Background Although shared decision making is championed as the preferred model for patient care by patient organizations, researchers and medical professionals, its application in daily practice... Show moreBackground Although shared decision making is championed as the preferred model for patient care by patient organizations, researchers and medical professionals, its application in daily practice remains limited. We previously showed that residents more often prefer paternalistic decision making than their supervisors. Because both the views of residents on the decision-making process in medical consultations and the reasons for their 'paternalism preference' are unknown, this study explored residents' views on the decision-making process in medical encounters and the factors affecting it. Methods We interviewed 12 residents from various specialties at a large Dutch teaching hospital in 2019-2020, exploring how they involved patients in decisions. All participating residents provided written informed consent. Data analysis occurred concurrently with data collection in an iterative process informing adaptations to the interview topic guide when deemed necessary. Constant comparative analysis was used to develop themes. We ceased data collection when information sufficiency was achieved. Results Participants described how active engagement of patients in discussing options and decision making was influenced by contextual factors (patient characteristics, logistical factors such as available time, and supervisors' recommendations) and by limitations in their medical and shared decision-making knowledge. The residents' decision-making behavior appeared strongly affected by their conviction that they are responsible for arriving at the correct diagnosis and providing the best evidence-based treatment. They described shared decision making as the process of patients consenting with physician-recommended treatment or patients choosing their preferred option when no best evidence-based option was available. Conclusions Residents' decision making appears to be affected by contextual factors, their medical knowledge, their knowledge about SDM, and by their beliefs and convictions about their professional responsibilities as a doctor, ensuring that patients receive the best possible evidence-based treatment. They confuse SDM with acquiring informed consent with the physician's treatment recommendations and with letting patients decide which treatment they prefer in case no evidence based guideline recommendation is available. Teaching SDM to residents should not only include skills training, but also target residents' perceptions and convictions regarding their role in the decision-making process in consultations. Show less
Some athletes use prohibited substances, a relevant problem given the coverage on doping in the media. In addition not all these athletes are being caught and clean athletes are sometimes falsely... Show moreSome athletes use prohibited substances, a relevant problem given the coverage on doping in the media. In addition not all these athletes are being caught and clean athletes are sometimes falsely accused. In short, doping is a problem in sports and society. The goal of this thesis is to contribute to a solution to this problem by applying knowledge of (clinical) pharmacology to handling the use and detection of doping. First, our research shows that there is no convincing evidence for performance enhancement for 18 out of 23 substance classes on the Prohibit List. This is problematic and is mainly due to a lack of knowledge. For this reason we evaluated one of the substances, erythropoietin (EPO), in a study that could serve as a model study for evaluating potential doping substances. This study showed that although EPO did have effects, EPO-treated cyclists did not perform any better than placebo-treated cyclists in a time trial or an uphill road race. Additionally, the doping detection methods we evaluated, for EPO and salbutamol, proved to have shortcomings in detecting cheating and protecting innocent athletes. Concluding, anti-doping efforts will need to become more evidence-based to effectively tackle the doping problem. Show less
Breast cancer is the most common malignancy diagnosed in women1. The incidence of breast cancer increases with age; currently, in developed countries more than 40% of breast cancer patients is 65... Show moreBreast cancer is the most common malignancy diagnosed in women1. The incidence of breast cancer increases with age; currently, in developed countries more than 40% of breast cancer patients is 65 years or older at diagnosis1. In the Netherlands in 2011, 5,441 women aged 65 years or older were diagnosed with breast cancer2. The remaining life expectancy of persons aged 65 is still increasing, from almost 19 years in 1980, up to more than 21 years in 2010. Moreover, in last decades the birth rate has decreased, resulting in a higher proportion of older persons in the general population3. Both an increasing life expectancy and the increasing number of elderly in the population will further enhance the number of elderly women confronted with breast cancer Show less
