Zackary Berger

Johns Hopkins Medicine | JHUSOM · Division of General Internal Medicine

Shared decision-making is a well-recognized model to guide decision-making in medical care. However, the shared decision-making concept can become exceedingly complex in adolescent patients with varying degrees of autonomy who have most of their medical decisions made by their parents or legal guardians. The complexity increases further in ethicall...

Objective Our aim was to use critical discourse analysis (CDA) to examine the most widely cited definitions of shared decision making so that we can evaluate how language is used to position participants. Based on our conceptual understanding, we presumed that shared decision making involves acts of communication where processes are collaborative....

Patient-centered communication (PCC) is critical to the delivery of quality health care services. Although numerous health outcomes have been connected to patient-provider communication, there is limited research that has explored the processes and pathways between communication and health. Research among young adults (ages 26-39 years) is even mor...

Purpose: To investigate whether coronavirus disease 2019 (COVID-19) vaccination campaigns targeted at health care personnel (HCP) in the United States have addressed the lived experiences of HCP on the frontlines of the COVID-19 pandemic and to analyze policy and legal considerations for improving COVID-19 vaccine uptake among HCP. Methods: We cond...

The COVID-19 pandemic has reshaped health care delivery for all patients but has distinctly affected the most marginalized people in society. Incarcerated patients are both more likely to be infected and more likely to die from COVID-19. There is a paucity of guidance for the care of incarcerated patients hospitalized with COVID-19. This article wi...

U.S. immigration policies and enforcement can make immigrants fearful of accessing healthcare. Although current immigration policies restrict enforcement in “sensitive locations” including healthcare facilities, there are reports of enforcement actions in such settings.

Policy Points • An estimated 700,000 people in the United States have “long COVID,” that is, symptoms of COVID‐19 persisting beyond three weeks. • COVID‐19 and its long‐term sequelae are strongly influenced by social determinants such as poverty and by structural inequalities such as racism and discrimination. • Primary care providers are in a uni...

In Long Covid, symptoms do not resolve within several weeks after acute infection with SARS-CoV-2. Patients with COVID-19 and long COVID face stigma and discrimination. One important type of discrimination is epistemic injustice which includes testimonial and hermeneutical injustices. Testimonial injustices occur when healthcare professional disreg...

In Long Covid, symptoms do not resolve within several weeks after acute infection with SARS-CoV-2. Patients with COVID-19 and long COVID face stigma and discrimination. One important type of discrimination is epistemic injustice which includes testimonial and hermeneutical injustices. Testimonial injustices occur when healthcare professional disreg...

Context: COVID-19 has prompted debates between bioethicists and disability activists over Crisis Standards of Care plans (CSCs), triage protocols determining the allocation of scarce lifesaving care. Methods: We examine CSCs in 35 states and code how they approach disability, comparing states that have revised their plans to those that have not. We...

During the Coronavirus (COVID-19) pandemic, in-person interpreters have been deemed “nonessential,” and thus eliminated to minimize viral exposure and conserve personal protective equipment. Considering alarming patterns of interpreter underuse, we evaluate how substitution for remote modalities (telephone or video) may exacerbate existing inequali...

Introduction: Patient safety in primary care is an emerging priority, and experts have highlighted medications, diagnoses, transitions, referrals, and testing as key safety domains. This study aimed to (1) describe how frontline clinicians, administrators, and staff conceptualize patient safety in primary care; and (2) compare and contrast these c...

As the COVID-19 pandemic worsens in the United States, colleges that have invited students back for the fall are finalizing mitigation plans to lessen the spread of SARS-CoV-2. Even though students have largely been away from campuses over the summer, several outbreaks associated with colleges have already occurred, foreshadowing the scale of infec...

As the COVID-19 pandemic worsens in the United States, colleges that have invited students back for the fall are finalizing mitigation plans to lessen the spread of SARS-CoV-2. Even though students have largely been away from campuses over the summer, several outbreaks associated with colleges have already occurred, foreshadowing the scale of infec...

Background Shared decision making (SDM) is a health communication model that evolved in Europe and North America and largely reflects the values and medical practices dominant in these areas. Objective This study aims to understand the beliefs, perceptions, and practices related to SDM and patient-centered care (PCC) of physicians in Israel, Jorda...

Medicine is not merely a job that requires technical expertise, but a profession concerned with making the best decisions and recommendations with reference to, and in consultation with, the patient. This means that the skill set required for healthcare professionals in order to provide good care is a combination of scientific knowledge, technical...

BACKGROUND Shared decision making (SDM) is a health communication model that evolved in Europe and North America and largely reflects the values and medical practices dominant in these areas. OBJECTIVE This study aims to understand the beliefs, perceptions, and practices related to SDM and patient-centered care (PCC) of physicians in Israel, Jorda...

Purpose We established the Primary Care for Cancer Survivor (PCCS) Clinic in 2015 to address transition and care delivery challenges unique to cancer survivors. We describe the clinical program, detail patients from the first 4 years of implementation, and discuss lessons learned during the process. Methods We abstracted relevant patient informati...

Purpose: Shared decision-making (SDM) has a significant role in surgical encounters, where decisions are influenced by both clinician and patient preferences. Herein, we sought to explore surgeons' practices and beliefs about SDM. Methods: We performed a qualitative study consisting of semi-structured individual interviews with 18 surgeons from...

Introduction: Management of cancer is often characterized by difficult decisions. The National Coalition for Cancer Survivorship (NCCS) has developed the "Know Yourself" tool, a question prompt list (QPL) to enable patients to participate in these decisions. Methods: We investigated the feasibility of using the NCCS tool by oncologists and their...

Faced with gastroesophageal reflux disease, a behavioral health disorder, and difficulty navigating the U.S. health care system, a Honduran immigrant stops working and takes up a collection to return home. His compound disadvantage has profound ethical implications.

Debate about whether and when to accommodate patient requests for concordant clinicians should consider evidence. This article examines how existing evidence could be used to interpret or inform ethical arguments about whether to accommodate such requests. Studies on patient-clinician concordance yield mixed and inconclusive results. Concordance mi...

Conference attendance and networking have long been a staple of career advancement in medicine. Presenting one's own research or chairing a conference panel provides academic physicians with the visibility necessary for career advancement and promotion. Unfortunately, this pathway to career advancement may be obstructed for some physicians. Women p...

Objective: How outside factors affect physician decision making remains an open question of vital importance. We sought to investigate the importance of various influences on physician decision making when clinical guidelines differ from patient preference. Methods: An online survey asking 469 primary care providers (PCPs) across four practice s...

In a rigorous systematic review, Dukhanin and colleagues categorize metrics and evaluative tools of the engagement of patient, public, consumer, and community in decision-making in healthcare institutions and systems. The review itself is ably done and the categorizations lead to a useful understanding of the necessary elements of engagement, and a...

Nearly 7% of children living in the United States, the vast majority of whom are US citizens, have at least 1 undocumented immigrant parent.¹ These children face several disadvantages, culminating in reduced lifetime socioeconomic mobility and reduced well-being.¹ One mechanism underlying these adverse consequences could be failure to receive criti...

In the light of US Central Intelligence Agency guidelines that limited routine care of detainees to promote torture, Zackary Berger and colleagues call for sanctions against health professionals who cooperate © Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to.

We discuss the role of prior authorization (PA) in supporting patient-centered care (PCC) by directing health system resources and thus the ability to better meet the needs of individual patients. We begin with an account of PCC as a standard that should be aimed for in patient care. In order to achieve widespread PCC, appropriate resource manageme...

Objectives To revise an existing three-talk model for learning how to achieve shared decision making, and to consult with relevant stakeholders to update and obtain wider engagement. Design Multistage consultation process. Setting Key informant group, communities of interest, and survey of clinical specialties. Participants 19 key informants, 15...

Supplementary information: Previous versions of the three-talk model and study surveys

Background There is substantial variation in the practice of preoperative medical evaluation (PME) and limited evidence for its benefit, which raises concerns about overuse. Surgeons have a unique role in this multidisciplinary practice. The objective of this qualitative study was to explore surgeons’ practices and their beliefs about PME. Methods...

Background: Patient and family engagement (PFE) is critical for patient safety. We systematically reviewed types of PFE strategies implemented and their impact on medication safety. Methods: We searched MEDLINE, EMBASE, reference lists and websites to August 2016. Two investigators independently reviewed all abstracts and articles, and articles...

Objective . Type 2 diabetes is a chronic disease which necessitates the development of a therapeutic alliance between patient and provider. This review systematically examines the association between treatment shared decision-making (SDM) and outcomes in diabetes. Methods . A range of bibliographic databases and gray literature sources was searche...

e21558 Background: Patient-physician communication is important to cancer care. The National Coalition for Cancer Survivorship developed the Know Yourself Tool, a 2-page form, to improve patients’ understanding of goals of care and clinicians’ understanding of patients’ priorities/expectations. We assessed the Tool’s use and usefulness. Methods: Th...

Background: Little is known about how hospitalized patients share decisions with physicians. Methods: We conducted an observational study of patient-doctor communication on an inpatient medicine service among 18 hospitalized patients and 9 physicians. A research assistant (RA) approached newly hospitalized patients and their physicians before mo...

41Background: Patients often face challenges in transitioning to the survivorship stage of cancer care and coordinating with primary care. Prior research has highlighted the uncertainty in who provides survivorship care, leaving patients “lost in transition”. Integrating primary care providers (PCP) into cancer care offers one potential solution. E...

Objective: Ambulatory care safety is of emerging concern, especially in light of recent studies related to diagnostic errors and health information technology-related safety. Safety reporting systems in outpatient care must address the top safety concerns and be practical and simple to use. A registry that can identify common near misses in ambula...

In contemporary bioethics, the autonomy of the patient has assumed considerable importance. Progressing from a more limited notion of informed consent, shared decision making calls upon patients to voice the desires and preferences of their authentic self, engaging in choice among alternatives as a way to exercise deeply held values. One influentia...

Background: Multiple studies have sought to determine variables associated with improved "response" to cardiac resynchronization therapy(CRT). Such variables, however, are often derived from inadequately controlled, single center cohort studies calling external validity into question. We sought to determine predictors of response to CRT-D and CRT-...

Pay-for-value initiatives include both depression and smoking screening. Evaluating how patterns of care differ for an established screening (smoking) versus newer screening (depression) can help programs better implement these measures. Our objective is to evaluate (1) patterns of smoking and depression screening and (2) how patient factors affect...

Objective: To ascertain whether physicians have favorite patients, their experiences with such patients, and how such relationships may influence patients and physicians. Methods: Semi-structured key informant interviews with 25 primary care internists practicing in several clinic settings at a large academic medical center. Results: The term...

Background: Clinicians and patients need updated evidence on the comparative effectiveness and safety of diabetes medications to make informed treatment choices. Purpose: To evaluate the comparative effectiveness and safety of monotherapy (thiazolidinediones, metformin, sulfonylureas, dipeptidyl peptidase-4 [DPP-4] inhibitors, sodium-glucose cot...

Objective: Shared decision making (SDM), an integrative patient-provider communication process emphasizing discussion of scientific evidence and patient/family values, may improve quality care delivery, promote evidence-based practice, and reduce overuse of surgical care. Little is known, however, regarding SDM in elective surgical practice. The p...

We systematically reviewed the effectiveness and safety of continuous subcutaneous insulin infusion (CSII) with insulin analogs compared with multiple daily injections (MDI) in pregnant women with diabetes mellitus. We searched Medline®, Embase®, and the Cochrane Central Register of Controlled Trials through May 2013. Studies comparing CSII with MD...

In shared decision-making (SDM), patient and physician deliberate together on the basis of shared evidence, supporting the patient's choice among multiple options, informed by her values and preferences. One factor complicating the implementation of SDM is uncertainty, which has long been recognized in medicine but perhaps not sufficiently addresse...

Background: Twitter is home to many health professionals who send messages about a variety of health-related topics. Amid concerns about physicians posting inappropriate content online, more in-depth knowledge about these messages is needed to understand health professionals’ behavior on Twitter. Objective: Our goal was to characterize the content...

Effective communication is a health care quality indicator. Patients with a good understanding of their health are likely to be more satisfied with it and more adherent to their treatment plans.¹,2 We sought to examine shared understanding between patients and clinicians in the hospital and how it might affect patient satisfaction. Article Informat...

Background: Clinicians face uncertainty about the prognostic value of troponin testing in patients with chronic kidney disease (CKD) without suspected acute coronary syndrome (ACS). Purpose: To systematically review the literature on troponin testing in patients with CKD without ACS. Data sources: MEDLINE, EMBASE, and the Cochrane Central Regi...

Background: Patients with chronic kidney disease (CKD) have high prevalence of elevated serum troponin levels, which makes diagnosis of acute coronary syndrome (ACS) challenging. Purpose: To evaluate the utility of troponin in ACS diagnosis, treatment, and prognosis among patients with CKD. Data sources: MEDLINE, EMBASE, and the Cochrane Centr...

Background Understanding the experiences of men leaving active surveillance programs is critical to making such programs viable for men with localized prostate cancer. Objective To generate hypotheses about the factors that influence patients’ decisions to leave an active surveillance program. Methods Using data from the Johns Hopkins active s...

Accountable care organizations (ACOs) are proliferating as a solution to the cost crisis in American health care, and already involve as many as 31 million patients. ACOs hold clinicians, group practices, and in many circumstances hospitals financially accountable for reducing expenditures and improving their patients' health outcomes. The structur...

Importance Many people meditate to reduce psychological stress and stress-related health problems. To counsel people appropriately, clinicians need to know what the evidence says about the health benefits of meditation. Objective To determine the efficacy of meditation programs in improving stress-related outcomes (anxiety, depression, stress/dis...

Patient-centeredness is central to healthcare. Hospitals should address patients' unique needs to improve safety and quality. Patient engagement in healthcare, which may help prevent adverse events, can be approached as an independent patient safety practice (PSP) or as part of a multifactorial PSP. This review examines how interventions encouragin...

Purpose: Public reporting (PR) of the costs and quality of healthcare providers was a feature of healthcare reforms in the US aimed at reducing healthcare disparities. While no evidence currently linking PR and disparities in outcomes, we aimed to synthesize a broader set of evidence, including subjective claims to better understand the potential i...

Fortuna et al.1 assess and compare the effectiveness of phone, mail, and personal reminders as methods to improve rates of breast and colorectal cancer screening in an underserved population. Compared to reminder letters alone, cancer screening rates were increased with the addition of reminders at the point of care or a personalized phone call. Ho...

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Providers and patients bring different understandings of health and disease to their encounters in the hospital setting. The literature to date only infrequently addresses patient and provider concordance on the reported reason for hospitalization, that is, whether they express this reason in similar ways. An agreement or common ground between such...

To review important patient safety practices for evidence of effectiveness, implementation, and adoption. Searches of multiple computerized databases, gray literature, and the judgments of a 20-member panel of patient safety stakeholders. The judgments of the stakeholders were used to prioritize patient safety practices for review, and to select wh...

Background: Patients with diabetes mellitus need information about the effectiveness of innovations in insulin delivery and glucose monitoring. Purpose: To review how intensive insulin therapy (multiple daily injections [MDI] vs. rapid-acting analogue-based continuous subcutaneous insulin infusion [CSII]) or method of monitoring (self-monitoring...

An initiative of the National Physicians Alliance, the project titled "Promoting Good Stewardship in Clinical Practice," developed a list of the top 5 activities in primary care for which changes in practice could lead to higher-quality care and better use of finite clinical resources. One of the top 5 recommendations was "Don't do imaging for low...

The main objective of the report is to review the evidence on the impact of health information technology (IT) that supports patient-centered care (PCC) on: health care processes; clinical outcomes; intermediate outcomes (patient or provider satisfaction, health knowledge and behavior, and cost); responsiveness to needs and preferences of patients;...

Background: Physicians can adhere to the principles of professionalism by practicing high-quality, evidence-based care and advocating for just and cost-effective distribution of finite clinical resources. To promote these principles, the National Physicians Alliance (NPA) initiated a project titled "Promoting Good Stewardship in Clinical Practice"...

Bayesian and frequentist approaches to statistical modelling in epidemiology are often pitted against each other as if they represented diametrically opposing philosophies. However, both approaches have a role to play in clinical epidemiology and the evaluation of clinical practice. Here I present an overview of the philosophical underpinnings of t...

“Progress in Bioethics” is an ambiguous title. I expect the ambiguity was intended. This is an informative, helpful, and even-tempered collection of essays about bioethics that concern themselves both with political philosophy (progressivism) and with liberal critiques of “progress” as a continuing assumption of biomedicine. The tension between pro...

Background: Nonadherence to asthma medications is associated with increased emergency department visits and hospitalizations. If adherence is to be improved, first-fill adherence is the first goal to meet after the physician and patient have decided to begin treatment. Little is known about first-fill adherence with asthma medications and the facto...

We used an interviewer-administered questionnaire to investigate workplace exacerbation of asthma symptoms (WEAS) among low-income, minority, working asthmatics admitted Bellevue Hospital Center in New York City from 2001 to 2002. We hypothesized that a high prevalence of WEAS would be found in this population among all jobs held and a subset of in...