Both in medicine and in psychiatry, it’s essential to thoroughly identify the cases in which it is necessary to intervene therapeutically, and justify a sick leave or make forensic interpretations, among others. Therefore, it is important to find a general concept and definition for medical and psychiatric disorders. Boorse, develops one of the most widespread models of medical disorder that aspired to be value-free and that was based in medical dysfunction. But values appear implicitly or explicitly with a deeper analysis of this concept. On the other hand, there is the overtly value laden (harm) component that has been used in the definition of disorder, defended as essential by several authors over the time, once symptoms and their consequences (disability, distress) have been considered as a priority in medicine. In this article, we intend to review, through a conceptual analysis, the proximity between the concepts of mental and physical disorders regarding the presence of values, and to propose a way to deal with the different kinds of values that might be present. It is concluded that values are present in the main concepts that have been used to define medical or psychiatric disorder. What is essential is to understand what is descriptive and what is value and to try to avoid moral values.

Rationale, aims, and objectives: Portenoy and Foley’s 1986 landmark study “Chronic use of opioid analgesics in non-malignant pain: report of 38 cases” has been reproached for opening the floodgates of opioid prescribing for chronic non-cancer pain and the attendant harms. This influential article has been cited over 500 times in the scientific literature over the last four decades. This study seeks to understand the impact of Portenoy and Foley’s article on subsequent discussions and research about opioids. Methods: We conducted a multi-method bibliometric analysis of all citations of this article from 1986 through 2019 using quantitative relational and qualitative content analysis to determine how uses and interpretations of this case series and associated prescribing guidance have changed over time, in relationship to the evolution of the North American opioid crises. Results: Using time series analysis, we identified three periods with distinct interpretations and uses of the index study. In the first “exploration” period (1986-1996), the index study was well-received by the scientific community and motivated further study of the effects of opioids. In the second “implementation” period (1997-2003, coinciding with the release of OxyContin®), this study was used as evidence to support widespread prescribing of opioid analgesics, even while it was recognized that long-term effects had not yet been evaluated. The third “reassessment” period (2004-2019) focused on how opioid-related harms had been overlooked, and in many cases these harms were directly attributed to this study. Conclusion: These changes in interpretation demonstrate shifting currents of the use and mobilization of evidence regarding pain and opioids, and how these currents both impact and are impacted by clinical practices and major sociohistorical phenomena such as the opioid crisis. Researchers and clinicians must account for these shifting dynamics when developing and interpreting scientific knowledge, including in the form of clinical practice guidelines.

RATIONALE, AIMS, AND OBJECTIVES: This study aims to investigate how reported comprehension of the Medicare program and its prescription drug benefits affects cost-related medication nonadherence (CRN) among Medicare beneficiaries with cardiovascular disease (CVD) risk factors. METHODS: This cross-sectional study used the 2017 Medicare Current Beneficiary Survey Public Use File data and included Medicare beneficiaries aged ≥ 65 years who reported having at least one CVD risk factor (i.e., hypertension, hyperlipidemia, diabetes, smoking, and obesity) (n=2,821). A survey-weighted logistic model was used to examine associations between lack of difficulty understanding the Medicare program and its prescription drug benefits and CRN, controlling for beneficiaries’ demographic (e.g., age) and clinical characteristics (e.g, comorbidities). This study further analyzed five subgroups based on the type of CVD risk factors involved. RESULTS: Among Medicare beneficiaries with CVD risk factors, 14.4% reported CRN. Medicare beneficiaries with CVD risk factors who reported difficulty understanding the overall Medicare program and its prescription drug benefits were more likely to report CRN, compared to those who reported easy understanding of the overall Medicare program (OR=1.49; 95% CI=1.09, 2.04; p<0.001) and its prescription drug benefits (OR=2.01; 95% CI=1.51, 2.67; p<0.001). Similar results were obtained for the subgroups with obesity, hypertension, or hyperlipidemia. CONCLUSIONS: Perceived lack of difficulty understanding the Medicare Program and its prescription drug benefits has a positive impact on CRN reduction among Medicare beneficiaries with CVD risk factors, especially those with obesity, hypertension or hyperlipidemia. Monitoring and enhancing Medicare beneficiaries’ overall understanding of the Medicare program may reduce CRN.

The commentary discusses the importance of developing Universal Health Coverage strategies through the lens of complex systems framework that evaluates policies not only in terms of the final desired outcome but also as an interplay of disparate views among diverse actors in the system. This view also confers a degree of agency and autonomy on the individual actors, whether they be patients or healthcare workers, and necessitates the inclusion of bottom-up participatory process in the development of UHC policies and interventions. These are consistent with the Primary Health Care principles articulated in the 1978 Alma Ata Declaration and will need to be integrated into the health system development framework to achieve UHC. Ultimately, this approach would encourage the creation of a more cooperative and adaptive policy environment in which each actor is encouraged to collaborate and are nudged toward a desirable outcome rather than through coercive means.

Job satisfaction and retention of healthcare staff remains an ongoing issue in many health systems. Huddles have been endorsed as a mechanism to improve patient safety by improving teamwork, collaboration, and communication in teams. This study synthesizes the literature to investigate the impact of huddles on job satisfaction, teamwork, and work engagement in multidisciplinary healthcare teams. Five academic databases were searched to conduct a systematic review of peer-reviewed literature published from January 2000 – January 2020. Articles were included if they (1) featured a daily huddle, were conducted in a healthcare setting, and involved a multidisciplinary team and (2) measured variables including job satisfaction, work engagement, or teamwork. Results were reported in accordance with the Systematic Synthesis Without Meta-analysis (SWiM) and Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. We identified 445 articles of which 12 met the eligibility criteria and are included in this review. All 12 studies found a predominantly positive impact on teamwork and job satisfaction. None of the studies discussed or reported evidence of the impact of huddles on work engagement. This review highlights the value of a daily multidisciplinary healthcare team huddle in improving job satisfaction and teamwork for the healthcare staff involved. However, there is a dearth of high-quality, peer-reviewed evidence regarding the direct impact of huddles on job satisfaction, teamwork and in particular on work engagement. Further research – particularly controlled studies on adoption, implementation, and outcomes for healthcare team culture – is needed to further assess this intervention.

A document by Shawn Mondoux. Click on the document to view its contents.

Rationale and aims: Precision medicine (PM) raises a key question: How can we know what works when the number of people with a health problem becomes small or one (n=1)? We here present a formative case from Norway. The Norwegian Board of Health Supervision was faced with a cancer patient, who had improved after treatment with a drug in the private health sector but was refused continued treatment in the public health service due to lack of clinical trial evidence. The Board overturned this decision, arguing that the drug had been unambiguously documented to work in the individual case. We aim to provide an in-depth analysis of this case and The Board´s decision and thereby to illustrate and elucidate key epistemological and ethical issues and developments in PM. Method: We provide our analysis and discussion using tools of critical thinking and concepts from philosophy of science and medicine such as uncertainty, evidence, forms of inference and causation. We also examine the case in the light of the history of evidence-based medicine (EBM). Results and discussion: The case reflects an epistemological shift in medicine where PM puts greater emphasis on evidence that arises in individual patients after the treatment is provided over preexisting population-based evidence. PM may rely more heavily on abduction to decide what works and qualitative, rather than quantitative judgments. The case also illustrates a possible shift in the concept of causation from regularity accounts to mechanistic and process accounts. We discuss ethical implications of a shift from more “traditional” to “personalized EBM”. Conclusion: A framework that is more based on abductions and evidence arising in the individual case has problems in creating quantifiable, reliable, and generalizable evidence, and in promoting transparency and accountability. PM currently lacks clear criteria for deciding what works in an individual, posing ethical challenges.

Sturmberg and Martin’s application of systems and complexity theory to understanding Universal Health Care (UHC) and Primary Health Care (PHC) is evaluated in the light of the influence of political economy on health systems. Further the role that neoliberal approaches to governance have had in creating increased inequities is seen as a key challenge for UHC. COVID-19 has emphasized long standing discrepancies in health and these disadvantages require government will and cooperation together with adequate social services to redress these discrepancies in UHC.

Rationale, aims and objectives: Increased incidence of chronic illnesses coupled with physician shortages have yielded strain on primary care providers (PCP) to meet care demands. Interdisciplinary providers such as nurse practitioners and physician assistants have increasingly been embedded into primary care teams to alleviate some workload demand. Little evidence exists about the impact of interdisciplinary PCP care delivery models on provider outcomes. The objective of this study was to investigate the impact of interdisciplinary PCP care delivery on provider burnout, job satisfaction and intention to leave current position. Methods: We conducted a cross sectional mail survey using Dillman methodology of primary care practices (e.g., internal medicine) across New York State. A random sample of interdisciplinary PCPs (physicians, nurse practitioners, and physician assistants) (n=333) responded. The Provider Co-management Index (α = .85) was used to measure how well interdisciplinary dyads co-management care delivery attributes (effective communication; mutual respect and trust; shared philosophy of care). Provider outcomes were measured with validated AHRQ and HRSA items for burnout, job satisfaction and intention to leave position. Descriptive statistics, logistic regression models, crude and adjusted odds ratios were calculated, controlling for participant and practice characteristics. Results: Almost 30% of participants reported burnout with three times the odds of intending to leave their current position within one year. With each unit increase in effective co-management between interdisciplinary dyads there was 15% less burnout and 10% less odds of intention to leave position. Conclusion: Incorporating interdisciplinary specialties in primary care appears promising to alleviate some adverse provider outcomes. Organizations contemplating delivery models to promote well-being and retention may consider co-management. Cost effectiveness research is needed to determine financial sustainability of interdisciplinary care delivery.

Rationale, aims and objectives: There is a large body of literature from all over the world that describes, analyzes, or evaluates home care models and interventions. The present article aims to identify the practical lessons that can be gained from a systematic examination of that literature. Method: We conducted a three-step sequential search process from which 113 documents were selected. That corpus was then narratively analyzed according to a realist review approach. Results: A first level of observation is that there are multiple blind spots in the existing literature on home care. The definition and delimitation of what constitutes home care services is generally under-discussed. In the same way, the composition of the basket of care provided and its fit with the need of recipients is under-addressed. Finally, the literature relies heavily on RCTs whose practical contribution to decisions or policy is disputable.At a second level, our analysis suggests that three mechanisms (system integration, case management and relational continuity) are core characteristics of home care models effectiveness. Conclusion: We conclude by providing advice for creating effective home care system change through rational and participatory design and evaluation alongside public dialogue about the purpose and future of home care.

Evidence-Based Medicine proposes a prescriptive model of physician decision-making in which “best evidence” is used to guide best practice. And yet, proponents of EBM acknowledge that EBM fails to offer a systematic theory of physician decision-making. In this paper, we explore how physicians from the neurology and emergency medicine communities have responded to an evolving body of evidence surrounding the acute treatment of patients with ischemic stroke. Through analysis of this case study, we argue that EBM’s vision of evidence-based medical decision-making fails to appreciate a process that we have termed epistemic evaluation. Namely, physicians are required to interpret and apply any knowledge — even what EBM would term “best evidence” — in light of their own knowledge, background and experience. This is consequential for EBM as understanding what physicians do and why they do it would appear to be essential to achieving optimal practice in accordance with best evidence.

This paper begs an ontological question about the nature of health and challenges some underpinning assumptions in western healthcare. In its analysis, the structure of health, in its various statuses, is framed as a complex adaptive system made up of dynamically interacting subsystems that include the physiological, psychological, spiritual, social, cultural, and more, realms. Furthermore, openness in complex systems such as health, is necessary for the exchange of energy, information, and resources. Yet, within healthcare much effort is invested in constraining systems’ behaviours, whether they be systems of knowledge, states of health, models of care, and more. This paper draws on the complexity sciences and Levinasian philosophy to explicate the essential role of system openness in individual and population health, and the viability of healthcare systems. It highlights holism to be ‘not whole-ism’, and system openness to be, not just a reality, but a critical feature of viability. Hence requisite openness is advocated as essential to efficacious and ethical healthcare practice and strategy, and vital for good quality health.

Rereading Popper’s “The Logic of scientific discovery”, at his 120th anniversary, brings some thoughts regarding the diagnostic process and decision making in medicine from the viewpoint of the classical scientific method. In recent years physicians are increasingly becoming technical experts who base their decision-making on uniform criteria, guidelines and classifications but unfortunately have moved away from understanding the basic concepts in the philosophy of science. This raises an ethically and philosophically important issue; what does a medical diagnosis mean? Is this an absolute or a relative truth? The implications of this question are enormous in terms of prognosis and treatment. Both patients and physicians should be educated about the nature of the diagnostic process.

Rationale, aims and objectives: Consistent data demonstrates negative psychological effects of caregiving on front-line health professionals. Evidence that psychological resilience factors can help minimise distress and the potential for low-cost interventions have created interest in resilience-based development programmes; yet evidence of perceived value amongst health professionals is lacking. This study explored health professionals’ experiences and perceptions of a novel, resilience-based intervention designed to pro-actively prepare staff for coping with error; to investigate their perceptions of what resilience meant to them, the relevance of the intervention, and impact of participation on ability to cope with error. Method: Semi-structured interviews 4-6 weeks post intervention with 23 randomly selected participants from seven cohorts (midwives, paediatricians, obstetrians/gynaecologists, paramedics) and trainees (physician associates, mammographers, sonographers). Thematic analysis of interview data. Findings: Participants reported various interpretations of, and a shift in perception regarding what the concept of psychological resilience meant to them and their practice. These included for example, resilience as a positive or negative concept and their awareness and response to a range of personal, organisational and system factors influencing personal resilience. They valued the prophylactic, clinically relevant, interactive and applied nature of the intervention; having developed and applied valuable skills beyond the context of involvement in error, noting that individuals needed to be willing to explore their own coping mechanisms and human fallibility to gain maximum benefit. There was also consensus that whilst proactively developing individual level psychological resilience is important, so too is addressing the organisational and system factors that affect staff resilience which are outside individual staff control. Conclusion: Enhancing resilience appears to be considered useful in supporting staff to prepare for coping with error and the wider emotional burden of clinical work, but such interventions require integration into wider system approaches to reduce the burden of clinical work for health professionals.

Rationale Prescribed opioids are major contributors to the current international public health opioid crisis. Such iatrogenic calamities usually result from collective decision failures of healthcare organizations rather than solely of individual organizations or professionals. Findings from a system-wide safety analysis of the iatrogenic opioid crisis that includes roles of pertinent healthcare organizations may help avoid or mitigate similar future tragedies. In this exploratory study, we report on such an analysis. Methods Root cause analysis, incorporating recent suggestions for improvement, was used to retrospectively identify possible causal factors from the literature. Based on their mandated roles and potential influences to prevent or mitigate the iatrogenic crisis, relevant organizations were grouped and stratified from most to least influential. Results The analysis identified a chain of multiple interrelated causal factors within and between organizations. The most influential organizations were: pharmaceutical, political and drug regulatory; next: experts and their related societies, and publications. Less influential: accreditation, professional licensing and regulatory, academic and healthcare funding bodies. Collectively, their views and decisions influenced prescribing practices of frontline healthcare professionals and advocacy groups. Financial associations between pharmaceutical and all other organizations/groups were common. Ultimately, patients were adversely affected. There was a complex association with psychosocial variables. Limitations Our analysis suggests associations not causality. Conclusions The iatrogenic crisis has multiple intricately linked interacting roots. The major catalyst: pervasive pharma-linked financial conflicts of interest (CoIs) involving most of the other healthcare organizations. These extensive financial CoIs were likely triggers for a cascade of erroneous decisions and actions that adversely affected patients. The actions and decisions of pharma ranged from unethical to illegal. The iatrogenic opioid crisis exemplifies widespread “institutional corruption of pharmaceuticals.”

Artificial intelligence and big data are more and more used in medicine, either in prevention, diagnosis or treatment, and are clearly modifying the way medicine is thought and practiced. Some authors argue that the use of artificial intelligence techniques to analyze big data would even constitute a scientific revolution, in medicine as much as in other scientific disciplines. Moreover, artificial intelligence techniques, coupled with mobile health technologies, could furnish a personalized medicine, adapted to the individuality of each patient. In this paper we argue that this conception is largely a myth: what health professionals and patients need is not more data, but data that are critically appraised, especially to avoid bias. The validity of data and the validity of inferences drawn from the data by algorithms are indeed a major epistemic issue, though rarely addressed as such by health professionals or philosophers of medicine. Considering the history of epidemiology, specifically the formation of the concept of bias, we propose three research priorities concerning the use of artificial intelligence and big data in medicine.

ABSTRACT ¬ Rationale, aims and objectives: Physician consultations are a limited resource. Anesthesiologists provide anesthesia during surgery and procedures, prepare patients for surgery in preoperative clinics, and provide postoperative care. This study sought to evaluate current consultation usage patterns, with an aim to determine possible opportunities for efficiency. Method: A retrospective comprehensive population-based cohort study was performed, evaluating all hospitals in the Canadian province of Ontario from 2002-2018. The main outcome measures were American Society of Anesthesiologists (ASA) classification of the patients, and whether the patients underwent surgery within 3 months following the anesthesia consultation. Results: A cohort of 2,023,499 patients, and a total of 2,920,100 preoperative anesthesia consultations was obtained. The number of consults per year doubled between 2003 (112,983/year) and 2017 (246,427/year). Each year, an average of 19.32% of the consults (range: 17.69-20.49%) were for patients that did not progress to having surgery. Of those that did have surgery following the anesthesia consult, 37.23% were ASA Classification I or II. The most common surgical procedures (percent of total) following anesthesia consult were: Knee implantation of internal device (9.46%), hip implantation of internal device (5.84%), cataract excision (4.09%), repair of muscle of chest/abdomen (3.31%), uterus excision (2.76%), and gallbladder excision (2.67%). Conclusions: This study reveals data on utilization and trends over time of preoperative anesthesia consultations. Potential opportunities for optimization were found, including patients who did not proceed to surgery, and healthier patients undergoing low to moderate risk surgery that may not require consultation.

Motion capture and analysis techniques are emerging in the surgical education and surgical education research literature as viable ways to augment the assessment of technical skills. In particular, these methods provide an opportunity to reveal objective information about the efficiency of surgical procedures, above and beyond the accuracy of procedural outcomes. One assessment that is very prevalent in the literature are counts of the number of movements a surgeon makes in completing a technical performance. In this commentary, the number of movements metric is explored from kinesiology and engineering perspectives; two disciplines that have contributed heavily to the development of rigorous motion analysis methods. Furthermore, the assumption that skill efficiency improves linearly as a learner progresses along the continuum of expertise is challenged. While movement efficiency does certainly improve, this assumption does not necessarily capture the way that learners flexibly prioritize particular aspects of performance in the intermediate stages of skill learning. By way of this commentary, important a priori decisions that should proceed effective motion capture and analysis are highlighted, a call for the standardization of procedures is made, and an opportunity to better understand the way that computerized movement analysis techniques may contribute (or be detrimental) to competency constructs in surgical education and assessment is realized.