Engaged humanities: moral work in the precincts of medicine

The medical humanities emerged in the late 1960s in response to shared concerns among a group of hospital chaplains, academic clinicians, and moral theologians and philosophers about the growing power of a technological imperative and a perceived trend toward depersonalization in medicine. Gathering themselves originally under the rubric of "health and human values," these reformers launched a new field of intellectual work and practice reminiscent of the revival of liberal learning spawned by the Renaissance humanists, who endeavored to link humanistic ideals to professional practice in the workaday world of their time. The task of appropriating and adapting the studia humanitatis to our time and circumstances is crucial to defining the evolving identity of the medical humanities field.     

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."     

构建融合医学人文教育的新型医学遗传学教学模式

医学遗传学是广泛涉及基础与临床学科的综合性课程,对于医学生是至关重要的必修课程。现代医学已由传统的生物-医学模式向生物-心理-社会医学模式转化,医学诊疗模式从最初的以"疾病为中心"到"以病人为中心"的方式转变,医生不仅精通医术,更要理解患者的心理,与其进行良好的沟通,因此现代医学成为了一门具有自然科学、人文社会科学双重属性的综合性科学体系。长期以来,我国医学院校的教学仍然是生物医学知识和技能占据主导地位,人文课程不受重视。因此,必须加强医学人文知识的学习和技能培训,只有这样才能在未来的医疗工作中掌握良好的医患沟通技巧,建立和谐的医患关系,对处理好日渐增多的医疗纠纷、维护医患双方的共同利益具有重要意义。     

人文素质教育与医学免疫学专业教育的整合

当前,人们的健康观念和生活方式发生了改变,对医疗卫生服务的需要和期望也发生了变化。然而,医学教育长期以来过分注重医学生的专业知识教育而忽视了人文素质教育,这使得医学生缺乏爱伤观念,对待病人冷漠、和不负责任,功利心较重,缺少奉献精神,从而加剧了医患关系紧张。因此,把医学生人文教育渗透到医学生专业学习的各个过程,使人文素质教育与医学专业教育完美的整合,才能培养出同时具有精湛医术和人文智慧、德才兼备的医生。医学免疫学是生命科学的前沿学科,是联系基础医学和临床医学的桥梁学科之一,也是医学本科生的一门重要的主干课程,其理论和实验技术发展迅猛。本文从医学免疫学专业理论课、实验课、考核等不同环节探讨了人文素质教育和医学免疫学专业教育的整合,进一步地寻找医学免疫学教学中人文素质教育的有效途径,为医学生的人文素质的全面提高提供有益的支持。     

Perceptions of medical school stressors: their relationship to age, year of study and trait anxiety

It has been noted that medical school is a stressful social environment. This study proposes to determine domains of medical school stressors and to investigate to what extent the perceived stressfulness of these domains is explained by age, year of study, marital status, sex, and trait anxiety. Data were obtained by self-administered questionnaires filled out by 131 students in four classes of a six-year medical school. Four clusters of stressors were revealed by factor analysis: "off-time death," "incurable condition," "patient contact," and "medical practice demands." Marital status, sex, and year of study did not correlate with any of these stressor domains. Age was positively correlated with the perception of off-time death as stressful and negatively correlated with patient contact. Trait anxiety was directly correlated with the perceived stressfulness of patient contact and medical practice demands. No independent variable explained differences in perception of all four domains. It is suggested that there are some experiences, such as facing off-time death, that are so painful that repeated exposure to them augments, rather than decreases, the perception of their stressfulness.     

医学人文在医学微生物学教学中的应用

在讲授医学微生物学知识的同时,对医学生进行医学人文教育,将有助于培养德才兼备的医学人才。本文提出了在医学微生物学课程中可融入人文教育的几项知识点,希望对该课程的医学人文教育有所启示。     

Maya mobile medicine in Guatemala: the "other" public health

Maya mobile medical providers in highland Guatemala and the goods and services that they offer from "soapboxes" on street corners, local markets, and on buses exemplify an important yet underinvestigated domain of localized health care, one that I refer to as the "other" public health. This medical and linguistic examination of traveling medical salespeople calls for a reconsideration (on a global scale) of what has come to be understood as "public health," arguing that "othered," local forms of public health that are often overlooked by anthropologists as "nontraditional" and delegitimized by bio-medicine as nonscientific merit serious consideration and investigation. This ethnography of marginalized forms of public health offers global insights into emerging heterodoxical forms of public health care that contest bio-medical authority and challenge our preexisting definitions of what counts as "access," wellness seeking, and even health care itself.     

High theory/mass markets: Newsweek magazine and the circuits of medical culture

Medicine is driven by much more than science and reason (ethics); it is also driven by the circuits of culture within which it operates. This article examines how postmodern theory deconstructs standard ideals of science and reason and allows medical humanities scholars to better contextualize the world of medicine. As such, postmodern theory provides an invaluable tool for understanding the circuits of popular culture and medicine's place within these circuits. Using a recent issue of Newsweek magazine devoted to health and technology to illustrate the main points, this essay argues that contemporary popular influences on medicine are deeply problematic, and that through an appreciation of the dynamics of culture, medical humanities scholars can join the struggle over medical culture. This perspective allows medical humanities to make important contributions toward alternative circuits of medical representation, consumption, and identification.     

"Sweeping up after the parade": professional, ethical, and patient care implications of "turfing"

"Turfing" denotes a patient transfer or triage from one physician to another when the care of that patient feels more troublesome than it is worth. A widespread phenomenon in medical training programs, turfing appears to allocate patient care to meet physicians' rather than patients' needs. Although turfing reportedly causes inter-physician discord and inter-specialty stereotyping, its deeper consequences are poorly understood. Turfing is an interpersonal conflict masquerading as a medical issue. After examining turfing alongside other patient-related slang, I analyze the distinction between "the turf," a person, and "to turf," a practice. Several explanatory models from medical practice are explored in order to illuminate turfing's implications for medical professionalism, ethics, and patient care. I suggest that a physician's medical specialty or practice type--that is, professional culture--may link to that physician's degree of altruism. If so, then what it means fundamentally to be a physician might vary across medical specialties. Such a link calls for a new notion of cultural competence, one that physicians may apply not to patients but to each other.     

Selling research, and it pays

While conceding that time has proven him wrong in doubting public acceptance of the idea of the "science shops," first sponsored by the Free University of Amsterdam to provide access to technical expertise for customers who could not afford more orthodox services, the author remains convinced that the somewhat analogous concept of "fee for service research," which offers experimental medical treatments for those who can afford to pay for them, is wrong. Such research has been justified as a private sector enterprise that provides patients who are unresponsive to standard forms of therapy with scientifically sound experimental options. However, the objections that such work might be kept secret and not contribute to medical knowledge, and that therapy would be available only to the rich, remain unanswered and pose an insurmountable obstacle to the support of this idea.     

The meaning of natural childbirth

The term "natural childbirth" encompasses a variety of methods, including the Lamaze, Bradley, and home-birth approaches, which place more or less reliance on medical technology. Aristotle's analysis of three levels of human activity--digestion and reproduction, perception and locomotion, and abstract thinking--and Pellegrino and Thomasma's classification of the "living body," "lived body," and "lived self," provide a principled framework in which each of these childbirth practices can be considered natural.     

"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."     

The core principles ("big ideas") of physiology: results of faculty surveys

Physiology faculty members at a wide range of institutions (2-yr colleges to medical schools) were surveyed to determine what core principles of physiology they want their students to understand. From the results of the first survey, 15 core principles were described. In a second survey, respondents were asked to rank order these 15 core principles and, independently, to identify the three most important for their students to understand. The five most important core principles were "cell membrane," "homeostasis," "cell-to-cell communications," "interdependence," and "flow down gradients." We then "unpacked" the flow down gradients core principle into the component ideas of which it is comprised. This unpacking was sent to respondents who were asked to identify the importance of each of the component ideas. Respondents strongly agreed with the importance of the component ideas we had identified. We will be using the responses to our surveys as we begin the development of a conceptual assessment of physiology instrument (i.e., a concept inventory).     

Wellness programs: a review of the evidence

OBJECTIVE: To review studies that have examined an association between wellness programs and improvements in quality of life and to assess the strength of the scientific evidence. DATA SOURCES: A MEDLINE search was constructed with the following medical subject headings: "psychoneuroimmunology," "chronic disease" and "health promotion," "chronic disease" and "health behaviour," "relaxation techniques," "music therapy," "laughter," "anger," "mediation" and "behavioural medicine." Searches using the text words "wellness" and "wellness program" were also carried out. References from the primary articles identified in the search and contemporary writing on wellness were also considered. STUDY SELECTION: Selection was limited to randomized controlled trials or prospective studies published in English that involved human subjects and that took place between 1980 and 1996. All studies with an intervention aimed at promoting wellness and measuring outcomes were included, except studies of patients with cancer and HIV and studies of health promotion programs in the workplace. Of the 1082 references initially identified, 11 met the criteria for inclusion in the critical appraisal. DATA EXTRACTION: The following information was extracted from the 11 studies: characteristics of the study population, number of participants (and number followed to completion), length of follow-up, type of intervention, outcome measures and results. All 11 studies were assessed for the quality of their evidence. DATA SYNTHESIS: All studies reported some positive outcomes following the intervention in question, although many had limitations precluding applicability of the results to a wider population. CONCLUSIONS: Despite the suggested benefit associated with wellness programs, the evidence was inconclusive. Whether the composition of the target group or the type of intervention has a role in determining outcomes is unknown. Although trends suggest that wellness programs may be cost-effective, further research is needed for confirmation.     

Scenario analysis of the future of medicines.

Planning future policy for medicines poses difficult problems. The main players in the drug business have their own views as to how the world around them functions and how the future of medicines should be shaped. In this paper we show how a scenario analysis can provide a powerful teaching device to readjust peoples'' preconceptions. Scenarios are plausible, not probable or preferable, portraits of alternative futures. A series of four of alternative scenarios were constructed: "sobriety in sufficiency," "risk avoidance," "technology on demand," and "free market unfettered." Each scenario was drawn as a narrative, documented quantitatively wherever possible, that described the world as it might be if particular trends were to dominate development. The medical community and health policy markers may use scenarios to take a long term view in order to be prepared adequately for the future.     

Chordal tethering: a unique cause of structural mitral regurgitation in dilated cardiomyopathy

Mitral regurgitation in dilated cardiomyopathy is usually considered "functional," and many such patients are treated medically. Surgery is often offered as a last resort in select patients who have failed medical therapy. We report a patient with dilated cardiomyopathy with ventricular tachycardia and ventricular dyssynchrony and "structural mitral regurgitation" due to chordal tethering, which was managed surgically using a minimally invasive approach.     

"Post-residency disease" and the medical self: identity, work, and health care among doctors who become patients

Doctors who become patients due to serious illnesses face many challenges related to issues of identity, work, and professionalism. In-depth interviews with such doctors reveal the complex ways in which illness threatens identity in these professionals. In comparison with "medical student's disease," these doctors now exhibit "post-residency disease"-minimizing physical symptoms that are in fact present, leading to decreases in care sought. Doctors often feel they are somehow invulnerable to disease and have to remain strong, not burdening others. Many describe themselves as "workaholics," which can prove to be a double-edged sword, posing problems as well as providing benefits. This professional commitment could interfere with preventive health behaviors and with "practicing what they preach." Some view their illness with their "medical self" - as if they were a physician observing another patient rather than themselves. These doctors often support their approach by choosing a colleague as a doctor who will not challenge them, thereby establishing a "denial system" as opposed to a support system. These doctor-patients confront difficult issues of how much their physicianhood is an identity or an activity, illustrating the intricate relationships and tensions between work, identity, professionalism, and health in contemporary medicine.     

Genetic determination of mental activity parameters in the families of schizophrenic patients

Psychological parameters of mental activity (30 in total) and their genetic determination were studied in 67 families of schizophrenia patients (67 patients, 107 parent, and 30 sibs). Abnormalities of most of the examined characteristics were found in both the patients and their healthy relatives. Parameters of attention shifting and emotionality exhibited the largest genetic component (25-75 and 17-98%, respectively) in all analyzed groups of relatives (probands-affected sibs, probands-healthy sibs, healthy parents-healthy children, affected parents-affected children). Significant impact of genetic factors was also found in parameters "steadiness of attention under conditions of continuous concentration," "mediated retention span" "productivity of arbitrary retention by reproduction data," "personal anxiety level," "reflection of unusual social groups," and "self-assessment." The relationships among the characteristics examined in the system of mental activity were established by means of cluster analysis. The results of this study can be used in medical genetic counseling for identifying persons at high risk for schizophrenia.     

The effects of clinical practice guidelines on patient outcomes in primary care: a systematic review

OBJECTIVE: To assess the evidence for the effectiveness of clinical practice guidelines (CPGs) in improving patient outcomes in primary care. DATA SOURCES: A search of the MEDLINE, HEALTHPLAN, CINAHL and FAMLI databases was conducted to identify studies published between Jan. 1, 1980, and Dec. 31, 1995, concerning the use of guidelines in primary medical care. The keywords used in the search were "clinical guidelines," "primary care," "clinical care," "intervention," "randomized controlled trial" and "effectiveness." STUDY SELECTION: Studies of the use of CPGs were selected if they involved a randomized experimental or quasi-experimental method, concerned primary care, were related to clinical care and examined patient outcomes. Of 91 trials of CPGs identified through the search, 13 met the criteria for inclusion in the critical appraisal. DATA EXTRACTION: The following data were extracted, when possible, from the 13 trials: country and setting, number of physicians, number of patients (and the proportion followed to completion), length of follow-up, study method (including random assignment method), type of intervention, medical condition treated and effect on patient outcomes (including clinical and statistical significance, with confidence intervals). DATA SYNTHESIS: The most common conditions studied were hypertension (7 studies), asthma (2 studies) and cigarette smoking (2 studies). Four of the studies followed nationally developed guidelines, and 9 used locally developed guidelines. Six studies involved computerized or automated reminder systems, whereas the others relied on small-group workshops and education sessions. Only 5 of the 13 trials (38%) produced statistically significant results. CONCLUSION: There is very little evidence that the use of CPGs improves patient outcomes in primary medical care, but most studies published to date have used older guidelines and methods, which may have been insensitive to small changes in outcomes. Research is needed to determine whether the newer, evidence-based CPGs have an effect on patient outcomes.     

Epistemological reflections on the art of medicine and narrative medicine

This article challenges the widespread view that there is both a science and an art of medicine. Through examination of recent work in medical humanities --Jodi Halpern's From Detached Concern to Empathy (2001), Kathryn Montgomery's How Doctors Think (2006), and Rita Charon's Narrative Medicine (2006)--I argue that while a variety of epistemic techniques are important in medicine, it is not helpful to dichotomize them as "science" versus "art." I assess the epistemic strengths and weaknesses of narrative medicine, a recent exemplar of humanistic medicine.