The COVID-19 has posed a wide range of urgent questions: about the disease, testing, immunity, treatments, and outcomes. Extreme situations, such as pandemics, call for exceptional measures. However, this threatens the production and application of evidence. This paper directs evidence production towards four types of uncertainty in order to address the challenges of the pandemic: Risk, Fundamental uncertainty, Ignorance, and Ambiguity. Eliminating ambiguity, being alert to the unknown, and gathering data to estimate risks are crucial to preserve evidence and save lives. Hence, in order to avoid fake facts and to provide sustainable solutions we need to pay attention to the various kinds of uncertainty. Producing high quality evidence is the solution, not the problem.
Sturmberg and Martin in 2020 argue that Universal Health Care (UHC) is mainly about financing and Primary Health Care (PHC) is about the right care at the right time to ensure health. They maintain the World Health Organisation (WHO) has recently sent the wrong message about the “pillars” of PHC in their relationship to UHC. An understanding of political economy is required in order to come to terms with the bases of PHC and the fundamentals of UHC, that dealing with inequities is not only an economic issue but fundamentally a political issue. Neoliberal decision making can enhance inequities in society. Two chronic health conditions, diabetes and multiple sclerosis are examples of conditions that lead to costly and debilitating consequences for patients but also lead to substantial economic costs in terms of lost workforce participation and lost productivity. These cases demonstrate the socio-political issues involved in the management of care for a number of illnesses. The upsurge of COVID–19 has placed an enormous strain on health and broader social and economic resources and challenged the pretext of UHC as health for all: substantial differences in equity and political commitment have emerged. Sturmberg and Martin argue that the joining of UHC and PHC needs leadership which involves local communities and resourcing. PHC is a changing system based on power relationships involving funders and the health community. In Australia as in several countries out of pocket costs have grown rapidly and have affected access for some groups to PHC and have challenged the pretext of equity in UHC. In the context of PHC and UHC we support the position that health for all goes beyond healthcare for all, to embrace healthy lives promoting wellbeing.
Competence based education (CBE) has become increasingly popular as of late among health professions training programs. Models of CBE have been developed and implemented by major licensing bodies and professional Colleges (and affiliated education programs), such as the Royal College of Physicians and Surgeons of Canada (RCPSC) and the Association of American Medical Colleges (AAMC). In this month’s issue of theJournal of Evaluation in Clinical Practice , several studies describe an experience with designing and implementing a CBE model [1-6]. On the surface, the desire to ensure that health professions trainees are competent is commendable – just as it is likely few would argue that the care they receive should not be evidence based, I suspect that few (if any) would be comfortable with the clinician prescribing or managing said care being less than competent. However, the notion of a need for a CBE model might suggest that there was some issue with competence in the training of past clinicians that needed remedy, i.e. there is a lack of competence among some clinicians entering their profession that is in part a product of their training.When considering public perception of clinician competence, that of physicians in particular, history is not kind. Over the past two millennia, medicine got it wrong more often than right – humoral theory, bloodletting, miasma and contagion were all highly subscribed among the healthcare community but are now relics of a bygone era. In fact, the poor track record of medicine was the basis for a need for evidence based medicine (EBM). Practitioners of healthcare were often portrayed as ineffective, as providing little more than palliative support while nature took its course for better or worse, or even crueler, as charlatans peddling nostrums . Artists were no kinder to clinicians. For example, Shaw’s The Doctors Dilemma portrays a group of physicians as self-absorbed, greedy, overly confident in their unproven (and presumably, ineffective) pet “cures”, with only the poorest among them as having any sense of humility and patient centred focus in his practice . It seems that only within the last century did clinicians develop a good public reputation, much of which might be more appropriately attributed to improvements in hygiene practices/standards of living at a societal level (e.g. the McKeown Thesis) or likewise to medical science and the discovery of “silver bullet” cures (e.g. antibiotics, insulin, etc.) rather than to a change in how clinicians approached the learning of their craft and care of their patients. However, a historical lack of curative success and a poor reputation does not entail a lack of competence. A clinician working in Europe during the first millennium of the Common Era would have been considered competent provided he (or much rarer, she) mastered humoralism according to the teachings of Galen. Is it possible that future generations will look at the clinicians of today – even those who train under CBE – in the same light as we do clinicians of the past? Should a failure of today’s medicine in the eyes of future generations invalidate the competence of contemporary clinicians? I suppose the impact of the answer to such questions on the issue of competence hinges on how we define (and measure) competence.What then makes a clinician competent? The obvious answer is technical knowledge in the clinician’s given area. By that, I assume that for a clinician to be considered competent, she requires a minimum understanding of the content and technique of her given profession contemporaneous with the period of practice.11A minimum understanding of content and technique is required to be accepted into the profession, but it is not the desirable end. Clinicians are expected to participate in a model of lifelong learning with a goal of mastery over that content and technique. However, knowledge might be considered the minimum requirement. Several frameworks of competence outline additional requirements. For example, the “CanMEDS” framework, issued by the RCPSC, identifies “the abilities physicians require to effectively meet the health care needs of the people they serve”22http://www.royalcollege.ca/rcsite/canmeds/canmeds-framework-e, accessed on June 8, 2020., which includes the roles of the physician as medical expert, communicator, collaborator, leader, health advocate, scholar, and professional. The criteria by which these “roles” were selected (and other “roles” excluded), including the theoretical and/or empirical justification for their inclusion as part of “competence” is not clear to me, nor is it entirely clear if available metrics are sufficient in demonstrating that the roles have in fact been achieved by the trainee or how one operationalizes those roles in practice. Are clinicians who lack ability in any of these “roles” incompetent? Does meeting all of them according to some threshold ensure competence? As health professions are typically self-regulating, it is up to the governing bodies of each profession to decide, which might suggest that competence is a product of the times rather than akin to a “natural kind”33If it is the case that “competence” in medical practice, for example, is in fact a standard set by the profession (which I think most people would agree is the case), then judging the competence of past or future physicians by the current standard might be inappropriate. That raises issues about differing standards of competency for currently practicing physicians who trained at different times. In Canada, we are currently going through a transition whereby our training programs have two cohorts – one that is training under the previous “time based” model and the other under the current “competence by design” model. Is it the case that there is a relatively less (or no) guarantee that those training under the previous model are competent? The answer to that question might impact the extent to which we should have confidence in currently practicing clinicians, or at least relative to the next generation. Regardless, all practicing clinicians are accountable to a standard set by their respective professional Colleges, which likely makes the issue moot once trainees enter independent practice..It would be silly to suggest that clinicians who trained under a pre-CBE model are not competent any more than it is to suggest that clinical decisions prior to the adoption of the EBM movement were not based on evidence. Certainly, we have no shortage of competent clinicians practicing today. Those clinicians were accepted into the profession (and maintain standing) on some assessment of competence. However, institutions may have good reason for implementing CBE beyond simple competence concerns. For example, CBE programs can facilitate the development of an infrastructure of accountability that extends beyond activities of remediation or accelerating advancement to independent practice. That infrastructure can be leveraged to ensure transparency in assessment and advancement, identify individualized training needs, etc. that can be important components of ensuring and achieving equitable access to health professions, particularly for traditionally underrepresented populations.44It is important to note that while CBE might drive the development of such an infrastructure, a CBE training model is not necessary to do so. Certainly, institutions can and should be striving to improve on accountability, equitable access, etc., irrespective of a CBE model.On the other hand, we have no shortage of experience with poor decisions, suboptimal patient outcomes, iatrogenic effects, etc., that often raise concern about clinician ability (or competence). Poor outcomes, or at least those not aligned with the expectations of the public (irrespective of if those expectations are realistic) could be construed by some as a result of incompetence. Likewise, inequitable access (within or between communities) to appropriate expertise might raise concern of a lack of professional competence (i.e. the profession is not meeting the needs of the population inclusively). One way such perceptions by the public can be problematic for healthcare professions is that may erode the powerful position of institutionalized healthcare (and its providers) that exists in many societies. One could argue that EBM had a powerful effect on securing the public’s trust in healthcare by leveraging public perception of science as apolitical, objective, etc. Does CBE play a similar role by highlighting high professional standards only achievable by those “worthy” of the profession, who were rigorously assessed using quantifiable (often presented as “objective”) metrics, irrespective of whether that results in better care for patients? If so, then CBE may constitute a political move to retain or grow power rather than a remedial exercise to ensure no one joins the profession without having the skills necessary to provide appropriate care (by some defined public standard) for those seeking service. In other words, one might argue that CBE is not a response to a concern about competence – it is a response to a potential loss of standing relative to alternative modes of care or other social services. I am not suggesting that is necessarily the case, as I know several health professions educators who are honest in their pursuit to train clinicians who will excel in serving and providing care for the community. That seems to be the rule rather than the exception. However, the goals of the educators may not always tightly align with the goals of the institution, which may also be responsible for securing funding, maintaining status, public accountability, etc.Models of health professions training that focus on assessing and achieving defined competencies rather than hoping that important abilities are acquired over a defined time period (that also relies on the reliability and validity of licensing exams) are admirable. It is difficult to argue that achieving competence should not be the explicit focus of training. Perhaps one of the greatest benefits of CBE is that it puts competence to the forefront, just as EBM did for evidence. However, we must be vigilant to ensure that “competence” stays more than a buzzword or a tool of branding. Terms lacking substance can have a negative effect on patient care – too often the terms “patient centred” and “evidence based”, for example, are invoked as placeholders for quality patient care without any evidence to support that whatever intervention or program those terms are describing has any positive impact beyond rhetorical. We have not entered into an era of clinician competence simply because CBE has been implemented. Rather, what I see as the greatest benefit of CBE is the opportunity for improving and ensuring accountability.ReferencesRich J, Young SF, Donnelly C, et al. Competency-based education calls for programmatic assessment: But what does this look like in practice? Journal of Evaluation in Clinical Practice 2020;26(4):Hamza DM, Ross S, Oandasan I. Process and outcome evaluation of a CBME intervention guided by program theory. Journal of Evaluation in Clinical Practice 2020;26(4):Egan R, Chaplin T, Szulewski A, et al. A case for feedback and monitoring assessment in competency-based medical education. Journal of Evaluation in Clinical Practice 2020;26(4):Katoue MG, Schwinghammer TL. Competency-based education in pharmacy: A review of its development, applications, and challenges. Journal of Evaluation in Clinical Practice 2020;26(4):Crawford L, Cofie N, McEwen L, Dagnone D, Taylor SW. Perceptions and barriers to competency-based education in Canadian postgraduate medical education. Journal of Evaluation in Clinical Practice 2020;26(4):Railer J, Stockley D, Flynn L, Hastings-Truelove A, Hussain A. Using outcome harvesting: Assessing the efficacy of CBME Implementation. Journal of Evaluation in Clinical Practice 2020;26(4):Porter R. The Greatest Benefit to Mankind: A Medical History of Humanity. New York: W.W. Norton & Company; 1997.Shaw, B. The Doctor’s Dilemma: A Tragedy. London: Constable and Co.; 1922.McKeown T. The role of medicine: Dream, mirage or nemesis? Nuffield Trust; 1976. Available at: https://www.nuffieldtrust.org.uk/files/2017-01/1485273106_the-role-of-medicine-web-final.pdf. Accessed on June 8, 2020.
Abstract Rationale: Our current global healthcare system is not sustainable. It is structured based on the principles of reductionist science which was discovered and developed over the past 400 – 600 years. Because of increasing pace of change and increasing complexity in our world we have increased fragmentation in our healthcare system leading to more harm and waste. Over 100 years ago, the principles of systems, or complexity, science were discovered, first in the discipline of physics. These principles accommodate the constant change and biologic variability in our world. While reductionist principles would be applicable in a static, mechanical world where parts of the system could be isolated, this does not exist in the real biologic world. Method: For the past decade, our abdominal wall hernia team has been applying the principles of systems science to real patient care. Some of the tools we have applied include continuous quality improvement for whole hernia patient processes and non-linear analytical tools to gain insight to improve value-based outcomes. Until we learn to apply and scale these principles across our whole global healthcare system, we will continue to suffer the consequences of our current unsustainable system. Results: We have learned that the application of systems and complexity science to real patient care can lead to lower costs and better outcomes in the context of patients with complex hernia problems. However, these concepts have not yet been adopted in our global healthcare system. Conclusion: Applying the principles of systems and complexity science to our global healthcare system has the potential to lower costs and improve patient outcomes for any patient care process to which it is applied.
Background: The COVID-19 pandemic represents one of the most stressful events of recent times. Among the population, healthcare professionals who treat COVID-19 patients are most likely to develop psychological distress and posttraumatic stress symptoms (PTSS). The present study thus aimed to investigate the psychological impact of the COVID-19 outbreak on Italian healthcare workers. Methods: The responses of 145 healthcare workers (72 medical doctors and 73 nurses) were included in the final dataset. Participants were asked to provide sociodemographic and clinical information, and to complete: 1) quality of life and health-related Visual Analogue Scales, 2) State-Trait Anxiety Inventory-Form Y1, 3) Beck Depression Inventory, and 4) PTSD Checklist for DSM-5. Results: A comparison between healthcare professionals working in COVID-19 wards and other units revealed that the former reported higher levels of both depressive symptoms and PTSS. Moreover, the results of regression analyses showed that in healthcare professionals working with COVID-19 patients, gender and marital status, and gender and age significantly predicted depressive symptoms and PTSS, respectively. Particularly, being female and not in a relationship were found to be associated with higher levels of depressive symptoms, whereas being female and older were found to be related to higher levels of PTSS. Conclusions: The current findings suggest that specific predisposing factors could identify healthcare workers who are at high risk of developing mental health symptoms when faced with COVID-19 patients.
This paper responds to one by Graham Martin and colleagues, who offered a critique of my previous publications on masks for the lay public in the Covid-19 pandemic. I address their charges that my co-authors and I had misapplied the precautionary principle; drawn conclusions that were not supported by empirical research; and failed to take account of potential harms. But before that, I remind Martin et al that the evidence on mask wearing goes beyond the contested trials and observational studies they place centre stage. I set out some key findings from basic science, epidemiology, mathematical modelling, case studies and natural experiments, and use this rich and diverse body of evidence as the backdrop for my rebuttal of their narrowly-framed objections. I challenge my critics’ apparent assumption that a particular kind of systematic review should be valorised over narrative and real-world evidence, since stories are crucial to both our scientific understanding and our moral imagination. I conclude by thanking my academic adversaries for the intellectual sparring match, but exhort them to remember our professional accountability to a society in crisis. It is time to lay straw men to rest and engage, scientifically and morally, with the dreadful tragedy that is unfolding across the world.
Since news of COVID-19 outbreak hit the mainstream media, I have received several calls from acquaintances about if and how they should be worried. I suspect many readers of the Journal of Evaluation in Clinical Practice have experienced the same. What makes communicating the risk difficult can be illustrated through a recent assignment I gave to my undergraduate class focused on how we use science in public policy. I asked the students to identify claims in the media regarding the virus and then search the literature to assess the level of support for such claims. Suffice it to say, they found several claims unsupported, and several others to be inconclusive. Not very good grounding for providing definitive (or even satisfying) advice.
Objective: High data quality is essential to ensure the validity of clinical and research inferences based on it. However, these data quality assessments are often missing even though these data are used in daily practice and research. Our objective was to evaluate the data quality of our high-resolution electronic database (HRDB) implemented in our pediatric intensive care unit (PICU). Design: A prospective validation study of a HRDB. Setting: A 32-bed pediatric medical, surgical and cardiac PICU in a tertiary care freestanding maternal-child health center in Canada. Population: All patients admitted to the PICU with at least one vital sign monitored using a cardiorespiratory monitor connected to the central monitoring station. Interventions: None Measurements and Main Results: Between June 2017 and August 2018, data from 295 patient days were recorded from medical devices and 4,645 data points were video recorded and compared to the corresponding data collected in the HRDB. Statistical analysis showed an excellent overall correlation (R2=1), accuracy (100%), agreement (bias=0, limits of agreement=0), completeness (2% missing data) and reliability (ICC=1) between recorded and collected data within clinically significant pre-defined limits of agreement. Divergent points could all be explained. Conclusions: This prospective validation of a representative sample showed an excellent overall data quality.
Rationale: Conventional models of cultural humility - even those extending analysis beyond the dyad of healthcare provider-patient to include concentric social influences such as families, communities and institutions that make the clinical relationship possible - aren’t conceptually or methodologically calibrated to accommodate shifts occurring in contemporary biomedical cultures. More complex models are required that are attuned to how advances in biomedical, communications and information technologies are increasingly transforming the very cultural and material conditions of health care and its delivery structures, and thus how power manifests in clinical encounters. Methodological Intervention: In this paper, we offer a two-pronged intervention in the cultural humility literature. At a first level of analysis, we suggest the need to broaden understandings of culture and associated workings of power to accommodate the effects of biomedicine’s technologising turn. A second level of intervention invites experimentation to broaden the availability of methodological tools to analyse and assess the multidimensionality of technologies and their agentic effects in healthcare encounters. Drawing from new materialism theories, practices of care are approached “diffractively” as contingent and dynamic material-discursive events. Our neo-materialist framework for cultural humility expands analytical sight-lines beyond hierarchical relationships and dichotomies privileging humans (practitioner and/or patient) as sole actants in the clinical exchange. Attended to are the ongoing dynamics of practices entangling big-data driven knowledges and interventions, pharmacological technologies and material instruments and devices, diseases, and the bodies/subjectivities of health care providers and patients. We investigate the implications for clinical assessment if a cultural humility framework is methodologically attuned to the clinical encounter as a discontinuous, discursive-material process producing multiple, contextually emergent data moments and objects for analysis. Engaging evaluative inquiry diffractively allows for a different ethical practice of care, one that attends to the forms of patient and health provider accountability and responsibility emerging in the clinical encounter.
Rationale and objectives: Changes in, and predictors of, quality of life (QoL) among unstable angina patients are informative for both clinical and public health practice. However, there is little research on this topic, especially in healthcare settings with limited resources. This study aims to detect changes in QoL and its associated factors among patients with unstable angina after percutaneous coronary intervention. Methods: A quasi-experimental design was conducted with two repeated rounds of measurements, one month and three months after intervention, using the generic SF-36 questionnaire, in 120 patients from Vietnam National Heart Institute. A linear mixed-effects model was used to assess changes in patient QoL over time while adjusting for other covariates. Results: Only 2 out of 8 QoL subscales (social functioning and emotional well-being) declined after one month, but these tended to rise again after three months, while scores of all other QoL subscales increased. Adjusting for covariates, QoL increased slightly after one month of intervention (β=0.65, 95%CI=-0.86-2.16) but improved by almost 6 QoL points after 3 months (β=5.99, 95%CI=4.48-7.50). Four confounders significantly associated with a decline in QoL were older age, being retired, living in rural areas, and having abnormal troponin level. Conclusion: QoL of the patients with unstable angina improves significantly three months after intervention, rather than after one month. To increase QoL, it is important to address risk factors and to improve the quality of healthcare delivery.
Background and Objective Clinical Practice Guidelines (CPGs) provide evidence-based recommendations to healthcare professionals, policy makers, patients and other stakeholders. Mexico is the biggest producer of CPGs in Latin America and Caribbean countries. The National Healthcare Technology Excellence Center (acronym in Spanish: CENETEC) is responsible for the CPG development, adaptation and update. The aim of this study was to assess the Mexican CPG quality and adherence to the GRADE framework. Study design We conducted a descriptive cross-sectional study of 86 CPGs representing all the CPGs produced by CENETEC between 2015 and 2017 and published in an online database called “Catalogo Maestro”. We performed quality assessment with the online AGREE II tool and assessed the reporting on the GRADE framework. Results Of the 86 CPGs, 34 were published in 2015, 21 in 2016 and 31 in 2017. The overall quality by AGREE II proved a median of 16.6% (Min 16.6%, Max 50%). Of the 86 CPGs, 25 (29%) used the GRADE framework; adherence to GRADE standards was, however, inconsistent and generally poor. Conclusion CPGs produced by CENETEC during this period had a low score by AGREE II standards and low adherence to the GRADE framework. A concerted initiative could rapidly improve CENETEC guidelines.
Background: Lack of time has consistently been reported as a major barrier to effective research evidence-uptake into clinical practice. There has been no research to our knowledge that explores time as a barrier within the Transtheoretical model of Stages of Change (SoC), to better understand the processes of physiotherapists’ uptake of clinical practice guidelines (CPG). This paper explores the concept of lack of time as a barrier for CPG uptake for physiotherapists at different SoC. Methods: A 6-step process is presented to determine the best-fit SoC for 31 physiotherapy interviewees. This process used an amalgamation of interview findings and socio-demographic data, which was layered onto the SoC and previously identified time-barriers to CPG uptake (few staff; high workload; access to CPGs; evidence-based practice as priority in clinical practice; “time is money” attitude; and knowledge on the use of CPGs). Results: The analysis process highlighted the complexities of assigning individuals to a SoC. A model of time management for better CPG uptake is proposed which is a novel approach to assist evidence implementalists and clinicians alike to determine how to progress through the SoC and barriers to improve CPG uptake. Conclusions: To the authors’ knowledge, this is the first attempt at exploring the construct of (lack of) time for CPG-uptake in relation to the physiotherapists’ readiness to behaviour change. This study shows that ‘lack of time’ is a euphemism for quite different barriers, which map to different stages of readiness to embrace current best evidence into physiotherapy practice. By understanding what is meant by ‘lack of time’, it may indicate specific support required by physiotherapists at different stages of changing these behaviours.
Background: Most studies on the transition from pediatric to adult care focus on practices at a single institution. We examine the transition for young adults with type 1 diabetes across an entire Canadian province with a small, mostly rural population: Newfoundland and Labrador (NL). Our aim is to determine a comprehensive picture of how transition is occurring in one jurisdiction and explore potential methods for improvement. Methods: A provincial diabetes database and hospital admission data were reviewed for a cohort of young adults who transitioned into adult care to determine the number of transfers occurring, patient characteristics, and the number of diabetes-related hospitalizations. Semi-structured interviews with pediatric and adult diabetes providers were conducted to determine the current process of transition and identify ways for improvement, including the potential role of family physicians. Results: Between 2008 and 2013, 93 patients with type 1 diabetes transitioned into adult care. Fifteen interviews were conducted across the province’s four regional health authorities. Various models of transition care are being employed, reflecting staff and resource availability. While no structured transition program was identified, many providers were comfortable with their current transition processes. Suggested improvements included more structured processes, shared educational resources, and a dedicated transfer clinic. Conclusions: In a province with a relatively small number of patients who transition out of pediatric care annually, we found different approaches for transitioning them into adult care, but this variation may not negatively impact patient outcomes.
Rationale, aims and objectives. Applying traditional industrial Quality Improvement (QI) methodologies to primary care is often inappropriate because primary care is best thought of as a network of highly interconnected agents in a complex adaptive system (CAS) that is particularly responsive to bottom-up rather than top-down management approaches. We report on a demonstration case study of improvements made in the Family Health Center (FHC) of the JPS Health Network in a refugee patient population that illustrate features of QI in a CAS framework as opposed to a traditional QI approach. Methods. We report on changes in health system utilization by new refugee patients of the FHC from 2016-2017 and summarize relevant theoretical understandings of quality management in complex adaptive systems. Results. Applying CAS principles in the FHC, utilization of the Emergency Department and Urgent Care by newly arrived refugee patients before their first clinic visit was reduced by more than half (total visits decreased from 31% to 14% of the refugee patients). Our review of the literature demonstrates that traditional top-down QI processes are most often unsuccessful in improving even a few single-disease metrics, and increases clinician burnout and penalizes clinicians who care for vulnerable patients. Improvement in a CAS occurs when front-line clinicians identify care gaps and are given the flexibility to learn and self-organize to enable new care processes to emerge, which are created from bottom-up leadership that utilize existing interdependencies made more sustainable as front-line clinicians use sensemaking to improve care processes. Conclusions and future directions. Recent reforms announced in primary care in Scotland, a few examples in the medical literature, and statements from some healthcare system leaders are examples of early adapters who are applying the principles of CAS to their QI efforts. Such initiatives and our example provide models for others to follow.
The onset of acute illness may be accompanied by a profound sense of disorientation for patients. Addressing this vulnerability is a key part of a physician’s purview, yet well-intended efforts to do so may be impeded by myriad competing tasks in clinical practice. Resolving this dilemma goes beyond appealing to altruism, as its limitless demands may lead to physician burnout, disillusionment, and a narrowed focus on the biomedical aspects of care in the interest of self-preservation. The authors propose an ethic of hospitality that may better guide physicians in attending to the comprehensive needs of patients that have entered “the kingdom of the sick”. Using philosophical methods, the authors explore what compels people to present to emergent medical attention and why altruism may not offer physicians a sustainable way to address the vulnerabilities that occur in such situations. They then present the concept of hospitality from a Derridean perspective and use it to interpret a narrative case of an on-call paediatrician caring for an infant with bronchiolitis to demonstrate how this approach may be practically implemented in the acute care hospital context. Hospitality allows physicians to acknowledge that clinical presentations that are routine in their world may be disorienting and frightening to patients experiencing them acutely. Further, it recognizes that the vulnerability that accompanies acute illness may be compounded by the unfamiliarity of the hospital environment in which patients have sought support. While it is unlikely that anything physicians do will make the hospital a place where patients and caregivers will desire to be, hospitality may focus their efforts upon making it less unwelcoming. Specifically, it offers an orientation that supports patients in navigating the disorienting and unfamiliar terrains of acute illness, the hospital setting in which help is sought, and engagement with the health care system writ large.
Academic journal publication is the currency of University faculty. It can go without saying that publications play an important role in securing an academic appointment and research grants, achieving promotion within the University, and more importantly, advancing knowledge, which is to me the primary purpose of any academic pursuit. Despite its importance, academics seem to receive little or no formal training in how to prepare a manuscript for publication or how to respond to reviewer criticism1. Quite often, such skills are acquired through mentorship during graduate training. Unfortunately, it is often the case that graduate students do not produce enough manuscripts during their training to develop expertise in how to translate completed research or scholarship into a published report. As an editor, I often see manuscripts that are diminished by how they are written, which often causes confusion in the reviewer, resulting in a recommendation for rejection. I do not profess to be an expert on writing for an academic audience. I have no idea exactly how I learned to get my work published (I assume it was through practice and good mentorship), nor do I have any idea if I am skilled at it – I am left to assume my level of expertise from my successes and failures. However, from reading several manuscripts each day, I have picked up on some common errors and have developed an appreciation for what editors and reviewers expect in a published manuscript. In what follows, I present a bit of what I have learned in my, albeit it short, time as an editor.2
Rationale, aims and objectives The article looks at how, during consultations, pregnant women identified as presenting an increased risk of giving birth to a child with an impairment, and practitioners in the field of prenatal diagnosis, decide whether or not to accept the risk of a miscarriage and proceed with a diagnostic examination. Methods We conducted 63 observations of consultations in France and 22 in England. Participants were women for whom an elevated risk of abnormality had been identified and the practitioners involved in their care. Our analytical approach consisted in suspending the normative concepts of non-directiveness and autonomy, and in drawing on Goffman’s (1974) notion of “frame” to take account of the experiential and structural aspects that the protagonists bring into the (inter)actions. Results We identified four frames: medico-scientific expertise, medical authority, religious authority and compassion. Observation of the ways in which the frames intertwine during consultations revealed configurations that facilitate or hinder the fluidity of the interactions and the decision-making process. The medico-scientific expertise frame, imposed by the guidelines, heavily dominated our observations, but frequently caused distress and misunderstanding. Temporary or sustained use of the compassion and/or medical authority frames could help to repair the discussion and create the conditions that enable women/couples to reach a decision. Variations in configuration highlighted the differences between practitioners in the two countries. Conclusions Combining frames allows protagonists to exert reflective abilities and to maintain/restore interactions. The frame analysis promotes a vision of autonomy that is sociological, relational and processual rather than philosophical. The frames are anchored in different structural conditions in England and France.
In the United States chronic illnesses have become a way of life for multiple generations – they are the number one cause of death and disability (accounting for more than 70% of deaths), 60% of American adults have at least one chronic disease, and 40% have multiple chronic conditions. Although multiple factors contribute to the growth in chronic disease prevalence, a major factor has been overreliance on health care systems for promoting health and preventing disease. Large health care systems are ill equipped for this role since they are designed to detect, treat, and manage disease, not to promote health or address the underlying causes of disease. Improving health outcomes in the U.S. will require implementing broad-based prevention strategies combining biological, behavioral, and societal variables that move beyond clinical care. According to community medicine, clinical care alone cannot create, support, or maintain health. Rather, health can only ensue from combining clinical care with epidemiology and community organization, because health is a social outcome resulting from a combination of clinical science, collective responsibility, and informed social action. During the past 20 years, our team has developed an operational community medicine approach known as community health science. Our model provides a simple framework for integrating clinical care, population health, and community organization, using community-based participatory research (CBPR) practices for developing place-based initiatives. In the present paper, we present a brief overview of the model and describe its evolution, applications, and outcomes in two major urban environments. The paper demonstrates means for integrating the social determinants of health into collaborative place-based approaches, for aligning community assets and reducing health disparities. We conclude by discussing how asset-based community development can promote social connectivity and improve health, and discuss how our approach reflects the emerging national consensus on the importance of place-based population system change.