Social Case-work in General Practice: An Alternative Approach

During a two-year period a senior case-worker was seconded by a voluntary family case-work agency, the Liverpool Personal Service Society, to work with three general practitioners. The commonest reasons for referral of the 157 new patients to the social worker over this study period were extreme poverty; housing, matrimonial, and psychiatric problems; and problems of fatherless families. The successful and valuable co-operation between the general practitioners, case-worker, and various specialist professional and financial services of the Society have proved that a professional social worker has an important role in the general-practice team.     

The Practitioner and School Age Child Problems

The extraordinary plasticity of the growing child offers the general practitioner an unusual opportunity to intervene either in a preventative or therapeutic manner. Such intervention, properly the task of any informed physician dealing with families, can alter unhealthy growth to healthier development. The whole child is just as important as his medical illnesses; the whole family usually needs help when there is an emotional disturbance in any child.Common problems that lend themselves readily to physician intervention are behavior disorders accompanying a neurological deficit, conduct disorders, enuresis and school phobias. Knowing how to elicit information, to evaluate clinical data and to utilize the findings of a skilled psychologist, and when to refer to a psychiatrist, plus a thorough knowledge of community resources are part and parcel of a physician''s equipment for dealing with children and families.     

CAN FAMILISM BE JUSTIFIED?

This paper argues against the continued practice of Confucian familism, even in its moderate form, in East Asian hospitals. According to moderate familism, a physician acting in concert with the patient's family may withhold diagnostic information from the patient, and may give it to the patient's family members without her prior approval. There are two main approaches to defend moderate familism: one argues that it can uphold patient's autonomy and protect her best interests; the other appeals to cultural relativism by construing the principle of 'family autonomy' to be incommensurable with that of individual autonomy. We respond to the first approach by explaining how the familist arguments either depend on some unreasonable assumptions or simply fail to articulate. The critique of the second approach is based on our recent survey showing that there is no dichotomy of relevant values between the East and the West: we believe that the result can effectively block the familist's reliance on certain traditional or cultural values to explain their resistance to the incorporation of pluralist values. Despite our disagreement with familism, we consider the Eastern emphasis on the family to be conducive to the communication between patient, family members and medical personnel, which is indispensible to the patient's well being and autonomy. We conclude that respect for patient autonomy is perfectly consistent with the involvement of the family in making medical decision as long as the family plays a merely consultant role.     

De novo prediction of three-dimensional structures for major protein families

The family 10 xylanase from Streptomyces olivaceoviridis E-86 contains a (beta/alpha)(8)-barrel as a catalytic domain, a family 13 carbohydrate binding module (CBM) as a xylan binding domain (XBD) and a Gly/Pro-rich linker between them. The crystal structure of this enzyme showed that XBD has three similar subdomains, as indicated by the presence of a triple-repeated sequence, forming a galactose binding lectin fold similar to that found in the ricin toxin B-chain. Comparison with the structure of ricin/lactose complex suggests three potential sugar binding sites in XBD. In order to understand how XBD binds to the xylan chain, we analyzed the sugar-complex structure by the soaking experiment method using the xylooligosaccharides and other sugars. In the catalytic cleft, bound sugars were observed in the xylobiose and xylotriose complex structures. In the XBD, bound sugars were identified in subdomains alpha and gamma in all of the complexes with xylose, xylobiose, xylotriose, glucose, galactose and lactose. XBD binds xylose or xylooligosaccharides at the same sugar binding sites as in the case of the ricin/lactose complex but its binding manner for xylose and xylooligosaccharides is different from the galactose binding mode in ricin, even though XBD binds galactose in the same manner as in the ricin/galactose complex. These different binding modes are utilized efficiently and differently to bind the long substrate to xylanase and ricin-type lectin. XBD can bind any xylose in the xylan backbone, whereas ricin-type lectin recognizes the terminal galactose to sandwich the large sugar chain, even though the two domains have the same family 13 CBM structure. Family 13 CBM has rather loose and broad sugar specificities and is used by some kinds of proteins to bind their target sugars. In such enzyme, XBD binds xylan, and the catalytic domain may assume a flexible position with respect to the XBD/xylan complex, inasmuch as the linker region is unstructured.     

Trade-off between reciprocal mutualists: local resource availability-oriented interaction in fig/fig wasp mutualism

1. The mechanisms that prevent competition (conflict) between the recipient and co-operative actor in co-operative systems remain one of the greatest problems for evolutionary biology. Previous hypotheses suggest that self-restraint, dispersal or spatial constraints can prevent direct competition for local resources or any other common resources, thereby maintaining stable co-operation interactions. In this study, we use the obligate fig-fig-wasp mutualism to examine whether the above mechanisms can maintain stable co-operation sufficiently between figs and fig wasps. 2. Our data on obligate co-operation between figs (Ficus racemosa Linn.) and fig wasps (Ceratoslen fusciceps Mayr) show that the number of viable seeds of figs is positively correlated with the number of pollinator offspring when the number of vacant female flowers is high while the foundress number is low (two foundresses). Meanwhile, they are negatively correlated when the number of vacant female flowers is low and the number of foundresses is increased manually (eight foundresses). The correlation coefficient between viable seeds and wasp offspring (galls) depends on vacant female flower availability. 3. Our data suggest that the interaction between figs and fig wasps is conditional, and that they co-operate when local resource availability is plentiful but are in conflict when local resource availability is limited. The self-restraint, dispersal and spatial heterogeneity previously hypothesized in maintaining stable co-operation cannot sufficiently prevent the symbionts from utilizing more local resources at the expense of the recipients. The conflict, which can disrupt the co-operation interaction, exists after the local resource is saturated with symbionts. The repression of symbiont increase, therefore repressing the utilization of local resources in the conflict period, is crucial in the maintenance and evolution of co-operation.     

Against the family veto in organ procurement: Why the wishes of the dead should prevail when the living and the deceased disagree on organ donation

The wishes of registered organ donors are regularly set aside when family members object to donation. This genuine overruling of the wishes of the deceased raises difficult ethical questions. A successful argument for providing the family with a veto must (a) provide reason to disregard the wishes of the dead, and (b) establish why the family should be allowed to decide. One branch of justification seeks to reconcile the family veto with important ideas about respecting property rights, preserving autonomy, and preventing harm. These arguments are ultimately unsuccessful. Another branch of arguments is consequentialist, pointing out the negative consequences of removing the veto. Whether construed as concerning family distress or as a potential drop in the organs available, these arguments are unsuccessful; the first fails to recognize the tremendous distress associated with waiting for an organ, while the second has little supporting evidence. A final section considers and rejects whether combining some of the arguments just examined could justify the family veto. We should thus remove the family veto in organ donation.     

Doing what the patient orders: maintaining integrity in the doctor-patient relationship

No profession has undergone as much scrutiny in the past several decades as that of medicine. Indeed, one might well argue that no profession has ever undergone so much change in so short a time. An essential part of this change has been the growing insistence that competent, adult patients have the right to decide about the course of their own medical treatment. However, the familiar and widely accepted principle of patient self-determination entails a corollary that has received little attention in the growing literature on the ethics of physician-patient relations: if patients are to direct the course of their own medical treatment, then physicians are at least sometimes to be guided in their actions on behalf of patients by values that are not, and may even be incompatible with, their own values. Unless it is supposed that it would be best if physicians were simply to accommodate any and all patient requests, a possibility I consider and reject in this paper, there are bound to be numerous instances of legitimate moral conflict between the preferences of physicians and patients. In this paper, I examine the implications of this sort of moral conflict from the standpoint of the integrity of the physician....I have also considered the common practice of patient referral from the standpoint of physician integrity, and asked whether a physician who refuses to treat a patient as a matter of conscience can consistently refer the patient to another physician for the same treatment....     

The Incidence of Palpable Liver and Spleen in the Postpartum Period

Abdominal examination was performed in 75 healthy women after normal delivery. The liver was palpable in 23 patients, the spleen in nine. The author believes that these organs were palpable because of ptosis rather than enlargement. Knowledge of this fact should keep the physician from attributing undue importance to the presence of a palpable liver and spleen in the postpartum period.     

Programme for specialization in family medicine

A programme for specialized training in family medicine at Tel Aviv University Medical School provides four years of postgraduate study, two of which are in recognized hospital departments and two in clinics recognized for training in family medicine. At the end of this four-year period the graduate must submit a thesis of original work or an approved research project on an aspect of family medicine. Continuing contact of the trainee with both the family medicine clinic and the hospital departments is maintained throughout the period. While in hospital the trainee spends half a day a week in the family clinic with his personal tutor, and when in the clinic he spends half a day a week in the hospital.This programme has been provisionally accepted as meeting the formal requirements of the Israel Medical Association for specialization in family medicine, and the first physician has started training.     

Current trends in teaching ethics of healthcare practices

The unprecedented progress in bio-medical sciences and technology during the last few decades has resulted in great transformations in the concepts of health and disease, health systems and healthcare organisation and practices. Those changes have been accompanied by the emergence of a broad range of ethical dilemmas that confront health professionals more frequently. The classical Hippocratic ethical principles, though still retaining their relevance and validity, have become insufficiently adequate in an increasing range of problems and situations. Healthcare that has been practised for centuries on the basis of a direct doctor-patient relationship has been increasingly transformed into a more complex process integrating the health-team, the patient (healthcare seeker) and the community. Systematic review of the specialised literatures revealed that Healthcare Ethics education has become a basic requirement for any training programme for health professionals, and should cover the different stages of undergraduate, postgraduate and continuing education. Both theoretical foundations and practical skills are required for the appropriate ethical reasoning, ethical attitude and decision-making abilities. There is growing evidence that physicians' professional and moral development is not only determined by the formal curriculum of ethics; rather more, it is determined by the moral environment of the professional practice, the 'hidden curriculum' which deserves serious consideration by medical education.     

The clinical psychologist; his role in private medical practice

The independent diagnosis and treatment of mental and nervous disorders according to California law constitutes practicing medicine. By this yardstick, an increasing number of clinical psychologists are entering the private practice of medicine. The medical profession has not provided through its leadership the opportunity for clinical psychologists to utilize their skills in a legitimate and supervised way in the treatment of private patients, nor has the medical profession taken sufficient interest in modern methods of treating patients with psychogenic disorders. If the psychiatric team is a feasible and practical approach to spreading the base of psychiatric treatment in hospitals and clinics, it should be applicable to private practice settings too. In the team setting, the psychologist can render great assistance to the physician in the diagnosis and treatment of patients with psychogenic disorders without compromising the principle that the primary responsibility for the patient is the physician's. By virtue of his training and experience, it is the psychiatrist who is best qualified to supervise the work of the psychologist; and until such time as the medical profession is better acquainted with psychotherapeutic techniques, the employment of psychologist assistants should be (according to good medical practice) left to the psychiatrist. The need for some regulation of the use of the title "psychologist" is increasing in order to protect the public from quacks who pose as psychologists. However, any law which is directed toward elimination of the quack should specifically define psychotherapy and contain provisions for its use under adequate medical supervision. The medical profession is obligated to take its traditional role in providing the best possible treatment for patients who are in need of it, and psychotherapy is an inherent part of treatment.     

Relative costs of specialist services in a family practice population

The frequency and cost of referrals to specialists in March 1984 for 8980 rostered patients attending a family practice clinic located in a teaching hospital were analysed. The patients made 1891 visits to specialists. In all age groups and for all specialties female patients were more likely to be seen. The total direct provider costs were higher for female patients than for male patients. However, costs per patient seen were higher for male patients, except for psychiatry and medicine. Visits to surgeons had the highest total cost, while visits to psychiatrists had the highest cost per patient seen. Of the direct provider costs 61% was for specialist services. The family physician, in the “gatekeeper” role, has an opportunity to control some of the costs of the health care system by ensuring that the best and most efficient use is made of the referral network.     

Family-specific approaches to the analysis of case-control family data

Case-control studies augmented by the values of responses and covariates from family members allow investigators to study the association between the response and genetics and environment by relating differences in the response directly to within-family differences in covariates. However, existing approaches for case-control family data parameterize covariate effects in terms of the marginal probability of response, the same effects that one estimates from standard case-control studies. This article focuses on the estimation of family-specific covariate effects and develops efficient methods to fit family-specific models such as binary mixed-effects models. We also extend the approach to cover any setting where one has a fully specified model for the vector of responses in a family. We illustrate our approach using data from a case-control family study of brain cancer and consider the use of weighted and conditional likelihood methods as alternatives.     

Controlled study of critical parent and family factors in the obesigenic environment

Objective: Critical gaps remain in our understanding of the obesigenic family environment. This study examines parent and family characteristics among obese youth presenting for treatment in a clinic setting. Research Methods and Procedures: Families of 78 obese youth (BMI z‐score = 2.4; age, 8 to 16 years; 59% girls; 49% African‐American) were compared with 71 non‐overweight (BMI z‐score = ?0.02) demographically matched comparisons. Parents completed measures assessing family demographics, psychological distress (Symptom Checklist 90‐Revised), and family functioning both broadly (Family Environment Scale: Conflicted, Support, Control) and at mealtimes (About Your Child's Eating‐Revised: Mealtime Challenges, Positive Mealtime Interaction). Height and weight were obtained from all participants. Results: Compared with mothers and fathers of non‐overweight youth, parents of obese youth had significantly higher BMIs (p < 0.001). Mothers of obese youth reported significantly greater psychological distress (p < 0.01), higher family conflict (p < 0.05), and more mealtime challenges (p < 0.01). Less positive family mealtime interactions were reported by both mothers (p < 0.01) and fathers (p < 0.05) of obese youth. These group differences did not vary by child sex or race. Logistic regression analyses indicated that maternal distress and mealtime challenges discriminated between obese and non‐overweight youth after controlling for maternal BMI. Family conflict was explained, in part, by maternal distress. Discussion: Obese youth who present for treatment in a clinic setting are characterized by psychosocial factors at the parent and family level that differ from non‐overweight youth. These data are critical because they identify factors that may be serving as barriers to a family's or youth's ability to implement healthy lifestyle behaviors but that are potentially modifiable.     

Regional variation in nonmedical factors affecting family physicians' decisions about referral for consultation

OBJECTIVE: To determine whether there is regional variation in environmental (non-medical) factors affecting referral decisions of family physicians (FPs). DESIGN: Cross-sectional interview survey. SETTING: Nova Scotia. PARTICIPANTS: A random sample of 125 FPs grouped into 1 of 5 functionally defined geographic regions of Nova Scotia (25 in each group). Groupings were based on access to general hospital beds through active staff hospital appointments or to specialist consultants in the community, or both. Participants were personally interviewed on site. No physician refused an interview. In 9 cases the physician indicated that he or she did not fit the profile of the assigned group; the physician was excluded from the study and the next doctor on the list was substituted. OUTCOME MEASURES: The questionnaire was designed to test several hypotheses about factors known to potentially influence decisions about referral. Geographic differences in factors affecting referral and in decisions about 5 hypothetical cases were assessed with the use of significance tests for proportions that were sensitive to specific orders across groups. RESULTS: Three factors affecting referral showed unequivocal variation across the 5 groups. Access to hospital facilities and remoteness from specialist care, leading to local styles of practice or treatment policies, and the FP''s relationship with specialist consultants appeared to be important nonmedical factors affecting referral decisions. For similar case scenarios the physicians living in rural areas would refer only half as often overall as those living in urban areas with tertiary care hospitals; for some cases, such as a severe asthma attack, the difference was more than 7-fold. CONCLUSIONS: Significant differences in nonmedical factors affecting referral, and in referral decisions about hypothetical cases, were found between the groups of FPs. Differences in access to resources, creating local styles of practice, appeared to explain most of the variation. The results may account for previously observed differences in actual rates of referral for these particular groups.     

Expression analysis suggests novel roles for members of the Pht1 family of phosphate transporters in Arabidopsis

The completion of the Arabidopsis thaliana genome has revealed that there are nine members of the Pht1 family of phosphate transporters in this species. As a step towards identifying the role of this gene family in phosphorus nutrition, we have isolated the promoter regions from each of these genes, and fused them to the reporter genes beta-glucuronidase and/or green fluorescent protein. These chimeric genes have been introduced into A. thaliana, and reporter gene expression has been assayed in plants grown in soil containing high and low concentrations of inorganic phosphate (Pi). Four of these promoters were found to direct reporter gene expression in the root epidermis, and were induced under conditions of phosphate deprivation in a manner similar to previously characterised Pht1 genes. Other members of this family, however, showed expression in a range of shoot tissues and in pollen grains, which was confirmed by RT-PCR. We also provide evidence that the root epidermally expressed genes are expressed most strongly in trichoblasts, the primary sites for uptake of Pi. These results suggest that this gene family plays a wider role in phosphate uptake and remobilisation throughout the plant than was previously believed.     

Idioms of distress: Somatic responses to distress in everyday life

In-depth interviews were conducted among 50 subjects residing in the industrial town of Newcastle, Australia. Half of these subjects were from the general population and half were currently seeking counselling for personal/family problems. None of the subjects were receiving any medical care at the time of interview, though seven had done so during the episode of distress they were discussing. The study shows that while the subjects psychologized their problems, members of both groups tended to somatize at a rate proportional to the level of distress. Subjects were unaware of any relationship between the distress they were experiencing and their physical complaints. The results of this study support previous research which argues that those experiencing distress and those who tend to introspect are also those who are likely to amplify somatic symptoms. At the same time these results depart from findings in the United States which suggest that in the West, people learn to express social and personal distress in psychological terms,, thereby reducing the level of somatization. Though not representative of the population as a whole, the findings raised questions warranting further study.