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Fear and anxiety can interfere profoundly with a person's ability to deliberate. Patients sometimes face critical medical decisions while subject to intense emotions which involve catastrophic (or wishful) convictions about the future. Medical teams, and even psychiatrists and bioethicists, lack a model for what to do in such cases. Philosophical accounts of autonomy and the clinical criteria for decision‐making capacity derived from them fail to address cases in which emotions do not merely skew judgment but rather block decision‐making capacity itself. This paper provides an account of when emotions undermine a person's freedom to deliberate, which is the basis of the capacity for autonomy. People subject to what I call 'concretized emotions' meet the cognitive criteria for decision‐making capacity. Yet their emotions dictate their views of reality and prevent them from meeting the basic conditions for deliberation. To deliberate one needs to be able to think through alternatives, and this thinking through alternatives needs to be responsive to evidence. With concretized fear, both the ability to think through alternatives and the ability to respond cognitively to evidence is undermined. The person can engage in apparent deliberation, but her thought processes regarding the feared matter are characterized by the rigid view that things are just as they seem from her emotional view. This paper develops a theoretical and clinical model for a more appropriate and nuanced approach to acting responsibly toward patients subject to intense fear and related emotional states that block their decision‐making capacity. [ABSTRACT FROM AUTHOR]

Morita therapy is one of the leading alternative psychotherapeutic approaches that has emerged from Japan and has adapted with notable success to the mores and demands of the Western medical establishment. Although still on the margin, Morita therapy has the potential to offer a viable option for those who seek therapeutic assistance for various neuroses and psychosomatic illnesses that culminate in psychiatric symptoms such as generalized anxiety disorder, obsessive‐compulsive disorder, or posttraumatic stress disorder. Diverging considerably from conventional Western psychiatric approaches, Morita therapy has its own modes of conceiving mental illness and offers distinct curative methods that are in some ways akin to the techniques of meaning‐centred psychotherapies, but in many other ways are rather different. In this paper, the meaning‐formation and the building of a constant sense of purpose in Morita therapy is explored, with a special focus on how these relate to creating a stable psychological framework for the client. [ABSTRACT FROM AUTHOR]

Rationale, aims & objective Tools for the assessment of the quality of research studies tend to be specific to a particular research design (e.g. randomized controlled trials, or qualitative interviews). This makes it difficult to assess the quality of a body of research that addresses the same or a similar research question but using different approaches. The aim of this paper is to describe the development and preliminary evaluation of a quality assessment tool that can be applied to a methodologically diverse set of research articles. Methods The 16-item quality assessment tool (QATSDD) was assessed to determine its reliability and validity when used by health services researchers in the disciplines of psychology, sociology and nursing. Qualitative feedback was also gathered from mixed-methods health researchers regarding the comprehension, content, perceived value and usability of the tool. Results Reference to existing widely used quality assessment tools and experts in systematic review confirmed that the components of the tool represented the construct of 'good research technique' being assessed. Face validity was subsequently established through feedback from a sample of nine health researchers. Inter-rater reliability was established through substantial agreement between three reviewers when applying the tool to a set of three research papers (κ = 71.5%), and good to substantial agreement between their scores at time 1 and after a 6-week interval at time 2 confirmed test-retest reliability. Conclusions The QATSDD shows good reliability and validity for use in the quality assessment of a diversity of studies, and may be an extremely useful tool for reviewers to standardize and increase the rigour of their assessments in reviews of the published papers which include qualitative and quantitative work. [ABSTRACT FROM AUTHOR]

The article comments on a study which focused on the deconstruction of patient-oriented paradigm in health sciences. It points out the lack of evidence for the pervasiveness of patient-oriented research and the failure of the study authors to show that patient-health research will foreclose on more radical forms of participatory research and engagement, as well as to provide examples of actual harms done by actual-patient-oriented health research.

The article comments on the elite's secret language or rhizome talk and the underlying theory of the psychological function of deconstructivist approach. It suggests deconstructivism as a narcissistic approach and the tendency of narcissists to combine a sense of entitlement with average readiness and hunger for power and adoration. It calls for understanding the engagement of individuals in ideological war to develop an idea of how to cope with the critical activist participatory politic.

Economics is en route to its further expansion in medicine, but many in the medical community remain unconvinced that its impact will be positive. Thus, a philosophical enquiry into the compatibility of economics and medicine is necessary to resolve the disagreements. The fundamental mission of medicine obliges physicians to practise science and compassion to serve the patient's best interests. Conventional (neoclassical) economics assumes that individuals are self-interested and that competitive markets will emerge optimal states. Economics is seemingly incompatible with the emphasis of putting patients' interests first. This idea is refuted by Professor Kenneth Arrow's health economics seminal paper. Arrow emphasizes that medical practice involves agency, knowledge, trust and professionalism, and physician-patient relation critically affects care quality. The term A rrow P hysician is used to mean a humanistic carer who has a concern for the patient and acts on the best available evidence with health equity in mind. To make this practice sustainable, implementing appropriate motivations, constitutions and institutions to enable altruistic agency is critical. There is substantial evidence that polycentric governance can encourage building trust and reciprocity, so as to avoid depletion of communal resources. This paper proposes building trusting institutions through granting altruistic physicians adequate autonomy to direct resources based on patients' technical needs. It also summarizes the philosophy bases of medicine and economics. It, therefore, contributes to developing a shared language to facilitate intellectual dialogues, and will encourage trans-disciplinary research into medical practice. This should lead to medicine being reoriented to care for whole persons again. [ABSTRACT FROM AUTHOR]

Abstract: Systems thinking and reference to complexity science have gained currency in health sector practice and research. The extent to which such ideas might represent a mere passing fad or might more usefully be mobilized to tackle wicked problems in health systems is a concern underpinning this paper. Developing the usefulness of the systems idea requires appreciating how systems ideas are used essentially as constructs conceptually bounded by practitioners. Systems are used for purposes of understanding and engaging the reality of health issues, with the intent of transforming the reality into one that is more manageable, equitable, and sustainable. We examine some manifestations of the systems idea in health practice and the traditions of systems practice that variously make use of them. This provides a platform for proposing a systems thinking in (health) practice heuristic: a learning device supporting how different tools and methods can address “wicked problems” in health praxis. The device is built on the use of “conversation” as a metaphor to help practitioners use systems ideas in tandem with existing disciplinary and professional skills and methods. We consider how the application of the heuristic requires, and helps to develop, human characteristics of humility, empathy, and recognition of fallibility. [ABSTRACT FROM AUTHOR]

This paper suggests how a patient may be able to give and receive the caring he/she wants with respect to a clinician whose (in)action he/she perceives to be uncaring. The approach suggested draws on the philosophy and psychology of framing and adopting Hans Vaihinger's 'as if' theory. I draw on my own experience as a patient to apply this approach that requires imagining and acting as if an apparently uncaring clinician is caring. This fiction need not be objectively true but nor is it necessarily false because the as if theory assumes that the only world anyone can know is one of appearances. At least when the lack of caring appears objectively minor and uncertain to the person feeling it, the caring fiction can be morally important, both for its own sake and for its utility to the patient, the clinician and the maintenance of their relationship. Lastly I discuss the strengths and limitations of the as if approach for clinical practice. [ABSTRACT FROM AUTHOR]

This paper addresses an implicit presupposition in research-supported psychological treatments and evidence-based practice in psychology. It argues that the notion of research-supported psychological treatments is based on a reductive conceptualisation of psychotherapy. Research-supported psychological treatments hinge upon an empirical reduction where psychotherapy schools become conceptualized as mere collections of empirical propositions. However, this paper argues that the different psychotherapy schools have distinct ethoses that are constituted by normative claims. Consequently, the evaluation of the different psychotherapy schools and the practice of psychotherapy should include the underlying normative claims of these ethoses., (© 2017 John Wiley & Sons, Ltd.)

Rationale, aims and objectives Challenging clinical encounters can often be frustrating and demoralizing not only for clinicians but also for patients. The paper's aims are twofold. The first is to analyse the nature and origins of such encounters. The second is to appraise the CALMER and REBELS models for managing them. Methods After reviewing the medical literature on challenging clinical encounters, a clinical case is briefly reconstructed from it. The reconstructed case is then used to analyse the nature and origins of challenging encounters and to evaluate the two models for handling them. Results The reconstructed clinical case is an apt example for examining and evaluating the medical literature on challenging clinical encounters. In terms of what challenging encounters are and what elicits them, the literature captures their frustrating, demoralizing, demanding and, at times, insufferable dimensions - as well as the role of patients in their origins - as the clinical case also illustrates. With respect to managing them, the CALMER and REBELS models are effective strategies for handling challenging encounters - again, as the clinical case exemplifies. Conclusions Although the clinical case supports the medical literature on challenging clinical encounters, the literature fails to provide an adequate account of their nature and origins. Specifically, challenging encounters are a type of dysfunction - not pathophysiological but existential - in a clinical setting, with their origins not only in patients but also in clinicians and health care systems. Finally, based upon the dysfunctional nature of such encounters, revisions of the CALMER and REBELS models are proposed for better managing these encounters. [ABSTRACT FROM AUTHOR]

The main thesis of this paper is that mental health practitioners can legitimately infer that a patient's given condition is a case of mental disorder without having diagnosed any specific mental disorder. The article shows how this is justifiable by relying either on psychopathological reasoning, on 'intentional' analysis or possibly on other modes of reasoning. In the end, it highlights the clinical and philosophical consequences of the plurality of modes of 'inferences to mental disorder'. [ABSTRACT FROM AUTHOR]

In this paper, we explore the recent emphasis, in various medical contexts, of the term 'critical' or the notion of 'being critical'. We identify various definitions of being critical and note that they differ strikingly. What are these different uses of the term trying to capture that is important in clinical medicine and medical education? We have analysed these qualities as responsibilist, epistemic virtues. We believe that a virtues approach is best able to make sense of the non-cognitive elements of 'being critical', such as the honesty and courage to question claims in the face of persuasion, authority or social pressure. Medical educators and professional bodies seem to agree that being critical is important and desirable. Yet, it is unclear how this quality can be optimally fostered and balanced with the constraints that act upon individual practitioners in the context of institutional medicine including professional standards and the demands of the doctor-patient relationship. Other constraints such as authoritarianism, intimidation and financial pressures may act against the expression of being critical or even the cultivation of critical thinking. The issue of the constraints on critical thinking and the potential hazards it entails will require further consideration by those who encourage being critical in medicine. [ABSTRACT FROM AUTHOR]

'Behavioural medicine' is poised to contribute to the quality of health to the benefit of patients and physicians. There is a need for medical students and residents to better understand the field of behavioural medicine, and for practising physicians to incorporate it in medical education and clinical practice. This paper seeks to correct an erroneous conceptualization of behavioural medicine as being limited to psychosocial and mental health adjustments, and to provide examples of selected applications for medical conditions, including those that are not primarily regarded as requiring changes in lifestyle or psychotherapy. In fact, there are dramatic treatment and intervention protocols available that employ behavioural procedures that can provide relief for patients in all medical and dental specialties and that deserve to be considered along with conventional treatment protocols. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives It is well established that clinical inertia generates suboptimal care in patients with chronic diseases, and policies and interventions have yet to satisfactorily address the problem. Methods This paper integrates the relevant literatures on clinical inertia and Regulatory Focus Theory (RFT) from psychology to identify an actionable explanatory mechanism. Results We review RFT and show that it provides a mechanism that may explain key provider contributions to clinical inertia. We then identify two general intervention strategies based on RFT: one that changes individual sensitivity to positive/negative outcomes and another that maintains the sensitivity to positive/negative outcome but frames how information is provided to match the sensitivity. Conclusions We conclude that RFT is a plausible explanation to guide the development of policies and interventions for mitigating clinical inertia. [ABSTRACT FROM AUTHOR]

Research on relationships often does not refer to a single person but rather to two persons. Nonetheless, such data has been often analysed by examining individuals in isolation, which falls short of capturing their truly interpersonal and non-independent nature. This paper highlights and illustrates some analytic tools for such dyadic data that are essential for theories about dyadic relationships to be tested adequately. The methodology is applied to clinical trial data from male patients treated for their erectile dysfunction and data from their partners with respect to treatment satisfaction. Multi-level modelling was used to analyse the data. The approaches outlined allow researchers to assess both individual effects and companion effects (e.g. of baseline intercourse satisfaction on subsequent treatment satisfaction), role of participant (e.g. patient or partner) or treatment condition (e.g. test or placebo) on outcome (e.g. treatment satisfaction), and differences on individual and companion effects when couples differ on important variables (e.g. differences on the individual and companion effects of baseline intercourse satisfaction on treatment satisfaction when couples differ with respect to treatment condition). Researchers are encouraged to consider implementing dyadic data analysis in their own work. [ABSTRACT FROM AUTHOR]

The article proposes that the enactment of patient-centered research (PCR) may serve other ends. It endorses the warning that participatory action research may be instrumentalized and subordinated and raises the political aspect of PCR in tokenism. It suggests the evaluation of patient/consumer participation in research via measures of stakeholder engagement and calls for public funding for universities determined by neoliberal governmental policies and imperatives to efficiency.

Rationale: A 'patient‐oriented' research paradigm, also known as patient and public engagement, has infiltrated the field of health sciences and continues to spread. At first blush, it is difficult to reprove anything labelled 'patient‐oriented'; however, the patient‐oriented paradigm may easily become an ideological 'good', leading to unintended consequences that may well prove more detrimental than beneficial. While patient‐oriented research has its roots in more radical forms of patient and public engagement, its recent instantiation betrays its roots and forecloses on more radical forms of engagement, such as critical participatory research. Aim and Objectives: The objective of this article is to deconstruct the patient‐oriented research narrative and to demonstrate how such a discourse imposes itself as a dominant approach in health sciences. Approach: Following Derrida's deconstructive approach, we bring to light the unexamined presuppositions, false pretences, and presumed 'goodness' and 'naturalness' of patient‐oriented discourse. Discussion: By deconstructing the patient‐oriented narrative we demonstrate how pre‐existing power structures (biomedical, economic, etc.) shape the conduct of the approach and serve to depoliticize the truly participatory aspects of research. Rather than being modelled on the evidence‐based movement or seen as its natural 'evolution', patient‐oriented research should resist by affirming itself as a radical form that is both participatory and emancipatory. [ABSTRACT FROM AUTHOR]

Background: Centred around the thesis that for those engaged in clinical practice there are two worlds present in parallel, this article defines the characteristics of the supposed second, qualitative world. Contrasting these characteristics to those of the world as seen in continuous metric dimensions of space and time, we derive the nature of the qualitative elements and their coherent interaction, as well as the rules governing these dynamic elements' interactions. Results: The second world claimed to exist turns out to be made of individual worlds centred in coherent perspectival interaction. Its polycentric agency enacts individual perspectives and mutual information uptake. This hermeneutical approach conforms with some recent developments in theory, such as that of Nobel Prize winner Elinor Ostrom, or the enactment theory of cognitive science. Conclusions: Following this theoretical process, two practical consequences are drawn. The first consists of an advanced model of biopsychosocial interaction, as extensively published throughout the years. The second presents the concept of quality‐oriented self‐aid groups open to all exposed to or working in care and healthcare. The corresponding training helps practitioners to consciously and deliberately move, perceive, and perform in the duplicity of worlds, the one the conventional quantifying, metric one, the other the mostly rationally unknown world emerging from qualifying interactive agency. [ABSTRACT FROM AUTHOR]

The article comments on a study which calls for a change in the approach to patient-oriented research and argues the inadequacy of improving patient engagement in research to determining what is important for a patient. It raises questions about participatory research including the content of participation, quality of engagement and generalizing from populations to individuals. It points out the incorporation of patient values and preferences in a patient-oriented approach.

An introduction is presented in which the editor discusses articles in the issue on topics including clinical judgment, philosophy of medicine and clinical epidemiology.

Background: While the quality of medical care delivered by physicians can be very good, it can also be inconsistent and feature behaviours that are entrenched despite updated information and evidence. The "nudge" paradigm for behaviour change is being used to bring clinical practice in line with desired standards. The premise is that behaviour can be voluntarily shifted by making particular choices instinctively appealing. We reviewed studies that are explicit about their use of nudge theory in influencing clinician behaviour. Methods: Databases were searched from April 2008 (the publication date of the book that introduced nudge theory to a wider audience) to November 2018, inclusive. The search strategy and narrative review of results addressed the Preferred Reporting Items for Systematic reviews and Meta‐Analyses extension for Scoping Reviews. Results: 22 studies were identified. Randomized trials or pre‐post comparisons were generally used in community‐based settings; single‐site pre‐post studies were favoured in hospitals. The studies employed eight intervention types: active choice; patient chart redesign; default and default alerts; partitioning of prescription menus; audit and feedback; commitment messages; peer comparisons; and redirection of workflow. Three core cognitive factors underpinned the eight interventions: bias towards prominent choices (salience); predisposition to social norms; and bias towards time or cost savings. Conclusions: Published studies that are explicit about their use of nudge theory are few in number and diverse in their settings, targets, and results. Default and chart re‐design interventions reported the most substantial improvements in adherence to evidence and guideline‐based practice. Studies that are explicit in their use of nudge theory address the widespread failure of clinical practice studies to identify theoretical frameworks for interventions. However, few studies identified in our review engaged in research to understand the contextual and site‐specific barriers to a desired behaviour before designing a nudge intervention. [ABSTRACT FROM AUTHOR]

The article presents the author's opinion on the legal and ethical issues related to assisted suicide. Commenting on a criticism to a paper written by the author, he dwells on the various issues raised by the criticism. He makes a distinction between family assisted and physician assisted suicide. Taking a philosophical approach, he comments that the use of anesthesia by doctors is already a king of mild euthanasia.

Background: Uncertainty is a ubiquitous and dynamic presence throughout healthcare systems and encounters, affecting the quality and safety of care. Although previous research has attempted to categorize varieties of uncertainty, it is not clear if these classifications are applicable across various healthcare settings. Objective: The purpose of this review was to examine the applicability of the issues of uncertainty delineated in an established taxonomy across diverse healthcare domains, professions, and countries and to consider the complexity of these issues. Methods: Drawing on empirical research from three databases, we conducted a scoping review of the literature to identify types of uncertainty experienced by healthcare professionals. A framework synthesis design was employed to review and synthesize the literature across multiple healthcare settings. Results: The search identified 2285 articles, of which 94 met the inclusion criteria. Findings from included studies suggested professional uncertainty in healthcare is complex and pervasive. On the basis of our inability to categorize some studies in the issues of uncertainty outlined in the existing taxonomy, we proposed a revised model of uncertainty for healthcare professionals. Conclusions: The revised model of uncertainty, the model of uncertainty in complex healthcare settings (MUCH‐S), is applicable to various healthcare ecosystems and proposes a reflexive archetype that recognizes different issues of uncertainty while establishing that these are often interrelated in healthcare systems. This review offers healthcare professionals greater levels of understanding of this complex phenomenon and may support more informed and reflective decision‐making, assisting them to better navigate uncertainties experienced in healthcare workplaces. [ABSTRACT FROM AUTHOR]

Abstract: How can overdiagnosis be defined, explained, and estimated on an individual level? The answers to this question are essential for persons to be able to make informed choices and give valid consents for tests. Traditional conceptions of overdiagnosis tend to depend on counterfactual thinking and prophetic abilities as you would have to know what would happen in the future if you did not test now. To avoid this, overdiagnosis can be defined in terms of the chance of diagnosing a person with a disease when this does not avoid or reduce manifest disease. To be able to relate this to 1's own life and deliberation, I argue that we need answers to specific questions such as the following: If I am tested, and the test and subsequent test results are positive, but I am not treated, what is the chance that I would not experience and suffer from manifest disease? A definition of overdiagnosis that aims at providing answers to this question is as follows: Prospectively overdiagnosis (of an individual person) is given by the estimated chance that a person having a positive test result would not experience and suffer from manifest disease if not treated or followed up in any way. Getting personal on overdiagnosis directs the attention of overdiagnosis estimates towards what matters in medicine: the experience of individual persons. [ABSTRACT FROM AUTHOR]

Abstract: Older people who live with a combination of conditions experience fluctuations over time, which others may interpret as a need for medical attention. For some nursing home residents, this results in transitions in and out of hospital. Such transfers may be arranged without expectation of improved quality of life, can be associated with significant morbidity and mortality, and may preclude end‐of‐life preferences. Factors affecting avoidable hospitalization for nursing home residents are not well understood. I aim to explore potential drivers, moving beyond deficit explanations relating to funding, training, and resources. I use a framework of analysis that firstly considers medicalization of frailty, as a state of vulnerability that provides focus for others' action. I then draw on Judith Butler's theory of performativity, to explore nursing homes as sites of identity work for staff, residents and families. I consider ways subjectivities can be effected through reiterative practice that is compelled by normative conventions. Trouble may arise when citational practice of health care staff, and performative acquiescence of residents and families, culminates in an inevitability of hospitalization when navigating grey areas of assumed clinical risk. Principles of coproduction could present a disruptive opening, to rework power asymmetries, and move toward aspirations for residents and their relatives to be at the centre of decisions about care. [ABSTRACT FROM AUTHOR]

Abstract: Mental health professionals such as psychiatrists and psychotherapists assess their patients by identifying disorders that explain their symptoms. This assessment requires an inference to the best explanation that compares different disorders with respect to how well they explain the available evidence. Such comparisons are captured by the theory of explanatory coherence that states 7 principles for evaluating competing hypotheses in the light of evidence. The computational model ECHO shows how explanatory coherence can be efficiently computed. We show the applicability of explanatory coherence to mental health assessment by modelling a case of psychiatric interviewing and a case of psychotherapeutic evaluation. We argue that this approach is more plausible than Bayesian inference and hermeneutic interpretation. [ABSTRACT FROM AUTHOR]

Abstract: Background: To improve the efficiency of the health care system, new interprofessional models of care are emerging. In 2015, two provincial professional colleges, regulating the practice of physiotherapists and that of pharmacists in the province of Québec, Canada, developed a new interprofessional model of care. This model is designed to guide non‐prescription medication recommendations by physiotherapists treating patients in primary care with neuromusculoskeletal disorders (NMSKD) with the collaboration of pharmacists. Purpose: To assess Québec physiotherapists' interests to use this model and explore their opinions concerning their ability to recommend non‐prescription medications to patients in primary care with NMSKD. Methods: An email invitation to complete an electronic survey was sent in February 2016 to all the Ordre professionnel de la physiothérapie du Québec's registered physiotherapists. The survey included a questionnaire with 31 questions divided into 5 sections. Descriptive analyses and Chi‐square tests (χ2) were performed to compare proportions (%) across demographic and clinical characteristics. Results: Two hundred twenty‐five physiotherapists completed the full survey. Of these, 70% of respondents knew of the model of care, but only 15% had previously used it. Perceived workload increase was one major reason reported for this lack of use (51%). Most of the respondents had a positive perception of this model and interactions with pharmacists and were confident regarding their ability to safely recommend medication (63%). However, 63% believed that further training was necessary to enable physiotherapists to provide efficient and safe non‐prescription medication recommendations to patients with NMSKD. Conclusions: Overall, physiotherapists have a positive perception of this model, but there remain opportunities for increased integration into practice. Most respondents believe that additional training is required regarding non‐prescription medication recommendations. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: This review of systems thinking (ST) case studies seeks to compile and analyse cases from ST literature and provide practitioners with a reference for ST in health practice. Particular attention was given to (1) reviewing the frequency and use of key ST terms, methods, and tools in the context of health, and (2) extracting and analysing longitudinal themes across cases. Methods: A systematic search of databases was conducted, and a total of 36 case studies were identified. A combination of integrative and inductive qualitative approaches to analysis was used. Results: Most cases identified took place in high‐income countries and applied ST retrospectively. The most commonly used ST terms were agent/stakeholder/actor (n = 29), interdependent/interconnected (n = 28), emergence (n = 26), and adaptability/adaptation (n = 26). Common ST methods and tools were largely underutilized. Social network analysis was the most commonly used method (n = 4), and innovation or change management history was the most frequently used tool (n = 11). Four overarching themes were identified; the importance of the interdependent and interconnected nature of a health system, characteristics of leaders in a complex adaptive system, the benefits of using ST, and barriers to implementing ST. Conclusions: This review revealed that while much has been written about the potential benefits of applying ST to health, it has yet to completely transition from theory to practice. There is however evidence of the practical use of an ST lens as well as specific methods and tools. With clear examples of ST applications, the global health community will be better equipped to understand and address key health challenges. [ABSTRACT FROM AUTHOR]

Abstract: For older adults with osteoporosis, a fall resulting in hip fracture is a life‐changing event from which only one‐third fully recover. Current best evidence argues strongly for elderly patients to bear weight on their repaired hip fracture immediately after their surgery to maximize their chances of full or nearly full recovery. Patient stakeholders in Canada have argued that some surgeons fail to issue “weight‐bearing‐as‐tolerated” (WBAT) orders in all eligible cases, protecting their bony repair but contributing to increased mortality and long‐term disability rates. In collaboration with a national stakeholder organization, Bone and Joint Canada, we interviewed 20 orthopedic surgeons across Canada who perform hip fracture repair surgery, with the aim of understanding their attitudes and behavior toward patient management regarding weight bearing. Qualitative content analysis, in which themes are identified and agreed by multiple coders, suggested that both patient characteristics and surgeon factors influence surgeons' postoperative weight‐bearing orders. While almost all respondents agreed that weight bearing as tolerated is indeed therapeutic for most hip fracture repair or replacement patients, surgeons also described certain patient characteristics that would diminish the value of immediate weight bearing, including poor bone quality and certain types of fracture pattern. Surgeon factors that affect postoperative mobilization orders include choice of construct, previous experience of construct failure, and lack of local audit data regarding past weight‐bearing decisions and patient outcomes. Thus, although familiar with best practice guidelines, surgeons also have “rules to break the rules.” In an era when “good” medicine leans toward science rather than art, the role of individual experience in decision making with regard to hip fracture care continues to be important and would benefit from being discussed openly. [ABSTRACT FROM AUTHOR]

Rationale, aims, and objectives Continuous subcutaneous insulin infusion (CSII; insulin pump) use is increasing. However, there is little information about how this technology is used compared with other insulin delivery methods (ie, injections) by young people with type 1 diabetes mellitus in Australia. This study explored young people's attitudes, perceptions, and experiences with diabetes management comparing those using with those not using CSII, and proportions likely to transition to adult services requiring initiation and/or support for CSII use. Methods A survey was undertaken of young people (aged 12 to 18 years) with type 1 diabetes mellitus and their parents/guardians living in Hunter New England, Australia, using a questionnaire designed to collect quantitative, descriptive, and demographic data. Most questions were based on previously developed and validated instruments. In total, 107 respondents returned partially or fully completed questionnaires. Results Respondents had positive attitudes and perceptions of their self-efficacy and diabetes management, but were moderately disturbed by their diabetes and reported experiencing suboptimal management outcomes. Patterns of associations were demonstrated between knowledge, attitudes, and experiences of diabetes modeled by regression analysis. There were no statistically significant differences in responses between users and nonusers of CSII. Over 40% indicated their intention to use the technology as adults. Conclusions Opportunities for enhanced diabetes service support were clear, and CSII did not appear to be used to its full potential. Service redesign could enhance support for this young population using all preferred insulin delivery methods and should align to patients' goals and preferences to maximize service and patient gain. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Public reporting of performance data is one of the most popular topics in health care field. The aim of this study was to investigate the transparency mechanism, that is, how public reporting influenced general practitioners' ( GPs) prescribing practices. Method GPs who had the license to prescribe medicine of all 10 primary care institutions were surveyed. Data were collected by an instrument, which exhibited satisfactory reliability and validity ( Cronbach's alpha > 0.7; average variance extracted > 0.5; composite reliability > 0.7). Data analysis was conducted by structural equation model. Results The results showed that GPs' perceived value ( GP's overall assessment of the worth of the public reporting) and attitude (the psychological reaction to public reporting) had a significantly direct effect on behavioural intention ( r = 0.28; r = 0.36), and were affected by information accessibility ( r = 0.63; r = 0.32). Attitude had a significant effect on perceived value( r = 0.45). Perceived risk (the perceptions of the possible loss due to public reporting, e.g. decreasing their income) did not have a significant relationship with information accessibility, attitude and behavioural intention( r = −0.09; r = 0.01; r = −0.07). Conclusion The information accessibility, perceived value and attitude have strong effects on prescribing practices of GPs, whereas perceived risk did not play a role in influencing the prescribing practices. Policymakers need to improve the accessibility of prescription quality indicators and pay attention to the perceived values and attitudes of GPs. Policymakers also need to strengthen the risk education of GPs and attach incentives to transparent regulation. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives This study aims to provide in-depth insight into the emotions and thoughts of physicians towards malpractice litigation, and how these relate to their incident disclosure behaviour. Methods Thirty-one Dutch physicians were interviewed and completed short questionnaires regarding malpractice litigation. We used hierarchical cluster analysis to identify physician clusters. Additional qualitative data were analysed. Results Physicians vary largely in their attitude towards malpractice litigation, and their attitude is not straightforward related to their disclosure behaviour. Based on their responses physicians could be divided into two clusters: one with a positive and one with a negative attitude. Physicians with a negative attitude showed often, but also 6 out of 15 not, a reluctance to disclose, whereas the majority in the positive attitude cluster (12 out of 16) showed no reluctance. If, what and how physicians disclose incidents depends on a complex interplay of their emotions and thoughts regarding litigation, and not only on their fear of litigation as many studies assume. Conclusions Due to the variation among physicians in their litigation attitude and behaviour in terms of incident disclosure the oft-heard call for 'openness' about medical incidents will not be easy to achieve. A coaching system in which physicians can share and discuss their differing attitudes and disclosure principles, teaching medical students and junior physicians about disclosure, and explaining how to organize emotional and legal support for oneself in case of litigation could decrease stress feelings and support open disclosure behaviour. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives The concept of emotions has gone through radical transformations during the last couple of centuries. Despite these severe re-specifications of its content, the concept of emotions (and especially some such as depression or anxiety) has acquired a central role in contemporary clinical Psychology and Psychiatry. This creates an apparent paradox, utilizing more and more concepts for which no clear conceptual understanding has been obtained. This paradox creates a challenge for researchers as well as clinicians, as on a daily basis, millions of people are currently ascribed with 'having' or 'being in' emotional states, which also entails certain interventions to be applied, without much clear insight into what exactly those states might really constitute. Method Conceptual research in aetiological and historical transformation of theoretical accounts of emotions as well as an overview of relevant empirical research on fundamental emotions. Examining of critical respective questions such as: whether there are any universal 'typical' emotional reactions to be found in each and every known culture, indicating their intrinsic existence as being a part of the human condition; whether there are 'basic' and 'secondary' emotions; whether emotions are merely bodily events, patterns of behavioural reactions to given types of stimuli or whether they rely inevitably on their cognitive content; whether emotions are necessarily intentional (in Brentano's sense) viz. are inevitably about a real or an imaginary object or whether there can be objectless emotional states; whether emotions are in a significant sense rational or fundamentally irrational responses and so forth. Moreover, more recent experimental data advocating for one or the other response to the aforementioned fundamental questions are scrutinized. Results In both conceptual research (including the works of thinkers such as the highly influential contributions of Darwin, James, Cannon, Freud, Ryle and Sartre or contemporary attempts such as the ones of theorists like Solomon, Nash, Rey, Pugmire and Lyons) as well as in comprehensive theoretical schemes combining experimental data (such as the ones provided by the works of Schachter and Singer, Ekman and Friesen, Panksepp, Damasio and Griffiths), there seems to be a radical indeterminacy of conceptual content and fundamental features of emotions in general, as well as of particular emotional states. Furthermore, there is an apparent conceptual incapability to include each and every feature of emotional states within a single comprehensive definition without making reference to contingent particularities of their biological instantiation. Conclusions At least in the crucial concept of emotional states, when examined carefully, it seems that (1) there are substantial barriers to the ambitious quest for a scientific grounding of taxonomies and definitions of phenomena like emotions, due to the inability to provide an independent verification of scientific propositions; (2) all major approaches in Psychology and Psychiatry seem to have serious shortcomings in defining emotions; (3) such shortcomings have to do with fundamental issues such as the nature of mental states; (4) most ordinary concepts of emotions utilized by clinicians and researchers tend to be circular and question begging when scrutinized theoretically; and (5) historically dominant beliefs, values and cultural systems tend to influence heavily both the acceptability of such representations of emotions as well as their very nature. [ABSTRACT FROM AUTHOR]

Cartwright and Munro argued that extrapolation of findings from randomized controlled trials to other settings can be difficult because information about the underlying causal structure and subgroups is often not available. They advocated the use of 'capacities' - that is fixed causal contributions - in predicting effects of interventions. In psychiatry, it is often not possible to determine what the fixed causal contributions are and one can only establish 'approximate capacities'. However, using 'approximate capacities' does imply a different way of evaluating health services, especially combined interventions. In health service research, if different studies, randomized controlled trials or other designs, have given different outcomes, the best way to investigate the effectiveness of a particular way of service organization is not to conduct more randomized controlled trials. It is preferable to study the effects of certain elements of the complex intervention, which have been tested before in other settings, that is investigating 'approximate capacities'. One should check whether the separate elements do form a part of the complex intervention in practice and whether they have the same effect as in other studies and if not, why not. This enhances knowledge about the underlying causal structure and increases the possibility of extrapolation of the findings. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives A person's beliefs about their illness may contribute to recovery and prognosis. Some degree of acceptance of illness and its impact is necessary to integrate the presence of a chronic disorder into one's lifestyle and adhere to necessary components of illness management; however, some individuals can become 'stuck' and have difficulty adjusting out of the sick role. Inventories exist to measure illness cognitions, attitudes and behaviours as they relate to hypochondria and psychosomatic illness, but there is no extant measure of sick role inertia. We describe the psychometric properties of a new scale, the Illness Cognitions Scale (ICS), a metric of investment in the sick role. Methods The ICS was administered to 97 individuals with bipolar or schizoaffective disorder, and the psychometric properties of the scale measured. Dimensionality was assessed using Principal Components Analysis with Oblimin rotation. Results The scale has a strong internal consistency, with a Cronbach's alpha of 0.858. Results of a factor analysis suggested the presence of one main factor, with three other smaller, related sub-factors, capturing aspects of maladaptive illness beliefs. Conclusion The ICS is a 17-item, internally validated scale measuring difficulty adjusting out of the sick role. The scale predominantly measures a single construct. Further research on external validity of the ICS is required as well as determination of the clinical significance and patient acceptability of the scale. [ABSTRACT FROM AUTHOR]

Objective The purpose of the current study was to assess, in patients scheduled for primary total knee replacement (TKR), the effects of pre-surgery waiting time on pain and functional limitations related to the knee joint undergoing surgery, on health-related quality of life (HRQoL) and on contralateral knee pain 6 months after surgery. Method A total of 141 patients scheduled for TKR were recruited from three hospitals in Quebec City, Canada, and followed up until 6 months after surgery. Pre-surgery wait, defined as the time between enrolment on the pre-surgery waiting list and surgery, was considered in four categories (≤3, >3-6, >6-9, >9 months). Pain and functional limitations were measured with the Western Ontario and McMaster Osteoarthritis Index (WOMAC). HRQoL was measured with the SF-36. Results Mean pre-surgery waiting time was 184 (SD: 120.8) days. Six months after TKR, a significant difference was seen between the four groups of pre-surgery wait in terms of HRQoL SF-36 role physical [ F(3, 136) = 2.74, P = 0.046] and contralateral knee WOMAC pain [ F(3, 136) = 5.78, P = 0.0009] scores. Participants with the longest pre-surgery wait (>9 months) showed the worst scores 6 months after TKR. Conclusions Longer pre-surgery waiting time had a negative clinically important impact on HRQoL and contralateral knee pain 6 months after surgery. [ABSTRACT FROM AUTHOR]

Objective During hospitalization older people often experience functional decline which impacts on their future independence. The objective of this study was to evaluate a multifaceted transitional care intervention including home-based exercise strategies for at-risk older people on functional status, independence in activities of daily living (ADLs) and walking ability. Methods A randomized controlled trial was undertaken in a metropolitan hospital in Australia with 128 patients (64 intervention, 64 control) aged over 65 years with an acute medical admission and at least one risk factor for hospital readmission. The intervention group received an individually tailored programme for exercise and follow-up care which was commenced in hospital and included regular visits in hospital by a physiotherapist and a registered nurse, a home visit following discharge and regular telephone follow-up for 24 weeks following discharge. The programme was designed to improve health-promoting behaviours, strength, stability, endurance and mobility. Data were collected at baseline, then 4, 12 and 24 weeks following discharge using the Index of ADL, Instrumental Activities of Daily Living (IADL) and the Walking Impairment Questionnaire (WIQ; modified). Results Significant improvements were found in the intervention group in IADL scores ( P < 0.001), ADL scores ( P < 0.001) and WIQ scale scores ( P < 0.001) in comparison to the control group. The greatest improvements were found in the first 4 weeks following discharge. Conclusions Early introduction of a transitional model of care incorporating a tailored exercise programme and regular telephone follow-up for hospitalized at-risk older adults can improve independence and functional ability. [ABSTRACT FROM AUTHOR]

Introduction Significant event analysis (SEA) is now well established in UK primary care. Previously, considerable variation has been reported in the knowledge, skills and attitudes of general practitioners undertaking SEA. Little is known about the wider team's understanding, participation or perceptions. We therefore aimed to determine the awareness, degree of analysis and perceived risk of recurrence of a recent significant event, types of discussion forums, staff groups' participation and perceived barriers. Comparisons were made with a 2003 survey and significant changes described. Method A postal questionnaire survey was undertaken of a random selection of general practice team members in National Health Service Greater Glasgow in 2008/9. Results In total, 375/711 respondents (53%) from 111 practices participated. The vast majority was aware of a recent significant event, 29% reported not implementing a change and 23% perceived the risk of recurrence as moderate to high. Administrative and community-based staff were infrequently involved in meetings. Dedicated significant event meetings remain uncommon ( P = 0.06). Perceptions improved since 2003, but lack of time remained a concern. Discussion This survey was the first known attempt to include all members of the primary care team while studying SEA. Awareness and analysis levels were high, but only lead to sustainable improvement of care quality and clinical safety if teams implement change. Greater use should be made of dedicated SEA meetings and participation of all staff groups increased to gain full benefits. Lack of time can be managed pragmatically by prioritizing events based on their perceived severity, potential for change and potential team involvement. [ABSTRACT FROM AUTHOR]

Medicine is predicated on a view of human nature that is highly positivist and atomistic. This is apparent in the way in which its students are taught, clinical consultations are structured and medical evidence is generated. The field of medical humanities originally emerged as a challenge to this overly narrow view, but it has rarely progressed beyond tinkering around the edges of medical education. This is partly because its practitioners have largely been working from within a pervasive medical culture from which it is difficult to break free, and partly because the field has been insufficiently armed with scholarly thinking from the humanities. This is beginning to change and there is a sign that research in medical humanities has the potential to mount a persuasive challenge to medicine's ways of teaching, working and finding out. This article problematizes medicine's narrow viewpoint, grounding its critique in philosophical ideas from phenomenology and pragmatism. I will reflect upon the historical context within which medical humanities has emerged and briefly examine specific examples of how its interdisciplinary approach, involving humanities scholars with clinicians and medical scientists, may develop new research directions in medicine. [ABSTRACT FROM AUTHOR]

Rationale Self-efficacy beliefs may provide a means to influence health care professionals' (HCPs) engagement in evidence-based practice (EBP) but no standardized measure of this construct exists. Objectives To create and evaluate the validity and comprehensibility of a scale measuring belief in ability to implement EBP, known as EBP self-efficacy, among HCPs. Methods Items describing the steps of EBP outlined in the literature were generated. Fourteen content experts reviewed the scale for face and content validity. A purposive sample of 10 HCPs from medicine, nursing, physical and occupational therapy and speech language pathology provided feedback on the clarity and meaning of scale wording in telephone interviews. Results Progressive refinement yielded an 11-item self-report scale. Each item describes an activity that is part of the process of implementing EBP, such as formulating a question to guide a literature search and asking your patient or client about his/her needs, values and treatment preferences. To complete the scale, HCPs rate their level of confidence on an 11-point scale ranging from 0% (no confidence) to 100% (completely confident) in their ability to perform each activity. Item-level responses are averaged to obtain a summary score that can range from 0% to 100%. Conclusion The newly created scale, named the EPIC (evidence-based practice confidence) scale, provides an opportunity to evaluate HCPs' beliefs in their ability to implement EBP and the effects of interventions on these beliefs. Psychometric evaluation of the test-retest reliability and construct validity of the scale is necessary prior to its widespread use. [ABSTRACT FROM AUTHOR]

Complex adaptive chronic care (CACC) is a framework based upon complex adaptive systems' theory developed to address different stages in the patient journey in chronic illness. Simple, complicated, complex and chaotic phases are proposed as diagnostic types. To categorize phases of the patient journey and evaluate their utility as diagnostic typologies. A qualitative case study of two cohorts, identified as being at risk of avoidable hospitalization: 12 patients monitored to establish typologies, followed by 46 patients to validate the typologies. Patients were recruited from a general practitioner out-of-hours service. Self-rated health, medical and psychological health, social support, environmental concerns, medication adherence and health service use were monitored with phone calls made 3-5 times per week for an average of 4 weeks. Analysis techniques included frequency distributions, coding and categorization of patients' longitudinal data using a CACC framework. Twelve and 46 patients, mean age 69 years, were monitored for average of 28 days in cohorts 1 and 2 respectively. Cohorts 1 and 2 patient journeys were categorized as being: stable complex 66.66% vs. 67.4%, unstable complex 25% vs. 26.08% and unstable complex chaotic 8.3% vs. 6.52% respectively. An average of 0.48, 0.75 and 2 interventions per person were provided in the stable, unstable and chaotic journeys. Instability was related to complex interactions between illness, social support, environment, as well as medication and medical care issues. Longitudinal patient journeys encompass different phases with characteristic dynamics and are likely to require different interventions and strategies - thus being 'adaptive' to the changing complex dynamics of the patient's illness and care needs. CACC journey types provide a clinical tool for health professionals to focus time and care interventions in response to patterns of instability in multiple domains in chronic illness care. [ABSTRACT FROM AUTHOR]

The cause of increased post-AMI (acute myocardial infarction) mortality associated with depression remains poorly elucidated. The objective of this study was to examine the extent to which self-reported cardiac functional status accounted for depression-mortality associations following AMI. Using a prospective cohort design ( n = 1941), the authors obtained self-reported measures of depression and developed profiles of the patients' pre-hospitalization cardiac risks, co-morbid conditions and drugs and revascularization procedures during or following index AMI hospitalization. To create these profiles, the patients' self-reports were retrospectively linked to no less than 12 years' worth of previous hospitalization data. Mortality rates 2 years after acute MI were examined with and without sequential risk adjustment for age, sex, income, cardiovascular risk, co-morbid conditions, selected process-of-care factors and self-reported cardiac functional status. Depression was strongly correlated with 2-year mortality rate [crude hazard ratio (HR) of severe vs. minimal depression category, 2.48 (95% CI 1.20-5.15); P = 0.01]. However, after sequential adjustment for age, sex, income and self-reported cardiac functional status, the effect of depression was greatly attenuated [adjusted HR for severe vs. minimal depression category, 1.35 (95% CI 0.63-2.87); P = 0.44]. Cardiac risk factors and non-cardiac co-morbidities had negligible explanatory effect. The main factor determining the increased mortality rate in depressed patients is self-reported cardiac functional status. Efforts to address increased mortality in depressed patients with cardiovascular illnesses should focus on processes that impact cardiac functional status. [ABSTRACT FROM AUTHOR]

Strategies to improve primary care in the Canadian Primary Care Reform include integrating different professionals to the medical team. This demonstration project explores the perceived impact on doctors and patients, of having family doctors and psychologists work together. Two family practices of Eastern Ontario, Canada Two board certified psychologists (one per practice) were integrated in the practices for 12 months. Psychologists conducted assessments, consultations and short-term treatments, as well as knowledge-transfer sessions for doctors. Outcome measures included referral patterns, patient outcomes, patient and provider satisfaction as well as doctors' billing. Three hundred and seventy-six participants received psychological care; most were women (68%) and between the ages of 25-64 (67%). Anxiety and depression were the most prevalent diagnoses. Reasons for referral included: psychological treatment (70%); emotional support and counselling (35%); clarification of diagnosis and case conceptualization (25%). Referrals could be for more than one reason. After intervention, 60% of patients had improvement on the outcome questionnaire-45 (OQ-45). Quality of life as measured by the EuroQol-5D also improved ( P < 0.001). Over 77% of patients reported increased confidence in handling their problems after treatment. Compared with their family doctor, patients felt the psychologist had more time and was better trained (75%) Doctors felt mental health problems were diagnosed more rapidly, patient care improved as well as their own knowledge of psychological management and treatment. Doctors felt it freed up their time and improved working conditions. Audit of the doctors' billing showed reduction in doctors' mental health billing. Having an on-site psychologist was highly satisfactory for patients and providers, resulting in improved patient care and outcomes. [ABSTRACT FROM AUTHOR]

The purpose of this study was to examine the hierarchical and cumulative nature of the 35 items of the Myocardial Infarction Dimensional Assessment Scale (MIDAS), a disease-specific health-related quality of life measure. Data from 668 participants who completed the MIDAS were analysed using the Mokken Scaling Procedure, which is a computer program that searches polychotomous data for hierarchical and cumulative scales on the basis of a range of diagnostic criteria. Fourteen MIDAS items were retained in a Mokken scale and these items included physical activity, insecurity, emotional reaction and dependency items but excluded items related to diet, medication or side-effects. Item difficulty, in item response theory terms, ran from physical activity items (low difficulty) to insecurity, suggesting that the most severe quality of life effect of myocardial infarction is loneliness and isolation. Items from the MIDAS form a strong and reliable Mokken scale, which provides new insight into the relationship between items in the MIDAS and the measurement of quality of life after myocardial infarction. [ABSTRACT FROM AUTHOR]

Rationale If the complexity of the patient's medical problems increases or the complexity of the interactions between the doctor and the patient, the staff or the health care system increase, then complexity of patient care will increase. This study examined trends in patient complexity, and identified doctor, practice and improvement strategy characteristics associated with perceived complexity. Methods This secondary analysis used data from three Community Tracking Surveys with 22 134 primary care doctors completing surveys about themselves, their practice setting, practice improvement strategies and complexity of care in three consecutive 2-year time periods (1996–1997, 1998–1999, 2000–2001). Data were analysed using hierarchical logistic regression. Results The proportion of primary care doctors who perceived that complexity of care had increased over the past 2 years rose from 31.5% to 35.9%. Perceived complexity of patient care was consistently related to being in solo practice and the belief that they could not frequently obtain high-quality services and referrals for patients. As availability of services increased, complexity decreased whereas as use of practice improvement strategies increased, complexity also increased. Conclusions Understanding that we cannot determine whether respondents understood care as ‘complicated’ or ‘complex’, potential consequences of this increase in complexity include an increase in medical errors and referral rates along with decreased quality of patient care and career satisfaction. [ABSTRACT FROM AUTHOR]

Objectives To explore to what extent psychological factors such as expectation, depression, anxiety and belief in alternative medicine impact placebo response and differential responses to separate placebo interventions. Methods We analysed data from a randomized controlled trial designed to compare the clinical response of two distinct placebo treatments (sham acupuncture device and placebo pill) in 119 participants with persistent distal upper arm pain due to repetitive stress injury. We used a multivariable linear regression model to identify potential correlates of self-reported upper extremity pain at the end of treatment in both placebo arms of the study combined. We also performed stratified analyses by placebo treatment. Results We did not find any of the psychological factors of interest to be associated with pain at the end of treatment in our combined analysis. We found higher baseline pain score and pain for longer than 1 year's duration to be significantly associated with higher pain scores at the end of treatment for the placebo treatments combined. In stratified analyses, for the sham acupuncture group, we found higher baseline depression score, higher baseline pain score and younger age to be independently correlated with higher pain score at the end of treatment. For the placebo pill group, only baseline pain was significantly correlated to pain score at the end of treatment. Conclusion In this trial, neither expectancy nor psychological states were associated with response to placebo, with the exception of baseline depression score for the sham acupuncture arm. [ABSTRACT FROM AUTHOR]

AbstractThe objectives of this study were to describe ways in which doctors make suboptimal diagnostic and treatment decisions, and to discuss possible means of alleviating those biases, using a review of past studies from the psychological and medical decision-making literatures. A number of biases can affect the ways in which doctors gather and use evidence in making diagnoses. Biases also exist in how doctors make treatment decisions once a definitive diagnosis has been made. These biases are not peculiar to the medical domain but, rather, are manifestations of suboptimal reasoning to which people are susceptible in general. None the less, they can have potentially grave consequences in medical settings, such as erroneous diagnosis or patient mismanagement. No surefire methods exist for eliminating biases in medical decision making, but there is some evidence that the adoption of an evidence-based medicine approach or the incorporation of formal decision analytic tools can improve the quality of doctors’ reasoning. Doctors’ reasoning is vulnerable to a number of biases that can lead to errors in diagnosis and treatment, but there are positive signs that means for alleviating some of these biases are available. [ABSTRACT FROM AUTHOR]