Descriptive study of cooperative language in primary care consultations by male and female doctors

ObjectiveTo compare the use of some of the characteristics of male and female language by male and female primary care practitioners during consultations.DesignDoctors’ use of the language of dominance and support was explored by using concordancing software. Three areas were examined: mean number of words per consultation; relative frequency of question tags; and use of mitigated directives. The analysis of language associated with cooperative talk examines relevant words or phrases and their immediate context.Subjects26 male and 14 female doctors in general practice, in a total of 373 consecutive consultations.SettingWest Midlands.ResultsDoctors spoke significantly more words than patients, but the number of words spoken by male and female doctors did not differ significantly. Question tags were used far more frequently by doctors (P<0.001) than by patients or companions. Frequency of use was similar in male and female doctors, and the speech styles in consultation were similar.ConclusionsThese data show that male and female doctors use a speech style which is not gender specific, contrary to findings elsewhere; doctors consulted in an overtly non-directive, negotiated style, which is realised through suggestions and affective comments. This mode of communication is the core teaching of communication skills courses. These results suggest that men have more to learn to achieve competence as professional communicators.

Key messages

• Standard teaching on medical communication promotes a cooperative approach to doctor-patient interaction
• In everyday life, however, cooperative language is more typical of female speech style, and this suggests that male doctors may find it harder to develop appropriate consulting styles; in a sample of 373 consultations, male and female general practitioners used examples of cooperative language equally
• Language based study of doctor-patient interaction can deepen understanding and provide useful insights

     

Thinking systemically about ecological interventions: what do system archetypes teach us?

To address the need for more holistic approaches to ecological management and restoration, we examine ecosystem interventions through the lens of systems thinking and in reference to systems archetypes, as developed in relation to organizational management in the business world. Systems thinking is a holistic approach to analysis that focuses on how a system's constituent parts interrelate and how systems work over time and within the context of larger systems. Systems archetypes represent patterns of behavior that have been observed repeatedly. These archetypes help relate commonly observed responses to environmental problems with their effect on important feedback processes to better anticipate connections between actions and results. They highlight situations where perceived solutions actually result in worse or unintended consequences, and where changing goals may be either appropriate or inappropriate. The archetypes can be applied to practical examples, and can provide guidance to help make appropriate intervention decisions in similar circumstances. Their use requires stepping back from immediately obvious management decisions and taking a more systemic view of the situation. A catalog of archetypes that describe common patterns of systems behavior may inform management by helping to diagnose system dynamics earlier and identifying interactions among them.     

Combining simple blood tests to identify primary care patients with unexpected weight loss for cancer investigation: Clinical risk score development,internal validation,and net benefit analysis

BackgroundUnexpected weight loss (UWL) is a presenting feature of cancer in primary care. Existing research proposes simple combinations of clinical features (risk factors, symptoms, signs, and blood test data) that, when present, warrant cancer investigation. More complex combinations may modify cancer risk to sufficiently rule-out the need for investigation. We aimed to identify which clinical features can be used together to stratify patients with UWL based on their risk of cancer.Methods and findingsWe used data from 63,973 adults (age: mean 59 years, standard deviation 21 years; 42% male) to predict cancer in patients with UWL recorded in a large representative United Kingdom primary care electronic health record between January 1, 2000 and December 31, 2012. We derived 3 clinical prediction models using logistic regression and backwards stepwise covariate selection: Sm, symptoms-only model; STm, symptoms and tests model; Tm, tests-only model. Fifty imputations replaced missing data. Estimates of discrimination and calibration were derived using 10-fold internal cross-validation. Simple clinical risk scores are presented for models with the greatest clinical utility in decision curve analysis. The STm and Tm showed improved discrimination (area under the curve ≥ 0.91), calibration, and greater clinical utility than the Sm. The Tm was simplest including age-group, sex, albumin, alkaline phosphatase, liver enzymes, C-reactive protein, haemoglobin, platelets, and total white cell count. A Tm score of 5 balanced ruling-in (sensitivity 84.0%, positive likelihood ratio 5.36) and ruling-out (specificity 84.3%, negative likelihood ratio 0.19) further cancer investigation. A Tm score of 1 prioritised ruling-out (sensitivity 97.5%). At this threshold, 35 people presenting with UWL in primary care would be referred for investigation for each person with cancer referred, and 1,730 people would be spared referral for each person with cancer not referred. Study limitations include using a retrospective routinely collected dataset, a reliance on coding to identify UWL, and missing data for some predictors.ConclusionsOur findings suggest that combinations of simple blood test abnormalities could be used to identify patients with UWL who warrant referral for investigation, while people with combinations of normal results could be exempted from referral.

Dr. Brian D Nicholson and colleagues investigate whether combinations of routine blood tests could be used to stratify patients in UK with unexpected weight loss based on their risk of cancer.     

The distinct effects of habitat fragmentation on population size

We sought to understand how the separation of habitats into spatially isolated fragments influences the abundance of organisms. Using a simple, deterministic model of population growth, we compared analytically exact solutions predicting abundance of consumers in two isolated patches with abundance of consumers in a single large patch where the carrying capacity of the large patch is the sum of the carrying capacities of the isolated ones. For the deterministic model, the effect of fragmentation was to slow the rate of population growth in the fragmented habitat relative to the intact one. We also analyzed a stochastic version of the model to examine the effect of fragmentation on population abundance when resources vary randomly in time. For the stochastic model, the effect of fragmentation was to reduce population abundance. We proved in closed-form, that for a non-equilibrium population exhibiting logistic population growth, fragmentation will reduce population size even when the total carrying capacity is not affected by fragmentation. We provide a theoretical basis for the prediction that habitat fragmentation amplifies the effect of habitat loss on the abundance of mobile organisms.     

Biogeography and the structure of coral reef fish communities on isolated islands

Aim To determine the applicability of biogeographical and ecological theory to marine species at two remote island locations. This study examines how biogeography, isolation and species geographic range size influence patterns of species richness, endemism, species composition and the abundance of coral reef fishes. Location Christmas Island and the Cocos (Keeling) Islands in the tropical eastern Indian Ocean. Methods Published species lists and underwater visual surveys were used to determine species richness, endemism, species composition and abundance of reef fishes at the islands. These data were statistically compared with patterns of species composition and abundance from the neighbouring ‘mainland’ Indonesian region. Results The two isolated reef fish communities were species‐poor and contained a distinct taxonomic composition with an overrepresentation of species with high dispersal potential. Despite low species richness, we found no evidence of density compensation, with population densities on the islands similar to those of species‐rich mainland assemblages. The mix of Indian and Pacific Ocean species and the proportional representations of the various regional faunas in the assemblages were not influenced by the relative proximity of the islands to different biogeographical provinces. Moreover, species at the edge of their range did not have a lower abundance than species at the centre of their range, and endemic species had substantially higher abundances than widespread species. At both locations, endemism was low (less than 1.2% of the community); this may be because the locations are not sufficiently isolated or old enough to promote the evolution of endemic species. Main conclusions The patterns observed generally conform to terrestrial biogeographical theory, suggesting that similar processes may be influencing species richness and community composition in reef fish communities at these remote islands. However, species abundances differed from typical terrestrial patterns, and this may be because of the life history of reef fishes and the processes maintaining isolated populations.     

Molecular characterization of proprotein convertase subtilisin/kexin type 9-mediated degradation of the LDLR

Proprotein convertase subtilisin/kexin type 9 (PCSK9) is a secreted protein that promotes degradation of cell surface LDL receptors (LDLRs) in selected cell types. Here we used genetic and pharmacological inhibitors to define the pathways involved in PCSK9-mediated LDLR degradation. Inactivating mutations in autosomal recessive hypercholesterolemia (ARH), an endocytic adaptor, blocked PCSK9-mediated LDLR degradation in lymphocytes but not in fibroblasts. Thus, ARH is not specifically required for PCSK9-mediated LDLR degradation. Knockdown of clathrin heavy chain with siRNAs prevented LDLR degradation. In contrast, prevention of ubiquitination of the LDLR cytoplasmic tail, inhibition of proteasomal activity, or disruption of proteins required for lysosomal targeting via macroautophagy (autophagy related 5 and 7) or the endosomal sorting complex required for trafficking (ESCRT) pathway (hepatocyte growth factor-regulated Tyr-kinase substrate and tumor suppressor gene 101) failed to block PCSK9-mediated LDLR degradation. These findings are consistent with a model in which the LDLR-PCSK9 complex is internalized via clathrin-mediated endocytosis and then routed to lysosomes via a mechanism that does not require ubiquitination and is distinct from the autophagy and proteosomal degradation pathways. Finally, the PCSK9-LDLR complex appears not to be transported by the canonical ESCRT pathway.