Justice and Innovation in Radiology.

Imaging is a central determinant of health outcomes, and radiologic disparities can cascade throughout a patient's illness course. Innovative efforts in radiology are constant, but innovation that is driven by short-term profit-making incentives without explicit regard for principles of justice can lead to exclusion of the vulnerable from potential benefits and widening of inequities. Accordingly, we must consider the ways in which the field of radiology can shape innovative efforts to ensure that innovation ameliorates injustice instead of exacerbating it. The authors propose a distinction between approaches to innovation that prioritize justice and those that do not. The authors argue that the field's institutional incentives should be adjusted to prioritize forms of innovation that are likely to ameliorate imaging inequities, and they provide examples of initial steps that can be taken to make these adjustments. The authors propose the term justice-oriented innovation as a way of describing forms of innovation that are motivated by reducing injustice and can reasonably be expected to do so.

"No Escalation of Treatment" Designations: A Multi-institutional Exploratory Qualitative Study.

BACKGROUND: No Escalation of Treatment (NoET) designations are used in ICUs internationally to limit treatment for critically ill patients. However, they are the subject of debate in the literature and have not been qualitatively studied. RESEARCH QUESTION: How do physicians understand and perceive NoET designations, especially regarding their usefulness and associated challenges? What mechanisms do hospitals provide to facilitate the use of NoET designations? STUDY DESIGN AND METHODS: Qualitative study at seven US hospitals, employing semistructured interviews with 30 physicians and review of relevant institutional records (eg, hospital policies, screenshots of ordering menus in the electronic health record). RESULTS: At all hospitals, participants reported the use of NoET designations, which were understood to mean that providers should withhold new or higher-intensity interventions ("escalations") but not withdraw ongoing interventions. Three hospitals provided a specific mechanism for designating a patient as NoET (eg, a DNR/Do Not Escalate code status order); at the remaining hospitals, a variety of informal methods (eg, verbal hand-offs) were used. We identified five functions of NoET designations: (1) Defining an intermediate point of treatment limitation, (2) helping physicians navigate prearrest clinical decompensations, (3) helping surrogate decision-makers transition toward comfort care, (4) preventing patient harm from invasive measures, and (5) conserving critical care resources. Across hospitals, participants reported implementation challenges related to the ambiguity in meaning of NoET designations. INTERPRETATION: Despite ongoing debate, NoET designations are used in a varied sample of hospitals and are perceived as having multiple functions, suggesting they may fulfill an important need in the care of critically ill patients, especially at the end of life. The use of NoET designations can be improved through the implementation of a formal mechanism that encourages consistency across providers and clarifies the meaning of "escalation" for each patient.

An Interprofessional Process for the Limitation of Life-Sustaining Treatments at the End of Life in France.

CONTEXT: The provision of potentially non-beneficial life-sustaining treatments (LSTs) remains a challenging problem. In 2005, legislation in France established an interprofessional process by which non-beneficial LSTs could be withheld or withdrawn, permitting exploration of the effects of such a legally-protected process and its implementation. OBJECTIVES: To characterize intensive care unit (ICU) interprofessional team decision-making and consensus-building practices regarding withholding and withdrawing of LSTs in two Parisian hospitals and to explore physician and nurse perceptions of and experiences with these practices. METHODS: This was an exploratory qualitative study utilizing thematic analysis of semi-structured, in-depth interviews of physicians and nurses purposively sampled based on level of training and experience from two hospitals in Paris, France. RESULTS: A total of 25 participants were interviewed. Participants reported that the two Parisian hospitals in this study have each created an interprofessional process for withholding or withdrawing non-beneficial LSTs, providing insight into how norms of decision-making respond to systems-level legal changes. Participants reported that these processes tended to be consistent across several domains: maintaining unified messaging with patients, empowering nurses to participate in end-of-life decision-making, reducing moral distress provoked by end-of-life decisions, and shaping the ethical milieu within which end-of-life decision-making takes place. CONCLUSIONS: The architecture of the interprofessional process created at two Parisian hospitals and its perceived benefits may be useful to clinicians and policy-makers attempting to establish processes, policies, or legislation directed at withholding or withdrawing potentially non-beneficial LSTs in the United States and elsewhere.

Recognizing the Role of Language in the Hidden Curriculum of Undergraduate Medical Education: Implications for Equity in Medical Training.

Medical education involves a transition from "outsider" to "insider" status, which entails both rigorous formal training and an inculturation of values and norms via a hidden curriculum. Within this transition, the ability to "talk the talk" designates an individual as an insider, and learning to talk this talk is a key component of professional socialization. This Article uses the framework of "patterns of medical language" to explore the role of language in the hidden curriculum of medical education, exploring how students must learn to recognize and participate fluently within patterns of medical language to be acknowledged and evaluated as competent trainees. The authors illustrate this by reframing the Association of American Medical Colleges' Core Entrustable Professional Activities for Entering Residency as a series of overlapping patterns of medical language that students are expected to master before residency. The authors propose that many of these patterns of medical language are learned through trial and error, taught via a hidden curriculum rather than through explicit instruction. Medical students come from increasingly diverse backgrounds and therefore begin medical training further from or closer to insider status. Thus, evaluative practices based on patterns of medical language, which are not explicitly taught, may exacerbate and perpetuate existing inequities in medical education. This Article aims to bring awareness to the importance of medical language within the hidden curriculum of medical education, to the role of medical language as a marker of insider status, and to the centrality of medical language in evaluative practices. The authors conclude by offering possible approaches to ameliorate the inequities that may exist due to current evaluative practices.

Variation in the design of Do Not Resuscitate orders and other code status options: a multi-institutional qualitative study.

BACKGROUND: US hospitals typically provide a set of code status options that includes Full Code and Do Not Resuscitate (DNR) but often includes additional options. Although US hospitals differ in the design of code status options, this variation and its impacts have not been empirically studied. DESIGN AND METHODS: Multi-institutional qualitative study at 7 US hospitals selected for variability in geographical location, type of institution and design of code status options. We triangulated across three data sources (policy documents, code status ordering menus and in-depth physician interviews) to characterise the code status options available at each hospital. Using inductive qualitative methods, we investigated design differences in hospital code status options and the perceived impacts of these differences. RESULTS: The code status options at each hospital varied widely with regard to the number of code status options, the names and definitions of code status options, and the formatting and capabilities of code status ordering menus. DNR orders were named and defined differently at each hospital studied. We identified five key design characteristics that impact the function of a code status order. Each hospital's code status options were unique with respect to these characteristics, indicating that code status plays differing roles in each hospital. Physician participants perceived that the design of code status options shapes communication and decision-making practices about resuscitation and life-sustaining treatments, especially at the end of life. We identified four potential mechanisms through which this may occur: framing conversations, prompting decisions, shaping inferences and creating categories. CONCLUSIONS: There are substantive differences in the design of hospital code status options that may contribute to known variability in end-of-life care and treatment intensity among US hospitals. Our framework can be used to design hospital code status options or evaluate their function.

Clerkship Ethics: Unique Ethical Challenges for Physicians-in-Training.

Three ethical conflicts in particular are paradigmatic of what we define as "clerkship ethics." First, a distinction that differentiates the clerkship student from the practicing physician involves the student's principal role as a learner. The clerkship student must skillfully balance her commitment to her own education against her commitment to patient care in a fashion that may compromise patient care. While the practicing physician can often resolve the tension between these two goods when they come into conflict, the clerkship student is left with a more ambiguous set of choices. Second, evaluative scrutiny during clinical clerkships often forces medical students to balance doing what is morally fitting against the perceived expectations of the medical teams in which they work. Third and finally, a deeply entrenched culture of medical hierarchy presents a particular challenge to innovation and improvement in ethics education during the clerkship years. Students regard faculty as exemplars, but are not provided with the tools to assess when technical medical competence is not matched by moral competence; moreover, these faculty are unlikely to have experienced the ethics education in which students are asked to demonstrate mastery.

How Should Physicians Respond to Patient Requests for Religious Concordance?

In which ways and in which circumstances should institutions and individual physicians facilitate patient-physician religious concordance when requested by a patient? This question suggests not only uncertainty about the relevance of particular traits to physicians' professional roles but also that medical practice can be construed as primarily bureaucratic and technological. This construal is misleading. Using the metaphor of shared language, this article contends that patient-physician concordance is always a question of degree and that greater concordance can, in certain circumstances, help to obtain important goals of medicine.

"Just do your job": technology, bureaucracy, and the eclipse of conscience in contemporary medicine.

Market metaphors have come to dominate discourse on medical practice. In this essay, we revisit Peter Berger and colleagues' analysis of modernization in their book The Homeless Mind and place that analysis in conversation with Max Weber's 1917 lecture "Science as a Vocation" to argue that the rise of market metaphors betokens the carry-over to medical practice of various features from the institutions of technological production and bureaucratic administration. We refer to this carry-over as the product presumption. The product presumption foregrounds accidental features of medicine while hiding its essential features. It thereby confounds the public understanding of medicine and impedes the professional achievement of the excellences most central to medical practice. In demonstrating this pattern, we focus on a recent article, "Physicians, Not Conscripts-Conscientious Objection in Health Care," in which Ronit Stahl and Ezekiel Emanuel decry conscientious refusals by medical practitioners. We demonstrate that Stahl and Emanuel's argument depends on the product presumption, ignoring and undermining central features of good medicine. We conclude by encouraging conscientious resistance to the product presumption and the language it engenders.