Background:
Shared decision making (SDM) is a process within the physician–patient relationship applicable to any clinical action, whether diagnostic, therapeutic, or preventive in nature. It has been defined as a process of mutual respect and participation between the doctor and the patient. The aim of this study is to determine the effectiveness of decision aids (DA) in primary care based on changes in adherence to treatments, knowledge, and awareness of the disease, conflict with decisions, and patients’ and health professionals’ satisfaction with the intervention.
Methods:
A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted in Medline, CINAHL, Embase, the Cochrane Central Register of Controlled Trials, and the NHS Economic Evaluation Database. The inclusion criteria were randomized clinical trials as study design; use of SDM with DA as an intervention; primary care as clinical context; written in English, Spanish, and Portuguese; and published between January 2007 and January 2019. The risk of bias of the included studies in this review was assessed according to the Cochrane Collaboration's tool.
Results:
Twenty four studies were selected out of the 201 references initially identified. With the use of DA, the use of antibiotics was reduced in cases of acute respiratory infection and decisional conflict was decreased when dealing with the treatment choice for atrial fibrillation and osteoporosis. The rate of determination of prostate-specific antigen (PSA) in the prostate cancer screening decreased and colorectal cancer screening increased. Both professionals and patients increased their knowledge about depression, type 2 diabetes, and the perception of risk of acute myocardial infarction at 10 years without statins and with statins. The satisfaction was greater with the use of DA in choosing the treatment for depression, in cardiovascular risk management, in the treatment of low back pain, and in the use of statin therapy in diabetes. Blinding of outcomes assessment was the most common bias.
Conclusions:
DA used in primary care are effective to reduce decisional conflict and improve knowledge on the disease and treatment options, awareness of risk, and satisfaction with the decisions made. More studies are needed to assess the impact of shared decision making in primary care.
There is a need for continuous advancement in the development of the concept, specific actions to encourage this and the improvement of evaluation methods for its study.
La Ley de Eutanasia española introduce un nuevo derecho que se incorpora a la cartera de servicios del sistema sanitario, como una prestación cuya aplicación se garantiza en el plazo de 40 días. Desde la experiencia clínica se argumenta que, sin el derecho efectivo a unos cuidados paliativos de calidad, y con el actual déficit en las ayudas a la dependencia, esta ley puede ser un mensaje coactivo para aquellas personas especialmente frágiles y dependientes, que se sientan como una pesada carga para su familia y para la sociedad.
Se razona de qué modo fundamentar el derecho a morir en la dignidad de la persona, puede tener repercusiones sociales inesperadas.
El texto normativo muestra debilidades propias de una ley apresurada y sin apoyo de órganos consultivos. Hay cuestiones pendientes de aclarar en su aplicación dentro del contexto de la medicina de familia. Se concluye que esta nueva norma planteará más problemas de los que pretende resolver.
At the University of Zaragoza in Spain we developed an innovative way to teach the concept of confidentiality to medical students, which we tested by comparing the use of customized comics with more traditional methods. We proved that using comics is more attractive to students than lectures and class discussions, that it increases class participation and students' self-awareness of learning, and that it maintains the same academic results. We share our experience visually in a two-page comic.
Objetivo. Medir el razonamiento moral de los estudiantes de medicina antes y después de recibir formación en bioética en dos ámbitos culturales diferentes (Zaragoza y Doha) y de los residentes al inicio de su residencia (MIR1), correlacionando el razonamiento moral con el ámbito cultural y el ambiente de aprendizaje.
Sujetos y métodos.Estudio observacional transversal del razonamiento moral con estudiantes de medicina y MIR1 y de intervención con seguimiento longitudinal del razonamiento moral antes y después de la formación en bioética, utilizando el test de razonamiento moral de Lind.Resultados. Se obtuvieron 273 cuestionarios iniciales de estudiantes (200 de Zaragoza y 73 de Qatar) y 141 de MIR1. Se tiene información antes y después de 122 estudiantes (44,7% del total), una quinta parte de Qatar. Antes de bioética, la media del C-score era de 14,24 ± 8,698 (n = 273). Después, la media era de 14,30 ± 10,111 (n = 194). La diferencia media antes-después fue de 0,79 ± 12,162 (n = 122). No hay diferencias del C-score por región, pero sí al dicotomizarlo en preconvencional (< 10) y convencional-posconvencional (≥ 10): 49% < 10 en Qatar frente a 30% en Zaragoza. También hay diferencias significativas en las respuestas dadas a los dos dilemas que conforman el test de razonamiento moral entre ambas regiones. Los MIR de Zaragoza muestran el mismo patrón de respuestas ante los dilemas que los estudiantes, pero su C-score es significativamente inferior (10,4 frente a 14,3).
Conclusiones.Se confirman las hipótesis iniciales, aunque conviene profundizar en esta línea de investigación durante más cursos académicos, o incluyendo otros campus universitarios de las mismas zonas culturales.Palabras clave. Bioética. Educación médica. Razonamiento moral.
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