Meredith Vanstone

Conflicting messages: examining the dynamics of leadership on interprofessional teams.

Purpose Despite the importance of leadership in interprofessional health care teams, little is understood about how it is enacted. The literature emphasizes a collaborative approach of shared leadership, but this may be challenging for clinicians working within the traditionally hierarchical health care system. Method Using case study methodology, the authors collected observation and interview data from five interprofessional health care teams working at teaching hospitals in urban Ontario, Canada. They interviewed 46 health care providers and conducted 139 hours of observation from January 2008 through June 2009. Results Although the members of the interprofessional teams agreed about the importance of collaborative leadership and discussed ways in which their teams tried to achieve it, evidence indicated that the actual enactment of collaborative leadership was a challenge. The participating physicians indicated a belief that their teams functioned nonhierarchically, but reports from the nonphysician clinicians and the authors’ observation data revealed that hierarchical behaviors persisted, even from those who most vehemently denied the presence of hierarchies on their teams. Conclusions A collaborative approach to leadership may be challenging for interprofessional teams embedded in traditional health care, education, and medical-legal systems that reinforce the idea that physicians sit at the top of the hierarchy. By openly recognizing and discussing the tensions between traditional and interprofessional discourses of collaborative leadership, it may be possible to help interprofessional teams, physicians and clinicians alike, work together more effectively.

Understanding responses to feedback: the potential and limitations of regulatory focus theory

Medical Education 2012:46:593–603

Music lessons: revealing medicine's learning culture through a comparison with that of music

Research on medical learning has tended to focus on the individual learner, but a sufficient understanding of the learning process requires that attention also be paid to the essential influence of the cultural context within which learning takes place. In this study, we undertook a comparative examination of two learning cultures – those of music and medicine – in order to unearth assumptions about learning that are taken for granted within the medical culture.

When surgeons face intraoperative challenges: a naturalistic model of surgical decision making.

BACKGROUND Surgery is an environment in which being an expert requires the ability to manage the unexpected. This feature has necessitated a shift in surgical decision-making research. The present study explores the processes by which surgeons assess and respond to nonroutine challenges in the operating room. METHODS We used a grounded theory methodology supported on intraoperative observations and postoperative interviews with 7 faculty surgeons from various specialties. A total of 32 cases were purposively sampled to compile a dataset of challenging situations. RESULTS Thematic data analysis yielded 3 main themes that were linked in a cyclic model: assessing the situation, the reconciliation cycle, and implementing the planned course of action. These elements were connected through 2 points of transition (ie, active and confirmatory reconciliation), during which time the surgeons continue to act although they may change the course of their action. CONCLUSIONS The proposed model builds on existing theories of naturalistic decision making from other high-stakes environments. This model elaborates on a theoretic language that accounts for the unique aspects of surgery, making it useful for teaching in the operating room.

Non-Invasive Prenatal Testing: Ethics and Policy Considerations

New technologies analyzing fetal DNA in maternal blood have led to the wide commercial availability of non-invasive prenatal testing (NIPT). We present here for clinicians the ethical and policy issues related to an emerging practice option. Although NIPT presents opportunities for pregnant women, particularly women who are at increased risk of having a baby with an abnormality or who are otherwise likely to access invasive prenatal testing, NIPT brings significant ethics and policy challenges. The ethical issues include multiple aspects of informed decision-making, such as access to counselling about the possible results of the test in advance of making a decision about participation in NIPT. Policy considerations include issues related to offering and promoting a privately available medical strategy in publicly funded institutions. Ethics and policy considerations merge in NIPT with regard to sex selection and support for persons living with disabilities.

Women’s Experiences of Publicly Funded Non-Invasive Prenatal Testing in Ontario, Canada: Considerations for Health Technology Policy-Making

Non-invasive prenatal testing (NIPT) via fetal DNA in maternal blood has been publicly funded in Ontario, Canada, for high-risk women since 2014. We solicited women’s experiences and values related to this new health technology to describe how this test is currently being used in Ontario and to provide information about patient priorities to inform future policy decisions about the use of NIPT. Guided by constructivist grounded theory methodology, we interviewed 38 women who had diverse personal experiences with NIPT. Participants’ accounts of their values for decision making about NIPT heavily relied on three mutually modulating factors: timing, accuracy, and risk. The values expressed by women conflict with the way that publicly funded NIPT has typically been implemented in Ontario. We offer recommendations for how NIPT might be integrated into prenatal care pathways in a way more consistent with women’s values.

Understanding clinical uncertainty: what is going on when experienced surgeons are not sure what to do?

Purpose In clinical settings, uncertainty is part of everyday practice. However, a lack of insight into how experts approach uncertainty limits the ability to explicitly teach and assess it in training. This study explored how experienced surgeons perceived and handled uncertainty during challenging intraoperative situations, to develop a theoretical language supporting both education and research. Method This constructivist qualitative study included observations and interviews during 26 surgical cases. The cases, drawn from seven staff surgeons from various specialties at a medical school, were purposively sampled after being preidentified by the surgeon as “likely challenging.” The authors combined template and inductive analyses. In template analysis, an existing theory was used to identify instances of uncertainty in the dataset. Inductive analysis was used to elaborate and refine the concepts. Results Template analysis confirmed that existing theoretical concepts are relevant to surgery. However, inductive analysis revealed additional concepts and positioned existing concepts within new relationships. Two new theoretical themes were recognizing uncertainty and responding to uncertainty, each with corresponding subthemes. Factors such as the novelty of the situation, difficulty in predicting the outcome, and difficulty deciding the course of action mainly characterize an uncertain situation in surgery according to the participants. Conclusions The results offer a refined language for conceptualizing uncertainty in surgery. Although further research could elaborate and test the explanatory power of this language, the authors anticipate that it has implications both for current discussions of surgical safety and for future development of explicit training for effective management of surgical uncertainty.

What Is “NIPT”? Divergent Characterizations of Noninvasive Prenatal Testing Strategies

Background: Noninvasive prenatal testing (NIPT) strategies that analyze cell-free fetal DNA found in maternal blood have proliferated in the past several years. Many different parties have been involved in the development, evaluation, and diffusion of NIPT, resulting in rhizomatic growth of this technology. Here, we use a technology studies lens to examine the way NIPT has been constructed in informational documents and offer suggestions for ethics analysis. Methods: An inductive qualitative content analysis was conducted on 20 documents produced by organizations that claim authority to construct a version of NIPT (13 vendor documents, 7 health professional society documents). Results: Analysis revealed that each document describes a different version of the test, offering different claims of purpose, target population, health care professional involvement, relationship to other technologies, fallibility, and risk. Conclusions: The different versions of NIPT technologies entail different sets of ethical questions and issues. An ethics analysis of NIPT should consider the specific features of the technology under consideration, which may open the analysis to consider more specific ethical, social, and organizational implications of that technology.

Examining the Influence of Context and Professional Culture on Clinical Reasoning Through Rhetorical-Narrative Analysis

According to the dual process model of reasoning, physicians make diagnostic decisions using two mental systems: System 1, which is rapid, unconscious, and intuitive, and System 2, which is slow, rational, and analytical. Currently, little is known about physicians’ use of System 1 or intuitive reasoning in practice. In a qualitative study of clinical reasoning, physicians were asked to tell stories about times when they used intuitive reasoning while working up an acutely unwell patient, and we combine socio-narratology and rhetorical theory to analyze physicians’ stories. Our analysis reveals that in describing their work, physicians draw on two competing narrative structures: one that is aligned with an evidence-based medicine approach valuing System 2 and one that is aligned with cooperative decision making involving others in the clinical environment valuing System 1. Our findings support an understanding of clinical reasoning as distributed, contextual, and influenced by professional culture.

Behavioral activation group therapy for reducing depressive symptoms and improving quality of life: a feasibility study

BackgroundDepression is associated with a loss of productivity and noticeable personal, social, and economic decline; it affects more than 350 million people worldwide. Behavioral activation (BA), derived from cognitive behavioral therapy, has drawn increasingly more interest as a means of treatment for major depressive disorder due to its relative cost-effectiveness and efficacy. In this study, we disseminate findings from a feasibility study evaluating barriers to implementing a group BA program for major depressive disorder. The purpose of this feasibility study is to assess both patient and clinician perceptions on components of a group-based behavioral activation (BA) program. In particular, this feasibility study provides in-depth evaluation of the acceptability of BA prior to the design and implementation of a randomized trial to investigate BA effectiveness. Findings from this study directly informed decisions regarding the design and implementation of BA during the pilot trial. Specific components of BA were assessed and modified based on the results of this study.MethodsThis qualitative study was completed through the Mood Disorders Program at St. Joseph’s Healthcare Hamilton. The authors of this study used data from two focus group sessions, one consisting of an interdisciplinary group of clinicians working in the Mood Disorders Program, and the other of registered outpatients of the Mood Disorders Program with a confirmed clinical diagnosis of depression. The benefits of offering this program in a group format, mainly social skill development opportunities and the use of technology such as activity tracking device, smart phones, and tablets during the therapy sessions, are a major focus of both the clinician and patient groups. Both groups emphasized the importance of offering sustainable activation.ResultsDifferences in opinions existed between staff and patient groups regarding the use of technology in the program, though ultimately it was agreed upon that technology could be useful as a therapeutic aid. All participants agreed that behavioral activation was essential to the development of positive habits and routines necessary for recovery from depression. Patients agreed the program looked sustainable and stressed the potential benefit for improving depressive symptoms.ConclusionsDiscussions from clinician and patient-centered focus groups directly informed decisions regarding the design and implementation of BA during the pilot trial. Specific components of BA were assessed and modified based on the results of this study. These findings provide insight for clinicians providing behavioral activation programming, and will serve as a framework for the development of the Out of the Blues program, a group-based BA program to be piloted in the Mood Disorders Program at St. Joseph’s Healthcare Hamilton.Trial registrationClinical Trials registration number NCT02045771