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Many patients use dietary supplements but do not inform their clinicians. Some allopathic clinicians' conscious and unconscious cognitive and emotional biases against complementary and alternative medicine can affect whether patients disclose details about dietary supplement use, the quality of communication during clinical encounters, and the information clinicians draw upon to make decisions and recommendations. This article describes 6 cognitive biases that can influence patient-clinician communication and shared decision making about dietary supplements and suggests 6 ways to mitigate biases' negative effects on patient-clinician relationships.

It has been over 1 year since we observed the policing of the George Floyd protests in the United States [R. R. Hardeman, E. M. Medina, R. W. Boyd, N. Engl. J. Med. 383, 197–199 (2020)]. Multiple injury reports emerged in medical journals, and the scientific community called for law enforcement to discontinue the use of less-lethal weapons [E. A. Kaske et al. , N. Engl. J. Med . 384, 774–775 (2021) and K. A. Olson et al. , N. Engl. J. Med. 383, 1081–1083 (2020)]. Despite progress in research, policy change has not followed a similar pace. Although the reasoning for this discrepancy is multifactorial, failure to use appropriate language may be one contributing factor to the challenges faced in updating policies and practices. Here, we detail how language has the potential to influence thinking and decision-making, we discuss how the language of less-lethal weapons minimizes harm, and we provide a framework for naming conventions that acknowledges harm.

The practice around informed consent in clinical medicine is both inconsistent and inadequate. Indeed, in busy, contemporary health care settings, getting informed consent looks little like the formal process developed over the past sixty years and presented in medical textbooks, journal articles, and academic lectures. In this article, members of the Society of Teachers of Family Medicine (STFM) Collaborative on Ethics and Humanities review the conventional process of informed consent and its limitations, explore complementary and alternative approaches to doctor-patient interactions, and propose a new model of consent that integrates these approaches with each other and with clinical practice. The model assigns medical interventions to a consent continuum defined by the discrete categories of traditional informed consent, assent, and nondissent. Narrative descriptions and clinical exemplars are offered for each category. The authors invite colleagues from other disciplines and from the academic ethics community to provide feedback and commentary.

The Nobel Prize in Physiology or Medicine is a prestigious award given every year for ostensibly the most important discovery in the field. Prizes in Medicine have typically gone to honor foundational knowledge rather than measurable impact. Two recent examples from global health (a rotavirus vaccine, child growth standards) offer alternatives for what might be lauded in medicine. These two examples and historical achievements regarding cholera and smallpox are worthy but do not fall within the scope of Nobel awards for Peace or Economics. The COVID-19 pandemic gives a new context for the idea that discovery and implementation are both keys to medicine. New patterns that redefine achievement in medicine could emerge by Nobel Prize precedent to promote greater health equity and international collaboration.

Primary care is a frequent source of pain treatment and opioid prescribing. The objective of the Prescribing Interventions for Chronic Pain using the Electronic health record (PRINCE) study is to assess the effects of two behavioral economics-informed interventions embedded within the electronic health record (EHR) on guideline-concordant pain treatment and opioid prescribing decisions in primary care settings.Setting: The setting for this study is 43 primary care clinics in Minnesota.The PRINCE study uses a cluster-randomized 2 × 2 factorial design to test the effects of two interventions. An adaptive design allows for the possibility of secondary randomization to test if interventions can be titrated while maintaining efficacy.One intervention alters the "choice architecture" within the EHR to nudge clinicians toward non-opioid treatments for opioid-naïve patients and toward tapering for patients currently receiving a "high risk" opioid. The other intervention integrates the prescription drug monitoring program (PDMP) directly within the EHR.The primary outcome for opioid-naïve patients is whether an opioid is prescribed in a primary care visit without a non-opioid alternative pain treatment. The primary outcome for current opioid-using patients is whether opioid prescriptions were tapered with a documented rationale.The PRINCE study will provide real-world evidence on two approaches to improving pain treatment in primary care using the EHR. The adaptive study design strikes a balance between establishing intervention efficacy and testing whether efficacy varies with intervention intensity.

Millum and Bromwich’s (2021) excellent article provides both conceptual and practical rationale for reexamining the fundamentals of the informed consent process for research and clinical interventi...

Background and Objectives: Precepting methods have significant impact on the financial viability of family medicine residency programs. Following an adverse event, four University of Minnesota Family Medicine residency clinics moved from using Medicare’s Primary Care Exception (PCE) and licensure precepting (LP) to a “universal precepting” method in which preceptors see every patient face to face. Variation in the implementation of universal precepting created a natural experiment of its financial impact. Methods: Universal precepting was implemented in October 2013 across four residency programs. Billing codes were measured 1 year before and 2.5 years after implementation by clinic and residency year. Results: There were significant financial differences between clinics based on original precepting method and implementation quality of universal precepting. The clinic moving from PCE to universal precepting with excellent implementation increased higher-level billing (99214) by 8%-10%. Clinics moving from LP demonstrated wide variation ranging from an 18% increase to a 13% decrease, consistent with the implementation quality. Conclusions: Clinics transitioning from PCE to universal precepting can see a significant increase in 99214 billing. Clinics transitioning from LP to universal precepting are at significant financial risk if poorly implemented, but may see increased 99214 billing with effective implementation. This suggests that both implementation quality and original precepting method impact 99214 billing rates when transitioning to universal precepting.

Background Healthcare quality measurements in the United States illustrate disparities by racial/ethnic group, socio-economic class, and geographic location. Redressing healthcare inequities, including measurement of and reimbursement for healthcare quality, requires partnering with communities historically excluded from decision-making. Quality healthcare is measured according to insurers, professional organizations and government agencies, with little input from diverse communities. This community-based participatory research study aimed to amplify the voices of community leaders from seven diverse urban communities in Minneapolis-Saint Paul Minnesota, view quality healthcare and financial reimbursement based on quality metric scores. Methods A Community Engagement Team consisting of one community member from each of seven urban communities —Black/African American, Lesbian-Gay-Bisexual-Transgender-Queer-Two Spirit, Hmong, Latino/a/x, Native American, Somali, and White—and two community-based researchers conducted listening sessions with 20 community leaders about quality primary healthcare. Transcripts were inductively analyzed and major themes were identified. Results Listening sessions produced three major themes, with recommended actions for primary care clinics. #1: Quality Clinics Utilize Structures and Processes that Support Healthcare Equity. #2: Quality Clinics Offer Effective Relationships, Education, and Health Promotion. #3: Funding Based on Current Quality Measures Perpetuates Health Inequities. Conclusion Community leaders identified ideal characteristics of quality primary healthcare, most of which are not currently measured. They expressed concern that linking clinic payment with quality metrics without considering social and structural determinants of health perpetuates social injustice in healthcare.

Injuries from Less-lethal Weapons during the George Floyd Protests In this analysis involving patients treated in Minnesota during protests after George Floyd’s death, 89 patients were identified w...

Arman A Shahriar,1 Kriti Prasad,1 Katherine Casty,1 Zarin I Rahman,1 Michael Westerhaus,2,3 David J Satin1 1University of Minnesota Medical School, Minneapolis, MN, USA; 2University of Minnesota, Global Medicine, Minneapolis, MN, USA; 3Center for International Health, St. Paul, MN, USACorrespondence: Arman A ShahriarUniversity of Minnesota Medical School, 420 Delaware St SE, Minneapolis, MN, 55455, USATel +1 952-270-7950Email shahr019@umn.eduPurpose: The field of medicine is becoming increasingly aware of the role that social determinants of health (SDH) play in shaping health and health outcomes. Organized medicine – including prominent physician groups and accreditation bodies – has endorsed SDH education as an integral component of medical school curricula. This study sought to describe medical student perspectives on the current state of SDH in preclinical curricula.Methods: The authors developed a 9-item survey to assess time being spent on SDH and attitudes toward the current level of SDH content in preclinical curricula. All medical students at both campuses of a large public medical school were invited to participate between December 2019 and February 2020.Results: Of 1010 medical students invited to participate, 515 (51.0%) responded. Of the 515 respondents, 480 (93.2%) reported spending at least 40 hours per week on medical school, and of those, 405 (84.4%) said they spend 0– 2 hours on SDH. The majority of all respondents (62.1%; 320/515) felt the current level of focus on SDH is “not enough”, while only eleven students (2.1%; 11/515) felt it is “too much”. In a multiple logistic model, Black students were over four times as likely as white students (aOR 4.19; 95% CI 1.37– 18.38) to feel the current level of focus on SDH is “not enough”. Likewise, women were 2.3-times (aOR 2.30; 95% CI 1.52– 3.49) as likely as men to feel the level of focus on SDH is “not enough”.Conclusion: In practice, medical students are spending considerably less time learning SDH than is advised by consensus of expert educators and administrators. Over sixty percent of medical students do not feel the current level of focus on SDH is sufficient. Further study is needed to determine why women and racial minority students are significantly more likely to feel this way.Keywords: social determinants of health, race/ethnicity, medical education, undergraduate medical education, undergraduate medical curriculum, social medicine, medical school, preclinical curriculum

Background and Objectives: Direct pharmaceutical marketing to physicians by pharmaceutical representatives is effective in changing behavior of health care providers, resulting in less evidence-based prescribing. Although much has been written about pharmaceutical marketing exposures among medical students, less is known about direct marketing exposures before students matriculate. This study examined the types of pharmaceutical representative direct marketing exposures for premedical students and where they occurred. Methods: From June to August of 2017, researchers surveyed students who accepted admission to US public medical schools. These prematriculated students completed our survey just prior to matriculation. The survey inquired about whether the students were exposed to pharmaceutical marketing directly from pharmaceutical salespeople, the types of marketing they observed or received, and where these interactions occurred. Results: Survey participants included 911 prematriculated students from 14 of the 188 medical schools invited to participate. Seventy-one percent (646) of the participants received or observed someone receiving pharmaceutical marketing gifts, small meals or snacks, articles, or samples. The two most common contexts for direct pharmaceutical marketing exposures were during shadowing experiences (54%, 346) and during employment (50%, 323). Conclusions: The findings suggest that it may be common for medical students to have interacted directly with pharmaceutical salespeople or observed other health professionals in these interactions before they matriculate in medical school. Because many of these interactions occur during clinical experiences required by institutions for admission, medical schools and premedical associations should consider delivering conflict-of-interest education early in medical school education or before students matriculate.

This paper examines how time pressure, an important constraint faced by medical care providers, affects productivity in primary care. We generate empirical predictions by incorporating time pressure into a model of physician behavior by Tai-Seale and McGuire (2012) . We use data from the electronic health records of a large integrated delivery system and leverage unexpected schedule changes as variation in time pressure. We find that greater time pressure reduces the number of diagnoses recorded during a visit and increases both scheduled and unscheduled follow-up care. We also find some evidence of increased low-value care, decreased preventive care, and decreased opioid prescribing.

Background Quality metrics, pay for performance (P4P), and value-based payments are prominent aspects of the current and future American healthcare system. However, linking clinic payment to clinic quality measures may financially disadvantage safety-net clinics and their patient population because safety-net clinics often have worse quality metric scores than non-safety net clinics. The Minnesota Safety Net Coalition’s Quality Measurement Enhancement Project sought to collect data from primary care providers’ (PCPs) experiences, which could assist Minnesota policymakers and state agencies as they create a new P4P system. Our research study aims are to identify PCPs’ perspectives about 1) quality metrics at safety net clinics and non-safety net clinics, 2) how clinic quality measures affect patients and patient care, and 3) how payment for quality measures may influence healthcare. Methods Qualitative interviews with 14 PCPs (4 individual interviews and 3 focus groups) who had worked at both safety net and non-safety net primary care clinics in Minneapolis-St Paul Minnesota USA metropolitan area. Qualitative analyses identified major themes. Results Three themes with sub-themes emerged. Theme #1: Minnesota’s current clinic quality scores are influenced more by patients and clinic systems than by clinicians. Theme #2: Collecting data for a set of specific quality measures is not the same as measuring quality healthcare. Subtheme #2.1: Current quality measures are not aligned with how patients and clinicians define quality healthcare. Theme #3: Current quality measures are a product of and embedded in social and structural inequities in the American health care system. Subtheme #3.1: The current inequitable healthcare system should not be reinforced with financial payments. Subtheme #3.2: Health equity requires new metrics and a new healthcare system. Overall, PCPs felt that the current inequitable quality metrics should be replaced by different metrics along with major changes to the healthcare system that could produce greater health equity. Conclusion Aligning payment with the current quality metrics could perpetuate and exacerbate social inequities and health disparities. Policymakers should consider PCPs’ perspectives and create a quality-payment framework that does not disadvantage patients who are affected by social and structural inequities as well as the clinics and providers who serve them. Electronic supplementary material The online version of this article (10.1186/s12939-018-0872-3) contains supplementary material, which is available to authorized users.

You can improve health outcomes and patient satisfaction--without increasing the length of the patient visit--by employing the tenets of shared decision-making.

Background: To fight racism and its poten­tial influence on health, health care profes­sionals must recognize, name, understand and talk about racism. These conversations are difficult, particularly when stakes feel high—in the workplace and in interracial groups. We convened a multidisciplinary, multi-racial group of professionals in two phases of this exploratory project to develop and pilot an intervention to promote effec­tive dialogues on racism for first year medi­cal students at the University of Minnesota Medical School.Methods: Informed by a Public Health Crit­ical Race Praxis (PHCRP) methodology in Phase I, initial content was developed by a group of seven women primarily from racial and ethnic minority groups. In a later phase, they joined with five White (primarily male) colleagues to discuss racism and race. Participants met monthly for 12 months from Jan 2016-Dec 2016. All participants were recruited by study PI. An inductive approach was used to analyze meeting notes and post intervention reflections to describe lessons learned from the process of employing a PHCRP methodology to de­velop the aforementioned curriculum with a multidisciplinary and multi-racial group of professionals dedicated to advancing conversations on racial equity.Results: Participants from Phase I described the early meetings as “powerful,” allowing them to “bring their full selves” to a project that convened individuals who are often marginalized in their professional environ­ments. In Phase II, which included White colleagues, the dynamics shifted: “…the voices from Phase I became quieter…”; “I had to put on my armor and fight in those later meetings…”Conclusions: The process of employing PHCRP in the development of an interven­tion about racism led to new insights on what it means to discuss racism among those marginalized and those with privilege. Conversations in each phase yielded new insights and strategies to advance a conver­sation about racism in health care. Ethn Dis. 2018;28(Suppl 1):271-278; doi:10.18865/ed.28.S1.271.

Miller JR, Larson BE, Satin D, Schuster L. Information-seeking and decision-making preferences among adult orthodontic patients: an elective health care model. Community Dent Oral Epidemiol 2011; 39: 79–86. © 2010 John Wiley & Sons A/S Abstract Objectives: When it comes to their own health care, adult patients traditionally demonstrate strong information-seeking desire but a somewhat lower desire to make their own treatment decisions in nonelective situations. Little is known about these desires in patients facing elective health care situations. We used the well-tested Autonomy Preferences Index (API) as a base to construct and test our elective Autonomy Preferences Index (eAPI) for both information-seeking and decision-making and analyzed demographic variables on both. Methods: The eAPI was constructed to mirror the API but uses elective scenarios rather than the API’s nonelective scenarios. It was validated using cognitive interviews to determine item intent and comprehension and by Cronbach’s alpha. Both the API and eAPI were distributed to 188 active-treatment patients at the Division of Orthodontics, University of Minnesota. API and eAPI items were scored using a 1 (low) to 5 (high) Likert scale of desire. Results: Mean information-seeking desire was universally high (>4, P

Steps can be taken to reach an ethically and professionally sound decision about participation in a pay-for-performance practice incentive program. Virtual Mentor is a monthly bioethics journal published by the American Medical Association.

Are the ethics of athletes complex? Consider that an elite bicyclist might inject himself with hormones to increase his exercise capacity,but if his opponent falls, then that same hormone-abusing athlete will likely stop until his opponent has regained control. This article reviews key concepts from the philosophy of sport. Using six cases from the sports archives, it presents a practical framework for interpreting and assessing the moral status of an athlete's behavior. This work enables readers to appreciate more clearly both the contextual subtleties and the robust relationship between ethics and the athlete.

The provocative essay by Maienschein and colleagues (2008) tends to an often overlooked area within the ethics of medical research—the ethics of the epistemic. They discuss the potentially distorti...

Performance-based bundled payments have emerged as the most recent iteration of pay for performance. These are programs in which providers are paid a single fee for a set of evidenced-based services related to a diagnosis. The payments are typically linked to outcomes as well as other quality measures. This paper reviews two prominent bundled payment programs--PROMETHEUS and ProvenCare--and discusses the potential pitfalls of these approaches.

The physician working on the sidelines of a public sporting event may encounter a unique set of ethical dilemmas. Many of the ethical pitfalls result from the physician's responsibilities, not only to the patient, but also to teams and events. Standard rules of confidentiality and patient autonomy may not apply. We propose the use of professionalism as a guide for the sideline physician when faced with difficult ethical situations.