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Background Evidence-based medicine (EBM) is important in training doctors for high-quality care. Yet little is known about whether ambulatory precepting incorporates the concepts and principles of EBM.Methods The authors observed and audiotaped 95 internal medicine residency precepting interactions and rated interactions using a qualitative analytic template consisting of three criteria: (1) presence of clinical questions; (2) presence of an evidence-based process; and (3) resident ability to articulate a clinical question.Results Sixty-seven of 95 audio tapes (71%) were of acceptable quality to allow template analysis. Thirty (45%) contained explicit clinical questions; 11 (16%) included an evidence-based process. Resident ability to articulate a clinical question when promptedwas rated as at least 'fair' in 59 of 67 interactions (88%).Conclusions EBM was not optimally implemented in these clinics. Future research could explore more systematically what factors facilitate or impair the use of EBM in the real-time ambulatory training context. [ABSTRACT FROM AUTHOR]

Governments, international agencies and corporations are increasingly investing in traditional herbal medicine research. Yet little literature addresses ethical challenges in this research. In this paper, we apply concepts in a comprehensive ethical framework for clinical research to international traditional herbal medicine research. We examine in detail three key, underappreciated dimensions of the ethical framework in which particularly difficult questions arise for international herbal medicine research: social value, scientific validity and favourable risk-benefit ratio. Significant challenges exist in determining shared concepts of social value, scientific validity and favourable risk-benefit ratio across international research collaborations. However, we argue that collaborative partnership, including democratic deliberation, offers the context and process by which many of the ethical challenges in international herbal medicine research can, and should be, resolved. By 'cross-training' investigators, and investing in safety-monitoring infrastructure, the issues identified by this comprehensive framework can promote ethically sound international herbal medicine research that contributes to global health. [ABSTRACT FROM AUTHOR]

BACKGROUND: We aimed to describe prevailing attitudes and practices of rheumatologists in the United States toward complementary and alternative medicine (CAM) treatments. We wanted to determine whether rheumatologists' perceptions of the efficacy of CAM therapies and their willingness to recommend them relate to their demographic characteristics, geographic location, or clinical practices. METHODS: A National Institutes of Health-sponsored cross-sectional survey of internists and rheumatologists was conducted regarding CAM for treatment of chronic back pain or joint pain. In this study we analyzed responses only from rheumatologists. Response items included participant characteristics and experience with 6 common CAM categories, as defined by the National Institutes of Health. Descriptive statistics were used to describe attitudes to CAM overall and to each CAM category. Composite responses were devised for respondents designating 4 or more of the 6 CAM therapies as 'very' or 'moderately' beneficial or 'very likely' or 'somewhat likely' to recommend. RESULTS: Of 600 rheumatologists who were sent the questionnaire, 345 responded (58%); 80 (23%) were women. Body work had the highest perceived benefit, with 70% of respondents indicating benefit. Acupuncture was perceived as beneficial by 54%. Most were willing to recommend most forms of CAM. Women had significantly higher composite benefit and recommend responses than men. Rheumatologists not born in North America were more likely to perceive benefit of select CAM therapies. CONCLUSIONS: In this national survey of rheumatologists practicing in the United States, we found widespread favorable opinion toward many, but not all, types of CAM. Further research is required to determine to what extent CAM can or should be integrated into the practice of rheumatology in the United States. [ABSTRACT FROM AUTHOR]

Background: In response to COVID-19, many states revised, developed, or attempted to develop plans to allocate scarce critical care resources in the event that crisis standards of care were triggered. To our knowledge, no prior analysis has assessed this plan development process, including whether plans were successfully adopted., Research Question: How did states develop or revise scarce resource allocation plans during the COVID-19 pandemic, and what were the barriers and facilitators to their development and adoption at the state level?, Study Design and Methods: Plan authors and state leaders completed a semistructured interview February to September 2022. Interview transcripts were qualitatively analyzed for themes related to plan development and adoption according to the principles of grounded theory., Results: Thirty-six participants from 34 states completed an interview, from states distributed across all US regions. Among participants' states with plans that existed prior to 2020 (n = 24), 17 were revised and adopted in response to COVID-19. Six states wrote a plan de novo, with the remaining states failing to develop or adopt a plan. Thirteen states continued to revise their plans in response to disability or aging bias complaints or to respond to evolving needs. Many participants expressed that urgency in the early days of the pandemic prevented an ideal development process. Facilitators of successful plan development and adoption include: coordination or support from the state department of health and existing relationships with key community partners, including aging and disability rights groups and minoritized communities. Barriers include: lack of perceived political will to adopt a plan and development during a public health emergency., Interpretation: To avoid repeating mistakes from the early days of the COVID-19 response, states should develop or revise plans with community engagement and consider maintaining a standing committee with diverse membership and content expertise to periodically review plans and advise state officials on pandemic preparedness., Competing Interests: Financial/Nonfinancial Disclosures The authors have reported to CHEST the following: S. M. W. and D. A. D. served as co-leads of the Minnesota COVID Ethics Collaborative 2020-22. None declared (K. A. R., N. V. N., J. S. E., R. R. S., J. C. T., E. S. D.)., (Copyright © 2024 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Context: Pain is a prevalent symptom in patients with serious illness and often requires interventional approaches for adequate treatment. Little is known about referral patterns and collaborative attitudes of palliative physicians regarding pain management specialists., Objectives: To evaluate referral rates, co-management strategies, and beliefs of palliative physicians about the value of Pain Medicine specialists in patients with serious illness., Methods: A 30-question survey with demographic, referral/practice, and attitudes/belief questions was mailed to 1000 AAHPM physician members. Responses were characterized with descriptive statistics and further analyzed for associations between training experiences, practice environment, and educational activities with collaborative practice patterns and beliefs., Results: The response rate was 52.6%. Most survey respondents had initial board certification primarily in internal medicine (n = 286, 56%) or family medicine (n = 144, 28%). A minority of respondents had completed a formal ABMS Hospice and Palliative Medicine fellowship (n = 178, 34%). Respondents had been in practice for a median of nine years, (range 1-38 years) primarily in community hospitals (n = 249, 47%) or academic hospitals (n = 202, 38%). The variables best associated with collaborative practices and attitudes was practice in an academic hospital setting and participation in regular joint academic conferences with pain medicine clinicians., Conclusion: This study shows that Palliative Care physicians have highly positive attitudes toward Pain Medicine specialists, but referrals remain low. Facilitating professional collaboration via joint educational/clinical sessions is one possible solution to drive ongoing interprofessional care in patients with complex pain., (Copyright © 2024 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: Financial toxicity associated with treatments for metastatic prostate cancer remains poorly defined. We sought to understand aspects of financial toxicity not captured in a commonly employed financial toxicity questionnaire and identify potential interventions to help alleviate financial toxicity through a convergent mixed methods approach., Methods: Patients seen at our institution's advanced prostate cancer clinic were approached for completion of the Comprehensive Score for Financial Toxicity (COST-FACIT) questionnaire (quantitative analysis). A maximal variation purposive sample was chosen to participate in focus group discussions (qualitative analysis). Conventional content analysis was performed using an inductive approach. COST-FACIT scores were compared between patients experiencing high and low financial toxicity using Wilcoxon rank sum test., Results: Three themes were identified through qualitative analysis: (1) workload, (2) coping strategies, and (3) communication. We found alignment with the existing theory of financial capacity across our findings. Two unique aspects of financial toxicity emerged that were not assessed quantitatively and deemed to be significant. Specifically, cost transparency (including health care teams knowledgeable about and willing to discuss costs) and inclusion of informal caregivers in financial toxicity screening and decision-making may guide future interventions aimed at limiting financial toxicity in this population., Conclusions: Prolonged treatment courses involving multiple lines of treatment with varying costs result in distinct financial toxicity components for patients with metastatic prostate cancer that are not assessed with COST-FACIT. Improving cost transparency, health care team knowledge and engagement, and providing resources to support informal caregivers may have a significant impact on the financial toxicity experienced by these patients.

AbstractPurpose: to characterize ethics course content, structure, resources, pedagogic methods, and opinions among academic administrators and course directors at U.S. medical schools., Method: An online questionnaire addressed to academic deans and ethics course directors identified by medical school websites was emailed to 157 Association of American Medical Colleges member medical schools in two successive waves in early 2022. Descriptive statistics were utilized to summarize responses., Results: Representatives from 61 (39%) schools responded. Thirty-two (52%) respondents were course directors; 26 (43%) were deans of academic affairs, medical education, or curriculum; and 3 with other roles also completed the survey (5%). All 61 schools reported some form of formal ethics education during the first year of medical school, with most ( n = 54, 89%) reporting a formal mandatory introductory course during preclinical education. Schools primarily utilized lecture and small-group teaching methods. Knowledge-based examinations, attendance, and participation were most commonly used for assessment. A large majority regarded ethics as equally or more important than other foundational courses, but fewer ( n = 37, 60%) provided faculty training for teaching ethics., Conclusions: Despite a response rate of 39 percent, the authors conclude that medical schools include ethics in their curricula in small-group and lecture formats with heterogeneity regarding content taught. Preclinical curricular redesigns must innovate and implement best practices for ensuring sound delivery of ethics content in future curricula. Additional large-scale research is necessary to determine said best practices.

Introduction: Testing healthcare delivery interventions in rigorous clinical trials is a critical step in improving patient care, but conducting multisite randomized clinical trials to test the effect of care delivery interventions has unique challenges and requires foresight and planning., Methods: We conducted the first care delivery trial (A191402CD) in the Alliance for Clinical Trials in Oncology, a National Cancer Institute Community Oncology Research Program research base, which tested the effectiveness of two different decision aids for supporting shared decision-making about prostate cancer treatment. Our experience illustrates the kind of challenges that confront care delivery researchers as they seek to test interventions to improve the experiences of patients., Results: Lessons learned include the following: cluster-randomized designs introduce complexity; workflow disruption can discourage site participation; evidence-based methods may not always be sufficient., Conclusion: We conclude with the following recommendations: assessing feasibility requires special rigor; relationships and interpersonal dynamics must be leveraged. Our experiences may inform future care delivery research.

Purpose: In response to the COVID-19 pandemic, many cancer practices rapidly adopted telehealth services. However, there is a paucity of data regarding ongoing telehealth visit utilization beyond this initial response. The purpose of this study was to assess changes in variables associated with telehealth visit utilization over time., Methods: This is a cross-sectional, year-over-year, retrospective analysis of telehealth visits conducted across a multisite, multiregional cancer practice in the United States. Multivariable models examined the association of patient- and provider-level variables with telehealth utilization across outpatient visits conducted over three 8-week periods from July to August in 2019 (n = 32,537), 2020 (n = 33,399), and 2021 (n = 35,820)., Results: The rate of telehealth utilization increased from <0.01% (2019) to 11% (2020) to 14% (2021). The most significant patient-level factors associated with increased telehealth utilization included nonrural residence and age ≤65 years. Among patients residing in rural settings, video visit utilization rates were significantly lower and phone visit utilization rates were significantly higher compared with patients from nonrural residences. Regarding provider-level factors, widening differences in telehealth utilization were observed at tertiary versus community-based practice settings. Increased telehealth utilization was not associated with duplicative care as per-patient and per-physician visit volumes in 2021 remained consistent with prepandemic levels., Conclusion: We observed continuous expansion in telehealth visit utilization from 2020 to 2021. Our experiences suggest that telehealth can be integrated into cancer practices without evidence of duplicative care. Future work should examine sustainable reimbursement structures and policies to ensure accessibility of telehealth as a means to facilitate equitable, patient-centered cancer care.

Misinformation among clinics advertising unproven stem cell interventions (SCIs) is pervasive and has resulted in patient and societal harms. Most bioethics commentaries have centered on advancing regulatory approaches to curtail the supply side of the market, but insufficient attention has been paid to considering strategies influencing patient demand. In this article, we offer an ethical justification for the design and deployment of persuasive patient education on unproven SCIs and distinguish it from didactic and manipulative education frames. Persuasive education should aim to correct and inoculate against misinformation about unproven SCIs and instill a sense of caution among patients considering experimental interventions outside of a clinical trial. We outline various communication strategies to effectively correct or inoculate against SCI misinformation. The stem cell community needs to invest in understanding patients' informational sources, attitudes, and beliefs about SCIs to develop and implement evidence-based persuasive education to promote informed decision-making about these therapies., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Importance: During the COVID-19 pandemic, many US states issued or revised pandemic preparedness plans guiding allocation of critical care resources during crises. State plans vary in the factors used to triage patients and have faced criticism from advocacy groups due to the potential for discrimination., Objective: To analyze the role of comorbidities and long-term prognosis in state triage procedures., Design, Setting, and Participants: This cross-sectional study used data gathered from parallel internet searches for state-endorsed pandemic preparedness plans for the 50 US states, District of Columbia, and Puerto Rico (hereafter referred to as states), which were conducted between November 25, 2021, and June 16, 2023. Plans available on June 16, 2023, that provided step-by-step instructions for triaging critically ill patients were categorized for use of comorbidities and prognostication., Main Outcomes and Measures: Prevalence and contents of lists of comorbidities and their stated function in triage and instructions to predict duration of postdischarge survival., Results: Overall, 32 state-promulgated pandemic preparedness plans included triage procedures specific enough to guide triage in clinical practice. Twenty of these (63%) included lists of comorbidities that excluded (11 of 20 [55%]) or deprioritized (8 of 20 [40%]) patients during triage; one state's list was formulated to resolve ties between patients with equal triage scores. Most states with triage procedures (21 of 32 [66%]) considered predicted survival beyond hospital discharge. These states proposed different prognostic time horizons; 15 of 21 (71%) were numeric (ranging from 6 months to 5 years after hospital discharge), with the remaining 6 (29%) using descriptive terms, such as long-term., Conclusions and Relevance: In this cross-sectional study of state-promulgated critical care triage policies, most plans restricted access to scarce critical care resources for patients with listed comorbidities and/or for patients with less-than-average expected postdischarge survival. This analysis raises concerns about access to care during a public health crisis for populations with high burdens of chronic illness, such as individuals with disabilities and minoritized racial and ethnic groups.

Purpose: Assessments of financial toxicity among patients with metastatic prostate cancer are lacking. Using patient surveys, we sought to identify coping mechanisms and assess characteristics associated with lower financial toxicity., Materials and Methods: Surveys were administered to all patients seen at a single center's Advanced Prostate Cancer Clinic over a 3-month period. Surveys included the COST-FACIT (COmprehensive Score for Financial Toxicity) and coping mechanism questionnaires. Patients with metastatic disease (lymph nodes, bone, visceral) were included for analysis. Coping mechanisms were compared between patients experiencing low (COST-FACIT >24) vs high (COST-FACIT ≤24) financial toxicity using Fisher's exact test. Multivariable linear regression was used to evaluate characteristics associated with lower financial toxicity., Results: Overall, 281 patients met inclusion criteria of which 79 reported high financial toxicity. In multivariable analysis, characteristics associated with lower financial toxicity included older age (estimate: 0.36, 95%CI: 0.21-0.52), applying for patient assistance programs (estimate: 4.42, 95%CI: 1.72-7.11), and an annual income of at least $100,000 (estimate: 7.81, 95%CI: 0.97, 14.66). Patients with high financial toxicity were more likely to decrease spending on basic goods (35% vs 2.5%, P < .001) and leisure activities (59% vs 15%, P > .001), as well as use savings (62% vs 17%, P < .001) to pay for their treatment., Conclusions: In this cross-sectional study, patients with metastatic prostate cancer and high financial toxicity were more likely to decrease spending on basic goods and leisure activities and use savings to pay for care. Understanding the impact of financial toxicity on patients' lives is crucial to inform shared decision-making and interventions designed to mitigate financial toxicity in this population.

Impostor phenomenon has gained increasing attention within the health care and health professions education literature. Although consistently depicted as a debilitating socioemotional experience, studies also suggest a strategic aspect to impostor phenomenon - denoting a conceptual ambiguity to impostor phenomenon that has yet to fully examined. Within this paper, we use humility as a conceptual sparring partner with impostor phenomenon to examine the similarities and differences between the concepts, as well as explore the various nuances associated with impostor phenomenon. By comparing and contrasting impostor phenomenon and humility from interdisciplinary perspectives and within the context of health professions specifically, we not only further refine their meaning and usage within the literature, but also spotlight key areas for future research., (Copyright © 2023 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the role of timing (either before or during initial consultation) on the effectiveness of decision aids (DAs) to support shared-decision-making in a minority-enriched sample of patients with localized prostate cancer using a patient-level randomized controlled trial design., Methods: We conducted a 3-arm, patient-level-randomized trial in urology and radiation oncology practices in Ohio, South Dakota, and Alaska, testing the effect of preconsultation and within-consultation DAs on patient knowledge elements deemed essential to make treatment decisions about localized prostate cancer, all measured immediately following the initial urology consultation using a 12-item Prostate Cancer Treatment Questionnaire (score range 0 [no questions correct] to 1 [all questions correct]), compared to usual care (no DAs)., Results: Between 2017 and 2018, 103 patients-including 16 Black/African American and 17 American Indian or Alaska Native men-were enrolled and randomly assigned to receive usual care (n = 33) or usual care and a DA before (n = 37) or during (n = 33) the consultation. After adjusting for baseline characteristics, there were no statistically significant proportional score differences in patient knowledge between the preconsultation DA arm (0.06 knowledge change, 95% CI -0.02 to 0.12, P = .1) or the within-consultation DA arm (0.04 knowledge change, 95% CI -0.03 to 0.11, P = .3) and usual care., Conclusion: In this trial oversampling minority men with localized prostate cancer, DAs presented at different times relative to the specialist consultation showed no improvement in patient knowledge above usual care., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Despite recent attention to social justice, diversity, equity, and inclusion within medical education, little is currently known about whether and to what extent that attention has translated into the language of formal documents articulating organization purpose: medical school mission statements. Mission statements are the marquee declaration of a medical school's identity and purpose, and a recommended tool for applicants to determine "fit" when applying. This study examines whether and to what extent social justice, diversity, equity, and inclusion have made it into the formal public statements of organizational purpose and identity over the last several years. Mission statements were extracted manually from the 2007, 2017, and 2021 AAMCs Medical School Admission Requirements (MSAR) database for both U.S. and Canadian M.D. granting medical schools. Then each mission statement version was coded for the presence and degree of diversity language including words like social justice, diversity, equity, and inclusion using an agreed-upon lexicon. Frequencies and within school changes over time were analyzed. Among 139 medical schools with discoverable mission statements from 2007, 91% (n=127) changed their MSs between 2007 and 2021. In 2007, 24% (n=33) of MSs contained diversity language. By 2017 nearly half of MSs; 47% (n=65) contained any reference to such language. But by 2021, despite 46 school having changed their MSs again, only a few more included diversity language in their MSs (56%; n=77). The most common terms used were "diversity," followed by the increasing presence of words like "inclusion," "equity," and "justice" by 2021. Curiously, a few schools redacted diversity language from 2007 to 2021. A Diversity Thesaurus of 22 terms was iteratively identified, with all terms searched in all MSs. Overall, mission statement change was quite common with most medical schools making changes across the 14 years covered in this study. And despite a doubling of the number of medical schools MSs mentioning diversity over a 10-year period, that increase seemed to slow in recent years even among schools who had a chance to change their MS. As of mid-2021, two in five US medical schools still have no mention of diversity related language in their most formal, said articulation of organizational purpose., (Copyright © 2022 National Medical Association. Published by Elsevier Inc. All rights reserved.)

Purpose: Out-of-pocket costs represent an important component of financial toxicity and may impact patients' receipt of care. Herein, we evaluated patient-level factors associated with out-of-pocket costs for contemporary advanced prostate cancer treatment options., Materials and Methods: We identified all commercially insured men receiving treatment for advanced prostate cancer between 2007 and 2019 within the OptumLabs Data Warehouse®. Patients were categorized into 3 treatment groups: androgen deprivation monotherapy, novel hormonal therapy, and nonandrogen systemic therapy. The primary outcome was out-of-pocket costs in the first year of treatment. The associations of treatment and patient variables with out-of-pocket costs were assessed using multivariable regression models. All costs were adjusted to reflect 2019 U.S. dollars using the Consumer Price Index., Results: In a cohort of 13,409 men 81% (n = 10,926) received androgen deprivation monotherapy, 6% (n = 832) novel hormonal therapy, and 12% (n = 1,651) nonandrogen systemic therapy. Mean treatment-related out-of-pocket costs in the first year were $165, $4,236, and $994 for androgen deprivation monotherapy, novel hormonal therapy, and nonandrogen systemic therapy, respectively. The adjusted difference in annual treatment-related out-of-pocket costs for novel hormonal therapy and nonandrogen systemic therapy were $2,581 (95% CI: $1,923-$3,240) and $752 (95% CI: $600-$903) higher than androgen deprivation monotherapy, respectively. Patient characteristics associated ( P < .05) with higher treatment-related out-of-pocket costs included older age (65-74 years), Black race, lower comorbidity scores, and lower household income., Conclusions: Patients receiving novel hormonal therapy for advanced prostate cancer had substantially higher treatment-related out-of-pocket costs. In addition to raising awareness among prescribers, these data support the inclusion of treatment associated financial toxicity in shared decision making for advanced prostate cancer and call attention to subgroups of patients particularly vulnerable to financial toxicity.

COVID-19 has widened the existing digital divide, especially for people from socially and economically deprived communities. We describe a program evaluation using a community participatory approach to develop self-reported items of patient experience with technology inclusive of digital access and literacy. The feedback received from Community Advisory Boards and Community Engagement Studio members led to the evaluation and refinement of the individual items. The community-based participatory approach highlighted in our paper to develop these items could serve as a model for other screening tool development for enhancing equity and inclusiveness in clinical care and research., (© The Author(s) 2022.)

Background: Prognostic information is key to shared decision-making, particularly in life-limiting illness like advanced chronic kidney disease (CKD)., Objective: To understand the prognostic information preferences expressed by older patients with CKD., Design and Participants: Qualitative study of 28 consecutively enrolled patients over 65 years of age with non-dialysis dependent CKD stages 3b-5, receiving care in a multi-disciplinary CKD clinic., Approach: Semi-structured telephone or in-person interviews to explore patients' preference for and perceived value of individualized prognostic information. Interviews were analyzed using inductive content analysis., Key Results: We completed interviews with 28 patients (77.7 ± SD 6.8 years, 69% men). Patients varied in their preference for prognostic information and more were interested in their risk of progression to end-stage kidney disease (ESKD) than in life expectancy. Many conflated ESKD risk with risk of death, perceiving a binary choice between dialysis and quick decline and death. Patients expressed that prognostic information would allow them to plan, take care of important business, and think about their treatment options. Patients were accepting of prognostic uncertainty and imagined leveraging it to nurture hope or motivate them to better manage risk factors. They endorsed the desire to receive prognosis of life expectancy even though it may be hard to accept or difficult to talk about but worried it could create helplessness for other patients in their situation., Conclusion: Most, but not all, patients were interested in prognostic information and could see its value in motivating behavior change and allowing planning. Some patients expressed concern that information on life expectancy might cause depression and hopelessness. Therefore, prognostic information is most appropriate as part of a clinical conversation that fosters shared decision-making and helps patients consider treatment risks, benefits, and burdens in context of their lives., (© 2021. Society of General Internal Medicine.)

Background: Decision aids (DAs) can improve knowledge for prostate cancer treatment. However, the relative effects of DAs delivered within the clinical encounter and in more diverse patient populations are unknown. A multicenter cluster randomized controlled trial with a 2×2 factorial design was performed to test the effectiveness of within-visit and previsit DAs for localized prostate cancer, and minority men were oversampled., Methods: The interventions were delivered in urology practices affiliated with the NCI Community Oncology Research Program Alliance Research Base. The primary outcome was prostate cancer knowledge (percent correct on a 12-item measure) assessed immediately after a urology consultation., Results: Four sites administered the previsit DA (39 patients), 4 sites administered the within-visit DA (44 patients), 3 sites administered both previsit and within-visit DAs (25 patients), and 4 sites provided usual care (50 patients). The median percent correct in prostate cancer knowledge, based on the postvisit knowledge assessment after the intervention delivery, was as follows: 75% for the pre+within-visit DA study arm, 67% for the previsit DA only arm, 58% for the within-visit DA only arm, and 58% for the usual-care arm. Neither the previsit DA nor the within-visit DA had a significant impact on patient knowledge of prostate cancer treatments at the prespecified 2.5% significance level (P = .132 and P = .977, respectively)., Conclusions: DAs for localized prostate cancer treatment provided at 2 different points in the care continuum in a trial that oversampled minority men did not confer measurable gains in prostate cancer knowledge., (© 2021 American Cancer Society.)

The U.S. Food and Drug Administration (FDA) allows patients with serious illnesses to access investigational drugs for "compassionate use" outside of clinical trials through expanded access (EA) Programs. The federal Right-to-Try Act created an additional pathway for non-trial access to experimental drugs without institutional review board or FDA approval. This removal of oversight amplifies the responsibility of physicians, but little is known about the role of practicing physicians in non-trial access to investigational drugs. We undertook semi-structured interviews to capture the experiences and opinions of 21 oncologists all with previous EA experience at a major cancer center. We found five main themes. Participants with greater EA experience reported less difficulty accessing drugs through the myriad of administrative processes and drug company reluctance to provide investigational products while newcomers reported administrative hurdles. Oncologists outlined several rationales patients offered when seeking investigational drugs, including those with stronger health literacy and a good scientific rationale versus others who remained skeptical of conventional medicine. Participants reported that most patients had realistic expectations while some had unrealistic optimism. Given the diverse reasons patients sought investigational drugs, four factors-scientific rationale, risk-benefit ratio, functional status of the patient, and patient motivation-influenced oncologists' decisions to request compassionate use drugs. Physicians struggled with a "right-to-try" framing of patient access to experimental drugs, noting instead their own responsibility to protect patients' best interest in the uncertain and risky process of off-protocol access. This study highlights the willingness of oncologists at a major cancer center to pursue non-trial access to experimental treatments for patients while also shedding light on the factors they use when considering such treatment. Our data reveal discrepancies between physicians' sense of patients' expectations and their own internal sense of professional obligation to shepherd a safe process for patients at a vulnerable point in their care., Competing Interests: The authors have declared that no competing interests exist.

Objective: The degree decision aids (DAs) can promote active surveillance (AS) for prostate cancer (PCa) remains poorly understood. Herein, we surveyed radiation oncologists (RO) and urologists (URO) about their attitudes towards DAs in counselling patients about AS for low-risk PCa., Methods: We conducted a national survey of RO (n = 915) and URO (n = 940) to assess their attitudes about DAs for AS for patients with low-risk PCa. Respondents were queried about their attitudes towards DAs and proportion of PCa patients managed with AS. Multivariable logistic regression models were used to examine physician characteristics related to attitudes about DAs., Results: The overall response rate was 37.3% (n = 691). Most respondents strongly agreed or agreed that DAs helped patients with low-risk PCa make informed decisions (93.9%) and also increased patient support for AS (86.6%). Having a high volume of their low-risk PCa patients on AS (>15%) was associated with endorsing the statement that use of DAs increased the likelihood of recommending AS (OR: 1.83; 95% CI: 1.00-4.61; p = .05) and being a URO versus a RO (OR: 3.37; 95% CI: 2.46-5.79; p < .001)., Conclusions: Most specialists view DAs as effective tools to facilitate more informed treatment decisions and facilitate greater use of AS in appropriately selected patients., (© 2020 John Wiley & Sons Ltd.)

With ever-growing emphasis on high-stakes testing in medical education, such as the Medical College Admission Test and the United States Medical Licensing Examination Step 1, there has been a recent surge of concerns on the rise of a "Step 1 climate" within U.S. medical schools. The authors propose an alternative source of the "climate problem" in current institutions of medical education. Drawing on the intertwined concepts of trust and professionalism as organizational constructs, the authors propose that the core problem is not hijacking-by-exam but rather a hijackable learning environment weakened by a pernicious and under-recognized tide of commodification within the U.S. medical education system. The authors discuss several factors contributing to this weakening of medicine's control over its learning environments, including erosion of trust in medical school curricula as adequate preparation for entry into the profession, increasing reliance on external profit-driven sources of medical education, and the emergence of an internal medical education marketplace. They call attention to breaches in the core tenets of a profession-namely a logic that differentiates its work from market and managerial forces, along with related slippages in discretionary decision making. The authors suggest reducing reliance on external performance metrics (high-stakes exams and corporate rankings), identifying and investing in alternative metrics that matter, abandoning the marketization of medical education "products," and attending to the language of educational praxis and its potential corruption by market and managerial lexicons. These steps might salvage some self-governing independence implied in the term "profession" and make possible (if not probable) a recovery of a public trust becoming of the term and its training institutions.

Background: Magnetic resonance imaging (MRI) of the prostate and fusion biopsy have been advanced to improve the detection of clinically significant prostate cancer (PCa). Yet, frequency of their use and contemporary attitudes among radiation oncologists (ROs) and urologists (UROs) remain largely unknown., Objective: We performed a national survey of UROs and ROs to assess the perceived attitudes towards and frequency of prostate MRI and fusion biopsy., Design, Setting, and Participants: We conducted a national survey of 915 ROs and 940 UROs about prostate MRI and fusion biopsy in 2017., Outcome Measurements and Statistical Analysis: The survey queried respondents about perceptions of prostate MRI and fusion biopsy and inquired about self-reported utilization. Pearson chi-square test and multivariable logistic regression were used to identify physician characteristics associated with survey responses., Results and Limitations: The overall response rate was 37% (n=691). Both UROs and ROs demonstrated similar positive views that MRI with fusion biopsy improves PCa risk stratification (67% vs 71%; p=0.19) and fusion biopsy increases the confidence recommending active surveillance (55% vs 60%; p=0.18). Yet, only a quarter of both specialties reported frequent use of prostate MRI for treatment decisions for low- and intermediate-risk PCa. Compared with respondents practicing in community practices, those in academic practices were more likely to report using prostate MRI for low- (44% vs 19%; adjusted odds ratio [OR]: 3.96; p<0.001) and intermediate-risk PCa (42% vs 24%; adjusted OR: 2.49; p<0.001). Our study was limited by a modestly lower response rate., Conclusions: While both specialties have perceived value in favor of prostate MRI and fusion biopsy, only a quarter of respondents report their use in clinical practice. Physicians practicing in academic medical centers had greater self-reported use., Patient Summary: Magnetic resonance imaging of the prostate and targeted biopsies have growing evidence of their use as a superior diagnostic methodology for prostate cancer diagnosis and treatment decisions. Our survey study found that a majority of radiation oncologists and urologists view both favorably in improving prostate cancer detection and treatment decisions. Yet, only a quarter report using it in routine clinical practice for men diagnosed with prostate cancer., (Copyright © 2018 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Introduction: Chemotherapy-induced peripheral neuropathy (CIPN) is a prominent clinical problem, with limited effective therapies. Preliminary non-randomized clinical trial data support that Scrambler Therapy is helpful in this situation., Methods: Patients were eligible if they had CIPN symptoms for at least 3 months and CIPN-related tingling or pain at least 4/10 in severity during the week prior to registration. They were randomized to receive Scrambler Therapy versus transcutaneous electrical nerve stimulation (TENS) for 2 weeks. Patient-reported outcomes (PROs) were utilized to measure efficacy and toxicity daily for 2 weeks during therapy and then weekly for 8 additional weeks., Results: This study accrued 50 patients, 25 to each of the 2 study arms; 46 patients were evaluable. There were twice as many Scrambler-treated patients who had at least a 50% documented improvement during the 2 treatment weeks, from their baseline pain, tingling, and numbness scores, when compared with the TENS-treated patients (from 36 to 56% compared with 16-28% for each symptom). Global Impression of Change scores for "neuropathy symptoms," pain, and quality of life were similarly improved during the treatment weeks. Patients in the Scrambler group were more likely than those in the TENS group to recommend their treatment to other patients, during both the 2-week treatment period and the 8-week follow-up period (p < 0.0001). Minimal toxicity was observed., Conclusions: The results from this pilot trial were positive, supporting the conduct of further investigations regarding the use of Scrambler Therapy for treating CIPN.

We reflect on Dr. Iserson's article in this journal, in which he suggests that clinicians must "shove" patients towards appropriate care. While recognizing that overt clinical guidance is part of care, we suggest that its use should be tempered by the guidance's responsiveness to the human and emotional experience of each patient., (Copyright 2020 The Journal of Clinical Ethics. All rights reserved.)

Objective: To determine the potential relationship between measures of patient-provider communication and patient body mass index (BMI) and gender in cancer care., Methods: We audio-recorded cancer patients' communication with their clinicians in an academic medical oncology practice from 2012-2014. We coded audio-recordings with the Roter Interaction Analysis System. We then examined whether BMI was associated with patient centeredness, time with doctor, global affect, and patient self-reported communication quality. Univariate associations with BMI were assessed with Chi-square and Kruskal-Wallis tests. A cumulative logit model adjusted for patient and visit characteristics in a multivariable model., Results: We recorded 327 patient interactions with 37 clinicians. After adjusting for patient sex, and visit characteristics, visit length, patient-centeredness, global affect (patient or clinician) and satisfaction did not differ. However, higher BMI was associated with shorter visit length, and lower Negative Global Affect (p = 0.03 and p = 0.03, respectively) in men only., Conclusion: In this exploratory analysis, communication characteristics did not vary by patient BMI overall. However, in men, higher BMI was associated with shorter visit length and more negative affect. Those differences did not persist after adjusting for multiple comparisons., Practice Implications: Patient body size may contribute to clinical communication in cancer care, particularly for obese men., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Purpose: Although prediction tools for prostate cancer (PCa) are essential for high-quality treatment decision-making, little is known about the degree of confidence in existing tools and whether they are used in clinical practice from radiation oncologists (RO) and urologists (URO). Herein, we performed a national survey of specialists about perceived attitudes and use of prediction tools., Methods: In 2017, we invited 940 URO and 911 RO in a national survey to query their confidence in and use of the D'Amico criteria, Kattan Nomogram, and CAPRA score. The statistical analysis involved bivariate association and multivariable logistic regression analyses to identify physician characteristics (age, gender, race, practice affiliation, specialty, access to robotic surgery, ownership of linear accelerator and number of prostate cancer per week) associated with survey responses and use of active surveillance (AS) for low-risk PCa., Results: Overall, 691 (37.3%) specialists completed the surveys. Two-thirds (range 65.6-68.4%) of respondents reported being "somewhat confident", but only a fifth selected "very confident" for each prediction tool (18.0-20.1%). 19.1% of specialists in the survey reported not using any prediction tools in clinical practice, which was higher amongst URO than RO (23.9 vs. 13.4%; p < 0.001). Respondents who reported not using prediction tools were also associated with low utilization of AS in their low-risk PCa patients (adjusted OR 2.47; p = 0.01)., Conclusions: While a majority of RO and URO view existing prediction tools for localized PCa with some degree of confidence, a fifth of specialists reported not using any such tools in clinical practice. Lack of using such tools was associated with low utilization of AS for low-risk PCa.

Purpose: To describe the frequency, content, dynamics, and patterns of cost conversations in academic medical oncology across tumor types., Patients and Methods: We reviewed 529 audio recordings between May 3, 2012, to September 23, 2014, from a prospective three-site communication study in which patients at any stage of management for any solid tumor malignancy were seen in routine oncology appointments. Recordings were deidentified, transcribed, and flagged for any mention of cost. We coded encounters and used qualitative thematic analysis., Results: Financial issues were discussed in 151 (28%) of 529 recordings. Conversations lasted shorter than 2 minutes on average. Patients/caregivers raised a majority of discussions (106 of 151), and 40% of cost concerns raised by patients/caregivers were not verbally acknowledged by clinicians. Social service referrals were made only six times. Themes from content analysis were related to insurance eligibility/process, work insecurity, cost of drugs, cost used as tool to influence medical decision making, health care-specific costs, and basic needs. Financial concerns influenced oncology work processes via test or medication coverage denials, creating paperwork for clinicians, potentially influencing patient involvement in trials, and leading to medication self-rationing or similar behaviors. Typically, financial concerns were associated with negative emotions., Conclusion: Financial issues were raised in approximately one in four academic oncology visits. These brief conversations were usually initiated by patients/caregivers, went frequently unaddressed by clinicians, and seemed to influence medical decision making and work processes and contribute to distress. Themes identified shed light on the kinds of gaps that must be addressed to help patients with cancer cope with the rising cost of care.

Background: Clinical factors and barriers affecting adoption of active surveillance (AS) for low-risk prostate cancer (PCa) remain poorly understood. We performed a national survey of radiation oncologists (RO) and urologists (URO) about the perceptions and recommendations of AS for low-risk PCa., Materials and Methods: In 2017, we surveyed 915 RO and 940 URO about AS for low-risk PCa in the United States. Survey items queried respondents about their attitudes toward AS and recommendations of AS for low-risk PCa. Pearson chi-square and multivariable logistic regression identified clinical and physician factors related toward AS for low-risk PCa., Results: Overall, the response rate was 37.3% (n = 691) and was similar for RO and URO (35.7% vs. 38.7%; P = .18). RO were less likely to consider AS effective for low-risk PCa (86.5% vs. 92.0%; P = .04) and more likely to rate higher patient anxiety on AS (49.5% vs. 29.5%; P < .001) than URO. Recommendations of AS varied modestly on the basis of age, prostate-specific antigen (PSA), and number of cores positive for Gleason 3 + 3 PCa. For a 55-year-old man with PSA 8 with 6 cores of Gleason 6 PCa, both RO and URO infrequently recommended AS (4.4% vs. 5.2%; adjusted odds ratio = 0.6; P = .28). For a 75-year-old patient with PSA 4 with 2 cores of Gleason 6 PCa, URO and RO most often recommended AS (89.6% vs. 83.4%; adjusted odds ratio = 0.5; P = .07)., Conclusion: RO and URO consider AS to be effective in the clinical management of low-risk PCa, but this varies by clinical and physician factors., (Copyright © 2019 Elsevier Inc. All rights reserved.)