The 29 institutions providing policies were relatively evenly distributed among the 4 U.S. geographic regions (range, 5 to 9 policies per region). Among the 26 unique policies analyzed, 3 (11.3%) were produced by state health departments. The most frequently cited triage criteria were benefit (25 policies [96.2%]), need (14 [53.8%]), age (13 [50.0%]), conservation of resources (10 [38.5%]), and lottery (9 [34.6%]). Twenty-one (80.8%) policies use scoring systems, and 20 of these (95.2%) use a version of the Sequential Organ Failure Assessment score. Among the policies that specify the triage team's composition (23 [88.5%]), all require or recommend a physician member, 20 (87.0%) a nurse, 16 (69.6%) an ethicist, 8 (34.8%) a chaplain, and 8 (34.8%) a respiratory therapist. Thirteen (50.0% of all policies) require or recommend that those making triage decisions not be involved in direct patient care, but only 2 (7.7%) require that their decisions be blinded to ethically irrelevant considerations.Limitation: The results may not be generalizable to institutions without academic bioethics programs.Conclusion: Over one half of respondents did not have ventilator triage policies. Policies have substantial heterogeneity, and many omit guidance on fair implementation.Primary Funding Source: None. [ABSTRACT FROM AUTHOR]

Introduction: Institutions have developed professionalism policies to help guide physician social media behavior in light of professionalism lapses that have resulted in serious consequences. Prior research has gathered perspectives on online professionalism; however, the public's views remain poorly understood. Importantly, the impact of physician social media behavior on patient trust is unknown. Methods: To determine whether patients' trust might change based on their physicians' social media behavior, we conducted a cross-sectional survey across three U.S. cities (n = 491). The survey assessed patient trust using hypothetical scenarios. Results: Most respondents reported they would have less trust if their physician posted racist comments online, wrote a disrespectful patient narrative, appeared intoxicated in a photograph, or wrote profanity. Respondent age and education impacted change in trust. Conclusions: We conclude that physicians' social media behavior may affect patient trust. Better understanding of how physicians' online presence impacts their relationships with patients can help guide policy and inform educational efforts. [ABSTRACT FROM AUTHOR]

Background: Financial ties between physicians and the pharmaceutical and medical device industry are common, but little is known about how patient trust is affected by these ties.Objective: The purpose of this study was to evaluate how viewing online public disclosure of industry payments affects patients' trust ratings for physicians, the medical profession, and the pharmaceutical and medical device industry.Design: This was a randomized experimental evaluation.Participants: There were 278 English-speaking participants over age 18 who had seen a healthcare provider in the previous 12 months who took part in the study.Interventions: Participants searched for physicians on an online disclosure database, viewed payments from industry to the physicians, and assigned trust ratings. Participants were randomized to view physicians who received no payment ($0), low payment ($250-300), or high payment (>$13,000) from industry, or to a control arm in which they did not view the disclosure website. They also were asked to search for and then rate trust in their own physician.Main Measures: Primary outcomes were trust in individual physician, medical profession, and industry. These scales measure trust as a composite of honesty, fidelity, competence, and global trust.Key Results: Compared to physicians who received no payments, physicians who received payments over $13,000 received lower ratings for honesty [mean (SD): 3.36 (0.86) vs. 2.75 (0.95), p < 0.001] and fidelity [3.19 (0.65) vs. 2.89 (0.68), p = 0.01]. Among the 7.9% of participants who found their own physician on the website, ratings for honesty and fidelity decreased as the industry payment to the physician increased (honesty: Spearman's ρ = -0.52, p = 0.02; fidelity: Spearman's ρ = -0.55, p = 0.01). Viewing the disclosure website did not affect trust ratings for the medical profession or industry.Conclusions: Disclosure of industry payments to physicians affected perceptions of individual physician honesty and fidelity, but not perceptions of competence. Disclosure did not affect trust ratings for the medical profession or the pharmaceutical and medical device industry. ClinicalTrials.gov identifier: NCT02179632 ( https://clinicaltrials.gov/ct2/show/NCT02179632 ). [ABSTRACT FROM AUTHOR]

Background: The Physician Payments Sunshine Act, part of the Affordable Care Act, requires pharmaceutical and medical device firms to report payments they make to physicians and, through its Open Payments program, makes this information publicly available.Objective: To establish estimates of the exposure of the American patient population to physicians who accept industry payments, to compare these population-based estimates to physician-based estimates of industry contact, and to investigate Americans' awareness of industry payments.Design: Cross-sectional survey conducted in late September and early October 2014, with data linkage of respondents' physicians to Open Payments data.Participants: A total of 3542 adults drawn from a large, nationally representative household panel.Main Measures: Respondents' contact with physicians reported in Open Payments to have received industry payments; respondents' awareness that physicians receive payments from industry and that payment information is publicly available; respondents' knowledge of whether their own physician received industry payments.Key Results: Among the 1987 respondents who could be matched to a specific physician, 65% saw a physician who had received an industry payment during the previous 12 months. This population-based estimate of exposure to industry contact is much higher than physician-based estimates from the same period, which indicate that 41% of physicians received an industry payment. Across the six most frequently visited specialties, patient contact with physicians who had received an industry payment ranged from 60 to 85%; the percentage of physicians with industry contact in these specialties was much lower (35-56%). Only 12% of survey respondents knew that payment information was publicly available, and only 5% knew whether their own doctor had received payments.Conclusions: Patients' contact with physicians who receive industry payments is more prevalent than physician-based measures of industry contact would suggest. Very few Americans know whether their own doctor has received industry payments or are aware that payment information is publicly available. [ABSTRACT FROM AUTHOR]

Policy Points:The policy context of direct‐to‐consumer personal genomic testing (DTC‐PGT) has been evolving over the last decade, with little empirical data available about consumers’ perspectives.A majority of consumers of DTC‐PGT supported expanded access to services and their integration into the medical context and opposed more governmental regulation.Consumers’ attitudes about access to services and regulation did not vary based on the specific genetic risk information they received from companies, but may vary based on whether consumers perceived their DTC experience negatively. Context: While policymakers have been considering the appropriateness of direct‐to‐consumer personal genomic testing (DTC‐PGT) for more than a decade, there is little empirical data on consumers’ views regarding the regulation of these products. No research has assessed whether consumers’ personal experience with testing is related to their views about access to and regulation of DTC tests. Methods: Data were analyzed from the PGen Study, a longitudinal prospective cohort of DTC‐PGT customers of 23andMe (n = 564) and Pathway Genomics (n = 377; total N = 941). Consumers were sent an electronic survey before receiving genetic test results and again 6 months after receipt of results. Findings: At the 6‐month follow‐up, more than 80% of participants believed that people have a right to access genetic information directly, that parents should be able to get DTC‐PGT testing for their children, and that genetic information should be kept private. Participants supported health insurance coverage of PGT (60%), wider availability of PGT (68%), and inclusion of genetic information in medical records (63%). Participants were less supportive of government regulation (28%) and restricting testing to clinical settings (14%). Conservative political ideology was associated with less support for government regulation (P < 0.001), as was feeling more confident in one's genetic knowledge (P < 0.05). Participants’ level of computed genetic risk for common diseases, as indicated by their actual test results received from companies, showed no relationship with attitudes. However, those who perceived that they had received elevated risk results expressed lower support for expanded availability and incorporation of PGT into health care (P < 0.01). Those who reported being upset by their genetic test results were less likely to endorse access to DTC products without a medical professional (P < 0.01). Conclusions: PGT consumers supported expanded access to these services and opposed additional regulation. Users who had a negative personal experience with PGT testing were less supportive of expanded availability without a medical professional. [ABSTRACT FROM AUTHOR]

Background: Prior studies have demonstrated how price transparency lowers the test-ordering rates of trainees in hospitals, and physician-targeted price transparency efforts have been viewed as a promising cost-controlling strategy.Objective: To examine the effect of displaying paid-price information on test-ordering rates for common imaging studies and procedures within an accountable care organization (ACO).Design: Block randomized controlled trial for 1 year.Subjects: A total of 1205 fully licensed clinicians (728 primary care, 477 specialists).Intervention: Starting January 2014, clinicians in the Control arm received no price display; those in the intervention arms received Single or Paired Internal/External Median Prices in the test-ordering screen of their electronic health record. Internal prices were the amounts paid by insurers for the ACO's services; external paid prices were the amounts paid by insurers for the same services when delivered by unaffiliated providers.Main Measures: Ordering rates (orders per 100 face-to-face encounters with adult patients): overall, designated to be completed internally within the ACO, considered "inappropriate" (e.g., MRI for simple headache), and thought to be "appropriate" (e.g., screening colonoscopy).Key Results: We found no significant difference in overall ordering rates across the Control, Single Median Price, or Paired Internal/External Median Prices study arms. For every 100 encounters, clinicians in the Control arm ordered 15.0 (SD 31.1) tests, those in the Single Median Price arm ordered 15.0 (SD 16.2) tests, and those in the Paired Prices arms ordered 15.7 (SD 20.5) tests (one-way ANOVA p-value 0.88). There was no difference in ordering rates for tests designated to be completed internally or considered to be inappropriate or appropriate.Conclusions: Displaying paid-price information did not alter how frequently primary care and specialist clinicians ordered imaging studies and procedures within an ACO. Those with a particular interest in removing waste from the health care system may want to consider a variety of contextual factors that can affect physician-targeted price transparency. [ABSTRACT FROM AUTHOR]

Background: Little is known about how primary care physicians (PCPs) in routine outpatient practice use paid price information (i.e., the amount that insurers finally pay providers) in daily clinical practice.Objective: To describe the experiences of PCPs who have had paid price information on tests and procedures for at least 1 year.Design: Cross-sectional study using semi-structured interviews and the constant comparative method of qualitative analysis.Participants: Forty-six PCPs within an accountable care organization.Intervention: Via the ordering screen of their electronic health record, PCPs were presented with the median paid price for commonly ordered tests and procedures (e.g., blood tests, x-rays, CTs, MRIs).Approach: We asked PCPs for (a) their "gut reaction" to having paid price information, (b) the situations in which they used price information in clinical decision-making separate from or jointly with patients, (c) their thoughts on who bore the chief responsibility for discussing price information with patients, and (d) suggestions for improving physician-targeted price information interventions.Key Results: Among "gut reactions" that ranged from positive to negative, all PCPs were more interested in having patient-specific price information than paid prices from the practice perspective. PCPs described that when patients' out-of-pocket spending concerns were revealed, price information helped them engage patients in conversations about how to alter treatment plans to make them more affordable. PCPs stated that having price information only slightly altered their test-ordering patterns and that they avoided mentioning prices when advising patients against unnecessary testing. Most PCPs asserted that physicians bear the chief responsibility for discussing prices with patients because of their clinical knowledge and relationships with patients. They wished for help from patients, practices, health plans, and society in order to support price transparency in healthcare.Conclusions: Physician-targeted price transparency efforts may provide PCPs with the information they need to respond to patients' concerns regarding out-of-pocket affordability rather than that needed to change test-ordering habits. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Redefining physicians' role in assisted dying," by J. J. Z. Prokopetz and L. S. Lehmann in the 2012 issue.

The care of Very Important Patients (VIPs) is different from other patients because they may receive greater access, attention, and resources from health care staff. Although the term VIP is used regularly in the medical literature and is implicitly understood, in practice it constitutes a wide and heterogeneous group of patients that have a strong effect on health care providers. We define a VIP as a very influential patient whose individual attributes and characteristics (eg, social status, occupation, position), coupled with their behavior, have the potential to significantly influence a clinician's judgment or behavior. Physicians, celebrities, the politically powerful, and philanthropists, may all become VIPs in the appropriate context. The quality of care may be inferior because health care professionals may deviate from standard practices when caring for them. Understanding the common features among what may otherwise be very different groups of patients can help health care providers manage ethical concerns when they arise. We use a series of vignettes to demonstrate how VIPs behavior and status can influence a clinician's judgment or actions. Appreciating the ethical principles in these varied circumstances provides health care professionals with the tools to manage ethical conflicts that arise in the care of VIPs. We conclude each vignette with guidance for how health care providers and administrators can manage the ethical concern. [ABSTRACT FROM AUTHOR]

We conducted a survey to assess the perspectives of principal investigators and Institutional Review Board (IRB) members on the impact of the IRB structure on the conduct of research and innovative therapy, defined as a nonstandard treatment intended to enhance the well-being of an individual patient. Although investigators and IRB members agreed that the IRB provides adequate protection to study subjects (97% vs. 100%) and an ethically insightful review (88% vs. 100%), a third of clinical investigators felt that the IRB review process limits clinical innovation, in comparison with only 4% of IRB representatives. Limitations of the current IRB review process were explored. We propose several measures to improve the IRB review process while maintaining the protection of human research subjects, including the use of centralized IRBs, the opening of IRB meetings to investigators, the development of metrics and outcome measures for the IRB, and the promotion of guidelines that distinguish research and innovative therapy. [ABSTRACT FROM AUTHOR]

As more research studies incorporate next-generation sequencing (including whole-genome or whole-exome sequencing), investigators and institutional review boards face difficult questions regarding which genomic results to return to research participants and how. An American College of Medical Genetics and Genomics 2013 policy paper suggesting that pathogenic mutations in 56 specified genes should be returned in the clinical setting has raised the question of whether comparable recommendations should be considered in research settings. The Clinical Sequencing Exploratory Research (CSER) Consortium and the Electronic Medical Records and Genomics (eMERGE) Network are multisite research programs that aim to develop practical strategies for addressing questions concerning the return of results in genomic research. CSER and eMERGE committees have identified areas of consensus regarding the return of genomic results to research participants. In most circumstances, if results meet an actionability threshold for return and the research participant has consented to return, genomic results, along with referral for appropriate clinical follow-up, should be offered to participants. However, participants have a right to decline the receipt of genomic results, even when doing so might be viewed as a threat to the participants’ health. Research investigators should be prepared to return research results and incidental findings discovered in the course of their research and meeting an actionability threshold, but they have no ethical obligation to actively search for such results. These positions are consistent with the recognition that clinical research is distinct from medical care in both its aims and its guiding moral principles. [Copyright &y& Elsevier]

Background: Whole genome sequencing (WGS) is already being used in certain clinical and research settings, but its impact on patient well-being, health-care utilization, and clinical decision-making remains largely unstudied. It is also unknown how best to communicate sequencing results to physicians and patients to improve health. We describe the design of the MedSeq Project: the first randomized trials of WGS in clinical care. Methods/Design: This pair of randomized controlled trials compares WGS to standard of care in two clinical contexts: (a) disease-specific genomic medicine in a cardiomyopathy clinic and (b) general genomic medicine in primary care. We are recruiting 8 to 12 cardiologists, 8 to 12 primary care physicians, and approximately 200 of their patients. Patient participants in both the cardiology and primary care trials are randomly assigned to receive a family history assessment with or without WGS. Our laboratory delivers a genome report to physician participants that balances the needs to enhance understandability of genomic information and to convey its complexity. We provide an educational curriculum for physician participants and offer them a hotline to genetics professionals for guidance in interpreting and managing their patients' genome reports. Using varied data sources, including surveys, semi-structured interviews, and review of clinical data, we measure the attitudes, behaviors and outcomes of physician and patient participants at multiple time points before and after the disclosure of these results. Discussion: The impact of emerging sequencing technologies on patient care is unclear. We have designed a process of interpreting WGS results and delivering them to physicians in a way that anticipates how we envision genomic medicine will evolve in the near future. That is, our WGS report provides clinically relevant information while communicating the complexity and uncertainty of WGS results to physicians and, through physicians, to their patients. This project will not only illuminate the impact of integrating genomic medicine into the clinical care of patients but also inform the design of future studies. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: Patients with limited English proficiency may be at increased risk for diminished understanding of clinical procedures. This study sought to assess patient predictors of comprehension of colposcopy information during informed consent and to assess differences in understanding between English and Spanish speakers. Methods: Between June and August 2007, English- and Spanish-speaking colposcopy patients at two Boston hospitals were surveyed to assess their understanding of the purpose, risks, benefits, alternatives, and nature of colposcopy. Patient demographic information was collected. Findings: There were 183 women who consented to participate in the study. We obtained complete data on 111 English speakers and 38 Spanish speakers. English speakers were more likely to have a higher education, greater household income, and private insurance. Subjects correctly answered an average of 7.91 ± 2.16 (72%) of 11 colposcopy survey questions. English speakers answered more questions correctly than Spanish speakers (8.50 ± 1.92 [77%] vs 6.21 ± 1.93 [56%]; p < .001). Using linear regression to adjust for confounding variables, we found that language was not significantly associated with greater understanding (p = .46). Rather, education was the most significant predictor of colposcopy knowledge (p < .001). Conclusion: Many colposcopy patients did not understand the procedure well enough to give informed consent. The observed differences in colposcopy comprehension based on language were a proxy for differences in education. Education, not language, predicted subjects’ understanding of colposcopy. These results demonstrate the need for greater attention to patients’ educational background to ensure adequate understanding of clinical information. [Copyright &y& Elsevier]

Since 1991, hospitals have asked patients whether they have advance directives, but few patients complete these documents. We assessed two simple interventions to improve completion of advance directives among elderly or chronically ill outpatients.We conducted a cluster randomized controlled trial involving 1079 patients from five general medicine clinics that were affiliated with an academic medical center. Patients were either ≥70 years of age or ≥50 years old with a chronic illness. The study comprised three arms: physician reminders recommending documentation of advance directives, physician reminders plus mailing advance directives to patients together with educational literature, or neither intervention (control). The main outcome measure was completion of an advance directive.After 28 weeks, 1.5% (5/332) of patients in the physician reminder group, 14% (38/277) in the physician reminder plus patient mailing group, and 1.8% (5/286) in the control group had completed advance directives. In multivariate analyses, patients in the physician reminder plus patient mailing group were much more likely than controls to have completed advance directives (odds ratio [OR] = 5.9; 95% confidence interval [CI]: 1.5 to 22), whereas patients in the physician reminder–only group were no more likely than controls to have completed advance directives (OR = 0.88; 95% CI: 0.21 to 3.7).Mailing health care proxy and living will forms and literature to patients before an appointment at which their physicians received a reminder about advance directives yielded a small but significant improvement in completion of these documents. A physician reminder alone did not have an effect. [Copyright &y& Elsevier]

Genomic testing has the potential to improve patient outcomes and reduce patient care costs by personalizing medication selection. Commercial pharmacogenetic (PGx) testing for psychotropic and other medications is widely available and promoted as a means to implement "precision medicine." Despite evidence that genetic variation affects the metabolism of psychotropic medications, the clinical utility of these test results has not been established. Moreover, implementing such testing in routine clinical care is complex, requiring informatics support and a systematic approach to patient and provider education. The PRIME Care program is designed to bridge this gap, applying both clinical trials and implementation science methods to conduct a program of research. It is centered on a large, pragmatic randomized clinical trial (RCT) in which 2000 Veterans with a major depressive disorder (MDD) and their health care providers are randomized together to receive PGx test results at the beginning of an episode of care or 6 months later. We hypothesize that providers who receive the PGx test results will prescribe an antidepressant guided by the PGx findings and Veterans whose care is guided by PGx testing will experience higher rates of remission from MDD. If the results of the trial replicate those of prior PGx studies, which provided preliminary evidence of the utility of PGx guided prescribing, it would strongly support using a precision medicine approach to treat MDD. This program of research is also evaluating dissemination influencers, other biomarkers (e.g., genetic variation associated with depression response), and the health care cost implications of PGx testing. ClinicalTrials.gov Identifier: NCT03170362. • This research program focuses on the impact of providing depressed Veterans and their treatment providers with the results of commercial pharmacogenetic (PGx) testing for psychotropic medications. • This program of research focuses on a clinical trial but also includes cost-benefit analyses and an exploration of implementation science methods and basic clinical studies. • The outcomes of greatest interest are whether and how patients and providers use commercial genetic test results given to them when initiating or switching an antidepressant to treat Major Depressive Disorder (MDD) and whether using the test results improves patient outcomes. • MDD, one of the most common conditions associated with military service and combat exposure, increases suicide risk and worsens the course of common medical conditions, making it a leading cause of functional impairment and mortality among Veterans. • Validation of the clinical utility of PGx testing to personalize the treatment of MDD represents an important opportunity to improve health care among Veterans and the general population. [ABSTRACT FROM AUTHOR]

BACKGROUND ANO OBJECTIVES: Ordering rates for imaging studies and procedures may change if clinicians are shown the prices of those tests while they are ordering. We studied the effect of 2 forms of paid price information, single median price and paired internal/ external median prices, on how often pediatric-focused and adult-oriented clinicians (most frequently general pediatricians and adult specialists caring for pediatric-aged patients, respectively) order imaging studies and procedures for 0- to 21-year-olds. METHODS: In January 2014, we randomized 227 pediatric-focused and 279 adult-oriented clinicians to 1 of 3 study arms: Control (no price display), Single Median Price, or Paired Internal/External Median Prices (both with price display in the ordering screen of electronic health record). We used 1-way analysis of variance and paired t tests to examine how frequently clinicians (1) placed orders and (2) designated tests to be completed internally within an accountable care organization. RESULTS: For pediatric-focused clinicians, there was no significant difference in the rates at which orders were placed or designated to be completed internally across the study arms. For adult-oriented clinicians caring for children and adolescents, however, those in the Single Price and Paired Price arms placed orders at significantly higher rates than those in the Control group (Control 3.2 [SD 4.8], Single Price 6.2 [SD 6.8], P < .001 and Paired Prices 5.2 [SD 7.9], P = .04). The rate at which adult-oriented clinicians designated tests to be completed internally was not significantly different across arms. CONCLUSIONS: The effect of price information on ordering rates appears to depend on whether the clinician is pediatric-focused or adult-oriented. [ABSTRACT FROM AUTHOR]