Do We Live in a ‘Post-Truth’ Era?

Have we entered a ‘post-truth’ era? This article is an attempt to answer this question by (a) offering an explication of the notion of ‘post-truth’ from recent discussions, (b) deriving a testable implication from that explication, to the effect that we should expect to see decreasing information effects – that is, differences between actual preferences and estimated, fully informed preferences – on central political issues over time and then (c) putting the relevant narrative to the test by way of counterfactual modelling, using election year data for the period of 2004–2016 from the American National Election Studies’ Times Series Study. The implication in question turns out to be consistent with the data: at least in a US context, we do see evidence of a decrease in information effects on key, political issues – immigration, same-sex adoption and gun laws, in particular – in the period 2004–2016. This offers some novel, empirical evidence for the ‘post-truth’ narrative.

Ovarian transposition in patients with cervical cancer prior to pelvic radiotherapy: a systematic review

Ovarian transposition aims to minimize ovarian exposure and damage during pelvic radiotherapy. One or both ovaries are separated from the uterus and mobilized away from the area where the radiation will be administered. A review of the available literature was conducted to evaluate the efficacy and safety of ovarian transposition among pre-menopausal women diagnosed with cervical cancer and eligible for pelvic radiotherapy. Outcomes evaluated were ovarian function preservation and complication rates. We also searched for information on pregnancy/live birth rates after ovarian transposition. Our search yielded a total of 635 manuscripts, of which 33 were considered eligible. A total of 28 full texts were selected for the current review, including 1377 patients who underwent ovarian transposition. The median or mean follow-up ranged between 7 and 87 months. Ovarian function preservation after ovarian transposition and pelvic radiotherapy, with or without chemotherapy, was 61.7% (431/699 patients), ranging from 16.6% to 100%. A total of 12 studies reported on 117 complications, accounting for 8.5%. Ovarian metastases were described in 5 (0.4%). Data about fertility preservation after ovarian transposition are scarce and definitive conclusions cannot be drawn. Based on the available data, ovarian transposition could be performed on young patients with tumors smaller than 4 cm, and it should be avoided in those with bulky tumors. A risk/benefit assessment should be carefully evaluated by a multidisciplinary team, and the decision regarding ovarian transposition should be always guided by the values and informed preferences of the patient.

Latin American Political Discussion in Comparative Perspective

This chapter fills a major gap in the literature on Latin American politics by providing descriptive information about the region's political discussion networks. It reports the absolute and relative prevalence of political discussion — compared to other countries and to other intermediaries — in Brazil, Mexico, and eight other Latin American countries. Latin American citizens discuss politics at a frequency that is typical or even above that prevailing in other countries, and their propensity to speak with residential neighbors is well above the global average. The chapter then portrays the amount of political disagreement and the disparity in political expertise between discussion partners. Rates of disagreement over vote choices in Latin America are high relative to those in the United States, and this is largely because the region's multiparty systems afford more opportunities for disagreement. Moreover, Latin Americans seek out discussion partners with relatively high political expertise, an important part of the socially informed preferences argument.

Discussion, Societal Exclusion, and Political Voice

This chapter explores the implications of horizontal intermediation for the normative issues of the quality and equity of political voice. Because its monetary costs are virtually nil, the realm of horizontal intermediation could be a haven for under-resourced and marginalized groups. The analyses of data from the panel studies and the Comparative National Elections Project (CNEP), however, show that political discussion in seven Latin American countries suffers from an exclusion problem. Individuals of high socioeconomic status (SES) are much more likely to discuss politics than individuals of lower status, and men discuss politics more than women. This has concrete consequences, as high-SES individuals and men have more political knowledge than low-SES individuals and women, respectively. The chapter then considers whether these inequalities distort the political voice of marginalized groups. In Brazil and Mexico, the degree of engagement in horizontal intermediation is positively correlated with voters' abilities to choose the candidates who best represent their issue attitudes. Because of this correlation, the poor are sometimes less likely than the rich to choose candidates who support their expressed values and beliefs about politics and policies. Moreover, the emergence of socially informed preferences during a campaign does not move voters toward their correct candidates.

A Shared Decison-Making Virtual Patient in Medical Education: A mixed methods evaluation (Preprint)

BACKGROUND Shared decision-making (SDM) is a process where clinicians and patients work together to select tests, treatments, management or support packages, based on clinical evidence and the patient’s informed preferences. Like any skill, SDM requires practice to improve. Virtual Patients (VPs) are simulations that allow one to practice their communication skills. VPs could be used to help professionals and students practice the communication skills required to engage in SDM, but this specific focus has not received much attention within the literature. OBJECTIVE To evaluate a VP workshop for medical students aimed at developing the communication skills required for SDM. METHODS A pre and post-intervention questionnaire followed by semi-structured interviews. RESULTS The interviews and questionnaires suggested that the VP was enjoyable and easy to use. When the participants were asked to rank their priorities in a consultation both pre and post-VP, there was a statistically significant change in the rank position of “respecting patient choices” (P = 0.038) with the median rank changing from 2nd to 1st. The VP allowed the participants to explore a consultation in a way that they could not with simulated or real patients; this may be part of the reason that the VP was suggested as a useful intervention for bridging from the early, theory focused years of the curriculum to the more patient focused ones later on. CONCLUSIONS The VP was well accepted by the participants. The multiple choice system of interaction was reported as both useful but also restrictive. Future work should look at further developing the mode of interaction and explore whether the VP results in any changes in observed behaviour or practice.

SHARED DECISION MAKING FOR OTHER GENERAL CONDITIONS

Shared decision making based on clinical evidence and the patient’s informed preferences improves patient knowledge and ability to participate in their care with improvement to those with long-term health problems. A common ground between the patient and the physician is achieved through empathic communication skills with the provision of evidence-based information about options, outcomes, and uncertainties, together with decision support counseling and a systematic approach to recording and implementing patient’s preferences. It is important to recognize that the complexities of the clinical decision-making process with the confounding variables create difficulties in obtaining and measuring reproducible outcomes.

Evaluation of a shared decision-making intervention for dialysis choice at four Danish hospitals: a qualitative study of patient perspective

ObjectiveTo evaluate the ‘Shared Decision-making and Dialysis Choice’ (SDM-DC) intervention with regard to patients’ experience and involvement.DesignSemistructured individual interviews and systematic text condensation for data analysis.SettingThe SDM-DC intervention was implemented and evaluated at four different hospitals in Denmark.ParticipantsA total of 348 patients had received the SDM-DC intervention, and of these 29 patients were interviewed.InterventionsSDM-DC was designed for patients facing a choice of dialysis modality. The available modalities were haemodialysis and peritoneal dialysis, either performed by patients on their own or with help from a healthcare professional. The intervention was tailored to individual patients and consisted of three meetings with a dialysis coordinator who introduced a patient decision aid named ‘Dialysis Choice’ to the patient.FindingsThe following were the four main findings: the decision was experienced as being the patient’s own; the meetings contributed to the decision process; ‘Dialysis Choice’ contributed to the decision process; and the decision process was experienced as being iterative.ConclusionsThe patients experienced SDM-DC as involving them in their choice of dialysis modality. Due to the iterative properties of the decision-making process, a shared decision-making intervention for dialysis choice has to be adapted to the needs of individual patients. The active mechanisms of the meetings with the dialysis coordinator were (1) questions to and from the patient, and (2) the dialysis coordinator providing accurate information about the options. The overview of options and the value clarification tool in the decision aid were particularly helpful in establishing a decision-making process based on informed preferences.

Blueprint for Advancing High-Value Maternity Care Through Physiologic Childbearing

The Blueprint for Advancing High-Value Maternity Care Through Physiologic Childbearing charts an efficient pathway to a maternity care system that reliably enables all women and newborns to experience healthy physiologic processes around the time of birth, to the extent possible given their health needs and informed preferences. The authors are members of a multistakeholder, multidisciplinary National Advisory Council that collaborated to develop this document. This approach preventively addresses troubling trends in maternal and newborn outcomes and persistent racial and other disparities by mobilizing innate capacities for healthy childbearing processes and limiting use of consequential interventions. It provides more appropriate care to healthier, lower-risk women and newborns who often receive more specialized care, though such care may not be needed and may cause unintended harm. It also offers opportunities to improve the care, experience and outcomes of women with health challenges by fostering healthy perinatal physiologic processes whenever safely possible.

Involvement of people with dementia in making decisions about their lives: a qualitative study that appraises shared decision-making concerning daycare

ObjectiveTo explore how people with dementia, their informal caregivers and their professionals participate in decision making about daycare and to develop a typology of participation trajectories.DesignA qualitative study with a prospective, multiperspective design, based on 244 semistructured interviews, conducted during three interview rounds over the course of a year. Analysis was by means of content analysis and typology construction.SettingCommunity settings and nursing homes in the Netherlands.Participants19 people with dementia, 36 of their informal caregivers and 38 of their professionals (including nurses, daycare employees and case managers).ResultsThe participants’ responses related to three critical points in the decision-making trajectory about daycare: (1) the initial positive or negative expectations of daycare; (2) negotiation about trying out daycare by promoting, resisting or attuning to others; and (3) trying daycare, which resulted in positive or negative reactions from people with dementia and led to a decision. The ways in which care networks proceeded through these three critical points resulted in a typology of participation trajectories, including (1) working together positively toward daycare, (2) bringing conflicting perspectives together toward trying daycare and (3) not reaching commitment to try daycare.ConclusionShared decision making with people with dementia is possible and requires and adapted process of decision making. Our results show that initial preferences based on information alone may change when people with dementia experience daycare. It is important to have a try-out period so that people with dementia can experience daycare without having to decide whether to continue it. Whereas shared decision making in general aims at moving from initial preferences to informed preferences, professionals should focus more on moving from initial preferences to experienced preferences for people with dementia. Professionals can play a crucial role in facilitating the possibilities for a try-out period.

Dying From Cancer

Medical oncologists and patients with advanced cancer struggle to discuss prognosis, goals, options, and values in a timely fashion. As a consequence, many patients die receiving aggressive treatment potentially inconsistent with their fully informed preferences and experience increased symptom burden and distress. The goals of patient - oncologist communication include exchanging information, building relationship, and engaging in shared decisions. Empathy is perhaps especially essential to effective patient - oncologist communication when the end of life is approaching. We speculate that, in addition to being a skilled response to a patient’s negative emotions, empathy is an emergent property of the relationship that allows the patient and oncologist to imagine what it will be like to navigate the transition from living with to dying from cancer; and to prepare for the transition. We propose that effective empathy: 1) requires an attentive, curious and imaginative physician; 2) acknowledges the complex and shifting goals as the end of life approaches; and 3) begins with a willingness of physicians to check in and find out what she may have misunderstood or misperceived. Empathy in end of life conversations cultivates the shared experiences necessary to co-create the new goals of care that underlie excellent end of life care.