'Well doctor, it is all about how life is lived': cues as a tool in the medical consultation

Introduction During consultations, the perspective of the patient and the family physician come together. In order to reach a shared view about the symptoms it is important to know the agenda of the patient. Cues (i.e. non-explicit remarks that can enclose a special meaning) can serve as a tool to clarify the agenda.Case report In this article, we describe a patient with unexplained palpitations during vacuuming. During one of the following consultations she provided an important psychosocial cue which changed my perspective on her palpitations, resulting in a deeper understanding of her symptoms.Discussion Recognition and exploration of cues is important for reaching mutual understanding of doctors and patients about the symptoms. Moreover, it enhances the therapeutic relationship and improves illness outcomes and patient satisfaction.Conclusion Noticing cues in the medical consultation helps the doctor to understand the patient's real worries. It gives us, as doctors, a better understanding of the patient's perspective.     

"You Are a Number, Not a Human Being": Israeli Breast Cancer Patients'' Experiences with the Medical Establishment

In the course of interviews with Israeli women who had recently been treated for breast cancer, we found that our informants tended to offer us "treatment narratives" rather than, or sometimes in addition to, the "illness narratives" made famous by Arthur Kleinman. For the women we interviewed, treatment narratives constitute verbal platforms on which to explore what it means to be human during a period in which one's body, spirit, and social identity are undergoing intense transformations. A central theme in these narratives is the Hebrew word yachas, loosely translated as "attitude," "attention," or "relationship." The women consistently contrasted the good yachas of medical staff who treated them "like humans" or like "real friends" with the bad yachas of staff who treated them like numbers, machines, or strangers. We argue that the women used language (in various contexts) as a means of resisting the medical culture's pattern of treating patients as "nonhumans."     

Toxic shock syndrome after suction lipectomy

We present a case of toxic shock syndrome with necrotizing fasciitis after suction lipectomy. The patient underwent aesthetic suction lipectomy of the abdomen, buttocks, and thighs during an office procedure by a cosmetic surgeon. On postoperative day 2, the patient was referred to the emergency department of our hospital because of pain. On admission, the patient was in toxic shock. She required intensive medical treatment for about 1 month, along with psychiatric help to adapt after the illness. Although toxic shock syndrome is a rare postoperative complication, every plastic surgeon should be acquainted with it. A combination of early recognition, diagnosis, and aggressive supportive therapy is the only successful treatment.     

On the epistemology of mental illness.

The most important epistemological problem in psychiatry is the detection of malingering. This is a consequence of the fact that there is no objective way to confirm any psychiatric diagnosis. Psychiatric diagnosis is based on subjective complaints. The discovery of objective markers for psychiatric diagnosis is problematic because it presupposes we can tell valid from faked subjective symptoms. But this is the difficulty. If we use pervasive irrationality as a sign of mental illness, we encounter the problem of identifying pervasive irrationality. To understand someone's behaviour, we have to assume it is largely rational. This precludes us from using behaviour to separate genuine from faked mental illness. There are a number of strategies used to solve any epistemological problem, and the most successful is the hypothetico-deductive method. If we use this, we can solve our epistemological problem. Genuine mental illness can be identified when it is the best explanation of the person's overall behaviour. Consilience of inductions is critical in supporting the validity of such explanations. This implies that it is merely a hypothesis that mental illness exists, and that we might discover that many mental illnesses, perhaps all, do not exist. We must embrace this possibility--only if we take a risk will we gain any knowledge.     

Arational Behavior and Medical Care, Report of Bureau of Research and Planning

Testing the hypothesis that arationality on the part of a patient in the treatment of an illness is in direct relation to perceived chance or danger inherent in that illness and is in inverse relation to medical knowledge about that illness, the authors of an unpublished doctoral dissertation conclude that "those who are scientifically more knowledgeable" in the area of medical practice are "also more rational." Arational behavior is categorized as 1) the type that involves the use of, or belief in the efficacy of accepted religious practices for the treatment of illness, 2) the use of some religious charms and trinkets, and 3) the use of ineffective or harmful health foods, herbs, and various compounds. The authors conclude that an increase in technological discoveries will result in a trend toward greater rationality and more rational behavior in seeking treatment for illness.     

Significance of time and language in view of the process of medical diagnostic processes. Philosophical methodologic preliminaries

The understanding of the patient is a prerequisite to philosophical and methodological thinking about the process of medical diagnosis-making. In regard to the philosophical discussion about the recently development of scientific knowledge, the comprehension of the medical object and the conceptions of health and illness has been modified. The human state of illness as a "Zeitgestalt" of intra- and intersubjective disturbances of communication is joined with the individuality and complexity of the subjective experiences of the patient. The modified conceptions of health and illness can help to overcome the division between subject and object, a consequence of Cartesian rationalistic thought. In this way new connections within medical thinking and a new comprehension of medical diagnosis appear. The medical diagnosis-making is simultaneously a process of knowledge to the physician and an instruction for his therapeutical action. The special significance of the medical diagnosis at all is the irreversibility and the temporal openness of the therapeutical action. Medical diagnosis is a form of communication leading to the action of the diagnosis-making physician and therefore a inseparable part of the physician-patient relation. The adequate valuation of the multi-dimensionality of the individual pathogenesis (physic, psychic, social) is possible only within this relation. The prediction of critical states presupposes the knowledge of the individual pathogenesis. Of course, such predictions are not completely quantifiable.     

Exploded worlds — Text as a metaphor for ethnography (and vice versa)

Conclusion There is a class of scholars who seek to write about and perpetuate the culture of all those who do not write about and perpetuate their own culture. Do these scholars write about and perpetuate their own culture?Paul Ricouer and others have put forward the text metaphor for social science production — for what we produce and the way we work with it. It is one of many metaphors that we anthropologists have available to enable us to grasp better our challenging and so often inchoate enterprise. I have expressed misgivings about this metaphor because it takes us back into a world, the academic one, where we do not really belong — with its concerns for distance, invariance, truth value — and away from a world — the variable and voluble world of discourse — where anthropology should be at work if not at home. It is also a metaphor that can beguile us into ignoring the pervasiveness of self-reference and self-replication in our (the intellectual's) creation of worlds and surely in our anthropological creation of other people's worlds. As the pronouns are the fundamental entities of the world of discourse, we have focused on what we can learn from them about the dynamics of self-reference and reference and particularly about the parlous shift from talking to persons — as with the first two persons of discourse — to talking about persons — which is to say the third or absent person of discourse. The pronouns also teach us about turn-taking. Here also one has misgivings about the text metaphor for it takes us into altogether too sui generis a world of the scholar alone with his writings and his imagined or self-created audience for those writings. It is the world of the I perpetually talking and the other perpetually listening. Anthropology in contrast works on the other side of turn-taking where we emphasize the other as an I talking and we ourselves as a you listening. In a world where the powerful military-industrial centers of things do most of the talking, it is altogether appropriate that the peripheries should have their turn through the work of anthropology. That those voices should be heard is a fundamental anthropological task.We should not pretend in the conclusion, however, that the channel for hearing those voices is absolutely clear and unimpeded by self-reference — from the insertion, as it were, of the anthropologist's own voice. We do not escape the need to negotiate these various voices. And for that reason I have placed as an epigraph to the conclusion a rephrasing for the anthropologist of Epimenides' paradox. It is a rephrasing that evokes the paradox involved in giving voice to the voices of others. but to recognize the problem at the very center of our enterprise does not justify the abandonment of that enterprise nor the admirable and unique efforts at turn-taking that characterize the calling of anthropologists.James W. Fernandez is Professor of Anthropology at Princeton University, Princeton, NJ.     

Circle of healing: traditional storytelling, part three

Southcentral Foundation had to overcome several organizational and procedural hurdles when developing their Circle of Healing program. Among these hurdles was finding a way to credential Alaska Native healers so the Foundation could be reimbursed for their services and pay the healers, and so the healers could work in the hospital along with the staff delivering Western and alternative medical treatment. Southcentral Foundation chose to develop a process for certifying Alaska Native healers as tribal doctors. Rita Blumenstein is the first such person to be certified. Lisa Dolchok is the second. An important strength of Lisa’s presentation is that she helps us broaden our understanding of healing from an Alaska Native perspective. So often we equate healing with curing, and while it can have this dimension, Lisa reminds us there is much more to it. She echoes LouAnn Benson’s presentation in asserting that healing can address illness of the spirit or wounds to the soul.     

An Analytical Framework for Contrasting Patient and Provider Views of the Process of Chronic Disease Management

Medical anthropologists involved in clinical research are often asked to help explain patients' "noncompliance" with treatment recommendations. The clinical literature on "noncompliance" tends to problematize only the patient's perspective, treating the provider's perspective as an uncontroversial point of departure. Explicating the articulation between provider and patient assumptions, expectations, and perceptions in managing chronic illness is an area well suited to the unique perspective of medical anthropologists. In this article we present an analytical framework for contrasting patient and provider goals, strategies, and evaluation criteria in chronic illness management, using examples from research on type 2 diabetes care in South Texas. This approach goes beyond contrasting patient and provider concepts and explanations of the illness itself and examines their contrasting views within the dynamic process of long-term care. This approach may prove especially useful for research aimed at a clinical audience, since it maintains a clinically relevant focus while giving serious consideration to the patient's perspective.     

Creating difficulties everywhere

In this essay we link the rationale for the medical humanities with radical hermeneutics, a move that infuses the medical humanities with incredulity and suspicion. This orientation is particularly important at this historical moment, when the evidence-based and competency blanket is threatening to overpower all aspects of medical education, including the medical humanities discourse itself. Radical hermeneutics works relentlessly against the final word on anything, and as such, it provides a critically provocative way of thinking about doctors, patients, illness, health, families, death--in short, the experience of being human. We use three literary examples to illustrate the complex, contradictory, perplexing, and disturbing questions related to a life in medicine: Rafael Campo's "Like a Prayer," Irvin Yalom's "Fat Lady," and Richard Selzer's "Brute."     

Beyond nescience: the intersectional insights of health humanities

Through a comparison of two graphic novels concerned with the experience of cancer diagnosis and treatment, Brian Fies's Mom's Cancer (2006) and Harvey Pekar and Joyce Brabner's Our Cancer Year (1994), this essay suggests some of the strengths and limitations of the medical humanities in responding to the experience of illness. It demonstrates how the graphic medium enables us to generate a new set of reading strategies and thus to articulate a more complex and powerful analysis of illness, disability, medicine, and health. Finally, the essay considers the question raised by the comparison of the graphic novels: whether the term "health humanities" might not be preferable to its predecessor, "medical humanities."     

Postmodernist theory and the physician-patient relationship

The author discusses the postmodernist claim that the "grand theories" have lost credibility, even in the field of medical science and practice. Rather than representing a shared reality among physician and patient, illness represents two quite distinct realities - the meaning of one being significantly and distinctively different from the meaning of the other. However, existential clinical narratives can function as important bridges between the world of the patient and the world of the physician. Such narratives provide important information regarding the patient's biographical situation and, particularly, the personal and cultural meanings which are a function of the biographical situation. At the same time, these narratives provide physicians with useful information for the practice of medicine.     

The new paternalism

The author argues that the belief that patient autonomy has great moral value has justified a new form of medical paternalism which can have effects similar to those of the old rejected form. He cites the argument that "all illness represents a state of diminished autonomy" and that therefore autonomy is not overridden when physicians make all decisions. Another view is that, in some situations, withholding information may prevent patient deterioration and loss of autonomy. Abridgement of present autonomy, then, is permissible if it promotes future autonomy. Strasser also rejects physician decision making based on patients' previously communicated values or on the theory that patient values are important but not decisive. He concludes that if we "allow paternalistic practices, then we should admit that we are denying autonomy in light of some other good rather than claim that, somehow, we are respecting autonomy by abridging it."     

Bonnes pratiques médicales : quelle place pour la recherche scientifique ?

The French medical community comes into the era of “good clinical practices”. But on what bases can we define a good practice ? It is tempting to take refuge behind data resulting from scientific research, from “evidence based medicine”. In psychiatry, it is even more tempting to reject in block scientific knowledge because of its epistemological limitations, and of its restricted statistical value, whereas clinical practice is ineluctably confronted to the singularity of the patient/doctor relationship.As often, a reasonable approach is surely intermediate : scientific data can help us to think; an honest and lucid interrogation on our practices, a confrontation, a discussion with our colleagues are essential to help us to consolidate our practices.     

Recruiting medical groups for research: relationships, reputation, requirements, rewards, reciprocity, resolution, and respect

Background

In order to conduct good implementation science research, it will be necessary to recruit and obtain good cooperation and comprehensive information from complete medical practice organizations. The goal of this paper is to report an effective example of such a recruitment effort for a study of the organizational aspects of depression care quality.

Methods

There were 41 medical groups in the Minnesota region that were eligible for participation in the study because they had sufficient numbers of patients with depression. We documented the steps required to both recruit their participation in this study and obtain their completion of two questionnaire surveys and two telephone interviews.

Results

All 41 medical groups agreed to participate and consented to our use of confidential data about their care quality. In addition, all 82 medical directors and quality improvement coordinators completed the necessary questionnaires and interviews. The key factors explaining this success can be summarized as the seven R's: Relationships, Reputation, Requirements, Rewards, Reciprocity, Resolution, and Respect.

Conclusion

While all studies will not have all of these factors in such good alignment, attention to them may be important to other efforts to add to our knowledge of implementation science.     

Chronic fatigue syndrome: understanding a complex illness

Chronic fatigue syndrome (CFS) is a debilitating illness that affects many people. It has been marred by controversy, from initial scepticism in the medical community about the existence of the condition itself to continuing disagreements--mainly between some patient advocacy groups on one side, and researchers and physicians on the other--about the name for the illness, its aetiology, its pathophysiology and the effectiveness of the few currently available treatments. The role of the CNS in the disease is central in many of these discussions. Nature Reviews Neuroscience asked four scientists involved in CFS research about their views on the condition, its causes and the future of research aimed at improving our understanding of this chronic illness.     

Health Culture and the Clinical Encounter: Vietnamese Refugees'' Responses to Preventive Drug Treatment of Inactive Tuberculosis

A majority of Vietnamese refugees entering the United States test positive for inactive tuberculosis (TB). In asymptomatic conditions like inactive TB, it is often difficult to obtain compliance with medical treatment. The clinical encounter has been analyzed as a form of symbolic action between doctor and patient critical to patient trust and compliance. However, it is equally, if not more, important to understand the health culture of patients, that is, the broader sociocultural context of the patient within which his or her illness is interpreted and understood. In this article I look at health culture elements that influence compliance and noncompliance by Vietnamese American clients with courses of preventive drug therapy for inactive TB. Key factors in compliance are: (1) cultural interpretations of the therapy's side effects as "hot"; (2) the role of family members and peers; and (3) community perceptions of the drug treatment. Culturally incongruent elements of the clinical encounter and the funding of community-based organizations for health education also are examined.     

The Presentation of Body Dysmorphic Disorder in Medical Settings

Body dysmorphic disorder (BDD) is a relatively common psychiatric illness that often presents to mental health professionals as well as nonpsychiatric physicians. However, BDD usually goes unrecognized and undiagnosed in clinical settings. It is important to recognize and accurately diagnose BDD because this often secret illness may be debilitating. Patients with BDD typically have markedly impaired functioning, notably poor quality of life, and a high rate of suicidal ideation and suicide attempts. Thus, it is important to screen patients for BDD and avoid misdiagnosing it as another illness. Nonpsychiatric treatments (eg, dermatologic, surgical), which most patients seek and receive, appear ineffective for BDD and can be risky for physicians to provide. This article provides a clinically focused overview of BDD, including its symptoms, morbidity, case examples, nonpsychiatric (ie, cosmetic) treatment, diagnostic "do's" and "don'ts," and suggestions for how to persuade patients to accept appropriate psychiatric care.     

A case for more curiosity-driven basic research

Having been selected to be among the exquisitely talented scientists who won the Sandra K. Masur Senior Leadership Award is a tremendous honor. I would like to take this opportunity to make the case for a conviction of mine that I think many will consider outdated. I am convinced that we need more curiosity-driven basic research aimed at understanding the principles governing life. The reasons are simple: 1) we need to learn more about the world around us; and 2) a robust and diverse basic research enterprise will bring ideas and approaches essential for developing new medicines and improving the lives of humankind.When I was a graduate student, curiosity-driven basic research ruled. Studying mating-type switching in budding yeast, for example, was exciting because it was an interesting problem: How can you make two different cells from a single cell in the absence of any external cues? We did not have to justify why it is important to study what many would now consider a baroque question. Scientists and funding agencies alike agreed that this was an exciting biological problem that needed to be solved. I am certain that all scientists of my generation can come up with similar examples.Open in a separate windowAngelika AmonSince the time I was a graduate student, the field of biological research has experienced a revolution. We can now determine the genetic makeup of every species in a week or so and have an unprecedented ability to manipulate any genome. This revolution has led to a sense that we understand the principles governing life and that it is now time to apply this knowledge to cure diseases and make the world a better place. While applying knowledge to improve lives and treat diseases is certainly a worthwhile endeavor, it is important to realize that we are far from having a mechanistic understanding of even the basic principles of biology. What the genomic revolution brought us are lists, some better than others. We now know how many coding genes define a given species and how many protein kinases, GTPases, and so forth there are in the various genomes we sequenced. This knowledge, however, does not even scratch the surface of understanding their function. When I browse the Saccharomyces cerevisiae genome database (my second-favorite website), I am still amazed how many genes there are that have not even been given a name.To me the most important achievement the new genome-sequencing and genome-editing technologies brought us is that nearly every organism can be a model organism now. We can study and manipulate the processes that most fascinate us in the organisms in which they occur, with the exception, of course, of humans. Thus, I believe that the golden era of basic biological research is not behind us but in front of us, and we need more people who will take advantage of the tools that have been developed in the past three decades. I am therefore hoping that many young people will chose a career in basic research and find an exciting question to study. The more of us there are, the more knowledge we will acquire, and the higher the likelihood we will discover something amazing and important. There is so much interesting biology out there that we should strive to understand. Some of my favorite unanswered questions are: What are the biological principles underlying symbiosis and how did it evolve? Why is sleep essential? Why do plants, despite an enormous regenerative potential, never die of cancer? Why do brown bears, despite inactivity, obesity, and high levels of cholesterol, exhibit no signs of atherosclerosis? How do sharks continuously produce teeth?One could, of course, argue that the knowledge we have accumulated over the past 50 years provides a reasonable framework, and it is now time to leave basic science and model organisms behind and focus on what matters—curing diseases, developing methods to produce energy, cleaning up the oceans, preventing global warming, building biological computers, designing organisms, or engineering whatever the current buzz is about. Like David Botstein, who eloquently discussed the importance of basic research in these pages in 2012 (Botstein, 2012 ), I believe that the notion that we already know enough is wrong and the current application-centric view of biology is misguided. Experience has taught us over and over that we cannot predict where the next important breakthrough will be emerge. Many of the discoveries that we consider groundbreaking and that have brought us new medicines or improved our lives in other ways are the result of curiosity-driven basic research. My favorite example is the discovery of penicillin. Alexander Fleming, through the careful study of his (contaminated) bacterial plates, enabled humankind to escape natural selection. More recent success stories such as new cures for hepatitis C, the human papillomavirus vaccine, the HIV-containment regimens, or treatments for BCR-ABL induced chronic myelogenous leukemia have also only been possible because of decades of basic research in model organisms that taught us the principles of life and enabled us to acquire the methodologies critical to develop these treatments. Although work from my own lab on the causes and consequences of chromosome mis-segregation in budding yeast has not led to the development of new treatments, it has taught us a lot about how an imbalanced karyotype, a hallmark of cancer, affects the physiology of cancer cells and creates vulnerabilities in cancer cells that could represent new therapeutic targets.These are but a few examples for why it is important that we scientists must dedicate ourselves to the pursuit of basic knowledge and why we as a society must make funding basic research a priority. Achieving the latter requires that we scientists tell the public about the importance of what we are doing and explain the potential implications of basic research for human health. At the same time, it will be important to manage expectations. We must explain that not every research project will lead to the development of new medicines and that we cannot predict where the next big breakthroughs will materialize. We must further make it clear that this means we have to fund a broad range of basic research at a healthy level. Perhaps a website that collects examples of how basic research has led to breakthroughs in medicine could serve as a showcase for such success stories, bringing the importance of what we do to the public.While conducting research to improve the lives of others is certainly a worthy motivation, it is not the main reason why I get up very early every morning to go to the lab. To me, gaining an understanding of a basic principle in the purest Faustian terms is what I find most rewarding and exciting. Designing and conducting experiments, pondering the results, and developing hypotheses as to how something may work is most exciting, the idea that I, or nowadays the people in my lab, may be (hopefully) the first to discover a new aspect of biology is the best feeling. It is these rare eureka moments, when you first realize how a process works or when you discover something that opens up a new research direction, that make up for all the woes and frustrations that come with being an experimental scientist in an expensive discipline.For me, having a career in curiosity-driven basic research has been immensely rewarding. It is my hope that basic research remains one of the pillars of the American scientific enterprise, attracting the brightest young minds for generations to come. We as a community can help to make this a reality by telling people what we do and highlighting the importance of our work to their lives.