Purpose This paper aims to elucidate the factors that play into physicians’ experience of receiving practice data and to subsequently develop a model that describes how individuals may interact with the data they receive. Methods In a prior study, we conducted a needs analysis of 105 physicians in the Hamilton-Niagara area in order to understand which data metrics were most valuable to physicians. Using these results, we designed an interview guide to study physicians’ perspectives on audit and feedback. By intentional sampling, we recruited 15 physicians amongst gender groups, types of practice (academic vs community), and duration of practice. The interviews were conducted by a single author and transcribed without identifiers. We then began with an open coding analysis for all of the transcripts, and thereafter conducted axial coding to group the data into larger themes. Results Several environmental and personal attributes were identified as either enabling or counterproductive attributes for participant improvement. The final proposed model identifies different zones of engagement on the basis of both the individual practitioner’s growth mindset and the quality of the existing data system. In the highest engagement zone, the mindset of the collective leadership is one of growth. Systemic supports are in place which potentiates learning that may come from an individual motivated to use their own data. Conclusion Our model shows how data feedback systems and individual growth-oriented mindsets interact to augment or hinder clinical practice improvement. This model provides important guidance to academic and administrative structures looking to develop appropriate performance feedback systems with clinicians.

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

Rationale and Objectives Medical humanities are becoming increasingly popular, required, and recognized as positively impacting medical education and medical practice. However, the extent of medical humanities teaching in medical schools is largely unknown. We aimed to review medical school curricula in Canada, the UK, and the US. Our secondary objective was to compare the inclusion of medical humanities in the curricula with rankings of medical schools. Methods We searched the curriculum websites of all accredited medical schools in Canada, the UK, and the US to check which medical humanities topics were taught, and whether they were mandatory or optional. We then noted rankings both by Times Higher Education and U.S. News and World Report and calculated the average rank. We formally explored whether there was an association between average medical school ranking and medical humanities offerings using Spearman’s correlation and inverse variance weighting meta-analysis. Results We identified 18 accredited medical school programmes in Canada, 41 in the UK, and 156 in the US. Of these, 9 (56%) in Canada, 34 (73%) in the UK and 124 (79%) in the US offered at least one medical humanity that was not ethics. The most common medical humanities were Unspecified Medical Humanities, History, and Literature (Canada), Sociology and Social Medicine, Unspecified Medical Humanities, and Art (UK), and Unspecified Medical Humanities, Literature, and History (US). There was a negative relationship between the ranking of the medical school and whether they offered medical humanities. Conclusions The extent and content of medical humanities offerings at accredited medical schools in Canada, the UK, and the US varies. The quality of our analysis was limited by the data provided on the Universities’ curriculum websites. Given the potential for medical humanities to improve medical education and medical practice, this variation should be investigated further.

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

ABSTRACT Rationale, aims and objectives The primary aim of the study was to understand the mindset of doctors and pharmacists, as they embark upon prescribing in a polypharmacy and multi-morbidity context during routine practice at a hospital acute admissions unit. The study also aimed to evaluate to what extent attitudes, embedded within real-life decision-making scenarios, relate to existing theory and models of prescribing decisions. Methods Anonymised case studies were identified from the medical notes of patients aged 65 and over with conditions likely to be associated with multi-morbidity, medication issues and polypharmacy: namely: fall, urinary tract infection, confusion or lower respiratory tract infection. A total of 39 doctors based on the acute medical admissions unit and 9 pharmacists were recruited to one of three focus groups. Patient case-studies provided the context for discussion from which verbatim transcripts were thematically analysed using an interpretative, qualitative approach. Sub-themes were matched to Murshid and Mohaidin’s proposed model of physician prescribing decisions. Results Seven principal themes were identified that were associated with prescribing decisions on the acute medical unit, namely, ‘patient characteristics’, ‘drug characteristics’, ‘pharmacist factors’, ‘trustworthiness’, ’reliability of medication history, ‘competing pressures and priorities’ and ‘responsibilities of prescribers’. Conclusion Prescribing decisions on the acute medical admissions unit were influenced by a variety of factors, some of which have already been acknowledged within existing theories and models. The findings provisionally offer new insights, which, subject to confirmation by further research, bring to light three attitudinal characteristics that may impact negatively upon the quality of prescribing decisions. These include, first, how perceived poor reliability of medication history may result in information gaps that compromise prescribing decisions; second, how competing pressures and priorities restrict doctors’ aptitude to conduct a review of medication and finally, how doctors may rationalise the assignment of medication review to the GP.

Background: The health care delivery model in the United States does not work; it perpetuates unequal access to care, favors treatment over prevention, and contributes to persistent health disparities and lack of insurance. The historical lack of support in the United States for primary health care, universal health coverage, population health, addressing the social determinants of health, and community empowerment, creates opportunities for community health scientists to develop innovative solutions for addressing community health needs. Methods: We developed a model community health science approach combining community-oriented primary care (COPC), community-based participatory research (CBPR), asset-based community development, and service learning principles. The approach defines health as a social outcome, resulting from a combination of clinical science, collective responsibility, and informed social action. Results: From 2000-2020, we established partnerships with community organizations to reduce the risk of chronic disease in vulnerable minority communities. Our programs have provided structured community health science training for hundreds of physicians and other health care workers in training. Conclusion: As the U.S. begins to seek solutions to chronic health disparities and health inequities, community health science provides useful lessons in how to engage communities to address the deficits of the current system. Perhaps the greatest error that U.S. health care systems could make in trying to better address population health and the social determinants of health, would be ignoring the important community initiatives already underway in most local communities. Building partnerships based on local resources and ongoing social determinants of health initiatives is the key for medicine to meaningfully engage communities for reducing health disparities. This has been the greatest lesson we have learned during the past two decades, has provided the foundation for our community health science approach, and accounts for whatever success we have achieved.

Our purpose is to assess epidemiological agent-based models– or ABMs - of the SARS-CoV-2 pandemic methodologically. The rapid spread of the outbreak requires fast-paced decision-making regarding mitigation measures. However, the evidence for the efficacy of non-pharmaceutical interventions such as imposed social distancing and school or workplace closures is scarce: few observational studies use quasi-experimental research designs, and conducting randomized controlled trials seems infeasible. Additionally, evidence from the previous coronavirus outbreaks of SARS and MERS lacks external validity, given the significant differences in contagiousness of those pathogens relative to SARS-CoV-2. To address the pressing policy questions that have emerged as a result of COVID-19, epidemiologists have produced numerous models that range from simple compartmental models to highly advanced agent-based models. These models have been criticized for involving simplifications and lacking empirical support for their assumptions. In order to address these voices and methodologically appraise epidemiological ABMs, we consider AceMod (the model of the COVID-19 epidemic in Australia) as an example of the modeling practice. Our case study shows that, although epidemiological ABMs involve simplifications of various sorts, the key characteristics of social interactions and the spread of SARS-CoV-2 are represented sufficiently accurately. This is the case because these modelers treat empirical results as inputs for constructing modeling assumptions and rules that the agents follow; and they use calibration to assert the adequacy to benchmark variables. Given this, we claim that the best epidemiological ABMs are models of actual mechanisms and deliver both mechanistic and difference-making evidence. Furthermore, the efficacy claims are not only internally valid but also adequately describe the effects of interventions in the targets of the models. We also discuss the limitations of ABMs and put forward policy recommendations.

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

Despite the great promises that artificial intelligence (AI) holds for health care, the uptake of such technologies into medical practice is slow. In this paper, we focus on the epistemological issues arising from the development and implementation of a class of AI for clinical practice, namely clinical decision support systems (CDSS). We will first provide an overview of the epistemic tasks of medical professionals, and then analyse which of these tasks can be supported by CDSS, while also explaining why some of them should remain the territory of human experts. Clinical decision-making involves a reasoning process in which clinicians combine different types of information into a coherent and adequate ‘picture of the patient’ that enables them to draw explainable and justifiable conclusions for which they bear epistemological responsibility. Therefore, we suggest that it is more appropriate to think of a CDSS as clinical reasoning support systems (CRSS). Developing CRSS that support clinicians’ reasoning process therefore requires that: 1) CRSSs are developed on the basis of relevant and well-processed data; and 2) the system facilitates an interaction with the clinician. Therefore, medical experts must collaborate closely with AI experts developing the CRSS. In addition, responsible use of an CRSS requires that the data generated by the CRSS is empirically justified through an empirical link with the individual patient. In practice, this means that the system indicates what factors contributed to arriving at an advice, allowing the user (clinician) to evaluate whether these factors are medically plausible and applicable to the patient. Finally, we defend that proper implementation of CRSS allows combining human and artificial intelligence into hybrid intelligence, were both perform clearly delineated and complementary empirical tasks. Whereas CDRSs can assist with statistical reasoning and finding patterns in complex data, it is the clinicians’ task to interpret, integrate and contextualise.

Rationale. Evidence-based practice (EBP) can improve health care in underprivileged countries. Bolivia’s EBP movement is nascent and the factors contributing to better implementation in nursing are unknown. Aim. To explore Bolivian nurses’ readiness to engage in EBP while highlighting the facilitators and barriers for pursuing EBP. Method. International collaborators used a sequential explanatory mixed methods study. First, general trends were disclosed via a survey of 170 nurses in La Paz, Bolivia, holding at least a baccalaureate regarding their perceived beliefs about EBP. The survey identified facilitators and barriers for implementing EBP in acute and ambulatory settings. Second, qualitative data was gathered via a focus group of nine nurses with the purpose of enhancing the survey findings. Results. The survey results showed that nurses believe that engaging in EBP can improve their clinical practice. However, the nurses’ research behaviors were found to be infrequent. Lack of support from the nurses’ clinics and hospitals and from non-nursing professionals were identified as barriers for engaging in EBP. The qualitative results revealed underlying limitations to nurses’ clinical practice, including “feeling undervalued.” Conclusions. There is a dearth of EBP knowledge among Bolivian nurses stemming from a lack of preparation in EBP environments, including EBP training opportunities. This situation affects nurses’ professional dimensions of relational work, power, and collaboration. Collaborative research among educators, professional nursing societies, and local and international organizations could provide initiatives for implementing EBP, based on local health profiles. Key words: international collaboration, evidence-based practice, nurse-multidisciplinary relationship, barriers to EBP.

In the United States chronic illnesses have become a way of life for multiple generations – they are the number one cause of death and disability (accounting for more than 70% of deaths), 60% of American adults have at least one chronic disease, and 40% have multiple chronic conditions. Although multiple factors contribute to the growth in chronic disease prevalence, a major factor has been overreliance on health care systems for promoting health and preventing disease. Large health care systems are ill equipped for this role since they are designed to detect, treat, and manage disease, not to promote health or address the underlying causes of disease. Improving health outcomes in the U.S. will require implementing broad-based prevention strategies combining biological, behavioral, and societal variables that move beyond clinical care. According to community medicine, clinical care alone cannot create, support, or maintain health. Rather, health can only ensue from combining clinical care with epidemiology and community organization, because health is a social outcome resulting from a combination of clinical science, collective responsibility, and informed social action. During the past 20 years, our team has developed an operational community medicine approach known as community health science. Our model provides a simple framework for integrating clinical care, population health, and community organization, using community-based participatory research (CBPR) practices for developing place-based initiatives. In the present paper, we present a brief overview of the model and describe its evolution, applications, and outcomes in two major urban environments. The paper demonstrates means for integrating the social determinants of health into collaborative place-based approaches, for aligning community assets and reducing health disparities. We conclude by discussing how asset-based community development can promote social connectivity and improve health, and discuss how our approach reflects the emerging national consensus on the importance of place-based population system change.

Health professions education is in constant pursuit of new ways of teaching and assessment in order to improve the training of healthcare professionals. Educators are often challenged with designing, implementing, and evaluating programs in the context of their professional practice, particularly those in response to dynamic and emerging social needs. This article explores the synergies and intersections of two approaches -- quality improvement and program evaluation -- and the potential utility of their combinations within our field to design, evaluate, and most importantly, improve educational programming. We argue that the inclusion of established quality improvement frameworks within program evaluation provides a proven mechanism for driving change, can optimize programming within the multi-contextual education systems, and, ultimately, that these two approaches are complementary to one another. These combinations hold great promise for optimizing programming in alignment with social missions, where it has been difficult for institutions worldwide to generate and capture evidence of social accountability.

Rationale The end of life (EOL) experience in the intensive care unit (ICU) can be psychologically distressing. The 3 Wishes Project (3WP) personalizes the EOL experience by carrying out wishes for dying patients and their families. While the 3WP has been integrated in academic, tertiary care ICUs, implementing this project in a community ICU has yet to be described. Objectives To examine facilitators of, and barriers to, implementing the 3WP in a community ICU from the clinician and key-stakeholder perspective. Methods This mixed-method study evaluated the implementation of the 3WP in a 20-bed community ICU in Southern Ontario, Canada. Patients were considered for the 3WP if they had a high likelihood of imminent death or planned withdrawal of life-sustaining therapy. Quantitative data include patient demographic data and wishes implemented. Following the qualitative descriptive approach, semi-structured interviews were conducted with purposively sampled clinicians and key-stakeholders. Data from transcribed interviews were analyzed in triplicate through qualitative content analysis. Results During the 10-month period, 66 of 67 wishes were completed, with a median of 4.5 wishes per patient-family dyad. Interviews with 12 participants indicated that the 3WP personalized and enriched the EOL experience for patients, families and clinicians. Interviewees indicated higher intensity education strategies were needed to enable spread as the project grew. Clinicians described many physical resources for the project but required more non-clinical project support for orientation, continuing education and data collection. Instead, these roles were completed by clinicians with saturated work capacity which may have inhibited the spread of the project. Conclusions In this community hospital, ICU clinicians and key stakeholders reported the 3WP improved EOL care for patients, families, and clinicians. Project implementation in a community ICU requires investigators take into account project characteristics and adapt the intervention to the community hospital context.

Background and Objective Clinical Practice Guidelines (CPGs) provide evidence-based recommendations to healthcare professionals, policy makers, patients and other stakeholders. Mexico is the biggest producer of CPGs in Latin America and Caribbean countries. The National Healthcare Technology Excellence Center (acronym in Spanish: CENETEC) is responsible for the CPG development, adaptation and update. The aim of this study was to assess the Mexican CPG quality and adherence to the GRADE framework. Study design We conducted a descriptive cross-sectional study of 86 CPGs representing all the CPGs produced by CENETEC between 2015 and 2017 and published in an online database called “Catalogo Maestro”. We performed quality assessment with the online AGREE II tool and assessed the reporting on the GRADE framework. Results Of the 86 CPGs, 34 were published in 2015, 21 in 2016 and 31 in 2017. The overall quality by AGREE II proved a median of 16.6% (Min 16.6%, Max 50%). Of the 86 CPGs, 25 (29%) used the GRADE framework; adherence to GRADE standards was, however, inconsistent and generally poor. Conclusion CPGs produced by CENETEC during this period had a low score by AGREE II standards and low adherence to the GRADE framework. A concerted initiative could rapidly improve CENETEC guidelines.

Rationale, aims and objectives: The diversity of safety signals (e.g., case reports, animal studies and observational studies) makes the assessment of the (un-)safety of a drug a formidable challenge. While frequentist viewpoints to uncertain inference struggle in aggregating these signals, the more flexible Bayesian approaches seem better suited for this quest. Artificial Intelligence (AI) offers great promise to these approaches for information retrieval, decision support and leaning probabilities from data. E-Synthesis is a Bayesian framework for drug safety assessments build on philosophical principles and considerations. It aims to aggregate all the available information, in order to provide a Bayesian probability of a drug causing an adverse reaction. We delineate and assess ways in which AI can support E-Synthesis. Results: We find that AI can help with information retrieval, usability (graphical decision making aids), learning Bayes factors from historical data, assessing quality of information and determining conditional probabilities for the so-called “indicators” of causation for E-Synthesis. Conclusions: Properly applied, AI can help the transition of philosophical principles and considerations concerning evidence aggregation for drug safety to a tool that can be used in practise.

Rationale, Aims and Objectives: Guidelines recommend inviting family members of intensive care unit (ICU) patients to rounds. We aimed to create a toolkit to support family participation in ICU bedside rounds, based upon evidence from research and in collaboration with ICU family member representatives and healthcare providers. Methods: A multi-method qualitative research program was conducted to provide an evidence-base. Ethnographic observations of rounds and interviews and focus groups with family members and ICU healthcare providers were analyzed for key themes, barriers and facilitators of participation, and suggestions. A full day workshop with family representatives and providers (physicians, nurses, social workers, and unit managers) from a diverse range of adult ICUs in Western Canada, including several community ICUs and a majority of large, urban ICUs enabled the collaborative development of key toolkit elements. Results: We have developed an evidence-informed approach to patient-and-family-centered rounds that highlights the importance of 6 key elements foundational to patient and family centered rounds: Invitation, Orientation, Engagement, Summary, Questions, and Communication Follow-Up. We describe strategies, techniques, and templates to optimize these elements and interactions so that communication is more meaningful, and to facilitate the ability of family members to adopt a meaningful role as contributing members of the care team. Conclusion: There is consensus on general strategies for facilitating family participation in rounds and meaningful communication between family and the healthcare team during rounds as an important element of the continuum of communication in the ICU. The incorporation of these elements should be standardized, though tailored to user needs.

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