Socioeconomic inequalities in attitudes towards cancer: An international cancer benchmarking partnership study

Socioeconomic status (SES) differences in attitudes towards cancer have been implicated in the differential screening uptake and the timeliness of symptomatic presentation. However, the predominant emphasis of this work has been on cancer fatalism, and many studies focus on specific community subgroups. This study aimed to assess SES differences in positive and negative attitudes towards cancer in UK adults. A population-based sample of UK adults (n=6965, age≥50 years) completed the Awareness and Beliefs about Cancer scale, including six belief items: three positively framed (e.g. 'Cancer can often be cured') and three negatively framed (e.g. 'A cancer diagnosis is a death sentence'). SES was indexed by education. Analyses controlled for sex, ethnicity, marital status, age, self-rated health, and cancer experience. There were few education-level differences for the positive statements, and overall agreement was high (all>90%). In contrast, there were strong differences for negative statements (all Ps<0.001). Among respondents with lower education levels, 57% agreed that 'treatment is worse than cancer', 27% that cancer is 'a death sentence' and 16% 'would not want to know if I have cancer'. Among those with university education, the respective proportions were 34, 17 and 6%. Differences were not explained by cancer experience or health status. In conclusion, positive statements about cancer outcomes attract near-universal agreement. However, this optimistic perspective coexists alongside widespread fears about survival and treatment, especially among less-educated groups. Health education campaigns targeting socioeconomically disadvantaged groups might benefit from a focus on reducing negative attitudes, which is not necessarily achieved by promoting positive attitudes.

'When I Look I am Seen, So I Exist to Change': Supplementing Honneth's Recognition Model for Social Work

The subject of identity continues to attract widespread interest and debate in the social sciences. The nature of who we are, our potential to be different, and our similarity with others, underpins many present-day social issues. This paper contributes to this debate by examining critically the work of Axel Honneth on optimal identity-formation. Although broadly supporting Honneth’s chief construct of inter-personal recognition, a gap in his thinking is highlighted and addressed through proffering a fourth dimension to his tripartite model. This additional dimension requires demonstrations of recognition that instil hope in the face of hardship and empower positive transformations in identity. The implications of this reworked model for social work are then considered in terms of a range of approaches that can be utilised to build flourishing identities characterised by self-esteem, self-confidence, self-respect and self-belief.

Managing pain medications in long-term care: nurses' views

The purpose of this study was to explore nurses' perceptions of their current practices related to administering pain medications to long-term care (LTC) residents. A cross-sectional survey design was used, including both quantitative and open-ended questions. Data were collected from 165 nurses (59% response rate) at nine LTC homes in southern Ontario, Canada. The majority (85%) felt that the medication administration system was adequate to help them manage residents' pain and 98% felt comfortable administering narcotics. In deciding to administer a narcotic, nurses were influenced by pain assessments, physician orders, diagnosis, past history, effectiveness of non-narcotics and fear of making dosage miscalculations or developing addictions. Finally, most nurses stated that they trusted the physicians and pharmacists to ensure orders were safe. These findings highlight nurses' perceptions of managing pain medications in LTC and related areas where continuing education initiatives for nurses are needed.

Nuclear disasters and health: lessons learned, challenges, and proposals

Past nuclear disasters, such as the atomic bombings in 1945 and major accidents at nuclear power plants, have highlighted similarities in potential public health effects of radiation in both circumstances, including health issues unrelated to radiation exposure. Although the rarity of nuclear disasters limits opportunities to undertake rigorous research of evidence-based interventions and strategies, identification of lessons learned and development of an effective plan to protect the public, minimise negative effects, and protect emergency workers from exposure to high-dose radiation is important. Additionally, research is needed to help decision makers to avoid premature deaths among patients already in hospitals and other vulnerable groups during evacuation. Since nuclear disasters can affect hundreds of thousands of people, a substantial number of people are at risk of physical and mental harm in each disaster. During the recovery period after a nuclear disaster, physicians might need to screen for psychological burdens and provide general physical and mental health care for many affected residents who might experience long-term displacement. Reliable communication of personalised risks has emerged as a challenge for health-care professionals beyond the need to explain radiation protection. To overcome difficulties of risk communication and provide decision aids to protect workers, vulnerable people, and residents after a nuclear disaster, physicians should receive training in nuclear disaster response. This training should include evidence-based interventions, support decisions to balance potential harms and benefits, and take account of scientific uncertainty in provision of community health care. An open and joint learning process is essential to prepare for, and minimise the effects of, future nuclear disasters.

Emotions and identity in the figured world of becoming a doctor

CONTEXT: There is little room in clerkship curricula for students to express emotions, particularly those associated with the development of a caring identity. Yet it is recognised that competence, alone, does not make a good doctor. We therefore set out to explore the relationship between emotions and identity in clerkship education. Our exploration was conceptually oriented towards Figured Worlds theory, which is linked to Bakhtin's theory of dialogism.

METHODS: Nine female and one male member of a mixed student cohort kept audio-diaries and participated in both semi-structured and cognitive individual interviews. The researchers identified 43 emotionally salient utterances in the dataset and subjected them to critical discourse analysis. They applied Figured Worlds constructs to within-case and cross-case analyses, supporting one another's reflexivity and openness to different interpretations, and constantly comparing their evolving interpretation against the complete set of transcripts.

RESULTS: Students' emotions were closely related to their identity development in the world of medicine. Patients were disempowered by their illnesses. Doctors were powerful because they could treat those illnesses. Students expressed positive emotions when they were granted positions in the world of medicine and were able to identify with the figures of doctors or other health professionals. They identified with doctors who behaved in caring and professionally appropriate ways towards patients and supportively towards students. Students expressed negative emotions when they were unable to develop their identities.

CONCLUSIONS: Critical discourse analysis has uncovered a link between students' emotions and their identity development in the powerful world of becoming and being a doctor. At present, identity development, emotions and power are mostly tacit in undergraduate clinical curricula. We speculate that helping students to express emotions and exercise power in the most effective ways might help them to develop caring identities.

Attending Physician Variability: A Model of Four Supervisory Styles

Purpose: There is wide variability in how attending physician roles on teaching teams, including patient care and trainee learning, are enacted. This study sought to better understand variability by considering how different attendings configured and rationalized direct patient care, trainee oversight, and teaching activities. 

Method: Constructivist grounded theory guided iterative data collection and analyses. Data were interviews with 24 attending physicians from two academic centers in Ontario, Canada, in 2012. During interviews, participants heard a hypothetical presentation and reflected on it as though it were presented to their team during a typical admission case review. 

Results: Four supervisory styles were identified: direct care, empowerment, mixed practice, and minimalist. Driven by concerns for patient safety, direct care involves delegating minimal patient care responsibility to trainees. Focused on supporting trainees’ progressive independence, empowerment uses teaching and oversight strategies to ensure quality of care. In mixed practice, patient care is privileged over teaching and is adjusted on the basis of trainee competence and contextual features such as patient volume. Minimalist style involves a high degree of trust in senior residents, delegating most patient care, and teaching to them. Attendings rarely discussed their styles with the team. 

Conclusions: The model adds to the literature on variability in supervisory practice, showing that the four styles reflect different ways of responding to tensions in the role and context. This model could be refined through observational research exploring the impact of context on style development and enactment. Making supervisory styles explicit could support improvement of team competence.

"Should I prioritize medical problem solving or attentive listening?": the dilemmas and challenges that medical students experience when learning to conduct consultations

Objective: Communication skills can be trained alongside clinical reasoning, history taking or clinical examination skills. This is advocated as a solution to the low transfer of communication skills. Still, students have to integrate the knowledge/skills acquired during different curriculum parts in patient consultations at some point. How do medical students experience these integrated consultations within a simulated environment and in real practice when dealing with responsibility?

Methods: Six focus groups were conducted with (pre-)/clerkship students.

Results: Students were motivated to practice integrated consultations with simulated patients and felt like 'real physicians'. However, their focus on medical problem solving drew attention away from improving their communication skills. Responsibility for real patients triggered students' identity development. This identity formation guided the development of an own consultation style, a process that was hampered by conflicting demands of role models.

Conclusion: Practicing complete consultations results in the dilemma of prioritizing medical problem solving above attention for patient communication. Integrated consultation training advances this dilemma to the pre-clerkship period. During clerkships this dilemma is heightened because real patients trigger empathy and responsibility, which invites students to define their role as doctor.

Practice Implications: When training integrated consultations, educators should pay attention to students' learning priorities and support the development of students' professional identity.

Early warning systems: problems, pragmatics and potential

Symposium Chair: Dr Jennifer McGaughey

Title: Early Warning Systems: problems, pragmatics and potential

Early Warning Systems (EWS) provide a mechanism for staff to recognise, refer and manage deteriorating patients on general hospital wards. Implementation of EWS in practice has required considerable change in the delivery of critical care across hospitals. Drawing their experience of these changes the authors will demonstrate the problems and potential of using EWS to improve patient outcomes.

The first paper (Dr Jennifer McGaughey: Early Warning Systems: what works?) reviews the research evidence regarding the factors that support or constrain the implementation of Early Warning System (EWS) in practice. These findings explain those processes which impact on the successful achievement of patient outcomes. In order to improve detection and standardise practice National EWS have been implemented in the United Kingdom. The second paper (Catherine Plowright: The implementation of the National EWS in a District General Hospital) focuses on the process of implementing and auditing a National EWS. This process improvement is essential to contribute to future collaborative research and collection of robust datasets to improve patient safety as recommended by the Royal College of Physicians (RCP 2012). To successfully implement NEWS in practice requires strategic planning and staff education. The practical issues of training staff is discussed in the third paper. This paper (Collette Laws-Chapman: Simulation as a modality to embed the use of Early Warning Systems) focuses on using simulation and structured debrief to enhance learning in the early recognition and management of deteriorating patients. This session emphasises the importance of cognitive and social skills developed alongside practical skills in the simulated setting.

Selecting the best targeted agent in first-line treatment of unresectable liver metastases from colorectal cancer:does the bench have the answers?

For physicians facing patients with organ-limited metastases from colorectal cancer, tumor shrinkage and sterilization of micrometastatic disease is the main goal, giving the opportunity for secondary surgical resection. At the same time, for the majority of patients who will not achieve a sufficient tumor response, disease control remains the predominant objective. Since FOLFOX or FOLFIRI have similar efficacies, the challenge is to define which could be the most effective targeted agent (anti-EGFR or anti-VEGF) to reach these goals. Therefore, a priori molecular identification of patients that could benefit from anti-EGFR or anti-VEGF monoclonal antibodies (i.e. the currently approved targeted therapies for metastatic colorectal cancer) is of critical importance. In this setting, the KRAS mutation status was the first identified predictive marker of response to anti-EGFR therapy. Since it has been demonstrated that tumors with KRAS mutation do not respond to anti-EGFR therapy, KRAS status must be determined prior to treatment. Thus, for KRAS wild-type patients, the choices that remain are either anti-VEGF or anti-EGFR. In this review, we present the most updated data from translational research programs dealing with the identification of biomarkers for response to targeted therapies.

Mathematics Learning Support in Ireland in 2015

The provision of mathematics learning support in higher-level institutions on the island of Ireland has developed rapidly in recent times with the number of institutions providing some form of support doubling in the past seven years. The Irish Mathematics Learning Support Network aims to inform all mathematics support practitioners in Ireland on relevant issues. Consequently it was decided that a detailed picture of current provision was necessary. A comprehensive online survey was conducted to amass the necessary data. The ultimate aim of the survey is to benefit all mathematics support practitioners in Ireland, in particular those in third-level institutions who require further support to enhance the mathematical learning experience of their students. The survey reveals that the majority of Irish higher-level institutions provide mathematics learning support to some extent, with 65% doing so through a support centre. Learners of service mathematics are the primary users: first-year science, engineering and business undergraduates, with non-traditional students being a sizeable element. Despite the growing recognition for the need to offer mathematics learning support almost half of the centres are subject to annual review. Further, less than half the support offerings have a dedicated full-time manager, while 60% operate with a staff of five or fewer. The elevation of mathematics support as a viable and worthwhile career in order to attract and retain high quality staff is seen by many respondents as the crucial next phase of development.

Anomaly Detection for Data with Spatial Attributes

The problem of detecting spatially-coherent groups of data that exhibit anomalous behavior has started to attract attention due to applications across areas such as epidemic analysis and weather forecasting. Earlier efforts from the data mining community have largely focused on finding outliers, individual data objects that display deviant behavior. Such point-based methods are not easy to extend to find groups of data that exhibit anomalous behavior. Scan Statistics are methods from the statistics community that have considered the problem of identifying regions where data objects exhibit a behavior that is atypical of the general dataset. The spatial scan statistic and methods that build upon it mostly adopt the framework of defining a character for regions (e.g., circular or elliptical) of objects and repeatedly sampling regions of such character followed by applying a statistical test for anomaly detection. In the past decade, there have been efforts from the statistics community to enhance efficiency of scan statstics as well as to enable discovery of arbitrarily shaped anomalous regions. On the other hand, the data mining community has started to look at determining anomalous regions that have behavior divergent from their neighborhood.In this chapter,we survey the space of techniques for detecting anomalous regions on spatial data from across the data mining and statistics communities while outlining connections to well-studied problems in clustering and image segmentation. We analyze the techniques systematically by categorizing them appropriately to provide a structured birds eye view of the work on anomalous region detection;we hope that this would encourage better cross-pollination of ideas across communities to help advance the frontier in anomaly detection.

Willingness to pay for cataract surgery in rural Southern China.

PURPOSE: To study willingness to pay for cataract surgery, and its associations, in Southern China. DESIGN: Cross-sectional willingness-to-pay interview incorporating elements of the open-ended and bidding formats. PARTICIPANTS: Three-hundred thirty-nine persons presenting for cataract screening in Yangjiang, China, with presenting visual acuity (VA) < or = 6/60 in either eye due to cataract. METHODS: Subjects underwent measurement of their VA and a willingness-to-pay interview. Age, gender, literacy, education, and annual income also were recorded. MAIN OUTCOME MEASURES: Maximum amount that the subjects would be willing to pay for cataract surgery. RESULTS: Among 325 (95.9%) subjects completing the interview, 169 (52.0%) were 70 years or older, 213 (65.5%) were women, and 217 (66.8%) had an annual income of <5000 renminbi (5000 = US 625 dollars). Eighty percent (n = 257) of participants were willing to pay something for surgery (mean, 442+/-444 renminbi [US 55 dollars+/-55]). In regression models, older subjects were willing to pay less (8 renminbi [US 1 dollar] per year of age; P = 0.01). Blind subjects were significantly more likely (odds ratio, 5.7; 95% confidence interval, 1.7-19.3) to pay anything for surgery, but would pay on average 255 renminbi (US 32 dollars) less (P = 0.004). Persons at the highest annual income level (>10,000 renminbi [US 1250 dollars]) would pay 50 dollars more for surgery than those at the lowest level (<5000 renminbi) (P = 0.0003). The current cost of surgery in this program is 500 renminbi (US 63 dollars). CONCLUSIONS: Sustainable programs will need to attract younger, more well-to-do persons with better vision, while still providing access to the neediest patients.

The TRAVATAN Dosing Aid accurately records when drops are taken.

PURPOSE:

To assess the accuracy of Travatan Dosing Aid recordings.

DESIGN:

Prospective evaluation of drop-recording accuracy.

METHODS:

Physicians and patients used the Dosing Aid, and logs of usage were compared to the data obtained from the Dosing Aid.

RESULTS:

Five physicians and 20 patients participated. Devices used by physicians recorded all drops dispensed. Extra readings were recorded when physicians carried the devices during the day. For patients, 93% of all drops were recorded, with 18 of 20 subjects having over 85% of the drops recorded. Seventy percent of patients would continue using the device.

CONCLUSIONS:

The Dosing Aid accurately recorded most eyedrops administered by patients and physicians. Given recent documentation of widespread under-compliance with medical therapy, the Dosing Aid could be a useful addition to clinical practice and research.

The Legitimacy of Subsidiary Issue Selling: Balancing Positive & Negative Attention from Corporate Headquarters

We consider how in issue selling, subsidiaries draw on different forms of legitimacy to attract corporate headquarters’ (CHQ) positive attention and minimise negative CHQ attention. Through case study evidence, we find that directing CHQ attention to subsidiary issues needs to be executed as a balancing act through forms of subsidiary legitimacy, namely; the personal legitimacy of key individuals at the subsidiary; consequential legitimacy vis-à-vis peer subsidiaries; and linkage legitimacy in the local environment. We develop a typology of subsidiary issue-selling roles and illustrate how negative CHQ attention results from a failure to legitimise issue selling.