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.     

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danger inherent in that illness and is in inverse relation to medical knowledge about that illness, the authors of an unpublished doctoral dissertation conclude that "those who are scientifically more knowledgeable" in the area of medical practice are "also more rational."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.     

美国国立卫生研究院概况

美国国立卫生研究院(the National Institutes of Health,NIH)是美国主要的医学与行为学(medical and behavioral research)研究机构,拥有27个研究所及研究中心和1个院长办公室(office of the director,OD),任务是探索生命本质和行为学方面的基础知识,并充分运用这些知识延长人类寿命,以及预防、诊断和治疗各种疾病和残障。NIH不仅拥有自己的实验室从事医学研究,还通过各种资助方式和研究基金全力支持各大学、医学院校、医院等的非政府科学家及其他国内外研究机构的研究工作,并协助进行研究人员培训,促进医学信息交流。世界一流的科学家在NIH的支持下,自由探索科学问题,取得了辉煌的成就,极大地改善了人类的健康和生存状况。本文旨在介绍NIH的概况、基金管理模式、经费预算等,希望对我国的医学研究事业有所借鉴。     

The Cultural Construction of Mental Illness in Prison: A Perfect Storm of Pathology

Large numbers of individuals in U.S. prisons meet DSM criteria for severe psychiatric disorder. These individuals also have co-occurring personality and substance abuse disorders, medical conditions, and histories of exposure to social pathologies. Based on nine months of ethnographic fieldwork in a U.S. prison, focusing on staff narratives, I utilize interpretivist and constructivist perspectives to analyze how mental health clinicians construct psychiatric disorder among inmates. Discrete categorization of disorders may be confounded by the clinical co-morbidities of inmates and the prison context. Incarcerated individuals’ responses to the institutional context substantially inform mental health staffs’ illness construction and the prison itself is identified as an etiological agent for disordered behaviors. In addition, diagnostic processes are found to be indeterminate, contested, and shaped by interactions with staff. Analysis of illness construction reveals that what is at stake for clinicians is not only provision of appropriate treatment, but also mandates for the safety and security of the institution. Enmeshed in these mandates, prison mental health becomes a particular local form of psychiatric knowledge. This paper contributes to anthropological approaches to mental disorder by demonstrating how local contexts mediate psychiatric knowledge and contribute to the limited ethnographic record of prisons.     

Unmet need for additional medical care for sick children in mother's view in rural Bangladesh: implications for improving child health services

While a country's health policy aims to provide health services to all who need them, very little in known about unmet need for additional medical care from users' perspectives in Bangladesh. This study examined unmet medical need (defined as whether a mother felt that, to manage sickness, her child had required medical care that was not available, regardless of reasons and medical care sought) of 2123 under-15 sick children by illness and child's socioeconomic characteristics in rural Bangladesh. The 1996 Health and Socioeconomic Survey conducted in Matlab recorded children's chronic (a disease or a condition lasting 3 months or more) and acute (a disease or a condition with a rapid onset and a short, severe course) morbidity, medical care sought to combat illness and unmet needs for additional medical services in mothers' views to manage the illness. The survey also recorded household socioeconomic data. Logistic regression was used to examine the data. The results reveal that unmet needs for additional medical care were 5.4% for children with acute illnesses, and 30.2% for children with chronic illnesses. For chronic illnesses, seeking medical care to manage illness from any health provider outside the home reduced unmet medical needs. Economic inequalities existed for both acute and chronic illnesses: the odds ratio of unmet medical needs for sick children of the least poor households was 0.42 (95% CI: 0.28-0.64) times that for sick children of the very poor households. The critically high unmet needs for children's chronic morbidity reveal that the chronic disease control programme in Bangladesh needs urgent revisiting and strengthening.     

Stress, illness, and illness behavior.

This paper examines adaptation as a transactive process involving the skills and capacities of individuals and their supporting groups on the one hand, and the types of challenges they face on the other. Many difficulties in understanding stress processes in illness result from the confusion between illness and illness behavior. It is argued that the medical record is as much a history of the individual's behavior and social selection processes as it is a reflection of levels of physical health. Various examples are discussed, illustrating how medical records can be misleading in research examining the relationship between stress and illness, and how influences attributed to stress may be the result of illness behavior. The paper concludes by examining alternative conceptual models for studying the relationships between life challenges, illness behavior and illness.     

Chronic illness and functional limitation in Ontario children: findings of the Ontario Child Health Study.

The Ontario Child Health Study (OCHS) was based on interviews of 1869 Ontario families who were selected by means of a stratified, multistaged sampling method from the 1981 census of Canada. Its primary purpose was to determine the prevalence and distribution of mental health problems in Ontario children aged 4 to 16 years and their families, but it also allowed an estimate of other significant medical conditions and provided an overview of these children''s use of health care, education and social services. Our results are based on questionnaire responses concerning 3294 children. Limitation of function without a chronic illness or medical condition was reported in 1.9%, the converse in 14.0%, and a chronic illness or medical condition with limitation of function in 3.7%. When the three groups are considered together, 19.6% of Ontario children had a chronic health problem. Children of lower socioeconomic status were much more likely to have chronic health problems. Overall, children with chronic health problems were more likely to use physician, special education, social and mental health services. These findings have implications for those who provide services for children, plan community programs or train professionals in caring for children.     

Intracultural Variation in Folk Medical Knowledge: A Comparison Between Curers and Noncurers

This paper investigates variation in folk medical beliefs in a Tarascan community in west-central Mexico. The data are from a structured interview completed with ten traditional curers and a like-sized comparison group of noncurers. Three possible patterns of interinformant agreement are described and tested using the quadratic assignment program. The results suggest that although curers and noncurers do differ, the differences are not so great that they represent two variant systems of medical beliefs. Rather, there is a single system of beliefs common to both groups, but with curers showing higher agreement among themselves in expressing this system than noncurers. This finding, and a related one showing higher agreement among older informants, are explained in terms of culture learning. Curers and older people share more knowledge about illness because of their greater experience in both dealing with and communicating about illness. A model of folk medical knowledge is then presented and systematic variation from this model examined.     

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."     

<Emphasis Type="BoldItalic">The Ethics of Biomedical Big Data</Emphasis>

The availability of diverse sources of data related to health and illness from various types of modern communication technology presents the possibility of augmenting medical knowledge, clinical care, and the patient experience. New forms of data collection and analysis will undoubtedly transform epidemiology, public health, and clinical practice, but what ethical considerations come in to play? With a view to analysing the ethical and regulatory dimensions of burgeoning forms of biomedical big data, Brent Daniel Mittelstadt and Luciano Floridi have brought together thirty scholars in an edited volume that forms part of Springer’s Law, Governance and Technology book series in a collection titled The Ethics of Biomedical Big Data. With eighteen chapters partitioned into six carefully devised sections, this volume engages with core theoretical, ethical, and regulatory challenges posed by biomedical big data.     

Prevention of Mental Disorder—The Role of the General Practitioner

As prevention in psychiatry really refers to early detection and consequent prevention of complications and chronicity, the general practitioner is the most important person in the medical community in preventing mental disorders. As more postgraduate courses in psychiatry become available to practicing family physicians, the majority of patients with psychiatric disorders will be effectively managed by the general medical practitioner.The family physician is already doing this, although not as well as he could. In some instances, he may be unaware of the extent to which the disease with which he deals is psychic disease. As the number of community health centers increases, family physicians will play a vital role in their function. With the necessary knowledge to detect psychic disturbance and to treat emotional disorders effectively, the family physician will prevent many of the instances of progression to chronic psychiatric illness with which we are now plagued. The psychiatrist of the future will act as consultant, treating only patients with the more complicated mental disorders.     

Special considerations in the treatment of patients with bipolar disorder and medical co-morbidities

BACKGROUND: The pharmacological treatment of bipolar disorder has dramatically improved with multiple classes of agents being used as mood-stabilizers, including lithium, anticonvulsants, and atypical antipsychotics. However, the use of these medications is not without risk, particularly when a patient with bipolar disorder also has comorbid medical illness. As the physician who likely has the most contact with patients with bipolar disorder, psychiatrists must have a high index of suspicion for medical illness, as well as a basic knowledge of the risks associated with the use of medications in this patient population. METHODS: A review of the literature was conducted and papers addressing this topic were selected by the authors. RESULTS AND DISCUSSION: Common medical comorbidities and treatment-emergent illnesses, including obesity, diabetes mellitus, dyslipidemia, cardiac disease, hepatic disease, renal disease, pulmonary disease and cancer are reviewed with respect to concomitant use of mood stabilizers. Guidance to clinicians regarding effective monitoring and treatment is offered. CONCLUSIONS: Mood-stabilizing medications are necessary in treating patients with bipolar disorder and often must be used in the face of medical illness. Their safe use is possible, but requires increased vigilance in monitoring for treatment-emergent illnesses and effects on comorbid medical illness.     

Hypoprothrombinemic hemorrhage due to cholestyramine therapy.

Somatization is the tendency to experience and communicate psychologic distress in the form of somatic symptoms that the patient misinterprets as signifying serious physical illness. Patients with persistent somatization relentlessly seek medical diagnosis and treatment despite repeated reassurance that physical illness is either absent or insufficient to account for their symptoms and disability. Such abnormal illness behaviour leads to overuse of health care facilities and contributes to the high cost of health care. Somatization may occur transiently in response to stressful life events or it may be persistent and result in chronic partial or total disability. Diagnostic and therapeutic guidelines that may help physicians identify and manage such patients more effectively are discussed.     

What can experience add to early medical education? Consensus survey

Objective To provide a rationale for integrating experience into early medical education (“early experience”).Design Small group discussions to obtain stakeholders'' views. Grounded theory analysis with respondent, internal, and external validation.Setting Problem based, undergraduate medical curriculum that is not vertically integrated.Participants A purposive sample of 64 students, staff, and curriculum leaders from three university medical schools in the United Kingdom.Results Without early experience, the curriculum was socially isolating and divorced from clinical practice. The abruptness of students'' transition to the clinical environment in year 3 generated positive and negative emotions. The rationale for early experience would be to ease the transition; orientate the curriculum towards the social context of practice; make students more confident to approach patients; motivate them; increase their awareness of themselves and others; strengthen, deepen, and contextualise their theoretical knowledge; teach intellectual skills; strengthen learning of behavioural and social sciences; and teach them about the role of health professionals.Conclusion A rationale for early experience would be to strengthen and deepen cognitively, broaden affectively, contextualise, and integrate medical education. This is partly a process of professional socialisation that should start earlier to avoid an abrupt transition. “Experience” can be defined as “authentic human contact in a social or clinical context that enhances learning of health, illness or disease, and the role of the health professional.”     

Census of single homeless people in Sheffield.

OBJECTIVE--To determine the number of single homeless people in Sheffield and to examine their demography and social and medical details. DESIGN--Census carried out between 8 am and 8 pm on one day. Participants completed a questionnaire designed to provide data relating to employment history, contact with welfare and health services, social state, prison history, medical history, and health state. SETTING--Sites in Sheffield identified by local workers as being places of residence of homeless people. SUBJECTS--340 single homeless people. MAIN OUTCOME MEASURES--Self reported history of alcohol or drug misuse, existence of a chronic medical condition, and use of general practitioner and hospital services. RESULTS--The mean age of the population was 42.5 years and a quarter of the population were aged less than 30; there were 48 women. Significant differences were noted between men and women with respect to self reported psychiatric illness (77/266 men v 27/42 women), self reported alcoholism (83/273 v 4/44), prison history (152/255 v 8/41), and registration with a general practitioner (73/275 v 38/46). Various chronic medical conditions were reported, and the perceived health state of the population was low; 129 claimed to have been admitted to a psychiatric hospital. 220 people were registered with a general practitioner, and 179 claimed to see their doctor. Sixty five had attended or been admitted to a general hospital in the month preceding the study, 45 for accident and emergency services. CONCLUSIONS--The homeless in this population were younger than those found in previous studies. The prevalence of psychiatric illness was high in the population, and the overall health state was poor. Most subjects obtained health services from general practitioners.     

Health,illness, and immigration. East Indians in the United States.

East Indian immigrants to the United States represent the diversity in religion, language, and culture that exists in India, so it is difficult to make unequivocal statements about their health beliefs and behaviors. Despite the diversity, an understanding of Ayurvedic humoral concepts of health and illness provides a key to some pervasive and persistent ideas and practices. India has a pluralistic medical system in which Western medicine, which is increasingly popular for some ailments, is one option among many. Even those who are familiar with the "Western" medical system in India may find American medicine alien.     

Dying under the bird's shadow: narrative representations of degedege and child survival among the Zaramo of Tanzania

In this article, I examine the cultural interpretations of degedege, an indigenous illness commonly recognized by the Zaramo people of coastal Tanzania as life threatening. Drawing on the narratives of three bereaved parents who lost a child to degedege, I analyze the contextual and circumstantial factors involved in these parents' negotiation of the identity of an illness and in their subsequent therapy seeking behavior. I show that even though cultural knowledge and etiological beliefs about degedege may be shared locally, there is significant variation in the therapeutic pathways that parents follow to deal with an actual episode of the illness. I emphasize the need for more contextualized data on health-seeking behaviors, and argue that it is necessary to pay attention to the micropolitics of health care decision making at the household level. Finally, I also call attention to the politics of provider-patient communication at public health facilities as a means to improve public health interventions to increase child survival.     

The impact of two education methods on knowledge of schistosomiasis transmission and prevention among schoolchildren in a rural community in northern Minas Gerais, Brazil

The objective of this study was to analyse the effect of using two health education approaches on knowledge of transmission and prevention of schistosomiasis of school children living in a rural endemic area in the state of Minas Gerais, Brazil. The 87 children participating in the study were divided into three groups based on gender, age and presence or absence of Schistosoma mansoni infection. In the first group the social representation model and illness experience was used. In the second group, we used the cognitive model based on the transmission of information. The third group, the control group, did not receive any information related to schistosomiasis. Ten meetings were held with all three groups that received a pre-test prior to the beginning of the educational intervention and a post-test after the completion of the program. The results showed that knowledge levels in Group 1 increased significantly during the program in regard to transmission (p = 0.038) and prevention (p = 0.001) of schistosomiasis. Groups 2 and 3 did not show significant increase in knowledge between the two tests. These results indicate that health education models need to consider social representation and illness experience besides scientific knowledge in order to increase knowledge of schistosomiasis transmission and prevention.     

Observed Deficiencies in Medical Student Knowledge of Transgender and Intersex Health

Objective: Lesbian, gay, bisexual, transgender, and intersex (LGBTI) patients face many well-documented disparities in care which among transgender and intersex people can often be traced to providers' lack of knowledge.Methods: We administered surveys to examine the self-assessed knowledge and attitudes of all medical students at Boston University regarding different LGBTI subpopulations. Survey questions were based on a Likert scale from 1 to 5; analysis was conducted with Wilcoxon rank sum tests.Results: Overall there was a response rate of 24%, with the number of responses varying by class. Three of the 4 surveyed classes reported lower knowledge about transgender health than LGB health. Every class reported significantly lower knowledge of intersex health in comparison to LGB. Comfort with transgender or with intersex patients was lower than with LGB patients for all surveyed classes. Students across all self-identified groups (LGBTI, ally, not an ally) reported significantly lower average responses for knowledge and comfort regarding transgender or intersex health in comparison to that of LGB. Students in their preclinical years reported lower levels of knowledge in comparison with students in their clinical years. Students who identified as LGBTI reported significantly higher knowledge and comfort with only LGB and transgender health when compared with students who didn't identify as LGBTI. Respondents more frequently requested additional learning opportunities in transgender and intersex health than in LGB health.Conclusion: Self-reported knowledge of transgender and intersex health lags behind knowledge of LGB health, though these deficits appear partially responsive to targeted educational intervention.Abbreviations: BUSM = Boston University School of Medicine LGB = lesbian, gay, and bisexual LGBT = lesbian, gay, bisexual, and transgender LGBTI = lesbian, gay, bisexual, transgender, and intersex M1 = first-year medical student class M2 = second-year medical student class M3 = third-year medical student class M4 = fourth-year medical student class