Communication practices in physician decision-making for an unstable critically ill patient with end-stage cancer.

BACKGROUND: Shared decision-making has become the standard of care for most medical treatments. However, little is known about physician communication practices in the decision making for unstable critically ill patients with known end-stage disease. OBJECTIVE: To describe communication practices of physicians making treatment decisions for unstable critically ill patients with end-stage cancer, using the framework of shared decision-making. DESIGN: Analysis of audiotaped encounters between physicians and a standardized patient, in a high-fidelity simulation scenario, to identify best practice communication behaviors. The simulation depicted a 78-year-old man with metastatic gastric cancer, life-threatening hypoxia, and stable preferences to avoid intensive care unit (ICU) admission and intubation. Blinded coders assessed the encounters for verbal communication behaviors associated with handling emotions and discussion of end-of-life goals. We calculated a score for skill at handling emotions (0-6) and at discussing end of life goals (0-16). SUBJECTS: Twenty-seven hospital-based physicians. RESULTS: Independent variables included physician demographics and communication behaviors. We used treatment decisions (ICU admission and initiation of palliation) as a proxy for accurate identification of patient preferences. Eight physicians admitted the patient to the ICU, and 16 initiated palliation. Physicians varied, but on average demonstrated low skill at handling emotions (mean, 0.7) and moderate skill at discussing end-of-life goals (mean, 7.4). We found that skill at discussing end-of-life goals was associated with initiation of palliation (p = 0.04). CONCLUSIONS: It is possible to analyze the decision making of physicians managing unstable critically ill patients with end-stage cancer using the framework of shared decision-making.

Making sense of health information technology implementation: A qualitative study protocol.

BACKGROUND: Implementing new practices, such as health information technology (HIT), is often difficult due to the disruption of the highly coordinated, interdependent processes (e.g., information exchange, communication, relationships) of providing care in hospitals. Thus, HIT implementation may occur slowly as staff members observe and make sense of unexpected disruptions in care. As a critical organizational function, sensemaking, defined as the social process of searching for answers and meaning which drive action, leads to unified understanding, learning, and effective problem solving -- strategies that studies have linked to successful change. Project teamwork is a change strategy increasingly used by hospitals that facilitates sensemaking by providing a formal mechanism for team members to share ideas, construct the meaning of events, and take next actions. METHODS: In this longitudinal case study, we aim to examine project teams' sensemaking and action as the team prepares to implement new information technology in a tiertiary care hospital. Based on management and healthcare literature on HIT implementation and project teamwork, we chose sensemaking as an alternative to traditional models for understanding organizational change and teamwork. Our methods choices are derived from this conceptual framework. Data on project team interactions will be prospectively collected through direct observation and organizational document review. Through qualitative methods, we will identify sensemaking patterns and explore variation in sensemaking across teams. Participant demographics will be used to explore variation in sensemaking patterns. DISCUSSION: Outcomes of this research will be new knowledge about sensemaking patterns of project teams, such as: the antecedents and consequences of the ongoing, evolutionary, social process of implementing HIT; the internal and external factors that influence the project team, including team composition, team member interaction, and interaction between the project team and the larger organization; the ways in which internal and external factors influence project team processes; and the ways in which project team processes facilitate team task accomplishment. These findings will lead to new methods of implementing HIT in hospitals.

Visual Disobedience: The Geopolitics of Experimental Art in Central America, 1990-Present

This dissertation centers on the relationship between art and politics in postwar Central America as materialized in the specific issues of racial and gendered violence that derive from the region's geopolitical location and history. It argues that the decade of the 1990s marks a moment of change in the region's cultural infrastructure, both institutionally and conceptually, in which artists seek a new visual language of experimental art practices to articulate and conceptualize a critical understanding of place, experience and knowledge. It posits that visual and conceptual manifestations of violence in Central American performance, conceptual art and installation extend beyond a critique of the state, and beyond the scope of political parties in perpetuating violent circumstances in these countries. It argues that instead artists use experimental practices in art to locate manifestations of racial violence in an historical system of domination and as a legacy of colonialism still witnessed, lived, and learned by multiple subjectivities in the region. In this postwar period artists move beyond the cold-war rhetoric of the previous decades and instead root the current social and political injustices in what Aníbal Quijano calls the `coloniality of power.' Through an engagement of decolonial methodologies, this dissertation challenges the label "political art" in Central America and offers what I call "visual disobedience" as a response to the coloniality of seeing. I posit that visual colonization is yet another aspect of the coloniality of power and indispensable to projects of decolonization. It offers an analysis of various works to show how visual disobedience responds specifically to racial and gender violence and the equally violent colonization of visuality in Mesoamerica. Such geopolitical critiques through art unmask themes specific to life and identity in contemporary Central America, from indigenous genocide, femicide, transnational gangs, to mass imprisonments and a new wave of social cleansing. I propose that Central American artists--beyond an anti-colonial stance--are engaging in visual disobedience so as to construct decolonial epistemologies in art, through art, and as art as decolonial gestures for healing.

Ink Under the Fingernails: Making Print in Nineteenth-Century Mexico City

This dissertation examines Mexico City’s material politics of print—the central actors engaged in making print, their activities and relationships, and the legal, business, and social dimensions of production—across the nineteenth century. Inside urban printshops, a socially diverse group of men ranging from manual laborers to educated editors collaborated to make the printed items that fueled political debates and partisan struggles in the new republic. By investigating how print was produced, regulated, and consumed, this dissertation argues that printers shaped some of the most pressing conflicts that marked Mexico’s first formative century: over freedom of expression, the role of religion in government, and the emergence of liberalism. Printers shaped debates not only because they issued texts that fueled elite politics but precisely because they operated at the nexus where new liberal guarantees like freedom of the press and intellectual property intersected with politics and patronage, the regulatory efforts of the emerging state, and the harsh realities of a post-colonial economy.

Historians of Mexico have typically approached print as a vehicle for texts written by elites, which they argue contributed to the development of a national public sphere or print culture in spite of low literacy levels. By shifting the focus to print’s production, my work instead reveals that a range of urban residents—from prominent printshop owners to government ministers to street vendors—produced, engaged, and deployed printed items in contests unfolding in the urban environment. As print increasingly functioned as a political weapon in the decades after independence, print production itself became an arena in struggles over the emerging contours of politics and state formation, even as printing technologies remained relatively unchanged over time.

This work examines previously unexplored archival documents, including official correspondence, legal cases, business transactions, and printshop labor records, to shed new light on Mexico City printers’ interactions with the emerging national government, and reveal the degree to which heated ideological debates emerged intertwined with the most basic concerns over the tangible practices of print. By delving into the rich social and cultural world of printing—described by intellectuals and workers alike in memoirs, fiction, caricatures and periodicals— it also considers how printers’ particular status straddling elite and working worlds led them to challenge boundaries drawn by elites that separated manual and intellectual labors. Finally, this study engages the full range of printed documents made in Mexico City printshops not just as texts but also as objects with particular visual and material qualities whose uses and meanings were shaped not only by emergent republicanism but also by powerful colonial legacies that generated ambivalent attitudes towards print’s transformative power.

Dedication and Display of Portrait Statues in Hellenistic Greece: Spatial Practices and Identity Politics

This dissertation models a new approach to the study of ancient portrait statues—one that situates them in their historical, political, and spatial contexts. By bringing into conversation bodies of evidence that have traditionally been studied in discrete categories, I investigate how statue landscapes articulated and reinforced a complex set of political and social identities, how space was utilized and manipulated on a local and a regional level, and how patrons responded to the spatial pressures and visual politics of statue dedication within a constantly changing landscape.

Instead of treating sites independently, I have found it to be more productive—and, indeed, necessary—to examine broader patterns of statue dedication. I demonstrate that a regional perspective, that is, one that takes into account the role of choice and spatial preference in setting up a statue within a regional network of available display locations, can illuminate how space shaped the ancient practice of portrait dedication. This level of analysis is a new approach to the study of portrait statues and it has proved to be a productive way of thinking about how statues and context were used together to articulate identity. Understanding how individual monuments worked within these broader landscapes of portrait dedications, how statue monuments functioned within federal systems, and how monuments set up by individuals and social groups operated along side those set up by political bodies clarifies the important place of honorific statues as an expression of power and identity within the history of the site, the region, and Hellenistic Greece.

When Consumption Embraces Faith: How Religious Beliefs and Practices Influence Consumption

Marketers have long looked for observables that could explain differences in consumer behavior. Initial attempts have centered on demographic factors, such as age, gender, and race. Although such variables are able to provide some useful information for segmentation (Bass, Tigert, and Longdale 1968), more recent studies have shown that variables that tap into consumers’ social classes and personal values have more predictive accuracy and also provide deeper insights into consumer behavior. I argue that one demographic construct, religion, merits further consideration as a factor that has a profound impact on consumer behavior. In this dissertation, I focus on two types of religious guidance that may influence consumer behaviors: religious teachings (being content with one’s belongings), and religious problem-solving styles (reliance on God).

Essay 1 focuses on the well-established endowment effect and introduces a new moderator (religious teachings on contentment) that influences both owner and buyers’ pricing behaviors. Through fifteen experiments, I demonstrate that when people are primed with religion or characterized by stronger religious beliefs, they tend to value their belongings more than people who are not primed with religion or who have weaker religious beliefs. These effects are caused by religious teachings on being content with one’s belongings, which lead to the overvaluation of one’s own possessions.

Essay 2 focuses on self-control behaviors, specifically healthy eating, and introduces a new moderator (God’s role in the decision-making process) that determines the relationship between religiosity and the healthiness of food choices. My findings demonstrate that consumers who indicate that they defer to God in their decision-making make unhealthier food choices as their religiosity increases. The opposite is true for consumers who rely entirely on themselves. Importantly, this relationship is mediated by the consumer’s consideration of future consequences. This essay provides an explanation to the existing mixed findings on the relationship between religiosity and obesity.