Teachers’ Interactions and their Collaborative Reflection Processes during Peer Meetings

Teachers’ reflections are often narrowly focused on technical questions (‘how to’) and less on the underlying moral, political and emotional aspects of their functioning. However, for a better understanding of teaching practice it is important to uncover beliefs and values that usually remain implicit. Meeting with others is considered crucial for enhancing the quality of teachers’ reflections. However, little is known about how any beneficial effects of such meetings are brought about. We explored the relationship between medical teachers’ interactions and collaborative reflection processes during peer meetings. Five experienced teachers and a teacher trainer participated in the study. Three peer meetings were videotaped and transcribed. Teachers’ interactions and collaborative reflective processes were analysed. The interactions promoted reflection not only on technical questions but also on moral, political, and emotional issues. ‘Guiding/directing’, ‘proposing an alternative’ and ‘exploring an alternative’ appeared to be the principal interactions. The results may be useful for teachers and trainers who are considering organising and/or improving peer meetings.     

Integrated Case Learning: teaching clinical reasoning

Learning how to ‘think like doctors’ can be difficult for undergraduate medical students in their early clinical years. Our model of collaborative Integrated Case Learning (ICL) and simulated clinical reasoning aims to address these issues. Taking a socio-cultural perspective, this study investigates the reflective learning interactions and practices of clinical thinking that emerged in the ICL environment. We also explore how third year medical students perceived their ICL experiences in relation to the clinical situations encountered in the hospital setting. The context for the inquiry is a rural Clinical School in North West Victoria, Australia. We used a qualitative case study methodology following eight third-year medical students over an academic year. Individual and group interviews were conducted, together with observations and document/artefact analysis. Data was analysed using content and narrative methods. The ICL program was well received. Findings suggest that the group-based, simulated clinical reasoning process appears to help undergraduate medical students to rehearse, articulate and question their clinical decision-making pathways. We argue that the ICL process offers a professionally challenging, but supportive group learning ‘space’ for students to practise what it might mean to ‘think’, ‘talk’ and ‘perform’ like doctors in real settings. The ICL environment also appears to create a connective bridge between the ‘classroom’ and clinical practice.     

Health technology assessment (HTA): ethical aspects

“HTA is a multidisciplinary process that summarizes information about the medical, social, economic and ethical issues related to the use of a health technology in a systematic, transparent, unbiased, robust manner. Its aim is to inform the formulation of safe, effective, health policies that are patient focused, and seek to achieve best value” (EUnetHTA 2007). Even though the assessment of ethical aspects of a health technology is listed as one of the objectives of a HTA process, in practice, the integration of these dimensions into reports remains limited. The article is focused on four points: 1. the HTA concept; 2. the difficult HTA-ethics relationship; 3. the ethical issues in HTA; 4. the methods for integrating ethical analysis into HTA.     

Hero or has-been: Is there a future for altruism in medical education?

The term ‘altruism’ is often used without definition, leading to contradictions in what we expect from medical students. In this reflection paper, we critique the concept of ‘altruism’ from the perspective of moral philosophy and social psychology and challenge its unquestioned usage within the medical education literature, especially that emerging from the USA. We will argue that ‘altruism’ is a social construction with a particular history, stemming from Kantian philosophy and perpetuated within newer disciplines such as social psychology. As it currently stands, ‘altruism’ seems to mean utter self-sacrifice—a position contradictory to recent recommendations by regulatory bodies in the UK, which suggest that graduates should look after the ‘self’ and achieve a work-life balance. In this article, we argue that it is undesirable to have ‘altruism’ as a learning outcome for medical students and we also argue that ‘altruism’ is not an observable behavior that can be measured. Instead, we suggest that medical educators should employ a more balanced term, borrowed from the social psychology literature i.e. pro-social behavior. We argue that whilst ‘pro-social behavior’ focuses on actions that benefit others, it does not do so at the expense of the self. In addition, it focuses on students’ observable behaviors rather than their inner motivations, so is measurable. We conclude our article by discussing the formation of physicians based upon a virtue ethics, where society and the profession are in dialogue about the telos of medicine and its virtues, and where the character of the young physician is formed within the crucible of that dialogue. Thus, central to this pro-social behavior is the concept of phronesis or prudence, including the balancing of self-interest such as self-care, and the interests of the other.     

Health technology assessment: the contribution of qualitative research

The pragmatism in health care has made health technology assessment (HTA) restrict its scope to a particular set of problems, c.q. methods. The "multidisciplinary and comprehensive nature" of HTA, as the concept is presented in certain definitions, is lacking. Health care is also dominated by a positivistic-rationalistic approach of evaluation. In contrast, social studies of evaluations learn that a major difference has to be made between scientific research on (potential) impact of a technology and valuing these effects. In this contribution, we will discuss how the positivistic scientific bias of current HTA practice can be made up with other research traditions. More specifically, we focus on the question of how social scientists and particularly how qualitative research can contribute to HTA, complementary to positivistic studies of evidence and efficacy.     

Is There Any Ideal of ‘High Quality Care’ Opposing ‘Low Quality Care’? A Deconstructionist Reading

The expressions ‘high quality care’ and ‘low quality care’ are cognitive and linguistic artefacts that help to structure people’s lives and thinking; for example, moves are now afoot internationally to pay bonuses to health professionals for delivering high quality care. United States programmes, most conspicuously, are assuming that high quality care can be validly distinguished from low quality care, and incentivised through bonuses. This distinction is always at least implicit, for high quality care has no meaning without low quality care. Through a ‘deconstructionist reading,’ this article discusses limitations of categorising the quality of care as either high or low. The limitations of this ‘binary opposition’ can include a lack of defining attributes; vagueness and fuzziness at the ‘boundaries’ between high quality care and low quality care; concealment of quality as a continuum; and use of the binary opposition to effect social order and control. Health policy implications of our analysis are discussed. Drawing upon the general medical services contract in the United Kingdom, we suggest an approach to overcoming the oversimplification and imprecision that categorisation tends to produce.     

Designing and Implementing Deliberative Processes for Health Technology Assessment: A Good Practices Report of a Joint HTAi/ISPOR Task Force

ObjectivesDeliberative processes for health technology assessment (HTA) are intended to facilitate participatory decision making, using discussion and open dialogue between stakeholders. Increasing attention is being given to deliberative processes, but guidance is lacking for those who wish to design or use them. Health Technology Assessment International (HTAi) and ISPOR—The Professional Society for Health Economics and Outcomes Research initiated a joint Task Force to address this gap.MethodsThe joint Task Force consisted of 15 members with different backgrounds, perspectives, and expertise relevant to the field. It developed guidance and a checklist for deliberative processes for HTA. The guidance builds upon the few, existing initiatives in the field, as well as input from the HTA community following an established consultation plan. In addition, the guidance was subject to 2 rounds of peer review.ResultsA deliberative process for HTA consists of procedures, activities, and events that support the informed and critical examination of an issue and the weighing of arguments and evidence to guide a subsequent decision. Guidance and an accompanying checklist are provided for (i) developing the governance and structure of an HTA program and (ii) informing how the various stages of an HTA process might be managed using deliberation.ConclusionsThe guidance and the checklist contain a series of questions, grouped by 6 phases of a model deliberative process. They are offered as practical tools for those wishing to establish or improve deliberative processes for HTA that are fit for local contexts. The tools can also be used for independent scrutiny of deliberative processes.     

Between the quack and the fanatic: movements in our self-belief

Separate from the question of whether our patients believe us as doctors is the question of whether we ourselves believe in our healing ‘performances’. Borrowing from Bernard Williams’ model of truth based on the two irreducible virtues of sincerity and accuracy, this article describes a spectrum of states of self-belief, from the quack who does not believe in his acts to the fanatic who does not ‘dis-believe’, with ranges of pious fraud and bad faith in between and on either side of a variable range of justified self-belief. I describe how as practitioners we move and are moved up and down this range throughout our careers and as a result of the behaviors of others. The model provides the basis for a critique of the marketing efforts of industries related to medical practice.     

Conceptualising Health: Insights from the Capability Approach

This paper suggests the adoption of a ‘capability approach’ to key concepts in healthcare. Recent developments in theoretical approaches to concepts such as ‘health’ and ‘disease’ are discussed, and a trend identified of thinking of health as a matter of having the capability to cope with life’s demands. This approach is contrasted with the WHO definition of health and Boorse’s biostatistical account. We outline the ‘capability approach’, which has become standard in development ethics and economics, and show how existing work in those areas can profitably be adapted to healthcare. Cases are used to illustrate the value of adopting a capability approach.

Small-cell lung cancer patients are just ‘a little bit’ tired: response shift and self-presentation in the measurement of fatigue

Background Response shift has gained increasing attention in the measurement of health-related quality of life (QoL) as it may explain counter-intuitive findings as a result of adaptation to deteriorating health. Objective To search for response shift type explanations to account for counter-intuitive findings in QoL measurement. Methods Qualitative investigation of the response behaviour of small-cell lung cancer (SCLC) patients (n = 23) in the measurement of fatigue with The European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire (EORTC QLQ-C30) question ‘were you tired’. Interviews were conducted at four points during 1st line chemotherapy: at the start of chemotherapy, 4 weeks later, at the end of chemotherapy, and 6 weeks later. Patients were asked to ‘think aloud’ when filling in the questionnaire. Results Fifteen patients showed discrepancies between their answer to the EORTC question ‘were you tired’ and their level of fatigue spontaneously reported during the interview. These patients chose the response options ‘not at all’ or ‘a little’ and explained their answers in various ways. In patients with and without discrepancies, we found indications of recalibration response shift (e.g. using a different comparison standard over time) and of change in perspective (e.g. change towards a more optimistic perspective). Patients in the discrepancy group reported spontaneously how they dealt with diagnosis and treatment, i.e. by adopting protective and assertive behaviour and by fighting the stigma. They distanced themselves from the image of the stereotypical cancer patient and presented themselves as not suffering and accepting fatigue as consequence of treatment. Conclusion In addition to response shift, this study suggests that ‘self-presentation’ might be an important mechanism affecting QoL measurement, particularly during phases when a new equilibrium needs to be found.     

Analytic methods for factors, dimensions and endpoints in clinical trials for Alzheimer’s disease

Alzheimer’s disease (AD) is a complex disease process, so finding a single biomarker to track in clinical trials has proven difficult. This paper describes and contrasts statistical methods that might be used with biomarkers in clinical trials for AD, highlighting their differences, limitations and interpretations. The first method is traditional regression, within which one dependent variable, the Best Empirically Supported Indicator (BESI), must be identified. In this approach one biomarker (e.g., the ratio of tau to Aβ42 from CSF) is the indicator for an individual’s disease status, and change in that status. The second approach is an exploratory factor analysis (EFA) to consolidate a multitude of candidate dependent variables into a sample-dependent, mathematically-optimized smaller set of ‘factors’. The third method is latent variable (LV) modeling of multiple indicators of an entity (e.g., “disease burden”). The LV approach can yield a complex ‘dependent variable’, the Best Measurement Model Indicator (BMMI). A measurement model represents an entity that several dependent variables reflect or measure, and so can include many ‘dependent variables’, and estimate their relative contributions to the underlying entity. The selection of a single BESI is an artifact of regression that limits the investigator’s ability to utilize all relevant variables representing the entity of interest. EFA results in sample-specific combination of biomarkers that might not generalize to a new sample — and fit of the EFA results cannot be tested. Latent variable methods can be useful to construct powerful, efficient statistical models that optimally combine diverse biomarkers into a single, multidimensional dependent variable that can generalize across samples when they are theory-driven and not sample-dependent. This paper shows that EFA can work to uncover underlying structure, but that it does not always yield solutions that ‘fit’ the data. It is not recommended as a method to build BMMIs, which will be useful in establishing diagnostic criteria, creating and evaluating benchmarks, and monitoring progression in clinical trials. a Collaborative for Research on Outcomes and -Metrics     

From selfish individualism to citizenship: Avoiding health Economics’ reputed ‘dead end’

Recent interpretations of citizenship are firmly rooted in the value of social membership and social participation. Citizens are described as having a moral right to draw upon the support of the community, but at the same time have a responsibility to contribute to the provision of social services such as health care. In contrast, contemporary health economics has been criticised for taking a narrow and individualistic view of human behaviour. This paper examines the extent to which economic theory and practice have been developed to accommodate a more ‘civic’ view, namely, the notions of mutual concern for community members, social participation and social rights. It is argued that because the provision of health care is often linked to feelings of compassion and social responsibility and not just to individual well-being, this sort of insight may enrich economic analysis and, in turn, provide a way around health economics’ reputed ‘dead end’.     

Health care policy: qualitative evidence and health technology assessment

Since the late 1990s health technology assessment (HTA) has gained influence as a research and evaluation approach supporting health care policy. The focus on this methodology is congruent with the growing importance of evidence-based health care. Although HTA is a multidisciplinary discipline from a theoretical point of view, practice shows that social, ethical and psychological aspects are seldom truly integrated into the assessment of health technology. HTA is still very much biased by the medical and pharmaceutical research traditions. This contribution focuses on the question of how qualitative research findings could be useful as an additional source of information or as 'evidence' in HTA. Medical and health care scientists are seldom acquainted with qualitative research or judge it as a less (or un-)reliable form of research. 'Qualitative dimensions' of health care are not considered 'real' evidence. This contribution argues that qualitative findings could be put higher in the hierarchy of evidence generating research in health care. First it can be realized by improving the knowledge of the nature of qualitative research. Second qualitative findings can become more trustworthy information, if researchers themselves respect methodological prerequisites and clarify their theoretical perspective, research aims and use of research methods. Some methodological characteristics of qualitative research and 'evidence' are discussed for their contribution to HTA and evidence-based health care.     

‘Healthy Ageing’ policies and anti-ageing ideologies and practices: on the exercise of responsibility

This paper explores how the exercise of the ethics of ‘responsibility’ for health care advanced through ‘healthy ageing’ and ‘successful ageing’ narratives in Western countries animates an array of ‘authorities’, including the ‘anti-ageing medicine’ movement as a strategy to address the anxieties of growing old in Western societies and as a tool to exercise the ethos of ‘responsibility’. The choice of this type of authority as a source of guidance for self-constitution and the exercise of the ‘responsible self’, this paper will argue, enables the enactment of a type of late modernity notion of citizenship for ageing individuals based on principles of agelessness, health, independence and consumption power. Through interviews with anti-ageing consumers, however, it is also possible to argue the existence of tensions and contradictions that such a rigid model of self-constitution in later life produces, and the potential forms of resistance and contestations that may emerge as a result. In this way the current ‘war on anti-ageing medicine’ (Vincent 2003) becomes also symptomatic of bigger ‘wars’ taking place not only between institutions competing for control over knowledge and management of ageing, but between those in favour and against the homogenisation of life under the language of universal science, reason and market rationality.     

Is Psychometric Scoring of the McNew Quality of Life After Myocardial Infarction Questionnaire Superior to the Clinimetric Scoring? A Comparison of the Two Approaches

Objective: ‘Clinimetric’ and ‘psychometric’ approaches are currently used to develop health related quality of life questionnaires. The Quality of Life after Myocardial Infarction questionnaire (QLMI) was originally developed using ‘clinimetric’ criteria; it was subsequently modified (McNew QLMI) and a new domain structure was defined using factor analysis. The objective of this study was to compare the measurement properties of the McNew QLMI scores when both approaches for scoring are used. Methods: The McNew QLMI and SF-36 were administered to patients 2 weeks and 2 months after myocardial infarction. Two sets of scores for the McNew QLMI were computed using the original ‘clinimetric’ and the subsequent ‘psychometrically’ derived scoring systems. Reliability statistics for the two sets of domains were compared and construct validity was assessed by establishing a priori hypotheses on the expected correlation between each score and the dimensions of the SF-36. Results: Both sets of scores had similar reliability (Cronbach’s α between 0.64 and 0.93) and responsiveness (SRMs between 0.17 and 0.87) while validity was better for the ‘clinimetric’ set of scores (concordance between observed and expected correlations was moderate for the ‘clinimetric’ scores and fair for the ‘psychometric’ scores). Conclusion: Since overall measurement properties of the ‘clinimetrically’ scored McNew QLMI are better than the ‘psychometrically’ scored version, we suggest that either the original ‘clinimetric’ system is used or that an improved ‘psychometric’ version is developed.     

Simultaneous trend analysis for evaluating outcomes in patient-centred health monitoring services

The research aim underpinning the Healthcare@Home (HH) information system described here was to enable ‘near real time’ risk analysis for disease early detection and prevention. To this end, we are implementing a family of prototype web services to ‘push’ or ‘pull’ individual’s health-related data via an system of clinical hubs, mobile communication devices and/or dedicated home-based network computers. We are examining more efficient methods for ethical use of such data in timeline-based (i.e. ‘longitudinal’) data analysis systems. A consistent data collation infrastructure is being created for use along the ‘patient path’—accessible wherever patients happen to be. This ‘patient-centred’ infrastructure can be applied in the evaluation of disease progression risk (in the light of clinical understanding of disease processes). In this paper we describe the requirements for making multi-data trend management ‘scale-up’, together with some requirements of an ‘end-to-end’ functioning data collection system. A Service-Oriented Architecture (SOA) approach is used to maximise benefits from (1) clinical evidence and (2) computational models of disease progression that can be made available elsewhere on the SOA. We discuss the implications of this so-called ‘closed loop’ approach for improving healthcare intervention outcomes, patient safety, decision support, objective measurement of service quality and in providing inputs for quantitative healthcare (predictive) modelling. To aid understanding, a concise glossary is provided for italicized technical or common ‘jargon’ terms that are not defined in the text.     

Molecular medicine and concepts of disease: the ethical value of a conceptual analysis of emerging biomedical technologies

Although it is now generally acknowledged that new biomedical technologies often produce new definitions and sometimes even new concepts of disease, this observation is rarely used in research that anticipates potential ethical issues in emerging technologies. This article argues that it is useful to start with an analysis of implied concepts of disease when anticipating ethical issues of biomedical technologies. It shows, moreover, that it is possible to do so at an early stage, i.e. when a technology is only just emerging. The specific case analysed here is that of ‘molecular medicine’. This group of emerging technologies combines a ‘cascade model’ of disease processes with a ‘personal pattern’ model of bodily functioning. Whereas the ethical implications of the first are partly familiar from earlier—albeit controversial—forms of preventive and predictive medicine, those of the second are quite novel and potentially far-reaching.     

Evidence and the end of medicine

Fifty years ago, in 1961, Feinstein published his first path-breaking articles leading to his seminal work Clinical Judgement and to the establishment of clinical epidemiology. Feinstein had an Aristotelian approach to scientific method: methods must be adapted to the material examined. Feinstein died 10 years ago and few years before his death he concluded that efforts to promote a person-oriented medicine had failed. He criticised medicine for not having recognized that only persons can suitably observe, evaluate and rate their own health status. Feinstein’s position was—as in Clinical Judgement—methodological. He didn’t espouse ethical principles. He pointed to methodological deficiencies in clinical epidemiology and evidence-based medicine. In this article we’ll provide a framework for understanding and justifying Feinstein’s call for a person-oriented medicine which recognizes patients as co-actors in clinical reasoning. It’s argued that craftsmanship and practical wisdom are integrated in clinical judgement and reasoning and that clinical reasoning is not only about means to achieve the end, health. We do also reason and deliberate about ends. The ‘defining end’ of medicine (health) has continuously been negotiated and so been the object of deliberation. For centuries among professionals, in recent years among professionals and patients. These negotiations and deliberations lead to ongoing specifications of health as a ‘guiding end’, i.e. an end guiding clinical reasoning about what to do in particular situations. Feinstein’s self-critical account to clinical epidemiology at the end of his professional career reflects the fact that patients during the last 30–40 years (i.e. in the period after the publication of Clinical Judgement) widely have been recognized as persons with rights to autonomy. Feinstein’s lesson is, however, that espousing and recognizing ethical ideals is not enough. A change of clinical practice and its methods is necessary. His critique also implies that clinical epidemiology and evidence-based medicine as practiced haven’t provided such a turn.     

What is primary care? Developments in Britain since the 1960s

Since 1994, health policy in the UK has focused explicitly on making the NHS ‘primary care-led’. However, the meaning of primary is contested by different health professions and by policy-makers. This paper charts the major points of debate since the 1960s and suggests that there are limitations as to what general practice can be expected to deliver in respect of primary care.     

The influence of context on residents' evaluations: effects of priming on clinical judgment and affect

Different lines of research have suggested that context is important in acting and learning in the clinical workplace. It is not clear how contextual information influences residents’ constructions of the situations in which they participate. The category accessibility paradigm from social psychology appears to offer an interesting perspective for studying this topic. We explored the effect of activating medically irrelevant mental concepts in one context, so-called ‘priming’, on residents’ interpretations as reflected in their judgments in another, work-related context. Obstetric-gynecologic residents participated in two unrelated-tasks experiments. In the first experiment residents were asked to indicate affect about a change in a routine procedure after performing an ostensibly unrelated ‘priming’ task which activated the concept of either ineffective coping or effective coping. The second experiment concerned residents’ patient management decisions in a menorrhagia case after ‘priming’ with either action or holding off. Contextually activated mental concepts lead to divergent affective and cognitive evaluations in a subsequent medical context. Residents are not aware of this effect. The strength of the effect varies with residents’ level of experience. Context influences residents’ constructions of a work-related situation by activating mental concepts which in turn affect how residents experience situations. Level of experience appears to play a mediating role in this process.