This paper responds to one by Graham Martin and colleagues, who offered a critique of my previous publications on masks for the lay public in the Covid-19 pandemic. I address their charges that my co-authors and I had misapplied the precautionary principle; drawn conclusions that were not supported by empirical research; and failed to take account of potential harms. But before that, I remind Martin et al that the evidence on mask wearing goes beyond the contested trials and observational studies they place centre stage. I set out some key findings from basic science, epidemiology, mathematical modelling, case studies and natural experiments, and use this rich and diverse body of evidence as the backdrop for my rebuttal of their narrowly-framed objections. I challenge my critics’ apparent assumption that a particular kind of systematic review should be valorised over narrative and real-world evidence, since stories are crucial to both our scientific understanding and our moral imagination. I conclude by thanking my academic adversaries for the intellectual sparring match, but exhort them to remember our professional accountability to a society in crisis. It is time to lay straw men to rest and engage, scientifically and morally, with the dreadful tragedy that is unfolding across the world.

The well-known clinical axiom stating that “common things are common” attests to the pivotal role of probability in diagnosis. Despite the popularity of this and related axioms, there is no operationalized definition of a common disease, and no practicable way of incorporating actual disease frequencies into differential diagnosis. In this expository essay, we aim to reduce the ambiguity surrounding the definition of a common (or rare) disease and show that incidence – not prevalence – is the proper metric of disease frequency for diagnosis. We explore how a numerical estimates of disease frequencies based on incidence can be incorporated into differential diagnosis as well as the inherent limitations of this method. These concepts have important implications for diagnostic decision making and medical education, and hold promise as a method to improve diagnostic accuracy.

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

The outbreak of the Covid-19 pandemic obliged us all to handle many dilemmas, some of which we took upon ourselves as philosophers, ethicists, doctors and nurses to discuss around four key ethical notions : responsibility, dignity, fairness and honouring death. The following collection of the symposium acts held online in May 2020 with the Paris Global Center of Columbia University and Columbia Global Centers, attempts to testify to the ongoing pandemic emergency and difficult challenges while evaluating whether the ethical principles in the official recommendations were able to meet the lived reality. Looking at accountability and consistency in regard to the context of exercise, it seemed equally important to examine, through an international exchange, whether the contextuality of Coronavirus across countries and cultures affected the ethical decision making processes. We hope that our discussion can serve as a resource for advanced care planning, helping medical providers and other specialists to consider the shared important aspects of medical ethics in times of great uncertainty.

Rationale, aims and objectives 39 Evidence-based medicine (EBM) holds that estimates of effects of health interventions based on 40 high-certainty evidence (CoE) are expected to change less frequently than the effects generated 41 in low CoE studies. However, this foundational principle of EBM has never been empirically 42 tested. 43 Methods 44 We reviewed all systematic reviews and meta-analyses in Cochrane Database of Systematic 45 Reviews from January 2016 through May 2021 (n=3,323). We identified 414(207x2) and 384 46 (192x2) pairs of original and updated Cochrane reviews that assessed CoE and pooled 47 treatment effect estimates. We appraised CoE using the Grading of Recommendations 48 Assessment, Development and Evaluation (GRADE) method. We assessed the difference in 49 effect sizes between the original versus updated reviews as a function of change in CoE, which 50 we report as a ratio of odds ratio (ROR). We compared ROR generated in the studies that 51 changed CoE from very low/low (VL/L) to moderate/high (M/H) vs. MH/H VL/L. We also 52 assessed the heterogeneity and inconsistency (using the tau and I2 statistic), the change in 53 precision of effect estimates (by calculating the ratio of standard errors) (seR), and the absolute 54 deviation in estimates of treatment effects (aROR). 55 Results 56 57 We found that CoE originally appraised as VL/L had 2.1 (95%CI: 1.19 to 4.12; p=0.0091) times 58 higher odds to be changed in the future studies than M/H CoE. However, the effect size was not 59 different when CoE changed from VL/L M/H vs. M/H VL/L [ROR=1.02 (95%CI: 0.74 to 1.39) 60 vs. 1.02 (95%CI: 0.44 to 2.37); p=1 for the between subgroup differences]. aROR was similar 61 between the subgroups [median (IQR):1.12 (1.07 to 1.57) vs 1.21 (1.12 to 2.43)]. We observed 62 large inconsistency (I 2=99%) and imprecision in treatment effects (seR=1.09). 63 Conclusions 64 We provide the first empirical support for a foundational principle of EBM showing that low65 quality evidence changes more often than high CoE. However, the effect size was not different 66 between studies with low vs high CoE. The finding that the effect size did not differ between low 67 and high CoE indicate urgent need to refine current EBM critical appraisal methods

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

Objectives: To estimate the frequency and factors associated with foregone and delayed medical care attributed to the COVID-19 pandemic among non-elderly adults from August to December 2020 in the US. Methods: We used three survey waves from the Urban Institute’s Household Pulse Survey (HPS) collected between August 19 to 31, October 14 to 26, and December 9 to 21. The final sample included 155,825 non-elderly (18 to 64) respondents representing 135,835,598 million individuals in the US. We used two multivariable logistic regressions to estimate the association between respondents’ characteristics and foregone and delayed care. Results: The frequency of foregone and delayed medical care were 26.9% and 35.9%, respectively. Across all income levels, around 60% of respondents reported difficulties in paying for usual household expenses in the last 7 days. More than half reported several days of mental health issues. The regression results indicated that foregone or delayed care were significantly associated with difficulties in paying usual household expenses (across all income levels) (P<.001), worse self-reported health status (P<.001), increased mental health problems (P<.001), Veterans Affairs (P<.001) or Medicaid (P=.002) coverage compared to private healthcare coverage, and older age groups. Individuals who participated in the latter two waves of the survey (October, December) were less likely to report foregone and delayed care compared to those who participated in wave 1 (August). Conclusion: Overall, the frequency of foregone and delayed medical care remained high from August to December 2020 among non-elderly US adults. Our findings highlight that pandemic-induced access barriers are major drivers of reduced healthcare provision during the second half of the pandemic and highlight the need for policies to support patients in seeking timely care.

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

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

Background: The COVID-19 pandemic represents one of the most stressful events of recent times. Among the population, healthcare professionals who treat COVID-19 patients are most likely to develop psychological distress and posttraumatic stress symptoms (PTSS). The present study thus aimed to investigate the psychological impact of the COVID-19 outbreak on Italian healthcare workers. Methods: The responses of 145 healthcare workers (72 medical doctors and 73 nurses) were included in the final dataset. Participants were asked to provide sociodemographic and clinical information, and to complete: 1) quality of life and health-related Visual Analogue Scales, 2) State-Trait Anxiety Inventory-Form Y1, 3) Beck Depression Inventory, and 4) PTSD Checklist for DSM-5. Results: A comparison between healthcare professionals working in COVID-19 wards and other units revealed that the former reported higher levels of both depressive symptoms and PTSS. Moreover, the results of regression analyses showed that in healthcare professionals working with COVID-19 patients, gender and marital status, and gender and age significantly predicted depressive symptoms and PTSS, respectively. Particularly, being female and not in a relationship were found to be associated with higher levels of depressive symptoms, whereas being female and older were found to be related to higher levels of PTSS. Conclusions: The current findings suggest that specific predisposing factors could identify healthcare workers who are at high risk of developing mental health symptoms when faced with COVID-19 patients.

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

Rational, aims and objectives: This study aimed to assess knowledge, attitude and practice (KAP) of using insulin pen in diabetes and determine the related factors to the KAP, adverse drug reactions (ADRs) and glycemic control status. Methods: In our descriptive study, 148 patients with diabetes were interviewed by 16-item questions on knowledge and 8 questions on attitude, and were asked to present the insulin pen injection technique with a sample insulin pen. Results: Proportions of patient having a good knowledge, positive attitude, and good practice were 45.9%, 78.4%, and 44.6%, respectively. The three most incorrect steps were skipping to prime pen needle (90.9%), not removing the used needle from the pen after using (87.8), and not holding for specific count time before withdrawal of pen needle from skin (50.7%). Patients having duration of insulin one year or more had better knowledge (p=0.025), more positive attitude (p=0.017), and better practice of insulin (p=0.042). Patients using insulin combined with oral diabetic medications or having history of using insulin vials had more positive attitude of insulin role (0.038). Frequency of having good knowledge was statistically significantly higher in participants who received counseling from health professionals previously (p=0.001). The study also found a positive correlation between good knowledge of patients and good practical skills (p<0.001). Patients with poor practice of insulin were more likely to have ADRs at the injection sites (p = 0.013). The worse knowledge of patients was significant related to the higher risk of hypoglycemia (p=0.001). KAP levels did not correlate with glycemic control status. Conclusions: Positive attitude in patients was recorded at a significant rate; however, knowledge and practice needs improvement. This study was helpful to shape the patient education and target specific patients for education.

Background: Optimizing the monitoring of peripheral venous catheters is essential. We developed a nursing record system at bedside (Patient Smart Reader®) to track peripheral venous catheters acts. Aims: Improve peripheral venous catheter monitoring. To improve the quality of monitoring, we aimed to increase the usage rate of nursing record system at bedside. Methods: We developed a “commitment intervention” course based on binding communication paradigm. Evaluation of its performance on monitoring was analyzed using a p-chart and time series analysis. Findings: Nurses observed a significant improvement in compliance with catheter monitoring over time (shifts after shifts), ranging from 27.6% (CI = [25.3; 30.0]) of compliance before commitment intervention to 47.4% (CI = [45.0; 49.9]) after training. The commitment intervention increased the chances of carrying out monitoring through the tool for acts related to peripheral venous catheter by 2.42 (odds ratio) (CI = [1.88; 3.11]). Conclusion: Binding communication provides an effective method for changing nurses’ behaviors in terms of safe care. The determinants of engagement (individual vs. collective) can be indicators for defining future communication and training strategies in care centers for all Health care workers.

Rationale, Aims and Objectives: One of the sectors challenged by the COVID-19 pandemic is medical research. COVID-19 originates from a novel coronavirus (SARS-CoV-2) and the scientific community is faced with the daunting task of creating a novel model for this pandemic or, in other words, creating novel science. This paper aims to explore the intricate relationship between the different challenges that have hindered biomedical research and the generation of scientific knowledge during the COVID-19 pandemic. Methods: During the early stages of the pandemic, research conducted on hydroxychloroquine (HCQ) was chaotic and sparked several heated debates with respect to the scientific methods used and the quality of knowledge generated. Research on HCQ is used as a case study in this paper. The authors explored biomedical databases, peer-reviewed journals, pre-print servers and media articles to identify relevant literature on HCQ and COVID-19, and examined philosophical perspectives on medical research in the context of this pandemic and previous global health challenges. Results: This paper demonstrates that a lack of prioritization among research questions and therapeutics was responsible for the duplication of clinical trials and the dispersion of precious resources. Study designs, aimed at minimizing biases and increasing objectivity, were, instead, the subject of fruitless oppositions. These two issues combined resulted in the generation of fleeting and inconsistent evidence that complicated the development of public health guidelines. The reporting of scientific findings highlighted the difficulty of finding a balance between accuracy and speed. Conclusions: The COVID-19 pandemic presented challenges in terms of (1) finding and prioritizing relevant research questions, (2) choosing study designs that are appropriate for a time of emergency, (3) evaluating evidence for the purpose of making evidence-based decisions and (4) sharing scientific findings with the rest of the scientific community. This paper demonstrates that these challenges have often compounded each other.

Rationale, aims, and objectives: The complexity of healthcare systems makes errors unavoidable. To strengthen the dialogue around how physicians experience and share medical errors, the objective of this study was to understand how experienced generalist physicians make meaning of and grow from their medical errors. Methods: This study used a narrative inquiry approach to conduct and analyze in-depth interviews from 26 physicians from the generalist specialties of emergency, internal, and family medicine. We gathered stories via individual interview, analyzed them for key components, and rewrote a ‘meta-story’ in a chronological sequence. We conceptualized the findings into a metaphor to draw similarities, learn from, and apply new principles from other fields of practice. Results: Through analysis we interpreted the story of an elite athlete (physician) who is required to make numerous decisions in a short period of time within the construct of a chaotic sports field (clinical environment) among spectators (the patient’s family) whilst abiding by existing rules and regulations. Through sharing stories of success and failure, the team coach (clinical mentor) helps optimize the players’ professional and psychological development. Similarly, through sharing and learning from stories, team members (colleagues) and junior team members (trainees) also contribute to the growth of the protagonist’s character and the development of the overall team (clinic/hospital) and sport (healthcare system). Conclusion: We draw parallels between the clinical setting and a generalist physician’s experiences of a medical error with the environment and practices within professional sports. Using this comparison, we discuss the potential for meaningful coaching in medical education.

The outbreak of the Covid-19 pandemic obliged us all to handle many dilemmas, some of which we took upon ourselves as philosophers, ethicists, doctors and nurses to discuss around four key ethical notions : responsibility, dignity, fairness and honouring death. The following collection of the symposium acts held online in May 2020 with the Paris Global Center of Columbia University and Columbia Global Centers, attempts to testify to the ongoing pandemic emergency and difficult challenges while evaluating whether the ethical principles in the official recommendations were able to meet the lived reality. Looking at accountability and consistency in regard to the context of exercise, it seemed equally important to examine, through an international exchange, whether the contextuality of Coronavirus across countries and cultures affected the ethical decision making processes. We hope that our discussion can serve as a resource for advanced care planning, helping medical providers and other specialists to consider the shared important aspects of medical ethics in times of great uncertainty.

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

Rationale, aims and objectives The concept of patient or case complexity is relevant – and widely used – at all levels and stages of mental health service provision, but there have been few methodologically robust attempts to define this term. This study aimed to establish a consensus on factors contributing to patient complexity in adult psychological services using Delphi Methodology. Method Applied psychologists in a single urban/suburban UK National Health Service setting took part in a three-round modified Delphi study. Twenty-eight respondents in round one gave qualitative data on factors they considered when assessing complexity, which was subject to thematic analysis. Twenty-five respondents in round two rated how central/peripheral each theme was to their judgement using Likert scales. In a third round, twenty respondents addressed discrepancies and possible utilities of the emerging framework. Results Thirteen factors contributing to patient/case complexity (Active Severe/Enduring Mental Health, Current Coping/Functioning, Engagement, Forensic History, Iatrogenic Factors, Interpersonal Functioning, Neuro-Cognitive Functioning, Physical Health, Problematic Substance Use, Risk, Severity/Chronicity of Presenting Problems, Systemic and Socio-Economic Factors and Trauma) were identified with a high degree of consensus. All were rated as central to complexity. Conclusions We conclude that applied psychologists do have a shared understanding of complexity and make recommendations for further research validating, developing and applying this empirically derived framework. Keywords: psychological, complexity, definition, operationalising, framework development, clinical judgement