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Biomedical subjects

Felicia Cohn

Publications and source records attributed to Felicia Cohn.

10 recordsLinked to original sources
PubMed2004

Fixing broken bones and broken homes: domestic violence as a patient safety issue.

BACKGROUND: Domestic violence (DV) is a significant problem in terms of both patient harm and cost. To better address this problem, the diagnosis and treatment of DV are considered within the emerging model of patient safety and medical error reduction. The case of a female patient who presents in the clinical setting following an incident of DV shows how medical errors can be analyzed as they are in medical cases not involving DV, such as when a person with abdominal pain is sent away from the emergency department with instructions to take an acid reducer and later suffers a burst appendix. ROOT CAUSE ANALYSIS: A number of factors inhibit the correct diagnosis and treatment of DV victims seeking additional treatment. Physicians often fail to screen for DV, misidentify symptoms, or deny the possibility of underlying DV, and patients often hide the symptoms and refuse to admit the problem. However, human factor errors related to knowledge, cultural norms, and individual biases; organizational factors, including lack of training and reimbursement; and technology factors related to information accessibility appear to play significant roles. CONCLUSION: Failure to diagnose or adequately address DV can be interpreted as medical errors. Addressing DV requires a systemic response, which might begin with integrating education and training about DV into the clinical setting, ensuring the use of existing screening tools, and providing adequate and appropriate reimbursement levels.

Adult↗
PubMed2003

Effect of ethics consultations on nonbeneficial life-sustaining treatments in the intensive care setting: a randomized controlled trial.

CONTEXT: Ethics consultations increasingly are being used to resolve conflicts about life-sustaining interventions, but few studies have reported their outcomes. OBJECTIVE: To investigate whether ethics consultations in the intensive care setting reduce the use of life-sustaining treatments delivered to patients who ultimately did not survive to hospital discharge, as well as the reactions to the consultations of physicians, nurses, and patients/surrogates. DESIGN: Prospective, multicenter, randomized controlled trial from November 2000 to December 2002. SETTING: Adult intensive care units (ICUs) of 7 US hospitals representing a spectrum of institutional characteristics. PATIENTS: Five hundred fifty-one patients in whom value-related treatment conflicts arose during the course of treatment. INTERVENTIONS: Patients were randomly assigned either to an intervention (ethics consultation offered) (n = 278) or to usual care (n = 273). MAIN OUTCOME MEASURES: The primary outcomes were ICU days and life-sustaining treatments in those patients who did not survive to hospital discharge. We examined the same measures in those who did survive to discharge and also compared the overall mortality rates of the intervention and usual care groups. We also interviewed physicians and nurses and patients/surrogates about their views of the ethics consultation. RESULTS: The intervention and usual-care groups showed no difference in mortality. However, ethics consultations were associated with reductions in hospital (-2.95 days, P =.01) and ICU (-1.44 days, P =.03) days and life-sustaining treatments (-1.7 days with ventilation, P =.03) in those patients who ultimately did not survive to discharge. The majority (87%) of physicians, nurses, and patients/surrogates agreed that ethics consultations in the ICU were helpful in addressing treatment conflicts. CONCLUSION: Ethics consultations were useful in resolving conflicts that may have inappropriately prolonged nonbeneficial or unwanted treatments in the ICU.

Adult↗
PubMed2002

Mediating the gap between the white coat ceremony and the ethics and professionalism curriculum.

OBJECTIVE: Like many other medical schools, the University of California, Irvine annually conducts a White Coat ceremony in which incoming students take a professional oath of ethical conduct.(1) We report a new educational activity to connect the values expressed in the oath taken to the Ethics and Professionalism (EP) curriculum for first-year medical students(2) and its potential impact on physician training. DESCRIPTION: Following the White Coat ceremony, students participated in the Patient Doctor Society course that integrates diverse curricular topics centered on physician-patient communication. During this course, the students were introduced to EP content through a collaborative peer exercise. With the assistance of background readings on professional values and ethics concepts, small groups of students were asked to construct their own codes of ethics. The process of working in a group became part of the learning. After developing a code of ethics, each group was asked to identify primary values embodied in its code; primary obligations to patients and their families, other members of the health care team, and the community; key factors influencing code development; and likely effects of the code on the conduct of medical students and physicians. The goals of the session were to recognize formally both individual values and the values to which students commit themselves during the White Coat ceremony, to facilitate understanding of those values, and to begin to reconcile differences between personal and professional values. The small groups convened to report their findings in a three-hour session. Common values expressed by the students included patient autonomy, respect, beneficence, and professionalism. The delivery of quality health care, communication, education, and the equitable distribution of health care were among the most often listed obligations. The students reported that culture, societal values, family, experience, religion, education, and assigned readings were the key sources of the values in their codes. Most of the students enjoyed and learned from the exercise, believing that a code of ethics will serve as a helpful educational guide while they are students and as an action guide in their future practices. Student evaluations, narrative feedback, and faculty observation indicated that the students appreciated the opportunity to work in teams and to explore professional values. The students' most common suggestion for improvement involved incorporating analysis of clinical cases in which questions about professional values arise. DISCUSSION: Medical educators suggest that students' values and professional behaviors change throughout medical school, but such change is difficult to assess. The code-development exercise established a baseline of values at entry to medical school. We plan to track this cohort of students by reintroducing this exercise in their fourth year and will compare the codes developed in their first and fourth years to identify changes in values and to suggest what the students have learned about values during medical school. The comparison will be used to inform further development of the EP curriculum toward the goal of shaping and supporting the positive professional growth of our student-physicians.

California↗
PubMed2002

Using literature as the framework for a new course.

OBJECTIVE: The award-winning book The Spirit Catches You and You Fall Down,(1) a true story of the collision between two cultures (American and Hmong) with heartrending consequences for the patient, the patient's family, and the medical professionals who care for them, has been favorably reviewed(2) and used to stimulate teaching of cultural diversity, ethics, and professionalism to students and residents. We used it as a required text for a new Patient Doctor Society (PDS) course for 184 first- and second-year medical students. This report describes the scope and contexts in which the book was used to meet specific course goals. DESCRIPTION: PDS is a required 90-hour introduction to medical interviewing, which integrates ethics, communication, clinical reasoning, cultural diversity, humanities, spirituality, integrative medicine, nutrition, and behavioral science. To provide a common experience among these diverse topics, faculty members were asked to use examples from the book to achieve their learning objectives. A required faculty development session illustrated strategies for effectively using the text. Focusing on chapter 13 ("Code X"), dramatic portrayals of differences in beliefs about end-of-life care and clinician-family communication, facilitated the introduction of methods including point-of-view writing, role-plays, and faculty-facilitated discussions as techniques for meeting course objectives. At PDS orientation, we used the same chapter, and had faculty members lead small groups of students using the teaching techniques they acquired. About 90% of students read the book prior to orientation. Students favorably reviewed this three-hour session. For the ethics session, unfacilitated small groups of students were asked to identify and discuss the ethical issues in chapter 11 ("The Big One"), which describes a major turning point in the health care provided to the text's central character, Lia. Each group presented its "moral diagnosis" and ethical arguments for resolution. Class discussion then focused on the diverse views presented, to emphasize the importance of justifying decisions and to practice using tools of ethical analysis. In the communication skills workshop, we excerpted dramatic readings from the book. Faculty members played the roles of the author, the patient's mother, and one of Lia's physicians. The interaction became a dialogue to illustrate the points of view of the participants. The dialogue was used to stimulate discussion about potential pitfalls in physician-patient communication and understanding. In a medical humanities session, excerpts from the book were compared with poetry explicating themes of physician arrogance and humility. DISCUSSION: The Spirit Catches You and You Fall Down provides a context appropriate to teaching students how to listen to, and learn from patient stories. The story will be reintroduced in the pediatrics clerkship. Caution will be exercised to (1) avoid overexposure to the text, (2) counteract the potential to interpret the story too narrowly, and (3) assure that faculty become familiar with the text and its uses. We intend to track outcomes in knowledge, skills and attitudes for each content area, and observe the degree that the book facilitates achievement of objectives. We will follow several cohorts of students to verify longitudinally the learning effects observed.

Cultural Diversity↗
PubMedDate not supplied

The costs of nonbeneficial treatment in the intensive care setting.

Ethics consultations have been shown to reduce the use of "nonbeneficial treatments," defined as life-sustaining treatments delivered to patients who ultimately did not survive to hospital discharge, when treatment conflicts occurred in the adult intensive care unit (ICU). In this paper we estimated the costs of nonbeneficial treatment using the results from a randomized trial of ethics consultations. We found that ethics consultations were associated with reductions in hospital days and treatment costs among patients who did not survive to hospital discharge. We conclude that consultations resolved conflicts that would have inappropriately prolonged nonbeneficial or unwanted treatments in the ICU instead of focusing on more appropriate comfort care.

Adult↗