David A Fleming

University of Missouri, Columbia, MO, United States

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Publications (29)

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    [Show abstract] [Hide abstract] ABSTRACT: Most current dental ethics curricula use a deontological approach to biomedical and dental ethics that emphasizes adherence to duties and principles as properties that determine whether an act is ethical. But the actual ethical orientation of students is typically unknown. The purpose of the current study was to determine the ethical orientation of dental students in resolving clinical ethical dilemmas. First-year students from one school were invited to participate in an electronic survey that included eight vignettes featuring ethical conflicts common to the health care setting. The Multidimensional Ethics Scale was used to evaluate the students’ ethical judgments of these conflicts. Students rated each vignette along 13 ethically relevant items using a 7-point scale. Nine of the thirteen items were analyzed because they represent the dominant ethical theories, including deontology. One hundred sixteen dental students successfully completed the survey. Of the analyzed items, those associated with deontology had comparatively weak associations with whether students judged the action to be ethical and whether students judged themselves likely to perform the action. Whether an action was judged to be caring had the strongest association with whether the action was judged to be ethical and whether students judged themselves likely to perform the action. These results suggest that adherence to duties or principles has weaker association with students’ ethical judgments and behavior compared to caring, which was found to be more influential in their ethical judgments and behavior. Current dental school curricula with a primary focus on deontology may not adequately prepare students to maintain ethical attitudes and behavior in practice.
    Full-text Article · Mar 2016
  • Robert M Centor · David A Fleming · Darilyn V Moyer
    Article · Jan 2015 · Annals of internal medicine
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    Blake C Corcoran · Lea Brandt · David A Fleming · Chris N Gu
    [Show abstract] [Hide abstract] ABSTRACT: As a medical student, I observed that different physicians had strikingly different attitudes and approaches when caring for patients. The care of one patient in particular continues to challenge my understanding of illness and moral responsibility in the practice of medicine. In this paper, I illustrate the care of this patient in order to evaluate the dominant ethics I was taught in medical school, in theory and in practice, and argue neither principlism nor the ethics of care fully captures the moral responsibility of physicians. Emphasising fidelity to the healing relationship, a core principle derived from Pellegrino's virtue theory, I conclude that this approach to clinical ethics fully explains physician responsibility. Pellegrino deconstructs the practice of medicine to clarify the moral event within the clinical encounter and offers a sufficiently useful and justified approach to patient care.
    Full-text Article · Jul 2014 · Journal of Medical Ethics
  • Saket A Kottewar · Dilip Bearelly · Smith Bearelly · [...] · David A Fleming
    Article · May 2014 · Journal of palliative medicine
  • Robert M Centor · David A Fleming · Darilyn V Moyer
    Article · May 2014 · Annals of internal medicine
  • [Show abstract] [Hide abstract] ABSTRACT: The purpose of this study is to determine the prevalence of diabetes distress and its relationship with health behaviours and clinical outcomes in low-income patients. Secondary analyses were conducted using baseline data from a clinical trial evaluating a diabetes self-management intervention. Interviews were conducted with 666 participants receiving care at nine safety net clinics in Missouri. Distress was measured using the Diabetes Distress Scale, and outcomes included medication adherence, physical activity, nutrition and clinical biomarkers (haemoglobin A1C (HbA1C), blood pressure, low-density lipoprotein (LDL) cholesterol). In a sample of 666 participants, 14.1% and 27.3% of patients were identified as highly and moderately distressed, respectively, with higher rates among younger, female and lower income patients. When compared with moderately and no distress groups, highly distressed patients were less adherent to medications (20.7% vs 29.9% vs 39.4%, p<0.001) and had higher HbA1C values (9.3% (SD=2.0) vs 8.2% (SD=1.8) vs 7.8% (SD=1.7), p<0.001), diastolic blood pressure (81.8 (SD=9.4) vs 80.2 (9.7) vs 78.9 (SD=8.8), p=0.02) and LDL cholesterol (104.6 (SD=42.4) vs 97.2 (34.3) vs 95.5 (37.9)) In multivariable analyses, high and moderate distress were associated with lower medication adherence (OR=0.44; 0.27 to 0.23, p=0.001) and (OR=0.58; 0.42 to 0.79; p=0.001), respectively, and higher HbA1C in only the highly distressed group (B=1.3; 0.81 to 1.85; p<0.001) compared with the no distress group. Diabetes distress is prevalent and linked to poorer adherence to health behaviours and glycemic control in a sample of patients receiving care from low-income clinics.
    Article · Jan 2014 · Journal of epidemiology and community health
  • [Show abstract] [Hide abstract] ABSTRACT: We compared two implementation approaches for a health literacy diabetes intervention designed for community health centers. A quasi-experimental, clinic-randomized evaluation was conducted at six community health centers from rural, suburban, and urban locations in Missouri between August 2008 and January 2010. In all, 486 adult patients with type 2 diabetes mellitus participated. Clinics were set up to implement either: 1) a clinic-based approach that involved practice re-design to routinely provide brief diabetes education and counseling services, set action-plans, and perform follow-up without additional financial resources [CARVE-IN]; or 2) an outsourced approach where clinics referred patients to a telephone-based diabetes educator for the same services [CARVE-OUT]. The fidelity of each intervention was determined by the number of contacts with patients, self-report of services received, and patient satisfaction. Intervention effectiveness was investigated by assessing patient knowledge, self-efficacy, health behaviors, and clinical outcomes. Carve-out patients received on average 4.3 contacts (SD = 2.2) from the telephone-based diabetes educator versus 1.7 contacts (SD = 2.0) from the clinic nurse in the carve-in arm (p < 0.001). They were also more likely to recall setting action plans and rated the process more positively than carve-in patients (p < 0.001). Few differences in diabetes knowledge, self-efficacy, or health behaviors were found between the two approaches. However, clinical outcomes did vary in multivariable analyses; carve-out patients had a lower HbA1c (β = -0.31, 95 % CI -0.56 to -0.06, p = 0.02), systolic blood pressure (β = -3.65, 95 % CI -6.39 to -0.90, p = 0.01), and low-density lipoprotein (LDL) cholesterol (β = -7.96, 95 % CI -10.08 to -5.83, p < 0.001) at 6 months. An outsourced diabetes education and counseling approach for community health centers appears more feasible than clinic-based models. Patients receiving the carve-out strategy also demonstrated better clinical outcomes compared to those receiving the carve-in approach. Study limitations and unclear causal mechanisms explaining change in patient behavior suggest that further research is needed.
    Article · Sep 2013 · Journal of General Internal Medicine
  • David A Fleming · Lois Snyder Sulmasy
    [Show abstract] [Hide abstract] ABSTRACT: To the Editor: We read with interest the Viewpoint by Drs Tilburt and Cassel1 on the ethics of parsimonious medicine vs rationing. We agree that parsimonious medical care should be distinguished from rationing and that parsimony is a virtue to which all physicians should strive in the practice of medicine.2However, we disagree with the statement in the article that “Both parsimonious medicine and rationing aim to reduce resource use.” The aim of medical parsimony is to provide the care necessary for the patient's good, not to reduce resource use (although it may in addition preserve resources3)—a difference in intention that helps form the foundation for the ethical distinction between parsimonious medicine and rationing.
    Article · Jun 2013 · JAMA The Journal of the American Medical Association
  • Karen E Edison · David A Fleming · Elizabeth Lewis Nieman · [...] · George Demiris
    [Show abstract] [Hide abstract] ABSTRACT: Background: The body of research is rapidly growing regarding the use of telemedicine in patient care, including cost-effectiveness, patient access, patient outcomes, etc. Less has been done describing physician communication during different aspects of the clinical visit (i.e., education, assessment, treatment, etc.) during actual versus virtual patient visits. The purpose of this study was to evaluate dermatology healthcare providers' communication via both modalities with regard to content and style. Subjects and methods: In-person and teledermatology patient visits were observed, audio-recorded, and transcribed over an 8-month period. A content analysis was performed. Results: The Wilcoxon rank sum test was used to compare the content differences between visit modalities for each category. A p value of 0.05 was considered as significant for all tests. There were no statistically significant differences between modalities in the average number of physician words in seven of eight communication categories: small talk, clinical assessment, psychosocial issues, patient education, patient compliance, patient treatment, and administrative issues (p value range, 0.16-0.91). As well, the same communication themes occurred in each modality to essentially the same degree. For instance, assessment and discussion of treatment occurred in 100% of in-person and teledermatology visits, as did small talk. Conclusions: This research indicates that physician providers communicate with similar style and content whether using teledermatology or in-person.
    Article · May 2013 · Telemedicine and e-Health
  • Win Phillips · David A Fleming
    [Show abstract] [Hide abstract] ABSTRACT: One might argue that beneficence entails a moral obligation for health care providers and systems to adopt electronic medical records (EMR). But this argument is thwarted because EMR systems are currently not required to meet existing standards of care for health care services. Yet using EMR systems may still be prudent if benefits of adoption significantly outweigh burdens. Future moral questions regarding EMR systems will shift from obligations of adoption to that of proper use.
    Article · Jul 2010 · Missouri medicine
  • Dominic E Sanford · David A Fleming
    [Show abstract] [Hide abstract] ABSTRACT: This essay explores the unique perspective of medical students regarding the ethical challenges of providing full disclosure to patients and their families when medical mistakes are made, especially when such mistakes lead to tragic outcomes. This narrative underscores core precepts of the healing profession, challenging the health care team to be open and truthful, even when doing so is uncomfortable. This account also reminds us that nonabandonment is an obligation that assumes accountability for one's actions in the healing relationship and that apologizing for mistakes can serve to heal. It argues that even medical students have an obligation to speak up when actions violate their moral beliefs, even if this means confronting a superior. Ethical principles cannot be abandoned in fear of adverse evaluation or failure to conform. Healthcare workers have an obligation to address mistakes made around the time of a patient's death with the patient's family. This responsibility trumps any selfish desire to avoid unpleasant feelings of guilt or regret. Such events often bring closure to already anguished relatives and spouses, and may help to facilitate the grieving process. This includes pressing forward the need to apologize to patients and/or their families when mistakes are made and when decisions are made that lead to poor outcomes for the patient, even when benevolently intended.
    Article · Jun 2010 · HEC Forum
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    Lanis L Hicks · David A Fleming · Adam Desaulnier
    [Show abstract] [Hide abstract] ABSTRACT: The objective of this study was to evaluate the impact of remote monitoring home telehealth on client and provider satisfaction, clinical outcomes, and cost. The project design was a pragmatic evaluation of the technology in a real-world setting at an operational scale rather than a controlled clinical trial. Patients receiving monitoring were selected by the home health agency, and a random sample of other agency clients was selected for comparative purposes. Data were collected on additional costs and benefits associated with home telehealth monitoring. Quantitative and qualitative data suggest that when remote monitoring telehealth technology was utilized in the home-care setting, both clients and providers were very satisfied with services; they felt it was easy to communicate, and that the technology was convenient and user friendly. Clients also felt that home telehealth technology had a very positive impact on the provider-client relationship and improved care. The study also suggests that home care monitoring reduces hospitalizations and decreases personnel expenses. This preliminary study provides evidence as to the value of remote monitoring home telehealth in the delivery of services to home care populations. It also provides evidence as to the positive impact that this form of technology may have on healthcare systems, provider and client satisfaction, and on the relationships that form between providers and clients.
    Full-text Article · Sep 2009 · Telemedicine and e-Health
  • Win Phillips · David Fleming
    [Show abstract] [Hide abstract] ABSTRACT: The use of electronic medical record systems raises important ethical concerns about patient privacy and confidentiality, medical errors, expectations of structured data entry by clinicians, documentation integrity, and provider-patient interaction. Clinicians and health care organizations need to define best practices and policies in the use of EMR systems to improve quality and maintain clinician efficiency without compromising patient welfare and safety.
    Article · Sep 2009 · Missouri medicine
  • David A Fleming · Karen E Edison · Hon Pak
    [Show abstract] [Hide abstract] ABSTRACT: The ethical implications of telehealth go well beyond providers' obligations to ensure privacy and confidentiality. The ethical conundrum of telehealth realizes the uniquely positive impact that telehealth can have on patients, providers, and clinical outcomes, as well as the potential for harm and abuse that may ensue. This article explores telehealth as one of many evolving information technologies that have ethical questions extending well beyond the confines of privacy and confidentiality. Providers and systems who utilize telehealth should also consider how it influences relationships with patients, access to healthcare, capacity for equitable treatment, cost, and quality of life. The ability to respond to these concerns will be important to the future development and deployment of this important technology as one means by which to improve access and quality of healthcare for all members of our society.
    Article · Sep 2009 · Telemedicine and e-Health
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    Full-text Article · Jun 2009 · Clinical Infectious Diseases
  • David A Fleming · Shari L Riley · Sue Boren · [...] · Charles S Brooks
    [Show abstract] [Hide abstract] ABSTRACT: Research is yet to fully examine the utility and effectiveness of telehealth in primary care resident ambulatory training. This study examined the attitudes of preceptors, residents, and nurses on (1) the impact of telehealth on healthcare; (2) the impact of telehealth on the work activity of resident clinics; (3) the impact of telehealth on resident training in the outpatient setting; and (4) the impact of telehealth on relationships. There were three focus groups, one each of preceptors (N = 5), residents (N = 10), nurses (N = 7). Eight focus group themes evolved regarding the use of telehealth in the resident clinic: (1) impact on patient/provider relationships; (2) consistent with the values of those using telehealth; (3) logistics; (4) reduces patient transfers; (5) appropriate level of care; (6) reimbursement concerns; (7) psychological risk; and (8) impact on resident/attending relationships. Though as yet not generalizable, results of this pilot study suggest that there is general acceptability of telehealth in ambulatory resident training settings, but there is concern about the impact that telehealth may have on relationships, logistics, finances, and the need to see patients face-to-face when there is greater complexity.
    Article · May 2009 · Telemedicine and e-Health
  • Don Reynolds · David A Fleming
    Article · Mar 2009 · The American Journal of Bioethics
  • David A Fleming · Don Reynolds
    Article · Dec 2008 · The American Journal of Bioethics
  • Cheryl Rathert · David A Fleming
    [Show abstract] [Hide abstract] ABSTRACT: Health care delivery teams have received much attention in recent years from researchers and practitioners. Recent empirical research has demonstrated that objective and subjective outcomes tend to be improved when care teams function smoothly and efficiently. However, little is known about how the work environment, or care context, influences team processes that lead to better outcomes. The purposes of this study were to explore acute care staff's perceptions of how two components of the work environment, the ethical climate and continuous quality improvement leadership, influence teamwork and to begin to identify actionable approaches for improving teamwork. Although ethical climate influences have been studied in several sectors, research is lacking in health care. A cross-sectional field study explored how the ethical climate impacted teamwork in an acute care setting and how continuous quality improvement leadership behaviors moderated the relationship between the ethical climate and teamwork. Results indicated that clinicians who perceived the ethical climate to be benevolent were significantly more likely to say that teamwork was better. Furthermore, we found that continuous quality improvement leadership styles moderated the relationship between the ethical climate and teamwork. Although a benevolent ethical climate appears to be associated with effective teamwork, it appears that the proximate continuous quality improvement behaviors exhibited by leaders have a significant impact as well, above and beyond the climate. Implications for research and practice are discussed.
    Article · Oct 2008 · Health care management review
  • David A Fleming · Don Reynolds
    Article · Apr 2008 · The American Journal of Bioethics