Medical concepts related to individual risk are better explained with "plausibility" rather than "probability"

Background

The concept of risk has pervaded medical literature in the last decades and has become a familiar topic, and the concept of probability, linked to binary logic approach, is commonly applied in epidemiology and clinical medicine. The application of probability theory to groups of individuals is quite straightforward but can pose communication challenges at individual level. Few articles by the way have tried to focus the concept of "risk" at the individual subject level rather than at population level.

Discussion

The author has reviewed the conceptual framework which has led to the use of probability theory in the medical field in a time when the principal causes of death were represented by acute disease often of infective origin. In the present scenario, in which chronic degenerative disease dominate and there are smooth transitions between health and disease the use of fuzzy logic rather than binary logic would be more appropriate. The use of fuzzy logic in which more than two possible truth-value assignments are allowed overcomes the trap of probability theory when dealing with uncertain outcomes, thereby making the meaning of a certain prognostic statement easier to understand by the patient.

Summary

At individual subject level the recourse to the term plausibility, related to fuzzy logic, would help the physician to communicate to the patient more efficiently in comparison with the term probability, related to binary logic. This would represent an evident advantage for the transfer of medical evidences to individual subjects.     

"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.     

"A gentle and humane temper": humility in medicine

Humility is the medical virtue most difficult to understand and practice. This is especially true in contemporary medicine, which has developed a culture more characterized by arrogance and entitlement than by self-effacement and moderation. In such a culture, humility suggests weakness, indecisiveness, or even deception, as in false modesty. Nonetheless, an operational definition of medical humility includes four distinct but closely related personal characteristics that are central to good doctoring: unpretentious openness, honest self-disclosure, avoidance of arrogance, and modulation of self-interest. Humility, like other virtues, is best taught by means of narrative and role modeling. We may rightly be proud of contemporary medical advances, while at the same time experiencing gratitude and humility as healers.     

Stored Guthrie cards as DNA "banks".

Recently there has been much discussion about the possibility of using dried blood spots on Guthrie cards as a source of DNA for research or testing purposes. The collections of Guthrie cards stored by state newborn-screening laboratories can thus be viewed as inchoate "DNA banks." This has generated concern among some persons who are interested in preserving the privacy of medical records. This study examines the policies of state newborn-screening laboratories in the United States, regarding their retention of Guthrie cards and the degree to which they permit the sharing of those cards with various third parties. We found that although most laboratories retain their cards, if at all, for only a short time, a growing number plan to keep them for an extended period--and, in several cases, indefinitely. We also found that although most laboratories would decline to release individually identifiable blood spots from the cards to third parties without a written release or other explicit authorization, a large number would at least consider sharing anonymous cards for research purposes.     

" 床旁教育" 在本科教学中的运用与价值

随着现代医学的发展,医学教育目标从1988年《爱丁堡宣言》中"培养促进全体人民健康的医生"进一步丰富完善,200年国际医学教育委员会公布了本科《医学教育全球最低基本要求》,包括职业价值、态度、行为与伦理、医学科学基础知识、临床技能、交流沟通技能、群体健康与卫生系统、信息管理、批判性思维与研究7个基本方面。在新的社会-医学模式中,本科医学教育也不再是单纯的课堂基础医学知识的教育,通过"床旁教育"培养学员职业价值、态度、行为伦理、临床技能、交流沟通、信息管理等能力也更加重要。我们在新的形式下,结合课堂基础医学知识学习,注重"床旁教育"多维一体的本科医学教育,实现了全面培养与提高学员的综合能力。"床旁教育"作为一种教学新模式,是培养学员思维能力和综合素质、提高教学效果的有效方法和手段,值得进一步完善和推广。     

The "amazing" fertility decline: Islam, economics, and reproductive decision making among working-class Moroccan women

Often it is understood that Islam prohibits family planning because the Qur'an does not explicitly address contraception. Public health and development officials have recently congratulated the Muslim world for decreases in fertility given the supposed constraints placed on reproductive healthcare by Islam, while popular culture writers have warned the West of threats by young Muslims if the population goes uncontrolled. This article draws on data collected through interviews with working-class women seeking reproductive healthcare at clinics in Rabat, Morocco, and with medical providers to challenge the link between Islamic ideology and reproductive practices and the correlation among Islam, poverty, and fertility. Morocco, a predominantly Muslim country, has experienced a dramatic decrease in fertility between the 1970s and today. I argue that patients and providers give new meanings to modern reproductive practices and produce new discourses of reproduction and motherhood that converge popular understandings of Islam with economic conditions of the Moroccan working class.     

Challenges and Opportunities in the Anthropology of Childhoods: An Introduction to "Children, Childhoods, and Childhood Studies"

Anthropological attention to children and childhoods has had an uneven but lengthy history, both within the discipline and in interdisciplinary endeavors. Recently, there has been a resurgence of interest in the study of children, with work often carried out under the rubrics of "Childhood Studies" or the "Anthropology of Childhoods." In these frameworks, children are at once developing beings, in possession of agency, and to varying degrees vulnerable. It has been a hallmark of anthropological work to recognize that these attributes manifest themselves in different times and places, and under particular social, political, economic, and moral circumstances and conditions. The five articles in this "In Focus" put forward some key challenges and opportunities for the anthropological study of children and childhoods.     

Commentary: "health has become secondary to a sexually attractive body"

This article focuses on the prevalence of cesarean section among upper class women for aesthetic purposes. In Latin America, the national cesarean section rate has risen to 40%, while in the early 1980s the rate was 75% in Brazil. In a survey conducted in the UK, 31% of women obstetricians would prefer to have cesarean section without any medical indication. This could perhaps be due to the obsession of maintaining a sexually appealing body. Health has then become secondary to the production of a sexually attractive body. The role of the medical profession lacks the definitive evidence on the issues regarding concerns of women and choices in childbirth particularly in some countries. The author suggests that the medical community and society should allow the women the choice between major surgery and childbirth.     

What research participants want to know about genetic research results: the impact of "genetic exceptionalism"

The disclosure of individual genetic results has generated an ongoing debate about which rules should be followed. We aimed to identify factors related to research participants' preferences about learning the results of genomic studies using their donated tissue samples. We conducted a cross-sectional survey of 279 patients from the United States and Spain who had volunteered to donate a sample for genomic research. Our results show that 48% of research participants would like to be informed about all individual results from future genomic studies using their donated tissue, especially those from the U.S. (71.4%) and those believing that genetic information poses special risks (69.7%). In addition, 16% of research participants considered genetic information to be riskier than other types of personal medical data. In conclusion, our study demonstrates that a high proportion of participants prefer to be informed about their individual results and that there is a higher preference among those research subjects who perceive their genetic information as riskier than other types of personal medical data.     

A history of noma,the "Face of Poverty"

Noma (necrotizing ulcerative stomatitis, stomatitis gangrenosa, or cancrum oris) is a devastating orofacial gangrene that occurs mainly among children. The disease has a global yearly incidence of 140,000 cases and a mortality rate of approximately 90 percent. Patients who survive noma generally suffer from its sequelae, including serious facial disfigurement, trismus, oral incontinence, and speech problems. The medical history of noma indicates that the disease was already known in classical and medieval civilizations in Europe. In the sixteenth and seventeenth centuries, Dutch chirurgeons clearly described noma as a clinical entity and realized that the popular name "water canker" was not sufficient, because this quickly spreading ulceration in the faces of children was different from "cancer." In the eighteenth century, awareness that noma is related to poverty, malnutrition, and preceding diseases such as measles increased in northwestern Europe. In the first half of the nineteenth century, extensive surgical procedures were described for the treatment of the sequelae of noma. At the end of that century, noma gradually disappeared in the Western world because of economic progress, which gave the poorest in society the opportunity to feed their children sufficiently. Only in the twentieth century were effective drugs (sulfonamides and penicillin) against noma developed, as well as adequate surgical treatment for the sequelae of noma. These modes of treatment remain inaccessible for the many present-day victims of noma because of their extreme poverty. The only truly effective approach to the problem of noma throughout the world is prevention, namely, combating the extreme poverty with measures that lead to economic progress. In the meantime, medical doctors in the Western world should not forget their own history and ignore this global health problem; rather, they should face "the face of poverty" with the eyes of mercy and concern suited to their profession.     

蕲州地区的蕲艾、青蒿、黄花蒿与茵陈的考订

<正> 蕲州是我国中药材主要产地之一,是湖北省蕲春县的一个集镇,,是我国中医药大师李时珍的家乡。该地区生长的菊科蒿属植物Artemisia Linn。颇多,其中入药的有十余种,并在李时珍《本草纲目》中曾有记载。这里仅对该地区常见入药的蕲艾、青蒿、黄花蒿与茵陈结合《本草纲目》记载的材料作初步的考订。     

"Action potentials" in Neurospora crassa, a mycelial fungus.

Occasional spontaneous "action potentials" are found in mature hyphae of the fungus Neurospora crassa. They can arise either from low-level sinusoidal oscillations of the membrane potential or from a linear slow depolarization which accelerates into a rapid upstroke at a voltage 5-20 mV depolarized from the normal resting potential (near-180 mV). The "action potentials" are long-lasting, 1-2 min and at the peak reach a membrane potential near-40 mV. A 2-to 8-fold increase of membrane conductance accompanies the main depolarization, but a slight decrease of membrane conductance occurs during the slow depolarization. Two plausible mechanisms for the phenomenon are (a) periodic increases of membrane permeability to inorganic ions, particularly H+ or Cl- and (b) periodic decreases in activity of the major electrogenic pump (H+) or the Neurospora membrane, coupled with a nonlinear (inverse signoid) current-boltage relationship. Identification of action potential-like disturbances in fungi means that such behavior has now been found in all major biologic taxa which have been probed with suitable electrodes. As yet there is no obvious function for the events in fungi.     

"Actually, I don't feel that bad": managing diabetes and the clinical encounter

A major issue for persons treating and managing adult-onset diabetes (NIDDM) is the "problem of compliance." I consider the clinical encounter in the overall context of diabetes management as a punctuated experience focused on the cultivation of an ideal self whose "technologies" and "ethics of self-care" mimic a capitalist logic that links self-discipline, productivity, and health. Both clinicians and their patients share and identify with many of the cultural referents and social values that circulate through medical advice and practice. However, using individual examples, I show how this shared logic can produce idiosyncratic regimes of self-care and clinical practice that result in hybrid medical practices incorporating differing objectives and emphases concerned with a tolerable present or an ideal future. Rather than organizing principles for research and medical practice, I suggest that medical compliance and noncompliance should be considered part of the rhetoric to be explained within the regimes of a pursuit of health.     

Decision making in the NICU--strategies,statistics, and "satisficing"

As science progresses, new issues in bioethics grab the headlines, but in neonatal medicine communication and decision making for sick and premature infants is as important today as it was thirty years ago. Decisions have to be made and made well, despite suboptimal time, data, or knowledge. To this end, the authors propose good communication and a cooperative model as key to interpreting the best interest standard in a way that respects parental rights and responsibility and allows best interest to be decided from an amalgam of medical facts and human values.     

Volunteers,doctors take palliative care into the community.

The face of palliative care is changing. In Ontario''s St. Catharines region there has been a concerted effort to make it more of a community-based procedure. A local college even teaches a 2-year course in palliative care. The trend is expected to continue because Canadians are living longer, and more frail elderly people will be dying at home. Dr. Sandra Hartman, a palliative-care consultant, says physicians interested in palliative care must remember that there is more to it than providing medical assistance. She considers bereavement counseling for the patient''s family a necessary part of follow-up preventive care.     

University acknowledges special risks,introduces drug program for anesthetists.

Anesthetists are at special risk for becoming addicted to some of the drugs they work with. The problem was highlighted by the recent death of a physician in Comox, BC, and a doctor''s brush with death at a hospital near Ottawa. The University of Ottawa has responded with a program, the professional Assistance Program for the Impaired or Disabled Physician, that is in the final stages of approval. Although it will be aimed initially at anesthetists and anesthesia residents in the university''s teaching hospitals, there are hopes the program will spread eventually to other medical departments.     

Ideas about heredity, genetics, and 'medical genetics' in Britain, 1900-1982

The aim of this paper is to understand how evolving ideas about heredity and genetics influenced new medical interests and practices and, eventually, the formation of 'medical genetics' as a medical specialism in Britain. I begin the paper by highlighting the social and institutional changes through which these ideas passed. I argue that, with time, there was a decisive convergence in thought that combined ideas about the familial aspects of heredity and the health needs of populations with an omnibus 'genetic' approach to health and illness that focused on the structures and activities of chromosomes and genes in individuals. I show how this convergence in thought was spurred on, first, by innovations in genetic science and technology in the years after 1960, and, second, by negotiated protocols and standards of medical practice worked out by bodies such as the relevant royal colleges, the linked associations and societies for medical professionals, affected training and research authorities, and the state. The notion of 'medical genetics' in Britain consequently gained a semblance of unanimity over its basic reference points and arrived at a meaning directly tributary to current acceptance of the term in the context of a medical specialism.     

Setting a standard for a "silent" disease: defining osteoporosis in the 1980s and 1990s

Osteoporosis, a disease of bone loss associated with aging and estrogen loss, can be crippling but is 'silent' (symptomless) prior to bone fracture. Despite its disastrous health effects, high prevalence, and enormous associated health care costs, osteoporosis lacked a universally accepted definition until 1992. In the 1980s, the development of more accurate medical imaging technologies to measure bone density spurred the medical community's need and demand for a common definition. The medical community tried, and failed, to resolve these differing definitions several times at consensus conferences and through published articles. These experts finally accepted a standard definition at an international consensus conference convened by the World Health Organization in 1992. The construction of osteoporosis as a disease of quantifiable risk diagnosed by medical imaging machines reflects contemporary trends in medicine, including the quantification of disease, the risk factor model, medical disciplinary boundaries, and global standardization of medical knowledge.     

W.H.R. Rivers Graduate Prize Essay (1996). "Imperfect angels" : narrative "emplotment" in the medical management of children with craniofacial anomalies

This article uses the paradigm of "therapeutic emplotment" to investigate the medical management of children with facial disfigurements at a craniofacial anomalies center in Northern California. Data are observations of, and semistructured interviews with, plastic surgeons, nurses, geneticists, orthodontists, and other medical professionals who composed the craniofacial anomalies team. Team members perceived that children feel socially stigmatized by their disfigurements. These medical professionals adjusted their own behavior according to these perceptions. They "emplotted" their actions, using the theme that disfigured children are attractive and worthy of attention and affection. Medical professionals attempted to depersonalize and neutralize the symbolically loaded disfigurements through the use of clinical language in an attempt to "separate" the child from his or her facial anomaly. The range of styles and approaches to interaction was diverse and varied in effectiveness, suggesting that some medical professionals were more skilled at emplotment than others.     

The Medical Practitioner,Alcoholism and Motivation

Adverse influences on motivation for recovery from alcoholism must be searched for in three areas: society, the medical practitioner and the patient. Society is ambivalent because there is a vicarious release through identification with the cheerful “drunk” coupled with unconscious envy and resentment leading to punitive action.The current “alcohol culture” decrees that to drink is to be well, not to drink is to be ill.The medical profession attempts to suppress, deny, rationalize or reject the problem of alcoholism because it involves a change in attitude and recognition of limitations.The alcoholic patient has a notorious lack of motivation, but this must be recognized as a symptom of his disease, and with certain techniques this symptom is treatable. Furthermore, motivation fluctuates and many opportunities for treatment are available when the medical practitioner can detect that motivation is high. At times a coercive approach is required, at times a permissive one; and the optimal use of such approaches will increase the motivation to an effective level.