Narrating Kidney Disease: The Significance Of Sensation And Time In The Emplotment Of Patient Experience

Drawing on research conducted among patients in Ireland, this article examines the narrative constructions of chronic kidney failure and explores the ways in which patient narratives cross-cut and subvert modernist medical constructions of transplantation as a therapeutic outcome, an endgame, a “gift of life.” In experience, patients dismantle this construction structure by emplotting their stories around the painful lack of an ending, ardently brought to bear by the lived realities of immunosuppressant drug therapy, the silent fears of graft rejection, and the isolation of recipiency. They articulate, instead, stories that disclose a multi-directional flow between past and future therapeutic interventions, between the altering nature of the renal body and personal experience. These storied dimensions are phenomenologically embedded in the sensory and temporal aspects of this condition as essential elements of chronic illness and as organizational properties of patient narratives.     

The Moral Aesthetics of Simulated Suffering in Standardized Patient Performances

Standardized patient (SP) performances are staged clinical encounters between health-professional students and people who specialize in role-playing the part of patients. Such performances have in recent years become increasingly central to the teaching and assessment of clinical skills in U.S. medical schools. SP performances are valued for being both “real” (in that they involve interaction with a real person, unlike written examinations) and “not real” (in that the SP does not actually suffer from the condition portrayed, unlike an actual patient). This article considers how people involved in creating SP performances reconcile a moral commitment to avoid suffering (to keep it “not real”), with an aesthetic commitment to realistically portray it (to keep it “real”). The term “moral aesthetic” is proposed, to indicate a sensibility that combines ideas about what is morally right with ideas about what is aesthetically compelling. Drawing on ethnographic research among SPs and SP program staff and medical faculty who work closely with them, this article argues that their work of creating “realism” in simulated clinical encounters encompasses multiple different (and sometimes conflicting) understandings and practices of realism, informed by three different moral aesthetics: (1) a moral aesthetic of induction, in which an accurate portrayal with a well-documented provenance serves to introduce experientially distant forms of suffering; (2) a moral aesthetic of inoculation, in which the authenticity and emotional impact of a performance are meant to inoculate students against the impact of future encounters with suffering; (3) a moral aesthetic of presence, generating forms of voice and care that are born out of the embodied presence of suffering individuals in a clinical space. All are premised on the assumption that risk and suffering can be banished from SP performances. This article suggests, however, that SP performances necessarily raise the same difficult, important, fundamentally ethical questions that are always involved in learning from and on human beings who are capable of suffering, and who need and deserve recognition and respect as well as care.     

“WE CAME TO TALK WITH THE PEOPLE BEHIND THE DISEASE:” COMMUNICATION AND CONTROL IN MEDICAL EDUCATION

To explore the ways in which biomedical culture responds to the new curricular addition of communication skills training, we observed activities related to the communication skills training of a class of 70 first-year medical students in an Israeli medical school during 2002–3. In addition, focus groups were conducted with medical students (n = 210) during 1998–2001. A gap was found between the rhetoric of “patient-centered communication” and “empathy” and the traditional concerns of medical authority, efficiency, and scientism. Communication skills and empathy training were appropriated into medical socialization by being reconstructed as clinical competence. Findings are further discussed in the context of medical professionalism, Israeli culture, service acting and service roles, and organizational learning.     

From “Lists of Traits” to “Open-Mindedness”: Emerging Issues in Cultural Competence Education

The incorporation of “culture” into U.S. biomedicine has been increasing at a rapid pace over the last several decades. Advocates for “cultural competence” point to changing patient demographics and growing health disparities as they call for improved educational efforts that train health providers to care for patients from a variety of backgrounds. Medical anthropologists have long been critical of the approach to “culture” that emerges in cultural competence efforts, identifying an essentialized, static notion of culture that is conflated with racial and ethnic categories and seen to exist primarily among exotic “Others.” With this approach, culture can become a “list of traits” associated with various racial and ethnic groups that must be mastered by health providers and applied to patients as necessary. This article uses an ethnographic examination of cultural competence training to highlight recent efforts to develop more nuanced approaches to teaching culture. I argue that much of contemporary cultural competence education has rejected the “list of traits” approach and instead aims to produce a new kind of health provider who is “open-minded,” willing to learn about difference, and treats each patient as an individual. This shift, however, can ultimately reinforce behavioral understandings of culture and draw attention away from the social conditions and power differentials that underlie health inequalities.     

“Not <Emphasis Type="Italic">Here</Emphasis>”: Making the Spaces and Subjects of “Global Health” in Botswana

This essay argues that what makes “global health” “global” has more to do with configurations of space and time, and the claims to expertise and moral stances these configurations make possible, than with the geographical distribution of medical experts or the universal, if also uneven, distribution of threats to health. Drawing on a study of public–private partnerships supporting Botswana’s HIV/AIDS treatment program, this essay demonstrates ethnographically the processes by which “global health” and its quintessential spaces, namely “resource-limited” or “resource-poor settings,” are constituted, reinforced, and contested in the context of medical education and medical practice in Botswana’s largest hospital. Using Silverstein’s work on orders of indexicality, I argue that the terms of “global health” are best understood as chronotopic, and demonstrate how actors orient themselves and others spatio-temporally, morally, and professionally by using or refuting those terms. I conclude by arguing that taking “global health” on its own terms obscures the powerful forces by which it becomes intelligible. At stake are the frames within which medical anthropologists understand their objects of study, as well as the potential for the spaces of “global health” intervention to expand ever outward as American medical personnel attempt to calibrate their experiences to their expectations.     

Is there a Real Nexus Between Ethics and Aesthetics?

Aesthetics is a vexed topic in philosophy, with a long history. For my purposes, an aesthetic experience is a foundational affective response to an object, to which terms such as “ugly”, “beautiful”, “pretty” or “harmonious” are applied. These terms are derived from a Discourse of aesthetics; some remain constant, others change from generation to generation. Aesthetics and ethics have been linked in Western thought since the days of Plato and Aristotle. This essay examines what is happening to that link in contemporary experience. It emphasises the ways in which the popular media exploit aesthetic appeal to penetrate their market, and to exploit and frame intuitive responses to current and past events. Production values, the artfulness of editors and the financial interests of producers and directors thus do much to determine contemporary aesthetic and ethical judgements. That which is beautifully presented invites the ethical involvement of the audience. Events whose images are beautifully presented constitute “hyperevidence”, a pre-judged, reinforced and amplified illusion of reality and participation. Understanding how aesthetic excellence draws audiences into ethical relationship with what is presented becomes an important part of education in ethics, including bioethics.     

The perfect learner

As a “base line” of memorization performance, the behavior of a “perfect learner” is considered. He is characterized by a perfect memory and by the ability to choose the best search procedure in problems where the correct response from a given repertoire is to be found to each of several stimuli under the condition of “right” and “wroing” promptings by the experimenter. Expected learning curves are derived for the case of disjoint response repertoires associated with the stimuli under cyclic and random presentation of the stimuli and for the case of a single response repertoire (a one-to-one matching problem) under cyclic presentation.     

The impact of the International Atomic Energy Agency (IAEA) program on radiation and tissue banking in Brazil

Until 2000, efforts into organising tissue banks in Brazil had not progressed far beyond small “in house” tissue storage repositories, usually annexed to Orthopaedic Surgery Services. Despite the professional entrepreneurship of those working as part time tissue bankers in such operations, best practices in tissue banking were not always followed due to the lack of regulatory standards, specialised training, adequate facilities and dedicated personnel. The Skin Bank of the Plastic Surgery Department of the Hospital das Clinicas of Sao Paulo, the single skin bank in Brazil, was not an exception. Since 1956, restricted and unpredictable amounts of skin allografts were stored under refrigeration for short periods under very limited quality controls. As in most “tissue banks” at that time in Brazil, medical and nursing staff worked on a volunteer and informal basis undergoing no specific training. IAEA supported the implementation of the tissue banking program in Brazil through the regional project RLA/7/009 “Quality system for the production of irradiated sterilised grafts” (1998–2000) and through two interregional projects INT/6/049 “Interregional Centre of Excellence in Tissue Banking”, during the period 2002–2004 and INT/6/052 “Improving the Quality of Production and Uses of Radiation Sterilised Tissue Grafts”, during the period 2002–2004. In 2001–2002, the first two years of operation of the HC-Tissue Bank, 53 skin transplants were carried out instead of the previous 4–5 a year. During this period, 75 individuals donated skin tissue, generating approximately 90,000 cm² of skin graft. The IAEA program were of great benefit to Brazilian tissue banking which has evolved from scattered make shift small operations to a well-established, high quality tissue banking scenario.     

The Futility of Futility: Death Causation is the ��Elephant in the Room�� in Discussions about Limitation of Medical Treatment

The term “futility” has been widely used in medical ethics and clinical medicine for more than twenty years now. At first glance it appears to offer a clear-cut categorical characterisation of medical treatments at the end of life, and an apparently objective way of making decisions that are seen to be emotionally painful for those close to the patient, and ethically, and also potentially legally hazardous for clinicians. It also appears to deal with causation, because omission of a futile treatment cannot surely be a cause of death. The problem is that futility can be argued to be a “false friend”, in that it gives an appearance of representing a reliable conceptual basis, in ethics, for limitation of medical treatment—usually in the context of dying—without actually doing so. In fact, the concept of futility is a conflation of clinical judgement about outcomes of treatment and the quality or even value of life, and has really failed to contribute much to the advancement of decision-making and hence care at the end-of-life. It also has the capacity to medicalise the personal space. Deliberations about the likely outcomes of medical treatment are necessary, and medical expertise is pivotal. However, futility is argued to have a better future in partnership with a broad social action agenda about the process of dying, such as that articulated in health promoting palliative care, as a basis for better “death-ways” in the 21st century (Kellehear 2005). Medicine needs to more honest and upfront about its limits, as death is, after all, the elephant in everybody's room.     

The occurrence and significance of amino acids in floral nectar

Approximately 1 500 angiosperm species, in previous papers, have been sampled for the assessment of the amino acids (a. a.) in their nectar. We reaffirm that the findings provide statistically significant data linking differences in the concentration with pollinator type. Flowers that are pollinated by animals that have alternative sources of protein-building a. a.’s show lower a. a. concentration than those that are not. There is a tendency for woody plant nectar a. a.’s to be less concentrated than those of herbaceous plants, but there can be “phylogenetic constraints” which may reduce the correlations of a. a. concentration with pollinator type and with life form. The individual a. a.’s form complements which are qualitatively extremely constant within species. Proline is a normal constituent of many nectars and does not necessarily indicate contamination of the nectar by pollen. Criticism of our findings byGottsberger & al. (1984) is answered by reference to our previous publications and those of other workers, and to the presentation of data from California native species, not published previously. All previous postulates are borne out by these new data with the exception of positive correlations of a. a. concentration with “primitive” and “advanced” floral characteristics taken one at a time, which appear to be inconsistent and are affected strongly by the nature of the family in which they occur. Summary data are provided for families and genera which indicate that high or low a. a. concentration can typify certain families and genera of both relatively “primitive” and relatively “advanced” nature. Needs for future research on an ecosystem basis are quoted.     

Two types of using of space in the resident common shrews <Emphasis Type="Italic">Sorex araneus</Emphasis> L.

The home range of resident animals is considered as “familiar area” including a “foraging area.” It has been revealed that the activity of an average animal unit in the “foraging area” could be approximated by normal distribution. Estimation of activity distribution in the “familiar area” (beyond the “foraging area”) was impeded by means of marking since it might be difficult to record distant movements, and the method does not provide an essential body of data. In the case of the common shrew Sorex araneus, the “familiar area” was estimated using pitfall as animals evade them in the known areal. The “foraging area” radius of the average shrew was taken to be 30 m (95% of the animal unit activity), the radius of “familiar area” was within the range of 180–240 m. The “foraging area” was expected to provide the animal with vital resources, and the “familiar area” reflects its need for exploratory activity.     

Where There is no Patient: An Anthropological Treatment of a Biomedical Category

This work anthropologically applies the concept of ‘personhood’ to the Western biomedical patient role, and through cross-cultural comparisons with wellness-seeker roles (e.g. among the Maya of Guatemala and others) it seeks to discern the implications for global healthcare of assuming the universality of the “patient” role. Here, particular ethnographic attention is given to the presumption of the “patient” role in places and situations where, because of cultural and linguistic variation in local wellness-seeker roles and practices, there may be no “patient.” It is hoped that establishing the biomedical patient role (with the clinical expectations, communicative and comportment practices that prefigure it) as acquired rather than intuitive, will help redirect cultural competence to the acquisition of patienthood, broadening it from an endless accrual of cultural inventories by physicians. Also it aims to shift existing biomedical associations of cultural variations in wellness-seeking away from a priori assessments of clinical defiance towards deeper understandings of the kinds of cultural differences that may make the difference treatment outcomes.

On the use of possibility theory in uncertainty analysis of life cycle inventory

Purpose  

The purpose of this paper is to enhance the mathematical and physical understanding of practitioners of uncertainty analysis of life cycle inventory (LCI), on the application of possibility theory. The main questions dealt with are (1) clear definition of the terms—“necessity–possibility,” “probability,” “belief–plausibility,” and of their mutual relationships; (2) what justifies the substitution of classical probability for possibility; (3) mutual comparison of, and transformations in both senses between probability and possibility uncertainty measures; (4) how to construct meaningful input possibility measures from available probabilistic/statistic information; and (5) comparative analysis of the solutions of the problem of data uncertainty propagation in LCI, afforded, respectively, by probabilistic Monte Carlo simulation and possibilistic fuzzy interval arithmetic.     

Malaria: Origin of the Term “Hypnozoite”

The term “hypnozoite” is derived from the Greek words hypnos (sleep) and zoon (animal). Hypnozoites are dormant forms in the life cycles of certain parasitic protozoa that belong to the Phylum Apicomplexa (Sporozoa) and are best known for their probable association with latency and relapse in human malarial infections caused by Plasmodium ovale and P. vivax. Consequently, the hypnozoite is of great biological and medical significance. This, in turn, makes the origin of the name “hypnozoite” a subject of interest. Some “missing” history that is now placed on record (including a letter written by P. C. C. Garnham, FRS) shows that Miles B. Markus coined the term “hypnozoite”. While a PhD student at Imperial College London, he carried out research that led to the identification of an apparently dormant form of Cystoisospora (synonym: Isospora). In 1976, he speculated: “If sporozoites of Isospora can behave in this fashion, then those of related Sporozoa, like malaria parasites, may have the ability to survive in the tissues in a similar way.” He adopted the term “hypnozoite” for malaria in 1978 when he wrote in a little-known journal that this name would “… describe any dormant sporozoites or dormant, sporozoite-like stages in the life cycles of Plasmodium or other Haemosporina.” At that time, the existence of a hypnozoite form in the life cycle of Plasmodium was still a hypothetical notion. In 1980, however, Wojciech A. Krotoski published (together with several co-workers) details concerning his actual discovery of malarial hypnozoites, an event of considerable importance.     

The Origin of the Vertebrate Eye

In his considerations of “organs of extreme perfection,” Charles Darwin described the evidence that would be necessary to support the evolutionary origin of the eye, namely, demonstration of the existence of “numerous gradations” from the most primitive eye to the most perfect one, where each such tiny change had provided a survival advantage (however slight) to the organism possessing the subtly altered form. In this paper, we discuss evidence indicating that the vertebrate eye did indeed evolve through numerous subtle changes. The great majority of the gradual transitions that did occur have not been preserved to the present time, either in the fossil record or in extant species; yet clear evidence of their occurrence remains. We discuss the remarkable “eye” of the hagfish, which has features intermediate between a simple light detector and an image-forming camera-like eye and which may represent a step in the evolution of our eye that can now be studied by modern methods. We also describe the important clues to the evolutionary origin of the vertebrate eye that can be found by studying the embryological development of our own eye, by examining the molecular genetic record preserved in our own genes and in the genes of other vertebrates, and through consideration of the imperfections (or evolutionary “scars”) in the construction of our eye. Taking these findings together, it is possible to discuss in some detail how the vertebrate eye evolved.     

Transforming Our Thinking about Transitional Forms

A common misconception of evolutionary biology is that it involves a search for “missing links” in the history of life. Relying on this misconception, antievolutionists present the supposed absence of transitional forms from the fossil record as evidence against evolution. Students of biology need to understand that evolution is a branching process, paleontologists do not expect to find “missing links,” and evolutionary research uses independent lines of evidence to test hypotheses and make conclusions about the history of life. Teachers can facilitate such learning by incorporating cladistics and tree-thinking into the curriculum and using evograms to focus on important evolutionary transitions.     

Source-sink landscape theory and its ecological significance

Exploring the relationships between landscape pattern and ecological processes is the key topic of landscape ecology, for which, a large number of indices as well as landscape pattern analysis model were developed. However, one problem faced by landscape ecologists is that it is hard to link the landscape indices with a specific ecological process. Linking landscape pattern and ecological processes has become a challenge for landscape ecologists. “Source” and “sink” are common concepts used in air pollution research, by which the movement direction and pattern of different pollutants in air can be clearly identified. In fact, for any ecological process, the research can be considered as a balance between the source and the sink in space. Thus, the concepts of “source” and “sink” could be implemented to the research of landscape pattern and ecological processes. In this paper, a theory of sourcesink landscape was proposed, which include: (1) In the research of landscape pattern and ecological process, all landscape types can be divided into two groups, “source” landscape and “sink” landscape. “Source” landscape contributes positively to the ecological process, while “sink” landscape is unhelpful to the ecological process. (2) Both landscapes are recognized with regard to the specific ecological process. “Source” landscape in a target ecological process may change into a “sink” landscape as in another ecological process. Therefore, the ecological process should be determined before “source” or “sink” landscape were defined. (3) The key point to distinguish “source” landscape from “sink” landscape is to quantify the effect of landscape on ecological process. The positive effect is made by “source” landscape, and the negative effect by “sink” landscape. (4) For the same ecological process, the contribution of “source” landscapes may vary, and it is the same to the “sink” landscapes. It is required to determine the weight of each landscape type on ecological processes. (5) The sourcesink principle can be applied to non-point source pollution control, biologic diversity protection, urban heat island effect mitigation, etc. However, the landscape evaluation models need to be calibrated respectively, because different ecological processes correspond with different source-sink landscapes and evaluation models for the different study areas. This theory is helpful to further study landscape pattern and ecological process, and offers a basis for new landscape index design. __________ Translated from Acta Ecologica Sinica, 2006, 26(5): 1444–1449 [译自: 生态学报]     

Pastoral Power and the Confessing Subject in Patient-Centred Communication

This paper examines the power relations in “patient-centred communication”. Drawing on the work of Michel Foucault I argue that while patient-centred communication frees the patient from particular aspects of medical power, it also introduces the patient to new power relations. The paper uses a Foucauldian analysis of power to argue that patient-centred communication introduces a new dynamic of power relations to the medical encounter, entangling and producing the patient to participate in the medical encounter in a particular manner.     

Basidiocarp development inCoprinus macrorhizus

The dikaryon #5026 (A2B2)+#5132 (A7B7) of the basidiomyceteCoprinus macrorhizus was treated with ultraviolet light (UV),N-methyl-N′-nitro-N-nitrosoguanidine (NG), and 5-bromouracil (BU) in order to induced developmental variations in fruiting. Among a total of 11,383 isolates, 742 were homokaryons. Fruiting test was made with the remaining 10,641 dikaryotic isolates, of which 1,594 showed abnormality in basidiocarp development. Both UV and NG were very efficient in inducing such variations, but BU was not. The induced variations were classified into seven basic types as follows: 1) “knotless”, in which hyphal knots, the first sign of fruiting, do not differentiate; 2) “primordiumless,” in which hyphal knots are formed, but no further development occurs; 3) “maturationles”, in which primordia are formed, but the maturation of primordia into adult fruit bodies does not occur; 4) “elongationless”, in which the elongation of stipe is blocked, and a basidiocarp with a very short stipe is produced; 5) “expansionless,” in which pilei do not expand normally; 6) “sporeless,” in which the formation of basidiospores is blocked and albinic pilei bearing none or only a small amount of spores are produced; and 7) “autolysisless,” in which the autolysis of pilei does not appear to occur. It has been noticed that the four steps of maturation, i.e. stipe elongation, pileus expansion, spore formation, and perhaps pileus autolysis, can proceed independently. Compound types of variations such as “elongation-expansionless,” “elongation-sporeless,” “expansion-sporeless,” and “elongation-expansion-sporeless” were also induced. UV treatment induced maturationless at the highest rate, while NG treatment sporeless. Contributions from the Division of Plant Morphology, Department of Biology, Faculty of Science, Okayama University. No. 117.