Why is Pain Still Under‐Treated in the Emergency Department? Two New Hypotheses

Across the world, pain is under‐treated in emergency departments (EDs). We canvass the literature testifying to this problem, the reasons why this problem is so important, and then some of the main hypotheses that have been advanced in explanation of the problem. We then argue for the plausibility of two new hypotheses: pain's under‐treatment in the ED is due partly to (1) an epistemic preference for signs over symptoms on the part of some practitioners, and (2) some ED practices that themselves worsen pain by increasing patients' anxiety and fear. Our argument includes the following logic. Some ED practitioners depart from formal guidance in basing their acute pain assessments on observable features rather than on patient reports of pain. This is potentially due to an epistemic preference for signs over symptoms which aims to circumvent intentional and/or unintentional misrepresentation on the part of patients. However, conducting pain assessments in line with this epistemic preference contributes to the under‐treatment of pain in at least three respects, which we detail. Moreover, it may do little to help the practitioner circumvent any intentional misrepresentation on the part of the patient, as we explain. Second, we examine at least four ED practices that may be contributing to the under‐treatment of pain by increasing patient anxiety and fear, which can worsen pain. These practices include failing to provide orienting information and partially objectifying patients so as to problem‐solve along lines pre‐established by modern medical science. We conclude by touching on some potential solutions for ED practice.     

医德视域下医学生医学精神的建构

近些年来,我国十分重视医学生职业道德教育,然而,在医德教学实践中仍存在着观念落后、内容失衡和方法单一等多方面问题。同时,随着我国多元结构社会的形成,医学生的思想状况和价值观趋于复杂化,从业时职业道德水平出现滑坡。针对目前医学生医德教育存在的种种问题,试图从加强和改进医学生医德教育的角度,探索医学生医德教育改革,增强医学生医德教育的实效性。     

基于京津冀一体化构想下的中医医疗联盟模式探讨

在中央提出京津冀协同发展的重大战略背景下,为了适应区域医疗均质化和医改的需要,为区域内百姓提供更优质的医疗服务,试构想创建中医医疗联盟。在医疗一体化建设方面,北京中医医院有着很好的中医联盟建设基础,试从北京中医医院医疗联盟建设的角度,对京津冀一体化构想下的医院托管模式进行探讨。     

Is infertility a disease and does it matter?

Claims about whether or not infertility is a disease are sometimes invoked to defend or criticize the provision of state‐funded treatment for infertility. In this paper, I suggest that this strategy is problematic. By exploring infertility through key approaches to disease in the philosophy of medicine, I show that there are deep theoretical disagreements regarding what subtypes of infertility qualify as diseases. Given that infertility’s disease status remains unclear, one cannot uncontroversially justify or undermine its claim to medical treatment by claiming that it is or is not a disease. Instead of focusing on disease status, a preferable strategy to approach the debate about state‐funded treatment is to explicitly address the specific ethical considerations raised by infertility. I show how this alternative strategy can be supported by a recent theoretical framework in the philosophy of medicine which avoids the problems associated with the concepts of health and disease.     

现代生物医学科技前沿与中西医结合交叉

本文讨论了中医现代化和中西医结合的有关问题,指出中医现代化工作可分为三个方面：第一方面,应当培养大批临床上过硬的中医人才,在临床上有所突破,以此为基础进行理论研究;第二方面,将中医理论转换成现代语言;第三方面,中医与包括现代生物医学在内的多学科结合。阐述了现代生物医学科技前沿与中西医结合交叉而产生的新学科一光子中医学。指出光子中医学将为中西医结合提供理论和技术平台,成为多学科研究中医的代表性学科,并将成为中医现代化的一个重要方向,为人类卫生事业作出重大贡献。     

提高中医院校医学遗传学教学质量的探讨

根据多年教学实践经验,对中医院校医学遗传学课程教学中的现状进行分析,提出要从优化教学内容、采用多种教学方法、创新教学手段、教学结合临床、改革考核方法等方面入手提高医学遗传学课程的教学质量。     

医师职业精神内源性驱动力的实证探讨

以“优质护理服务工程”、产科“一贯制”工作模式与传统工作模式为基础,分析了医务人员职业精神内源性驱动力在的差异。结果表明：不同工作模式下心理契约有显著差异,变革组高于试点组; “医患交流互动”因素对工作行为发生积极变化的重要性有显著的差异,变革组高于传统组;在相同工作环境下,不同自尊水平的医务人员,其职业精神的表现有显著差异,自尊水平越高,员工满意度和工作敬业度得分越高、工作倦怠得分越低,即职业精神表现越好。提出医师职业精神的内源性驱动力来自3个方面：内部组织赋予医务人员的内心体验,外部顾客（患者）赋予医务人员的内心体验,医务人员自我人格特征。     

Conscientious objection in healthcare: How much discretionary space best supports good medicine?

Daniel Sulmasy has recently argued that good medicine depends on physicians having a wide discretionary space in which they can act on their consciences. The only constraints Sulmasy believes we should place on physicians’ discretionary space are those defined by a form of tolerance he derives from Locke, whereby people can publicly act in accordance with their personal religious and moral beliefs as long as their actions are not destructive to society. Sulmasy also claims that those who would reject physicians’ right to conscientious objection eliminate discretionary space, thus undermining good medicine and unnecessarily limiting religious freedom. I argue that, although Sulmasy is correct that some discretionary space is necessary for good medicine, he is wrong in thinking that proscribing conscientious objection entails eliminating discretionary space. I illustrate this using Julian Savulescu and Udo Schuklenk’s system for restricting conscientious objections as a counter‐example. I then argue that a narrow discretionary space constrained by professional ideals will promote good medicine better than Sulmasy’s wider discretionary space constrained by his conception of tolerance. Sulmasy’s version of discretionary space would have us tolerate actions that are at odds with aspects of good medicine, including aspects that Sulmasy himself explicitly values, such as fiduciary duty. Therefore, if we want the degree of religious freedom in the public sphere that Sulmasy favours then we must decide whether it is worth the cost to the healthcare system.     

Focus: A Multifaceted Battle Against Cancer: Ashley W. Oughterson,MD: Surgeon,Soldier, Leader

Ashley W. Oughterson, MD, (1895-1956) was a longtime faculty surgeon at Yale University. He performed some of the earliest pancreatic resections in the United States. During World War II, Colonel Oughterson was the primary “Surgical Consultant” in the South Pacific and present at nearly every major battle. His meticulously kept diary is regarded as the foremost source detailing wartime surgical care. Colonel Oughterson led the initial Army team to survey Hiroshima and Nagasaki following the nuclear attacks. Thoughout his academic career at Yale, Oughterson was a key leader in several medical and surgical societies. As scientific director of the American Cancer Society, Oughterson lectured widely and guided research priorities in oncology following World War II. Oughterson also authored numerous benchmark papers in surgical oncology that continue to be cited today. These extensive contributions are examined here and demonstrate the wide-ranging impact Oughterson exerted during a formative period of American surgery.     

医学研究伦理学的发展现状与前景

创新技术的开展和转化医学的注重给医学的发展注入了新的活力,但同时,也带来了一系列社会伦理问题和法律问题。生命医学伦理学的兴起和发展催生了医学研究伦理学分支学科形成,目的在于推进解决涉及人体的医学研究的伦理问题。当前,面临的最突出的伦理问题在于,对医学研究合法性、先进性及伦理性的把握,对医学研究伦理审查必要性的认知,对医学研究方案设计与伦理道德的匹配,对医学研究知情同意的告知,对医学研究风险与受益的平衡。逐步与国际接轨,加强伦理委员会制度建设;提高伦理审查能力建设,形成高水平的伦理审查队伍;学术组织和团体共同努力,推进医学研究伦理学的发展,这将助推医学研究伦理学的发展。