Cognitive bias research in forensic science: A systematic review.

The extent to which cognitive biases may influence decision-making in forensic science is an important question with implications for training and practice. We conducted a systematic review of the literature on cognitive biases in forensic science disciplines. The initial literature search including electronic searching of three databases (two social science, one science) and manual review of reference lists in identified articles. An initial screening of title and abstract by two independent reviewers followed by full text review resulted in the identification of 29 primary source (research) studies. A critical methodological deficiency, serious enough to make the study too problematic to provide useful evidence, was identified in two of the studies. Most (n = 22) conducted analyses limited to practitioners (n = 17), forensic science trainees (n = 2), or both forensic science practitioners and students (n = 3); other analyses were based on university student or general population participants. Latent fingerprint analysis was examined in 11 studies, with 1-3 other studies found in 13 other disciplines or domains. This set of studies provides a robust database, with evidence of the influence of confirmation bias on analysts conclusions, specifically among the studies with practitioners or trainees presented with case-specific information about the "suspect" or crime scenario (in 9 of 11 studies examining this question), procedures regarding use of exemplar(s) (in 4 of 4 studies), or knowledge of a previous decision (in 4 of 4 studies). The available research supports the idea of susceptibility of forensic science practitioners to various types of confirmation bias and of the potential value of procedures designed to reduce access to unnecessary information and control the order of providing relevant information, use of multiple comparison samples rather than a single suspect exemplar, and replication of results by analysts blinded to previous results.

Development and validation of a tool to improve paediatric referral/consultation communication.

OBJECTIVE: To develop a template to promote brief but high-quality communication between paediatric primary care clinicians and consulting specialists. METHODS: Through an iterative process with academic and community-based paediatric primary care providers and specialists, the authors identified what content elements would be of value when communicating around referrals. The authors then developed a one-page template to encourage both primary care and specialty clinicians to include these elements when communicating about referrals. Trained clinician reviewers examined a sample of 206 referrals from community primary care providers (PCPs) to specialists in five paediatric specialties at an academic medical centre, coding communication content and rating the overall value of the referral communication. The relationship between the value ratings and each content element was examined to determine which content elements contributed to perceived value. RESULTS: Almost all content elements were associated with increased value as rated by clinician reviewers. The most valuable communications from PCP to specialist contained specific questions for the specialist and/or physical exam features, and the most valuable from specialist to PCP contained brief education for the PCP about the condition; all three elements were found in a minority of communications reviewed. CONCLUSIONS: A limited set of communication elements is suitable for a brief communication template in communication from paediatric PCPs to specialists. The use of such a template may add value to interphysician communication.

Nurse-physician communication in the long-term care setting: perceived barriers and impact on patient safety.

PURPOSE: Clear and complete communication between health care providers is a prerequisite for safe patient management and is a major priority of the Joint Commission's 2008 National Patient Safety Goals. The goal of this study was to describe nurses' perceptions of nurse-physician communication in the long-term care (LTC) setting. METHODS: Mixed-method study including a self-administered questionnaire and qualitative semistructured telephone interviews of licensed nurses from 26 LTC facilities in Connecticut. The questionnaire measured perceived openness to communication, mutual understanding, language comprehension, frustration, professional respect, nurse preparedness, time burden, and logistical barriers. Qualitative interviews focused on identifying barriers to effective nurse-physician communication that may not have previously been considered and eliciting nurses' recommendations for overcoming those barriers. RESULTS: Three hundred seventy-five nurses completed the questionnaire, and 21 nurses completed qualitative interviews. Nurses identified several barriers to effective nurse-physician communication: lack of physician openness to communication, logistic challenges, lack of professionalism, and language barriers. Feeling hurried by the physician was the most frequent barrier (28%), followed by finding a quiet place to call (25%), and difficulty reaching the physician (21%). In qualitative interviews, there was consensus that nurses needed to be brief and prepared with relevant clinical information when communicating with physicians and that physicians needed to be more open to listening. CONCLUSIONS: A combination of nurse and physician behaviors contributes to ineffective communication in the LTC setting. These findings have important implications for patient safety and support the development of structured communication interventions to improve quality of nurse-physician communication.

Cluster randomized trials to study the comparative effectiveness of therapeutics: stakeholders' concerns and recommendations.

PURPOSE: To describe the concerns raised by health plan members, providers and purchasers related to studying the comparative effectiveness of therapeutics using cluster randomized trials (CRTs) within health plans. An additional goal was to develop recommendations for increasing acceptability. METHODS: Eighty-four qualitative in-depth telephone interviews were conducted; 50 with health plan members, 21 with providers, and 13 with purchasers. Interviews focused on stakeholders' concerns about and recommendations for conducting CRTs in health plans. RESULTS: Members expressed concerns that CRTs might compromise their healthcare. Providers and purchasers recognized the value of and the need for comparative effectiveness research. Providers expressed concerns that they would not have sufficient time to discuss a CRT with patients, and that participation in such a study could negatively impact their relationships with patients. Purchasers would want assurances that study participation would not result in members receiving lesser care, and that benefits would remain equitable for all members. CONCLUSIONS: This study provides insight into how health plan members, providers and purchasers might react to a CRT being conducted in their health plan. The recommendations reported here provide guidance for researchers and policy makers considering this methodological approach and suggest that with sufficient preparation and planning CRTs can be an acceptable and efficient methodology for studying the comparative effectiveness of therapeutics in real world settings.

Comparing drug effectiveness at health plans: the ethics of cluster randomized trials.

"Cluster randomized trials," in which groups of patients are randomly assigned to different therapeutic interventions, provide a powerful way of evaluating drugs. CRTs have not been widely used, in good part because of concerns about whether patients must give informed consent to participate in them. A better understanding of how CRTs fit into clinical practice resolves the concerns.

Patients' beliefs and preferences regarding doctors' medication recommendations.

BACKGROUND: An estimated 20-50% of patients do not take medications as recommended. Accepting a doctor's recommendation is the first step in medication adherence, yet little is known about patients' beliefs and preferences about how medications are prescribed. OBJECTIVE: To explore patients' beliefs and preferences about medication prescribing to understand factors that might affect medication adherence. METHODS: Fifty members from 2 health plans in Massachusetts participated in in-depth telephone interviews. Participants listened to an audio-vignette of a doctor prescribing a medication to a patient and were asked a series of questions related to the vignette. Responses were reviewed in an iterative process to identify themes related to participants' beliefs and preferences about medication prescribing. RESULTS: Participants' beliefs and preferences about medication prescribing encompassed 3 major areas: patient-doctor relationships, outside influences, and professional expertise. Important findings included participants' concerns about the pharmaceutical industry's influence on doctors' prescribing practices and beliefs that there is a clear "best" medication for most health problems. CONCLUSIONS: Patients' beliefs and preferences about medication prescribing may affect medication adherence. Additional empiric studies that explore whether doctors' relationships with pharmaceutical representatives impact medication adherence by affecting trust are indicated. In addition, it would be worthwhile to explore whether discussions between patients and doctors regarding equipoise (no clear scientific evidence for 1 treatment choice over another) affect medication adherence.

Cluster randomized trials: opportunities and barriers identified by leaders of eight health plans.

BACKGROUND: Cluster randomized trials (CRTs) offer unique advantages over standard randomized controlled clinical trials (RCTs) and observational methodologies, and may provide a cost-efficient alternative for answering questions about the best treatments for common conditions. OBJECTIVES: To describe health plan leaders' views on CRTs, identify barriers to conducting CRTs, and solicit recommendations for increasing the acceptability of CRTs. RESEARCH DESIGN: Qualitative in-depth telephone interviews with leaders from 8 health plans. SUBJECTS: : Thirty-four health plan leaders (medical directors, pharmacy directors, Institutional Review Board leaders, ethics leaders, compliance leaders, and others). MEASURES: Qualitative analysis of interview transcripts to identify barriers, factors influencing leaders' views, ethical issues, aspects of CRTs that appeal to leaders, and recommendations for increasing acceptability of CRTs. RESULTS: Multiple barriers were identified, including financial costs, concerns about stakeholders' perceptions of CRTs, impact on physicians' prescribing habits, and formulary changes. Most leaders recognized the potential value of studying the comparative effectiveness of therapeutics, and many stressed the need for head-to-head trials. Leaders' views would be influenced by variations in study design and implementation. Recommendations for increasing acceptability of CRTs included ensuring that the fiscal impact of a CRT be budget neutral, and that researchers educate stakeholders and decision-makers about CRTs. CONCLUSIONS: Overall, health plan leaders recognized the need for studies of the comparative effectiveness of therapeutics under real world conditions, and many expressed support for CRTs. However, researchers seeking to conduct CRTs in health plans are likely to face numerous barriers, and preparatory work will be essential.

Assessing professionalism in the context of an objective structured clinical examination: an in-depth study of the rating process.

INTRODUCTION: Professionalism is fundamental to the practice of medicine. Objective structured clinical examinations (OSCEs) have been proposed as appropriate for assessing some aspects of professionalism. This study investigated how raters assign professionalism ratings to medical students' performances in OSCE encounters. METHODS: Three standardised patients, 3 doctor preceptors, and 3 lay people viewed and rated 20 videotaped encounters between 3rd-year medical students and standardised patients. Raters recorded their thoughts while rating. Qualitative and quantitative analyses were conducted. Comments about observable behaviours were coded, and relative frequencies were computed. Correlations between counts of categorised comments and overall professionalism ratings were also computed. RESULTS: Raters varied in which behaviours they attended to, and how behaviours were evaluated. This was true within and between rater type. Raters also differed in the behaviours they consider when providing global evaluations of professionalism. CONCLUSIONS: This study highlights the complexity of the processes involved in assigning ratings to doctor-patient encounters. Greater emphasis on behavioural definitions of specific behaviours may not be a sufficient solution, as raters appear to vary in both attention to and evaluation of behaviours. Reliance on global ratings is also problematic, especially if relatively few raters are used, for similar reasons. We propose a model highlighting the multiple points where raters viewing the same encounter may diverge, resulting in different ratings of the same performance. Progress in assessment of professionalism will require further dialogue about what constitutes professional behaviour in the medical encounter, with input from multiple constituencies and multiple representatives within each constituency.

Dietary supplementation with fruit polyphenolics ameliorates age-related deficits in behavior and neuronal markers of inflammation and oxidative stress.

Dietary supplementation with fruit or vegetable extracts can ameliorate age-related declines in measures of learning, memory, motor performance, and neuronal signal transduction in a rat model. To date, blueberries have proved most effective at improving measures of motor performance, spatial learning and memory, and neuronal functioning in old rats. In an effort to further characterize the bioactive properties of fruits rich in color and correspondingly high in anthocyanins and other polyphenolics, 19-month-old male Fischer rats were fed a well-balanced control diet, or the diet supplemented with 2% extract from either blueberry, cranberry, blackcurrant, or Boysenberry fruit for eight weeks before testing began. The blackcurrant and cranberry diets enhanced neuronal signal transduction as measured by striatal dopamine release, while the blueberry and cranberry diets were effective in ameliorating deficits in motor performance and hippocampal HSP70 neuroprotection; these changes in HSP70 were positively correlated with performance on the inclined screen. It appears that the polyphenols in blueberries and cranberries have the ability to improve muscle tone, strength and balance in aging rats, whereas polyphenols in blueberries, cranberries and blackcurrants have the ability to enhance neuronal functioning and restore the brain's ability to generate a neuroprotective response to stress.