Data analyses were conducted using grounded theory methods and revealed a fundamental mismatch between the information provided by GCs and the information desired and meaningful to patients. Several components of the communication that contributed to this mismatch and often resulted in ineffective communication included: (1) too much information; (2) complex terminology and conceptually difficult presentation of information; (3) information perceived as not relevant by the patient; (4) unintentional inhibition of patient engagement and question-asking; (5) vague discussions of screening and prevention recommendations. Our findings indicate a need to transform the standard model of genetic counseling communication using evidence-based principles and strategies from other fields of Medicine. The high rates of limited health literacy in the US, increasing access of diverse populations to genetic services, and growing complexity of genetic information have created a perfect storm. If not directly addressed, this convergence is likely to exacerbate health disparities in the genomic age.As genetics and genomics become part of mainstream Medicine, these advances have the potential to reduce or exacerbate health disparities. Gaps in effective communication  are widely recognized as a major contributor to health disparities. The purpose of this study was to examine GC-patient communication in real time, to assess its effectiveness from the patient perspective, and then to pilot intervention strategies to improve the communication. We observed 64 English-, 35 Spanish- and 25 Chinese-speaking ( As genetics and genomics become part of mainstream Medicine, these advances have the potential to reduce or exacerbate health disparities. Hereditary cancer services are becoming more accessible to a broader cross-section of the US population as criteria for cancer genetic services expand, insurance coverage increases, and costs go down. Yet access alone is not sufficient to ensure high quality GC and appropriate testing. Gaps in effective communication  are widely recognized as a major contributor to health disparities  or basic (skills necessary to perform simple and everyday literacy activities) literacy , meaning they have genomic health literacy  have been well documented , we conducted direct observations at two public county hospitals in large metropolitan areas of California where nearly all patients have Medicaid or Medicare or are uninsured. Masters level licensed GCs provided counseling and testing, which was available to patients free of charge through a variety of means, including Medi-Cal , Medicare, county health programs, laboratory hardship programs and foundation support.At Site 1, GCs who specialize in cancer see patients independently. Patients are referred through community clinics and the hospital’s mammography, primary care, and oncology clinics. GCs typically see a patient two or three times: (1) a pre-test appointment to discuss family history, assess risk, and educate about hereditary cancer and genetic testing; (2) a second pre-test appointment to update pedigree with additional information if requested by the GC, review risk assessment and pre-test education, and draw blood/collect saliva; (3) a results appointment to discuss implications of test results for patient and family, and screening/prevention options. Some positive patients also return for a follow-up appointment. Medical interpretation is provided remotely by phone or video.At Site 2, GCs are generalists who see patients with the support of an MD geneticist who was sometimes consulted during the visit or joined the GC for part of the visit. Patients are referred through oncology and primary care. GCs typically see patients for a pre-test appointment to assess risk and draw blood, and call the patient with test results. Patients with positive or variant of uncertain significance (VUS) results are invited for an in-person follow-up appointment. Medical interpretation is provided remotely by phone.Association for Molecular Pathology v. Myriad Genetics), we expanded our criteria to include patients suspected of having Lynch and other hereditary cancer syndromes who were frequently being offered the same panel test. Except for the occasions when a patient declined participation or asked not to be recorded, the researcher directly observed and audio-recorded patient-genetic counselor appointments. Spanish and English speakers rarely declined to be audio recorded; in contrast, 12 of 40 observed Chinese participants did not consent to be recorded. The researcher took detailed field notes to record the dynamics of each session, communication challenges, emotional tenor, body language, etc.   during 170 GC sessions with 10 GCs at the two sites. Sessions included pre-test, results and results follow up appointments. We invited all 49 patients who were offered testing to participate in an interview, and all accepted either after the pre-test or results appointment. (See Table We observed English- (64), Spanish- (35) and Chinese-speaking (25) patients  = 3.28, p < .05  in a sample with higher levels of education .Demographic characteristics of the interviewed patients are in Table F , 44 = 3.05 Table  reportedTable Too much InformationA key component of the mismatch we identified was in the amount of information patients wanted compared with what GCs provided. While GCs are trained to provide education about genetics, we found that in the context of long explanations of heredity, genetics and genetic testing, counselors’ key messages often got lost and patients felt overwhelmed. In the following example, the GC offered “background” information that involved technical terminology , an analogy (“a gene is like an instruction book”), and complex scientific concepts .Through analysis of the observations and interviews, we identified a fundamental mismatch of patient information needs and information provided by counselors Table . Here we(Audio Playback of Counseling Session during Interview)GC: We have our genetic material in our body and we have, we actually have two copies of every gene, a gene being an instruction that keeps our body working properly, the cells working properly. When they need to, they make new cells or when they need to die, they die. So, cells are normally dying and growing at one time. So there are certain genes that regulate that process, that make sure that the cells grow and die at the right time and they don't form tumor cells.(Interview)Interviewer: What did you understand about that?Participant: I just understood about the genes, that we only have two genes and how some eventually die and how one can still function with one. That's all that I really understood. .Rather than clarifying, the background information confused the patient and obscured the main point that the GC wanted to convey about how cancer may be inherited.(Audio Playback of Counseling Session during Interview)GC: …so if it's something that you're interested in, we could get it started today. But if it's something that you don't know if you would be interested in, you could take time to think about it. Okay?Patient: I like [to] take time to think about it.GC: Okay, you're not sure if you want the test, the blood test?Patient: Mm-hm.GC: Okay. Tell me more. Tell me what--what are your thoughts?Patient: The only problem is I don't like--I don't like the needles, so I just been like two times yesterday, today. So, I don't want no more today.GC: Okay.... how important is this kind of information to you, though? Like to know if there is a genetic reason why you have cancer?(Interview)Interviewer: What were you thinking there when she asked you that?Patient: Well, I didn't know how important because the truth is-- all of this was just like-- Ah! Too much information sometimes. So really... I knew and I know that it is important, but at that moment it was like, this is too much right now. Let me go home. [ENG/SP-65 Pre-test].2.Complex Terminology and Conceptually Difficult Presentation of Informationmutación vs. mutilación). This 62 year-old bilingual Latina struggled with the technical terminology.I really didn't pick up too much. I just feel that sometimes doctors go in and they're using all these words and stuff. No. Tell me layman’s terms, because I'm not dumb, but something like that I don't really understand. [28-ENG/SP Pre-test]The complex terminology used by GCs and the use of conceptually complex linguistic constructions like analogies and hypotheticals contributed to patients’ misunderstanding and overwhelm. GCs used many specialized terms, including “genes”, “hereditary”, “BRCA”, “chromosome”, “deleterious”, “genetic factors”, “predisposition”, “risk”, “sporadic”, “mutation”, and “variant”. Even “genetic counselor” was a confusing term for many who had never heard it prior to being referred. “Mutation” presented particular challenges. Although counselors described “mutation” as a “change in a gene,” and then used the term interchangeably with “change,” many patients did not understand it. In the context of breast cancer treatments in which mastectomy can easily be perceived as a form of mutilation, several Spanish speakers confused the less familiar “mutation” with the more familiar “mutilation” ” indicates a point in the conversation where the GC paused to allow the medical interpreter to translate the counselor’s speech into Spanish).Audio Recording:Interpreter) and that would tell us, does she have a change in those genes that had contributed to her breast cancer? But because she is not alive that’s not a test we can obviously do. (Interpreter) So what we will do is we will go ahead and look at your BRCA1 and BRCA2 genes. (Interpreter) If we see a mutation then we would just make the assumption that you had inherited that mutation from your mother. (Interpreter) So, if your test comes back normal, meaning both genes are just the way they're supposed to be, there's no mutation, that's good news. But we still, interpret that with a little bit of caution. (Interpreter) …let's say your mom did have a mutation on one of these genes, let's say BRCA1 gene, we have two copies of every gene, because we get one from our mother and one from our father. (Interpreter) So if your mother carried a copy of this gene with a mutation, every time she'd have a child, it's a fifty-fifty chance whether she passed on the copy that causes the higher risk of cancer, or the normal copy... (Interpreter).GC: …The best way for us to figure out if it’s genetic would have been to actually test your mom and look at her two BRCA genes . While some patients could relate to and understand these analogies, for others lack of cultural or linguistic equivalence made them meaningless. In the following example, the medical interpreter anticipated the potential for confusion on the part of a Spanish-speaking patient.3.Information Perceived as not Relevant by the PatientAlthough the interpreter tried to guide her, the GC continued to try to use the spellcheck analogy. This patient never returned to the clinic after this appointment, and never responded to our attempts to reach her for an interview.And chromosomes. Those were really kind of fascinating but it wasn't something that I really wanted to see. I just wanted to know how it [the test] was going to benefit me… I think the bottom line is, I just want to know at what percentage rate is it going to come back. [ENG-33 Pre-test].As the previous two themes suggest, patients wanted information that was simpler, narrower in scope, and more directly relevant to their immediate situation than what GCs provided Table . Most imIt wasn’t because of the interpreter, nor was it because the topic was too complicated. It mainly depends on if I think the information…has any impact on me. It’s like when I take a test I only want to know the score. I don’t care about anything else, plus I don’t even remember those other things. …Anything else just doesn’t stick in my mind. [CHI-16 Results].Importantly, this patient did not understand that the main purpose of the test was to determine her risk for new cancers of the breast and the ovary rather than risk of recurrence. Similarly, a 46-year-old monolingual Cantonese speaker with breast cancer said she only wanted to hear about the test results. She wasn’t interested in how the test works, what it examines or how the GC makes her risk assessment. As a result, that information did not “stick”.I only wanted to know the results. Yeah, I mean I don’t understand these kinds of things. I don’t know what they do inside. I can’t change that fact…I don’t know anything about how genes mutate. They are inside our bodies. I can’t control them and I don’t know what I can do. There’s nothing I can do. [CHI-16 Results].The details about genetics were beyond her comprehension and interest, and therefore not relevant to her treatment or prevention decision-making. When asked later in the interview about her understanding of “mutation,” she replied:4.Unintentional Inhibition of Patient Engagement and Question-AskingDespite not understanding much of what was said in their GC appointments, many patients did not ask substantive questions, and counselors often were unable to bridge this gap. While counselors frequently asked if patients had any questions, or if they were following the explanation, these patients typically said they had no questions or that they understood. For this bilingual Latina, the GC’s pace and use of technical language led her to believe she would not understand even if she asked a question.Again, the details about mutations and genes were of no interest to her, given that they were beyond her understanding and control.Patient: …Another thing, she can speak fast in English, but how does she make sure we understood? Even if she asks [if we understand], most likely we're going to say “yes”. So the term genetics, medical terminology sometimes a person with less knowledge isn't going to understand anything…my daughter and I have gone to school and have a certain level of education …So, this is what I can tell you really happened that day. Because I'm even listening to it right now and I don't understand.Interviewer: What was the reason that you didn't ask her to, for example, repeat the information?Patient: I didn't ask her to repeat the information because even if she were to repeat it, I probably wouldn't have understood again for the same reason because there is vocabulary that's not in my, in my chip. (LAUGHS) [SP-4 Pre-test].Other patients did not ask questions because they did not know what to ask or how to formulate the question. During our interview with this Cantonese-speaking 70 year-old, she wondered why she got breast cancer in the absence of a genetic mutation. Although the GC asked if she had any questions, the patient had declined to ask because she did not know how she was “supposed” to engage with a provider.Patient: They said that I didn’t particularly have a greater chance than other people in getting cancer. The fact that I did get cancer, is it because of my mood, the food that I eat, the air that I breathe, or other factors? If that’s true, then everyone has a chance of getting cancer.Interviewer: Did you ask [the genetic counselor] this question last time?Patient: No. I didn’t know how to ask. Sometimes when I’m asked if I have any questions, I do not know what questions I’m supposed to ask. [CHI-11 Results]Occasionally, when patients did ask questions, we sometimes observed that counselors provided indirect answers or attempted to explain the context, rather than answering directly and clearly, as in the case of this ATM carrier.Audio RecordingPatient: Do you think, in my lifetime, what's the chance that I'm going to--GC: --Develop breast cancer? That's a great question.Patient: Yes.GC: So, twelve or thirteen percent is the average woman. The one that you don't have that we were really worried about was like the eighty, eighty-five percent lifetime risk. For ATM carriers like you, it's about twenty-five to thirty-five percent.InterviewInterviewer: So, what does it mean the percentage that she gave you, between twenty-five and thirty-five? What does that number mean to you, to you?Patient: Means that I have thirty-five percent of chance, twenty-five, thirty-five percent to be in this case on the, the pool, the gene pool of cancer. You know. That's what I understood. She, she, she spoke very technically, you know?Interviewer: Mm-hm.Patient: Like, if someone been trained. But I've not been trained for that. So, yeah. She's supposed to be, be very plain, simple. Of course facts, but more the language that I understand. Not the language, you know. [ENG-59 Results].5.Vague Discussions of Screening and Prevention RecommendationsIn contrast to much of the counseling content described above, GCs and patients found more common ground on the topic of risk reduction through screening and prevention options for the patient and her family. Yet, our interviews revealed that many patients left their results appointments with no clear understanding of what to do next. For example, GCs frequently used general terminology such as “breast exams” which patients understood as mammography, rather than the complete range of exams including a clinical breast exam, mammography and MRI that the GCs intended to convey. Patients often forgot or did not completely understand recommendations for the age to start screening and the specific type of screening for patients and their relatives.One patient who had been diagnosed with Lynch syndrome did not understand the nature of the syndrome or the difference between risk of metastasis and the risk of new primary cancers; thus she saw no reason to undergo a hysterectomy.Although the counselor’s response was clearly intended to contextualize the patient’s risk as between average population risk and high risk, the patient, who spoke English as a second language, found the explanation too technical.Patient: Right. She recommended that I remove my uterus, but I didn’t want to.Interviewer: Why do you think she recommended you to remove it?Patient: Well if I remove it, then [the cancer] wouldn’t go there. I didn’t think it was necessary, since it can go anywhere. If it doesn’t go to the uterus, it will go to the ovaries and my ovaries are in the same area. I don’t think it’s necessary. [9-CHI Results].Walking away from the appointment, I was definitely feeling overwhelmed and just the idea that I should find a doctor who knows me and like gets to know me and I can have this relationship with over these years. …I was kind of thrown off by this idea of getting regular screenings…I like the idea of doing that but it felt like intimidating or kind of impossible or that I would really need to change my lifestyle to benefit my health in that way. … Realistically I’ll probably just do it every year. [ENG-17 Results].Other participants who did understand the recommendation were not confident that they would be able to obtain the recommended care. One 30-year-old unaffected BRCA+ patient explained how she felt about the counselor’s recommendations after her results appointment:She recognized that the recommended follow-up care, including screening by alternating MRI and mammogram every six months, presumed consistent access to health care and an ongoing relationship with a provider, but she had never had either. As a result, she was resigned to annual screening, rather than the recommended six-month interval.This study of cancer risk counseling communication with diverse public hospital patients documented a mismatch between the information provided by counselors and what patients want and need to know. We found that patients preferred less information overall than counselors typically delivered, and they wanted it in a form that was less conceptually and linguistically complex. The quantity and form of information delivery unintentionally inhibited patient engagement and question asking. As a result, patients’ fundamental questions were sometimes left unanswered despite the counselors’ best intentions. These findings reflect the experiences of English-, Spanish- and Chinese-speaking participants in our study, even though English speakers had a higher educational level overall compared with Spanish and Chinese speakers and higher SNS than the Spanish speakers in our study.how they make the risk assessment, the underlying biology of cancer heredity, and the technical process of genetic testing . A full examination of the perspectives of the GCs in our study is beyond the scope of this paper, but will be reported in a subsequent publication. Cultural issues specific to Latina and Chinese immigrant patients, and communication challenges specific to medical interpretation also will be described in subsequent publications.Expanding testing criteria, health care reform, and reduced costs are making counseling and testing available to many more patients of LHL, LEP, and diverse cultural backgrounds. Going forward, the All of Us Research Program (formerly known as the Precision Medicine Initiative) and other NIH initiatives that require inclusion of diverse populations in genomic research will expose broad segments of the US population to genomic medicine. Although inequities in utilization of cancer genetic testing persist  tailored pre-counseling educational materials to support patients coming to genetic counseling with little or no prior knowledge of counseling or testing (Joseph et al. Our findings indicate a need to transform the standard model of genetic counseling communication to adapt to the communication needs of patients. The high rates of LHL in the US, increasing access of diverse populations to genetic services, and growing complexity of genetic information have created a perfect storm. If not directly addressed, this convergence is likely to exacerbate health disparities in the genomic age.


The “gamification” of science has gained a lot of traction in recent years, and games that convey scientific concepts or themes are increasingly popular. While a number of existing games touch on microbiology, very few consider the beneficial  aspects of microbes. We designed a board game called “Gut Check: The Microbiome Game” to fill this gap. The game is meant to be both educational as well as challenging and fun. Here we discuss the development of the game, some of the logistics of game development in this context, and offer suggestions for others thinking of similar projects. Making science more accessible and interesting to the public through the process of “gamification” has become increasingly popular in recent years . GamificRecently, “gamification” has also been applied to get players to interact with real-life biological systems, a concept known as “biotic games” –9. TheseOverall, the vast majority of educational literature on games relates only to video or computer games e.g., –13). Non. Non13])Timeline [Evolution [Voyager: Satellites [Control-Alt-Hack [ChemMend [Go Extinct! [KEEP COOL [Parasites Unleashed [We think it is important to make a distinction between science-based games (those that use scientific concepts or ideas as part of their theme or mechanics) and science pedagogy games . Examples of science-based games include Timeline , which avolution , which atellites   focus on pathogens (“bad” microbes) and what can be viewed as the negative aspects of microbiology. From spreading the plague, to zombie-inducing viruses, to global pandemics, microbes are a popular antagonist. While this approach meshes with a common negative perception of microbes, it does not accurately represent the fact that microbes can have beneficial effects on other organisms. Beneficial microbes play critical (but largely underappreciated) roles in diverse areas from human health to agriculture to the global carbon cycle to animal behavior.Our goal was to create a science pedagogy game that would be challenging and interesting to play, require strategic thinking, and also educate people about nonpathogenic microbes. Our intended target audience was high school students and undergraduates with an interest in biology (though in fact the game has been popular with children as young as six). We chose to focus on the human microbiome—the collection of microbes that live in and on people, including the dangerous, the beneficial, and everything in between. The result is Gut Check: The Microbiome Game , availabIn Gut Check, players compete to develop a healthy microbiome for themselves as well as disrupt their opponents’ efforts. The game gives players the ability to play pathogens , beneficial  microbes, and numerous opportunistic microbes (microbes that can be “good” or “bad” depending on context). Many concepts from microbiology make an appearance, including antibiotic resistance, lateral gene transfer (the movement of genes from one species to another), hospital-acquired infections, probiotics , prebiotics , and fecal transplants . A basic game takes around 30 minutes with experienced players, and optimal play involves cycling cards, choosing where to play microbes, timing various events, and deciding whether to foster your own efforts  or interfere with your opponents.As part of the design and development process, we did playtesting with both gamers  and biologists in order to develop the twin goals of education and player engagement. These different perspectives were invaluable and highlighted the challenge of educational game design. For example, a microbiologist might ask “why does a fecal transplant  cause you to lose health?” whereas a gamer would respond “because otherwise the card is too powerful to be balanced ”. Conversely more than a couple of gamers asked about the utility of the lateral gene transfer card, but the application of transferring antibiotic resistance from a beneficial to a pathogenic microbe is intuitive to a microbiologist.Clostridium difficile, responsible for numerous fatal hospital-acquired infections) or their likelihood to be recognized by nonscientists . However, most of the playtesting was done with the beneficial microbe cards labeled as “Good Bug #2” or “Opportunistic Bug #4” or such. Finding real-world equivalents that had been shown to behave like their in-game counterparts turned out to be challenging. In early versions of the game, there were microbes that allowed a player to digest lactose, grains, or meat. While we were able to find plausible microbes that could carry out the digestion of lactose and grains, we were unable to find solid examples of putative meat digesters. In the final version of Gut Check, this is reflected in several ways: “meat” became “plants,” “Good Bug #2” became Bacteroides ovatus, and “Opportunistic Bug #4” became Treponema carateum, two bacteria that are putatively involved in digesting fiber.To us, one of the most interesting parts of development was identifying real-life organisms to replace what started out as unnamed placeholders for key microbes. Pathogens were easy to decide on and were mostly chosen for either their reported importance in the human microbiome  where major flaws or problems cropped up in the games that should have been eliminated through playtesting. As discussed above, playtesting should ideally involve people from a variety of backgrounds, including those who are well versed in the science of the game as well as nonscientists who play a lot of board games. We estimate that our many months of playtesting involved at least a dozen scientists, several self-described “gamers” without a scientific background, and several people who were both “gamers” and scientists.On a related note, prototyping early in the process is really helpful for developing a feel for how the game will actually play. Also, we would encourage people to dive into the extensive resources available for people developing new board games. These resources are not targeted specifically at educational games but are incredibly helpful in helping find ideas about game mechanics including balance, gameplay, probability, time management, etc. Examples include boardgamegeek.com, the Board Game Designers Forum , publishWhen thinking about production and manufacturing, we want to emphasize the amount of work it actually entails to go from an idea at lab meeting to a finished product, available for purchase on a shelf somewhere . We say Knowing the funding landscape in advance would also be a huge advantage for someone wanting to develop an educational game. For example, obtaining a grant for a set amount of money would constrain the printing and design options from the start. On the other hand, a crowdfunding approach leaves the designers with a lot of up-front work for an unknown amount of future capital. Corporate sponsorship, the route that we took in the end, trades financial security for a lack of control. Were we to ever design another game, we would make this decision in advance of the design process. Other things that we would do differently include ensuring a long-term distribution channel , involving educators in the design process itself, and creating a plan for formal pedagogical assessment before finalizing the game. Lastly, our focus here was primarily on making a fun and challenging game, and we did not adequately consider the educational utility from the perspective of a teacher. Considering things like target audience, classroom setting, length of a high school class, and specific curriculum goals would have lowered the barriers to classroom use.Science pedagogy games have the potential to engage and excite students and aid in the retention and learning of knowledge. To be sufficiently compelling, we believe such games should be both fun and challenging. To successfully produce a “fun and challenging” game requires extensive playtesting and a significant investment (time and money) in production and manufacturing. Fortunately, the increasing popularity of such board games, abundant internet resources, and the existence of crowdfunding all help lower the barriers to success. We hope Gut Check can serve as a model of a “fun and challenging” science pedagogy board game, and hope to play many others in the future. Funding organizations wishing to support such development could offer calls explicitly for game development, as well as opportunities to foster collaboration between scientists and game designers.


Scientists often perceive a trade-off between quantity and quality in scientific publishing: finite amounts of time and effort can be spent to produce few high-quality papers or subdivided to produce many papers of lower quality. Despite this perception, previous studies have indicated the opposite relationship, in which productivity (publishing more papers) is associated with increased paper quality . We examine this question in a novel way, comparing members of the National Academy of Sciences with themselves across years, and using a much larger dataset than previously analyzed. We find that a member’s most highly cited paper in a given year has more citations in more productive years than in in less productive years. Their lowest cited paper each year, on the other hand, has fewer citations in more productive years. To disentangle the effect of the underlying distributions of citations and productivities, we repeat the analysis for hypothetical publication records generated by scrambling each author’s citation counts among their publications. Surprisingly, these artificial histories re-create the above trends almost exactly. Put another way, the observed positive relationship between quantity and quality can be interpreted as a consequence of randomly drawing citation counts for each publication: more productive years yield higher-cited papers because they have more chances to draw a large value. This suggests that citation counts, and the rewards that have come to be associated with them, may be more stochastic than previously appreciated. This ciplines , 7–10, wibutions , 12.and better [Within the scientific community, one can find pressures on both fronts: to publish both more d better . These pd better , 13, 14,d better . Yet, thd better .This conflict is apparent in job applications as well. Applications which require a listing of all publications put an emphasis on the number of articles published—“the length of one’s vita” . AlternaWith the rise of easy-to-access bibliometric data, a slew of metrics have been devised to enumerate quality in an “objective” way, the most notable being the Impact Factor . The incTraditionally, scientists have sought to identify trade-offs between quantity and quality through comparing authors (or groups of authors) with high productivities to those with lower productivities, looking for correlation with a metric of quality. Yet, this approach poses a difficult problem of equivalence: how should one quantify the effect of age or specific field of study? Flexibility in identifying valid comparisons runs the risk of capturing undesired correlates, while a conservative approach results in small samples sizes and a lack of statistical power .We take a different tack, comparing authors with themselves across time. If a trade-off between quantity and quality exists in scientific publishing, one would expect to find a negative relationship between the number of papers a scientist publishes in a given time-frame and the quality of those papers. Perhaps the simplest way to quantify this for a given author is to draw two of their papers at random and compare both their “quantity” and “quality”. If the paper with the higher quality is also the one coming from the less productive year, then there is evidence for a trade-off, and if it was published in the more productive year, there is evidence for a positive relationship. We can repeat this for all possible pairs of papers for a given author to determine whether or not (or how often) they experience a trade-off. Likewise, we can repeat this for very many authors to investigate the presence of a trade-off between quantity and quality more generally.While quantity is relatively straightforward to enumerate as the number of papers published in the same year as a target paper, quality has proven to be a more controversial topic , 20, 23.In this work, we use the number of citations as a proxy for quality, but find the results are also robust to using citation rates instead . In partq = log(#Citations + 1) (using the number of citations accumulated as of October 2016) and quantity, or productivity, p, defined as the number of papers published in the same year as the focal paper. Thus, each paper has an associated value for p and q. If q1 > q2 and p1 > p2 or q1 < q2 and p1 < p2, i.e. the paper with a higher number of citations was published in a year with higher quantity, then we call the pair concordant, while if the inequalities do not match up, i.e. the paper with a higher number of citations was published in the year with lower quantity, we call the pair discordant. Discordance is indicative of a trade-off (negative correlation) between these two values  and a value of 1 indicates that, for every pair, the higher quality paper was published in the year with higher quantity   .There are two issues with this naive analysis. First, it ignores the effect of time on the researcher herself: as a researcher produces more papers, they grow more experienced, their laboratory develops, their name becomes more established, and possibly their research topics evolve as well. To address this, we implement a restriction to the above analysis, in which we introduce a temporal “sliding window”: only comparing papers published within 1, 2, 3, … years of each other  scrambling the citation counts among an author’s publications , effectiet al. [et al. [This result, though broader in scope, agrees with other studies on the distribution of impact throughout one’s scientific career. For instance, Sinatra et al.  recently [et al.  found th [et al.  elucidatThough the majority of the observed effect can be explained by random sampling, there is still a small but statistically significant deviation of the empirical correlations from the randomly sampled ones in most cases . Furtherp ≪ 0.001) more papers-per-year per year over the past 75 years. Put another way, the average output of a member of the NAS increases by about one paper-per-year every twelve years  the best strategy would not be to produce one, highly cited paper, but rather, to spread self-citations among many papers to get more papers above a given citation threshold. Second, most metrics do not take year of publication into account, so there is not an obvious incentive for the papers an author choses to inflate coming from more, as opposed to less productive years. Third, the percentage of citations for a given work that are self-citations has been observed decreases over time [First, we do not see an incentive for authors to selectively cite papers from more productive years than less productive ones. Indeed, if one’s aim were to “game” the system, as alluded to above, a self-citation strategy might differ depending on the metric. For at least some such metrics in use today, ver time , so we ever time , then thver time ).A mechanistic alternative to the hypothesis of random sampling is that each scientist has some inherent ability and our measures of quality and quantity are actually just a reflection of this hidden variable. Alternatively, there could be a positive feedback loop operating in which the acts of publishing and receiving citations increase one’s propensity of producing more papers and receiving more citations. Allison and Stewart  describeTo investigate these hypotheses more thoroughly in the framework presented here, we would have to re-structure the hypotheses. For instance, for accumulative advantage to explain these results, it would have to be temporally restricted: in years that a scientist is most inspired, he produces more papers which gain him reputation and thus more citations. Yet, this recognition would have to fade rapidly, such that the gained citations only apply to papers published in that same year. Thus, while we cannot conclusively exclude these mechanisms from the interpretation of our results, our method of comparing authors with themselves and only across adjacent years substantially reduces the intuitiveness of these explanations.e.g. multiple authorship, self-citation, etc.), the fact that this pattern is so closely replicated by completely scrambling an authors citation record suggest that such explanations are not necessary to explain these results. Even if all of these mechanisms are nullified by completely scrambling citation counts among an author’s publications, we still see increased maximum citations and decreased minimum citations in more productive years.Regardless of the underlying mechanisms at play which might produce the observed empirical pattern  of the 2,027 members of the Academy within the selected sections (1729 (85%) of which had at least one article cataloged on Scopus), and extract information about their collective 320,294 published papers.We restricted our analysis to papers published between 1980 and 2006 (inclusive). This time-range balanced the availability of accurate citation records with consideration of the effects of paper age and discovery. Finally, we restricted the analysis to authors with at least twenty publications in this time-frame. This was to ensure sufficient potential pairs to evaluate the correlation. Following these constraints brought our final sample size to 1629 authors and 194,952 publications.https://git.io/vMPoBCode to replicate the analysis and data collection are available online at S1 Supporting Information(PDF)Click here for additional data file.


This article discusses Donald Capps’s use of Erik H. Erikson’s life-cycle theory as the basic psychological framework for his theory of pastoral care. Capps was attracted to Erikson’s existential-psychological model, his hermeneutic approach, and his religious sensitivity. Capps’s thought develops from first exploring biblical foundations for using Eriksonian theory for pastoral care to gradually embracing certain postmodern features. The article concludes with reflections on the usefulness of Erikson’s life-cycle theory and Capps’s work for contemporary pastoral care. A text becomes a classic because readers find it personally meaningful to them and … it remains a classic because readers discover over the course of their lives new ways in which it is meaningful to them.Young Man Luther—Capps , p. 328 I came across the name of Donald Capps for the first time while doing my doctoral research on Erik H. Erikson. Richard Hutch, an Australian colleague in psychology of religion, suggested that I read Capps’s article “Erikson’s Life-Cycle Theory: Religious Dimensions” Capps . I was eYoung Man Luther. It was the first book I read during my studies in psychology of religion in which religion was not reduced to bodily, psychic, social, or cultural factors but instead analyzed as a distinct yet intricately related dimension of human development. In his psychohistorical studies of homines religiosi—great religious figures such as Luther, Gandhi, and Jesus—Erikson elaborately shows how the existential-religious, the psychosocial, and the cultural-historical dimensions of reality interconnect in human development. For this reason, I chose to focus in my doctoral research on Erikson’s life-cycle theory as an analytic hermeneutical tool in psychology of religion. How, I wondered, do existential-religious and psychosocial development interact in shaping in human lives and societies? In his rich 1984 article, Capps showed that Erikson’s life-cycle theory is a religious construct in the sense that Erikson increasingly incorporated existential and religious language in his life-cycle theory. I elaborated on this basic idea in my book on Erikson  but an appropriate way of working “along Eriksonian lines.”I met Donald Capps in person only a few times on visits to Princeton Theological Seminary. A vivid image of him emerges: as a tall, lean figure wandering the grounds of Princeton Theological Seminary—not taking the paved paths but walking right across the lawns—and as a gracious and modest host and moderator. But I have the feeling I know him quite well, for his work has such a personal touch. His writing drew on case studies and his own experiences and reflections. Capps was a leading figure in American Protestant pastoral theology, rooted in the Evangelical Lutheran denomination, in the last two decades of the twentieth and the first decade of the twenty-first centuries. He was very much aware of the changes in American society and church life and used Erikson’s life-cycle theory to develop a dynamic theory of pastoral care and counseling.My context is a different one. I am a liberal female Protestant theologian and psychologist of religion, a generation—twenty-some years—younger than Capps. I have worked as a pastor in the liberal wing of the Dutch Reformed Church for 14 years and have taught psychology of religion and spiritual care for 25 years. I am living and working in an utterly secularized country, teaching “non-denominational spiritual care” Zock , 2010. OSo, my cards are on the table. In the following discussion of Capps’s use of Erikson’s life-cycle theory, I will focus on its meaning for pastoral care in a changing, pluralistic, secular context. I will proceed as follows. First, I will consider Erikson’s model of existential development, as this is the basic psychological framework for Capps’s theory of pastoral care. Then, I will sketch why Capps may have been attracted to Erikson’s work, by illustrating some characteristics of both Erikson’s and Capps’s approaches. Next, I will discuss how Capps creatively uses and adapts Erikson’s life-cycle theory in Capps’s four works on pastoral care mentioned above. I will conclude with some reflections on the usefulness of Erikson’s life-cycle theory for contemporary pastoral care.Erikson’s life-cycle theory is undisputedly a “classic” and influential theory in developmental psychology, mentioned in every handbook in the field. Erikson is acknowledged as having originated the first life-span theory of development, extending development into old age. Moreover, his description of the eight stages, each focused on a psychosocial task, is widely cited. His concepts of “basic trust” as the cornerstone of development, and of the “identity crisis”—identity being a central issue in modern and postmodern times—have been especially influential. The existential-religious character of his theory, however, is not generally acknowledged.The Life Cycle Completed  and negative (“dystonic” or disintegrating) poles, described in Erikson’s very first formulation of the life-cycle theory Erikson /1984: ba Erikson , p. 135.I is influenced by William James; it concerns the introspective capacity and has a mystical and existential flavor. To speak of I is a way to confront one’s own “nothingness”; the search for our origins takes us back before our earliest parental images to “the unborn core of creation, the—as it were, preparental—center where God is pure nothing: ein lauter Nichts, in the words of Angelus Silesius” ; and in the religious nature of Erikson’s theory.Life Cycle Theory and Pastoral Care  and a personal issue with which he wrestled in midlife . Capps introduces here the moral term n” Capps , p. 35 tDeadly Sins and Saving Virtues  care. That is why he looks for biblical underpinnings of Erikson’s approach and theory. He finds this foundation in the biblical wisdom tradition and in Jesus’ teachings.It is evident that Capps is using Erikson’s general theory for designing a theory of Life Cycle Theory and Pastoral Care, Capps also offers a theological underpinning of his Eriksonian theory of pastoral care. He notes that there are strong and multiple affinities between Erikson’s developmental theory and the biblical wisdom tradition, especially Proverbs, in terms both of their underlying world view and of specific themes addressed.In viewing pastoral care as “life orientation,” Capps builds on Erikson’s general existential-psychological terminology intended to grasp the “meaning” of specific human realities in different cultural contexts and epochs. But in First, both speak of practical wisdom as it gets shaped in everyday life. The biblical “wise” were advisers to the king in dealing with the messy business of reigning. Capps suggests that they may be compared to contemporary “advice columnists” Capps , p. 114—Another similarity between Erikson and the wisdom tradition, according to Capps, is that both depart from the conviction that there is an existent “order” in human reality, i.e., in the natural, social, and inner worlds Capps , ch. 5. Deadly Sins and Saving Virtues  and uses the imagery of pilgrim in talking about the Bible: “The pilgrimage begins in the expulsion from the Garden of Eden and culminates in the fields, or perhaps on the threshing floor, of Boaz. The pilgrimage from Genesis to Ruth portrays the victory of the saving virtues over the deadly sins. And like the blessed assurances of Jesus’ Beatitudes, the story has the power to create the very restitution it portrays”  stages for Capps here focus on the adult, three of these on older adulthood. Capps likewise adds two psychosocial issues he attributes to very old age: The Decades of Life? Capps’s point of reference is no longer Proverbs; instead, Ecclesiastes is quoted time and again. Could this be because the latter biblical book better matches a postmodern sense of the relativity of human existence? It is striking that Capps, even more than in earlier writings, freely and loosely uses different cultural sources to explain his new model of development and to illustrate the individual case-histories he presents—not only the Psalms and Bunyan’s Pilgrim’s Progress, but also Shakespeare, poems, and nursery rhymes. I also observe that, surprisingly, any reference to “sins” is absent in The Decades of Life. Is this because Capps’s focus shifted to positive aspects of development? Or did he perhaps consider the traditional language of sins, associated narrowly with specific religious traditions, as less appropriate in the present time?In the new ten-decades model, development no longer culminates in “wisdom,” the virtue of Erikson’s last stage and now of Capps’s eighth decade. Is it a coincidence that the biblical wisdom tradition figures less in Still Growing  are ministering to and with individuals from diverse ethnic, religious, and racial backgrounds in a confusing secular environment. At the same time, pastoral authority is often questioned and the influence of religious institutions is declining. It is no longer routinely accepted that wisdom “resides in the community, not in the individual” (Capps The processes of globalization and secularization have only multiplied in significance since Donald Capps published his The Decades of Life, is useful in offering guidance to and with secular persons in a postmodern age. This vocabulary may resonate with both religious and non-religious people because it addresses basic human existential themes and challenges (see Zock I have drawn attention to a development in Capps’s writing and thinking of an increasing postmodern sensitivity. He started by seeking a biblical-theological justification for his developmental model of pastoral care as one reflecting a natural and divine order. However, he gradually began to use the theory more freely in literary, hermeneutic, and personal ways. In my view, it is precisely because of its focus on “meaningful” aspects of psychosocial development that Erikson’s life-cycle theory remains a powerful instrument for pastoral care today see Zock . Speakinsee Zock . While tThere are many questions in this respect I would have loved to discuss with Donald Capps. How would he integrate ideas about the multi-voiced, fragmented, postmodern self in his theory of pastoral care? How might he assess new “pastoral services” outside the churches? How should cooperation in multidisciplinary care teams take shape? Would he agree with the demand for evidence-based, social-scientific research on what pastors actually do and in what their contribution to healthcare consists? Is a literary hermeneutic approach enough for the present-day pastor?ethos—should be structurally addressed in order to understand existential and religious developments in our time. But the personal and artistic ways in which Capps freely uses his own experiences and religious tradition is a wonderful example of postmodern life and scholarship. Fixed anchors no longer exist, and biblical as well as other cultural traditions have become personal sources of inspiration rather than guiding frameworks. For me, Erikson’s life-cycle theory, if seen as a general, hermeneutic, contextual model for analyzing the existential dimensions of human life and development and as a tool of cultural analysis, is of enormous value in the postmodern context. The work of Donald Capps helped me to better understand the intricate and often hidden religious dimensions of meaning-making in developmental processes and cultural phenomena. His expansive thinking, resourcefulness, and creativity in developing ways to address deeply existential dimensions of human life will be an enduring source of inspiration to me.In my view, not only a psychological but also a social, cultural, and historical multidisciplinary analysis should be part of pastoral theology in a postmodern world. The sociocultural context—what Erikson called


There have been consistent recommendations for multicomponent and multidisciplinary approaches for obesity management. However, there is no clear agreement on the components, disciplines or processes to be considered within such an approach.In this study, we explored multicomponent and multidisciplinary approaches through an examination of knowledge, skills, beliefs, and recommendations of stakeholders involved in obesity management. These stakeholders included researchers, practitioners, educators, and patients.We used qualitative action research methods, including convergent interviewing and observation, to assist the process of inquiry.The consensus was that a multicomponent and multidisciplinary approach should be based on four central meta-components , and specific components of these factors were identified. Psychologists, dieticians, exercise physiologists and general practitioners were nominated as key practitioners to be included.A complex condition like obesity requires that multiple components be addressed, and that both patients and multiple disciplines are involved in developing solutions. Implementing cycles of continuous improvement to deal with complexity, instead of trying to control for it, offers an effective way to deal with complex, changing multisystem problems like obesity. There is a global pandemic of obesity . DespiteTo solve the refractory nature of obesity, a recurrent recommendation is for a stronger evidence base for managing the condition –10. It iA key issue in this lack of traction in addressing obesity may be the ability to translate the existing research into practice. A survey of dietetic practice in weight management provides evidence of the gap between research and practice in obesity management. The survey was conducted 6 years after the release of the 2005 Dietetic Association of Australia (DAA) Dietetic Best Practice Weight Management Guidelines for Overweight and Obesity in Adults. It found that fewer than half of the respondents had read the guidelines in full. Only one in ten had attended a professional development event that trained them in how to properly implement the guidelines .A temptation may be to solely blame a lack of evidence translation on practitioners—if the problem may be solved by better training about the evidence and related practice guidelines, better supervision, or increased cues and incentives for them to implement evidence-based practice would be required. As important as these factors may be, another potential reason is the applicability of the research they are asked to implement. Whether a particular treatment achieves statistically significant outcomes in a research trial does not necessarily mean that these outcomes can be replicated in naturalistic settings , 17, notRecognition of the complexity of drivers associated with obesity is reflected in recommendations identified in position papers , 21 and There is consensus that obesity is a complex and multisystem condition and therefore unlikely to be solved using simplistic causal models , 27. ThiWe aimed to make progress towards addressing the intractability of obesity, the gap between theory and practice among practitioners, limitations of using narrowly defined evidence-based treatments for a condition that is complex and multi-systemic, and the lack of clarity in how multicomponent, multidisciplinary (MCMD) approaches could be more effectively applied in practice.The specific aims of this research were to operationalize a MCMD approach for obesity management and to develop a theoretical model that could guide the approach. The model and approach were intended to guide practitioners in generating sound practice-based evidence and integrating that evidence with research. We expected that this would address the gap between evidence-based recommendations and routine practice , 14, by In consideration of the concern that approaches to obesity management are often formulated by people who do not engage with end users directly, we planned that our current treatment model would be informed by a variety of stakeholders, including researchers, practitioners, educators, and patients.We did not identify any literature that clearly outlined a theoretical framework for a multicomponent and multidisciplinary approach to obesity management, so regarded the current research as exploratory. Rao and Perry , 35 haveA benefit of using action research as a theoretical framework for this study was its ability to function as a meta-process under which other methods for data collection can be managed . In utilWe used convergent interviewing as the main source of data, because it is both an interview technique and a process for data interpretation . The tecThe criterion for qualitative sampling is not the sample size but rather case contrast , and alsWhen using convergent interviewing, Dick  suggesteThe first author conducted the interviews. The person deemed to be the most representative of the target population, DN, a dietician nutritionist, was interviewed first. DN had worked in clinical practice, research, education, government policy, and as a national representative of her profession. The breadth of DN’s knowledge and opinion formed a broad platform for subsequent interviews. A patient, P1, was interviewed next. She was representative of the target population, but in other respects unlike DN. P1 had struggled with her weight for more than 20 years and had been unsuccessful in losing weight despite using numerous approaches to weight loss. The general practitioner, DR1, was the third interviewee because she was the next most representative member of the target population, but was unlike the first two, and so the sequence continued.Convergent interviewing was chosen because the interviewer is not required to make a priori assumptions about which questions to ask. The process began with a broad initial question: “What do you believe needs to be included in a weight management assessment or approach to optimize outcomes or ensure success?” Responses of those interviewed were used to generate the themes for questions to be posed in later interviews, so we could establish confirmatory or disconfirmatory evidence from the data collected. As Dick  proposesAn iterative analysis of data commenced at the same time as the first data were collected. We used a computerized qualitative data management system, nVivo , to construct conceptual frameworks from the large volume of data generated by the convergent interviews. This thematic analysis was achieved by analyzing the data and breaking them down into interpretable and meaningful categories, often referred to as conceptual “codes” or “nodes” . ResearcIterative analyses of data from the interviewees allowed us to identify patterns and generate explanations for phenomena. We commenced by sorting the first interviewee’s data into free nodes. A property of a free node is that it represents a theme evident in the data but does not presume relationships or connections with other nodes.As we progressed with individual analysis, free nodes that clustered together became more obvious and we sorted and grouped them into categories called tree nodes . In eachObservation in the “real world” helped to provide insight into the thematic concerns and build a picture of the context in which the research problem existed . ObservaWe conducted most of the observational data collection in group settings, with a series of observational events being explicitly dedicated to having stakeholders put forward their ideas for developing a MCMD approach to obesity management. Settings used as part of this research included multidisciplinary network meetings that the primary researcher either facilitated or participated in; talks she gave on obesity, including questions and comments from the participants; multidisciplinary team meetings and obesity talks she attended as an observer; obesity training events and conferences; and conversations she had with colleagues, including her doctoral supervisors, and patients. Field notes were either taken during the observation or written up immediately after the event to improve accuracy . On seveA review of the obesity literature, was conducted and this formed the basis for the thematic concerns on which the research was based. We used the EBSCO database and explored terms relating to the effectiveness of variants of individual weight management interventions, health promotion strategies, health care models and recent thinking about participatory and multilevel approaches to obesity management. In addition, consistent with the practice of action research , referenThe process of action research involved the collection of data through interviews (action) and the subsequent analysis of that data in light of theoretical (literature review) and practical considerations (observation). Distilling the data through successive action research cycles facilitated sense-making, model building and theory development. The use of multiple methods facilitated triangulation of the data and optimised rigor. By triangulating the interview data with observational data and the literature, we were able to corroborate and elaborate on the aim of developing a MCMD approach to obesity management.A preliminary step in the research analysis was to determine whether or not stakeholders believed that current obesity approaches have not been effective. A second step was to identify whether stakeholders endorsed the development of a multicomponent multidisciplinary (MCMD) approach for obesity management as recommended by position papers e.g., .Stakeholders endorsed the importance of clarifying a MCMD approach to obesity management as a focus for the current research. Eleven of the 14 interviewees reported disillusionment with current weight management strategies. The remaining three interviewees did not provide an opinion. The general practitioner, DR1, said, “I don’t think that our current interventions are actually doing anything.” The endocrinologist, DR2, agreed: “We’ve all got buckets of patients who’ve tried dieting and it hasn’t worked. Obesity clinics around the globe will tell you the same story.” The dietician, DN, further concurred: “Public health messages don’t work. Nothing has worked. We have got worse.” The second patient, P2, offered a patient perspective: “I’ve tried everything. If anything was going to work, it would have.”When scanning the observational data, we were unable to find any disconfirming evidence for the consensus generated by the convergent interviews regarding disillusionment with current obesity management approaches. Similarly, we identified scant support for the effectiveness of individual-focused weight management approaches in the literature reviews , 49–51. The majority of stakeholders and observational data supported position papers and obesity guideline recommendations for pursuing MC and MD approaches for weight management. Two interviewees did not support a MCMD approach. The first patient we interviewed, P1, said she preferred to consult only a dietician for weight management. DR2 was the only practitioner who did not support a MCMD approach. DR2 said, “I think a MD approach is overcomplicating a simple issue.” DR2 believed all general practitioners (GPs) conducted medical histories of their patients, according to NHMRC guidelines, as a regular practice. However, both patients, (P1 and P2), countered DR2’s claim when they complained about short consultation times that hampered GPs being able to address their weight issues. “You are in and you are out,” said P2.As mentioned previously, data from the first interviewee, DN, were coded as free nodes. For example, an analysis of the first interview conducted with DN, revealed a likely free node to be ‘practitioner barriers’ to obesity management. Sample comments made by DN that led to the creation of the ‘practitioner barrier’ category included: “The doctor won't use anything that is not fast”, “Dieticians are lucky to get one week of training in obesity”, and “Most allied health professionals are overweight themselves.”practitioner factors. We identified other comments made by DN as more process-oriented and created another metacomponent called process factors. This established a second tree node. We labelled one free node under this tree node ‘practitioner processes’. We evolved this free node from factors DN viewed as either unhelpful or helpful approaches for obesity management. Sample statements by DN that were reflective of ‘practitioner processes’ included: “Diet histories were great when everyone ate a standard type of meal”, and “Get into a partnership system with the patient where the patient has ownership, a self-management approach.”The contents of the free node, ‘practitioner barriers’, were related to practitioner factors, so it was decided to house this free node within an overarching category we termed a metacomponent. We labelled this metacomponent or tree node DN’s focus during her interview reflected her more recent work history as a tertiary educator, researcher, and policy influencer. Her clinical experience with patients occurred early in her career, which might explain why she did not focus on patient-related issues during her interview. We determined that the content of ensuing interviews either converged with or diverged from DN’s viewpoint, contributing to the evolution of the tree nodes and the development of a MCMD approach. Summary themes were refined iteratively as more data were entered.patient factors. P1’s comments both converged with and diverged from comments made by DN, substantiating free nodes and their placement under metacomponents, and introducing new understandings and concepts. For example, unlike DN, P1 viewed dieticians as the obesity experts, but agreed with DN that doctors were not experts in weight management: “I don’t think the doctor is the expert. I think they are too busy. I think a dietician is the expert in the field.” P1’s comments endorsed DN’s view that practitioners needed to ask patients what they want. This led to the creation of a free node, ‘person-practitioner fit’, which we placed under the metacomponent, process factors. P1 clarified what she expected from a practitioner: “I want someone to really listen and not be judgmental”, “You need encouragement, understanding, empathy, kindness”, and “To be treated as an individual.” P1’s comments supported the free node, ‘practitioner processes’, which we had already conceptualized from DN’s comments, and assigned to the metacomponent, process factors.The second interviewee was patient 1, P1. We created a free node called ‘patient barriers’ to weight loss based on P1’s comments. Sample comments justifying the inclusion of patient barriers included: “When things are going bad, I hit the fridge or I comfort eat”, “I eat unconsciously”, and “It’s a vicious cycle.” Based on P1’s comments we introduced an additional metacomponent, Ensuing interviews converged with or diverged from the preceding interviewee’s viewpoint, contributing to the evolution of a MCMD approach. We achieved data saturation for the four metacomponents within the 14 interviews that were conducted. It is intended to elaborate the categories within these metacomponents during the actionable phase of the model. However, we believe that we have gained enough information for an initial structure on which to develop a MCMD approach.Below is an analysis and interpretation of the tree nodes we used to evolve the framework for the MCMD approach using NVivo.patient factors, practitioner factors, and process factors. We referred to these overarching factors as metacomponents. These metacomponents mirrored the data sources (patients and practitioners) and their ideas for approaches to weight management (processes). A subsequent reference to the literature showed that these same components were also distilled in a Cochrane Collaboration review investigating MC interventions for diabetes [In the early stages of the action research process, three central themes were evident in the interview data and were labelled: diabetes .parent components [child components. This process continued with child components spawning a layer of grandchild components, and so on. The progressive and deeper levels of generational analysis illustrated the multifaceted complexity of obesity. However, as a way of managing the large volume of data, only a summary of the parent components for each metacomponent have been included in this article.To improve the conceptual clarity of the nodal hierarchies, the tree nodes positioned under each metacomponent were referred to as mponents . Parent patient factors as a metacomponent and reflected the central role attributed to the patient in current weight management initiatives. This outcome also provided insight into the mental model stakeholders hold in relation to multicomponent approaches to obesity management.When stakeholders were invited to specifically identify what they believed were the most important components to include in a MCMD approach to obesity management, they nominated the following parent components, in order of emphasis: ‘psychology’, ‘food and nutrition’, ‘physical activity’, and ‘medicine’. These components substantiated the inclusion of The interviewees did not mention the other three metacomponents , or their subcomponents, as specific components for a MCMD approach. The overall pattern of the metacomponents and parent components we present below were distilled from a comparison of the interview data and observational data and the relevant literature. Because we used an action research methodology, we assumed that the components nested under each metacomponent would be modified through successive cycles of inquiry and action within both the current research and in future work. The deconstruction of data taking place throughout this study forms a starting point only.patient factor metacomponent was composed of the components directly relating to the patient. They included ‘psychology and social’, ‘diet and nutrition’, ‘bio-medical’, ‘health behaviours – eating behaviour and physical activity’, ‘demographics’ and ‘weight-related’ factors. Some other components were considered relevant  but were not as prominent in the data and are therefore not explicated further in this paper.The The purpose of briefly surveying the following parent components is to justify and explain the component’s inclusion and to begin building a picture of what a preliminary MCMD model for weight management could be.Most stakeholders firmly supported the inclusion of ‘psychology’ as a component in a MCMD approach. The research psychologist, PR, said, “Psychology has a massive place in obesity research and treatment. It is one of the major causes of obesity.” The psychologist in private practice, PP, believed “everyone with a BMI over 30 should be referred to a psychologist”. A patient we interviewed echoed the sentiments of the psychologists: “I think the psychological is something that is really missing; my weight gain is definitely psychological” (P1). The majority of stakeholders who attended observational sessions also strongly believed ‘psychology’ and psychologists should play a role in obesity management.The two stakeholders we interviewed that did not endorse ‘psychology’ as a component were the medical practitioners. Neither DR1 nor DR2 referred their obese patients to psychologists. DR1 had not considered it. However, DR2 was not supportive of psychological interventions because of his belief that “patients fundamentally don’t have any interest in losing weight.”When we reviewed the literature, we identified a number of areas that supported the inclusion of ‘psychology’ in obesity management. These include: eating and stress , self-co‘Social’ factors also have a powerful influence on our food choices and eating habits. This influence justified their inclusion in a MCMD model. For example, interruptions to self-care caused by events such as injury or illness, financial and living insecurity, as well as institutional care, are factors that affect one’s ability to manage one’s food intake . Social Observational data also supported the importance of ‘social’ factors in obesity management. Clients viewed eating as an important component of their social interactions and a major barrier to weight loss.There was agreement between all stakeholders and across the reviewed literature e.g., , 67, 68 The practitioners with medical backgrounds  openly supported the inclusion of ‘bio-medical’ factors and doctors in a weight management approach. However, the interviewed patients and members of non-medical disciplines did not underscore the role of ‘bio-medical’ factors in weight management. Their focus was on behavior, diet and exercise.Theoretically, a medical examination, particularly in cases of severe obesity, should assist the practitioner to identify any physiological or pharmacological causes of obesity, and assess health risks including the presence of weight-related comorbidities such as diabetes mellitus type 2, sleep apnea, insulin resistance and hypertension , 70. MedThe majority of stakeholders acknowledged that ‘physical activity’ was a necessary component of a weight loss program. Our review of the literature also supported the inclusion of ‘physical activity’ as a component in a MCMD approach –74. HoweInterview and observational data also highlighted the relevance of including ‘eating behaviors’ in the MCMD model. Stakeholders identified their issues with food and eating behaviors as reasons they gained weight and could not maintain weight loss. Poor ‘eating behaviors’ cited by stakeholders included over-eating, bingeing and emotional eating.Triangulation with the literature supported the inclusion of ‘eating behavior’ as a component for a MCMD model. The World Health Organization  has reco‘Demographic’ factors were not strongly identified as a stand-alone component for a MCMD approach by the stakeholders we interviewed. However, ‘demographic’ factors were distilled as a parent component during the nVivo analysis and triangulation with observation and the literature. Subcomponents of the ‘demographic’ parent component, which we referred to as child components, were also clearly identified as factors that could inform obesity management. These included, gender , occupat‘Weight-related’ factors are a face valid inclusion in any model for obesity management. Preliminary components distilled for this component included: barriers to weight loss, monitoring, follow-up, anthropometry, achievement, weight goals and weight history.practitioner factors metacomponent included: ‘roles and boundaries’, ‘resources and barriers’, and ‘patient-practitioner fit’.The parent components for the The parent component, ‘roles and boundaries’, arose from several stakeholders’ comments. The medical educationalist, MEd, explained that he scoured the literature to find the best evidence for producing change. His search led him to the conclusion that “changing clinician behavior related to better patient health outcomes.” This finding is supported by work in psychotherapy . The dieThe ‘resources and barriers’ parent component contained items referring to practitioner abilities and constraints, which could affect a practitioner’s ability to treat obesity and achieve positive outcomes. Numerous barriers to a MCMD approach were reported. Notably, acknowledgement of a “silo mentality” by stakeholders in the current research was captured in a number of statements. MEd summarized, “Clinicians have a silo mentality”. The psychologist in private practice agreed: “I don’t know how to work outside my own silo” (PP). A nurse who worked in a multidisciplinary team commented: “You see some people who just sit in their discipline and feel like they shouldn’t be on a multi-disciplinary team. It’s the person who’s really about the multi-disciplinary team and sees the value in the multidisciplinary team rather than being in a discipline specific team that you need” (N1).A silo mentality is a current challenge in healthcare, because it makes it difficult to achieve integration and collaboration among the disciplines providing services to the patient . McNair Kreindler et al.  argued tpractitioner factor metacomponent, ‘patient-practitioner fit’ received the strongest support in the convergent interviews. The two patients who were interviewed endorsed the importance of therapeutic alliance. They stressed that “liking” their practitioner was a prerequisite for retention in weight loss programs. Published studies also confirmed that personality congruence between the patient and the practitioner optimizes alliance [‘Patient-practitioner fit’ refers to the quality of the relationship between the patient and his or her practitioner. A closely related concept is referred to as the therapeutic or working alliance . Of the alliance . Inclusialliance . Optimizalliance .Although there is a significant body of research papers on working alliance and psychotherapy outcomes, there are very few published articles on working alliance and obesity. An exception was a study that explored patient-practitioner relationships and obesity management outcomes . This stprocess factors metacomponent contained processes that assist in tailoring the MCMD approach and implementing the interventions in a dynamic manner that is responsive to the patient’s condition and situation at any given time. Implementation of these processes would promote ongoing engagement by the patient and optimize coordination of treatment across the disciplines. Process factors were divided into the three parent components: ‘patient processes’, ‘practitioner processes’, and ‘team processes’.The Patient processes involved the steps employed to assist the patient to self-manage. DN said:Public health approaches fail because they do not engage at all with the public. Self-management approaches engage with the patient. You have a therapeutic relationship, but the patient has ownership. Overweight is so complex. If you don’t have the patient generating the suggestions and a counsellor asking ‘Why do you do this? How do you get your food?’, you won’t engage the patient and give them ownership.A nurse agreed, “We promote self-management and patient focus and ask questions like, ‘what is your problem and how can we work together to get over it?’” (N1). The medical educationalist suggested: “Train the clinicians in the skills they need to help the patients self-manage. Promote partnership between clinician and patient” (MEd). Similar to the dietician and nurse, MEd believed this approach put both the practitioner and the patient “on the same page” and thereby optimized outcomes.Our health care systems were historically predicated on acute conditions in which the patient played a passive role, and were not designed to meet the needs of chronic conditions like obesity, which require multidisciplinary treatment and self-management approaches , 92. PeoThis parent node referred to the processes that practitioners preferred to use for weight management interventions. Most stakeholders supported a multidisciplinary approach. However, there was no clear agreement on who should perform the assessment and coordination of a MCMD approach. Both of the interviewed doctors believed it was the doctor’s role. However, the four allied health professionals held that the primary health care professional should perform the assessment, regardless of their discipline.This diversity of opinion regarding MCMD approaches and obesity management in general was also reflected in observational data and the literature. Both the data collected during the interviews and the observations indicated that most practitioners do not use systems that collect, summarize and evaluate individual or cumulative patient data to inform care. The consensus was that dynamic approaches to obesity management that are responsive to both the practitioner and the patient could be effective. To manage chronic conditions effectively requires delivery designs that facilitate productive practitioner-patient interactions .‘Team processes’ are integral to team effectiveness . The praDue to insufficient collaboration between the participating practitioners, observational sessions did not result in the desired outcome of developing a MCMD approach. A “silo mentality” appeared to prevail.The literature we reviewed on multicomponent and/or multidisciplinary studies for obesity management did not refer to ‘team processes’ when exploring the effectiveness of these approaches e.g., , 99. Howenvironmental factors on the development and maintenance of obesity. Although we initially designated environmental issues as a parent component under the patient factors metacomponent, we also acknowledged that interviewees did not consistently refer to the patient’s environment as a consideration in weight management. The psychologist (PP) and social worker (SW), both of whom treated individual patients, referred to the patient’s social environment. Only the dietician, DN, the health epidemiologist (HEp), and the endocrinologist (DR2) referred to the broader environment. HEp encapsulated the relationship between obesity and the environment as follows: “Obesity is a signal that something is going wrong in the whole environment.”The advantage of triangulating the interview data with observational data and reference to the literature was that it facilitated deliberation on components that were considered important, but were not strongly emphasized by stakeholders during the interviews. The most outstanding example of this was the impact of environmental factors could be attributed to the “creeping” nature of obesity, as suggested by HEp, and to practitioners providing data from the framework in which they worked, as suggested by DN.Considering the prominent role that environmental issues play in obesity , 102, itenvironmental factors were significant enough to stand alone and be considered as a fourth metacomponent. This reinforced the advantage of using a methodology that took into account the perspective of patients, practitioners, the patient-practitioner interface, the literature, and other relevant data sources.Literature sources that explored more innovative approaches to managing obesity and chronic disease consistently incorporated an environmental focus , 103. ThFeedback that was produced by iterative action research cycles provided both converging information and additional perspectives across multiple metacomponents and parent components. This allowed the derivation of a model of practice-based evidence that was also informed by evidence-based practice. Figure The scope of the parent nodes housed under the four metacomponents justified why multiple disciplines are necessary in effectively treating obesity. We analyzed the interview and observational data to identify which disciplines received the strongest support for inclusion in a MCMD approach. The roles receiving the most emphasis included the dietician, psychologist, exercise physiologist, and to a lesser extent, the general medical practitioner (GP). These roles mirrored the components identified as being the most relevant and important to include in a MCMD approach. Physiotherapists and nurses were given secondary emphasis in our data. There was only cursory reference to occupational therapists, complementary medicine practitioners and bariatric surgeons. During implementation, we would expect the team providing the treatment to recruit other practitioners as their inclusion became relevant.We noted that practitioners appeared to interpret obesity through the lens of their own discipline. There was a lack of knowledge about other practitioners’ roles and how these roles could be applied in obesity management. The importance of including a range of disciplines in obesity management is evident in recent NHMRC obesity guidelines . These gThe MCMD model we have developed endorses obesity as a complex problem that involves multiple actors and factors . These mA limitation of current approaches to obesity has been the inability to incorporate a theoretical framework that integrates the multiple factors that impact on a person and their weight , 107. WhGlaser  makes a The responsiveness of action research methods to the emerging needs of a person and situation is a valuable asset in an ever-changing world . By teacIn partial summary, it is evident that there are many different influences affecting the behaviour of a person seeking to reduce obesity. The literature relevant to these influences therefore spans multiple disciplines. Each patient is affected by her or his own life conditions and local environment. In addition, even an ideal treatment (if there is one) will work in many instances only with substantial commitment to it by the patient. Theory derived from the literature will contribute. However, by itself it is unlikely to be sufficient. There are more factors affecting obesity than any team of practitioners will understand fully. Further, there may be local conditions that the theoretical literature doesn’t address. Local practice-based evidence can be derived from the practice of each individual case. For good outcomes, it can be integrated with theoretical understanding from the literature. The following case study illustrates the unavoidable complexity of obesity treatment.Judith presented for treatment of depression and morbid obesity with a psychologist and dietician. She was 65 years old and divorced. Her mobility was poor and she ambulated with a walking stick. She lived alone in a house her daughter owned. Judith reported feeling isolated, unwanted, useless and worthless. She had numerous medical issues, was anxious about her finances and was disillusioned with her efforts to find employment and lose weight. The MCMD approach was presented and collaborative goals established. Her first goal was to find more suitable housing that would also enable her sister to live with her. Strategies were also identified that would assist Judith in renting two pieces of real estate she owned in the country. Several real estate agents were engaged, and family members invited to assist her with this task. Completing these tasks reduced Judith’s financial pressure considerably and introduced social support. Judith then worked with her GP in relation to her medical issues, and consulted a number of specialists. Concurrent to working with her GP and psychologist, Judith self-initiated an energy controlled meal service and lost 15kgs. Her weight loss enabled her to walk without her walking cane. She reported accepting that she was retired and stopped pressuring herself to find work. However, over the Christmas period she relapsed and her depression rekindled. Using action research methodologies and the support of her practitioners, Judith was able to learn from her lapse and replan a path that would minimise the likelihood of relapse. She lost another lost 21kgs.The iterative cycles are a fundamental component of action research. “The cycle is a natural and logical way of responding to a complex and therefore uncertain situation that requires action” ; it parallels the way people problem solve a situation. In Judith’s case, she relapsed (an action), discussed her action with her practitioners then established a new plan to prevent relapse in the future (planning). This iterative facility within action research gave her permission to learn by doing and became a template for continuous improvement. Accepting that learning to lose weight through trial and error mitigates against the “all or nothing” thinking that is cited as a common reason for relapse . Judith Obesity is a chronic relapsing condition that has been resistant to resolution by non-surgical treatment approaches . The intPsychologists, dieticians, exercise physiologists and general practitioners were most likely to be nominated as the practitioners to be included initially in a MCMD approach. However, there was a lack of general knowledge about one another’s role and how the roles could be applied in obesity management. The collective data emphasized that increased practitioner accountability in weight loss initiatives would likely benefit weight management outcomes. Both patients, P1 and P2, described how the interaction between the patient and practitioner influenced their decisions to either continue or discontinue weight management initiatives. During this research, comments were frequently made in relation to practitioner limitations, both by patients and practitioners during data collection. As recommended by the NHMRC guidelines , it is sBased on the model we deconstructed from the data, we conclude that complex solutions will likely offer the best approach for a complex condition like obesity. Assessment procedures for a MCMD approach should have the potential to assess a broad array of causative and maintenance factors for obesity, which would provide the basis for interventions to be tailored to the individual , 115–117This research study demonstrated that dynamic and responsive methodologies like action research appear to lend themselves to the management of a complex condition like obesity. Implementing cycles of continuous improvement to deal with complexity, instead of trying to control for it, offers an effective way to deal with complex, changing multisystem problems like obesity . As relaThe research forms the data collection phase of an action research cycle to develop and test a viable MCMD approach. We vigorously used processes that would identify any disconfirming evidence and thereby substantiate the efficacy of the research. The model we present is notional and will require ongoing modification during the implementation phase.Given the general nature of the topic, the literature that we could have accessed was enormous and impossible to source in its entirety. The qualitative research was also potentially affected by the pre-existing assumptions and attitudes of the researchers, and the limited number of participants. This research therefore depicts a snapshot in time of a body of research that is limited by our own subjectivity, the subjectivity of the stakeholders, our interpretation of the responses and the literature we accessed. The research is thus of necessity incomplete. However, action research works well for open-ended “messy” systems such as obesity management, because the action research cycles need never end, and there is opportunity for the understandings in this work to be updated over time.Interventions required to reverse “globesity” might need to be applied at several levels. We have focused on individual behavior change. Even if this individual MCMD approach is demonstrated to be more effective than existing approaches, it will not be sufficient to reverse global obesity , but wil