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PubMed2002

Patient perspectives on the doctor of the future.

BACKGROUND AND OBJECTIVES: Health care reform has been the subject of considerable debate, particularly among those in politics, insurance, and business. Patients, however, have largely been ignored in this discussion. As the role of the health care consumer receives increased attention, it is important to consider patient values and preferences for a future system of care. This study describes what patients want and value in a future doctor METHODS: This study was conducted in 1999-2000, using focus group methodology involving 78 members of communities in seven regions of Colorado. Participants were selected to ensure a distribution of rural/urban, racial/ethnic groups and different regions of the state. All participants had visited a health care provider in the previous 10 years. Data were analyzed with a team-based editing approach. RESULTS: Participants identified several primary domains and subthemes that describe what they want in a doctor of the future. The primary themes related to future doctors' medical and contextual knowledge of the patient, their personal characteristics and philosophical approach to health and health care, and desired qualities of the doctor-patient relationship. CONCLUSIONS: Patients wanted their future doctors to improve their experience of care and to be patient-centered, family-oriented, and community-oriented doctors. Patient perspectives of the doctor of the future should be considered in decisions about health care policy.

Female↗
PubMed2000

Classifying clinical decision making: a unifying approach.

This is the first of two linked papers exploring decision making in nursing which integrate research evidence from different clinical and academic disciplines. Currently there are many decision-making theories, each with their own distinctive concepts and terminology, and there is a tendency for separate disciplines to view their own decision-making processes as unique. Identifying good nursing decisions and where improvements can be made is therefore problematic, and this can undermine clinical and organizational effectiveness, as well as nurses' professional status. Within the unifying framework of psychological classification, the overall aim of the two papers is to clarify and compare terms, concepts and processes identified in a diversity of decision-making theories, and to demonstrate their underlying similarities. It is argued that the range of explanations used across disciplines can usefully be re-conceptualized as classification behaviour. This paper explores problems arising from multiple theories of decision making being applied to separate clinical disciplines. Attention is given to detrimental effects on nursing practice within the context of multidisciplinary health-care organizations and the changing role of nurses. The different theories are outlined and difficulties in applying them to nursing decisions highlighted. An alternative approach based on a general model of classification is then presented in detail to introduce its terminology and the unifying framework for interpreting all types of decisions. The classification model is used to provide the context for relating alternative philosophical approaches and to define decision-making activities common to all clinical domains. This may benefit nurses by improving multidisciplinary collaboration and weakening clinical elitism.

Clinical Competence↗
PubMed1989

Philosophy and health.

This paper employs a philosophical approach in order to explore the nature of the concept of health. It is designed to provoke further thought and discussion by posing a number of questions such as 'What is health?' and 'How is ill-health experienced?'. The authors argue that some philosophical ability is necessary to enable the professional carer to reflect clearly and logically on both their theory and practice. In addition this paper argues that professional carers should aim to achieve a balance between science and humanism. Also reasons are suggested why a role should be given to non-scientific language in the planning of individual-centred care.

Disease↗
PubMed2006

Scientific misconduct and science ethics: a case study based approach.

The Schön misconduct case has been widely publicized in the media and has sparked intense discussions within and outside the scientific community about general issues of science ethics. This paper analyses the Report of the official Committee charged with the investigation in order to show that what at first seems to be a quite uncontroversial case, turns out to be an accumulation of many interesting and non-trivial questions (of both ethical and philosophical interest). In particular, the paper intends to show that daily scientific practices are structurally permeated by chronic problems; this has serious consequences for how practicing scientists assess their work in general, and scientific misconduct in particular. A philosophical approach is proposed that sees scientific method and scientific ethics as inextricably interwoven. Furthermore, the paper intends to show that the definition of co-authorship that the members of the Committee use, although perhaps clear in theory, proves highly problematic in practice and raises more questions that it answers. A final plea is made for a more self-reflecting attitude of scientists as far as the moral and methodological profile of science is concerned as a key element for improving not only their scientific achievements, but also their assessment of problematic cases.

Authorship↗
PubMed1982

Impotence: the surgical approach.

Techniques are now available to restore erectile potency. Several prosthetic devices have been developed that afford a high degree of reliability. The inflatable prosthesis is cosmetically superior, but it is associated with the highest mechanical complication rate. Penile revascularization is a technique with great potential, but the methodology at this point requires further development. Surgeons involved with the treatment of impotency must acquire both the surgical skills required by the operative techniques as well as a philosophical approach to the psychological aspects involved in such therapy. Restoration of penile rigidity can, for some men, mean a new lease on life, but in the improperly selected patient a surgical success may be associated with utter patient dissatisfaction.

Counseling↗
PubMed1994

[Morals, logic and ethics in reproductive medicine].

Human reproduction has always been a matter of philosophical interrogations and controversies. This situation has been reinforced by the technical evolution which has occurred during the past years. Both hopes and concerns have been raised at the same time. Two recent advancements deserve consideration and are given as demonstrative examples: intracytoplasmic injection of spermatozoon, preimplantatory diagnosis. Their consequences are very important for both the medical and the philosophical approach. One of the questions which arises at this occasion is to determine if research on pre embryos is legitimate or not. This evolution has provoked some reluctancy and several criticisms concerning the future of the children obtained by such techniques: the risk of slippery slope, possibly leading to a form of eugenics, and the fundamental and philosophical problem of the status of the embryo. However, behind these discussions a deeper and heavier controversial matter may be discovered; it deals with the role and the responsibilities of the governmental power. An opposition does exist between two different perceptions: on the one hand, the concept of a powerful governmental body, responsible for the respect of a statutory law, grounded on a sort of universal ethical rule, to be followed by all, a concept which bears the risk of totalitarianism; on the other hand, the concept of a law with a limited responsibility to protect public order, allowing a normal social life. Amongst the numerous responsibilities of the governmental power, one is often neglected, everywhere; its concerns the protection of the female life and health. Some examples are given. However the most frightening risk, much more dangerous than the frequently alleged risk of biological eugenics, is what can be called "economical eugenics". Again some examples are given, in all the systems of social protection. Submitted to ethical rules imposed by political and legal powers, and to the influence of economical forces, what will be the role and the responsibilities of the practitioner? Unfortunately the answer may be obvious: the only way is leading to a relinquishment of medical responsibility. Far away from the dialogue which was the rule of the "dual relationship" between the patient and the practitioner, away too from the more complicated situation of today, characterized by the intervention of "third parties", the evolution, probably unavoidable, appears to be towards the withdrawal of the psychological, moral, human and humanistic involvement of the practitioner, leading him or her to a technical role.(ABSTRACT TRUNCATED AT 400 WORDS)

Ethics, Medical↗
PubMed1995

Evaluation of partial classification algorithms using ROC curves.

When using computer programs for decision support in clinical routine, an assessment or a comparison of the underlying classification algorithms is essential. In classical (forced) classification, the classification rule always selects exactly one alternative. A number of proven discriminant measures are available here, e.g.sensitivity and error rate. For probabilistic classification, a series of additional measures has been developed [1]. However, for many clinical applications, there are models where an observation is classified into several classes (partial classification), e.g., models from artificial intelligence, decision analysis, or fuzzy set theory. In partial classification, the discriminatory ability (Murphy) can be adjusted a priori to any level, in most practical cases. Here the usual measures do not apply. We investigate the preconditions for assessment and comparison based on medical decision theory. We focus on problems in the medical domain and establish a methodological framework. When using partial classification procedures, a ROC analysis in the classical sense is no longer appropriate. In forced classification for two classes, the problem is to find a cutoff point on the ROC curve; while in partial classification, you have to find two of them. They characterize the elements being classified as coming from both classes. This extends to several classes. We propose measures corresponding to the usual discriminant measures for forced classification (e.g., sensitivity and error rate) and demonstrate the effects using the ROC approach. For this purpose, we extend the existing method for forced classification in a mathematically sound manner. Algorithms for the construction of thresholds can easily be adapted. Two specific measurement models, based on parametric and non-parametric approaches, will be introduced. The basic methodology is suitable for all partial classification problems, whereas the extended ROC analysis assumes a rank order of the selected alternatives. The method is based on the black box principle and makes use only of the results of the compared algorithms and some general intuitive principles. Therefore, algorithms arising from different "philosophical" approaches may also be compared according to their results. For demonstration purposes, a clinical example from cranial computed tomography is presented. Linear discriminant analysis as a reference is compared to a Bayesian and a fuzzy procedure.

Algorithms↗
PubMed2004

Food for life, love and hope: an exemplar of the philosophy of palliative care in action.

The World Health Organization's (1990) definition of palliative care describes an holistic approach to care for patients with advanced progressive illness. Issues relating to nutrition, lack of appetite and the subsequent weight loss the individuals may experience present a challenge to all concerned with providing both formal and informal care to this patient group. The philosophy of palliative care requires a multidisciplinary approach to the constellation of issues and problems related to food that are faced by both patients and carers in receipt of palliative care. The literature in this area is mainly related to those patients with a cancer diagnosis. The developing role of palliative care in patients with non-malignant disease provides further challenges for health care professionals. The present paper aims to reflect an entire philosophical approach to care through an examination of one area of practice.

Appetite↗
PubMed2006

Uncovering frustrations. A qualitative needs assessment of academic general internists as geriatric care providers and teachers.

BACKGROUND: General internists commonly provide medical care for older adults and geriatric education to trainees, but lack the necessary knowledge and skills to fulfill these tasks. OBJECTIVE: Assess the geriatric training needs of academic general internists in 3 hospital systems in Portland, OR. DESIGN: Ten focus groups and 1 semi-structured interview. Interview transcripts were analyzed using thematic analysis, a well-recognized qualitative technique. PARTICIPANTS: A convenience sample of 22 academic general internists and 8 geriatricians from 3 different teaching hospitals. MEASUREMENTS: We elicited stories of frustration and success in caring for elderly patients and in teaching about their care. We asked geriatricians to recount their experiences as consultants to general internists and to comment on the training of Internists in geriatrics. RESULTS: In addition to deficits in their medical knowledge and skills, our Internists reported frustration with the process of delivering care to older adults. In particular, they felt ill prepared to guide care transitions for patients, use multidisciplinary teams effectively, and were frustrated with health care system issues. Additionally, general internists' approach to medical care, which largely relies on the medical model, is different from that of geriatricians, which focuses more on social and functional issues. CONCLUSIONS: Although our findings may not be broadly representative, improving our general internists' abilities to care for the elderly and to teach learners how to do the same should address deficits in medical knowledge and skills, barriers to the processes of delivering care, and philosophical approaches to care. Prioritizing and quantifying these needs and measuring the effectiveness of curricula to address them are areas for future research.

Academic Medical Centers↗
PubMed2005

Science-based assessment of welfare: aquatic animals.

Terrestrial animal welfare has been a matter for exploration for many years. In contrast, approaches towards improving the welfare and humane treatment of aquatic animals are relatively new, as is the thinking behind them. Several issues complicate the process of addressing the welfare of aquatic animals in a consistent manner. These include the following: - the huge diversity among aquatic animals, the majority of which are poikilothermic vertebrates and invertebrates - understanding the practices involved in fisheries, aquaculture and aquatic animal production, and their purpose - the relative paucity of scientific information - understanding the philosophical approaches, policies, guidance and regulations that may influence the provision of optimal welfare and humane practices for aquatic animals. In this paper, the authors attempt to provide an overview of all these elements, relating what is known and understood about these issues for the primary group used in aquaculture and fisheries, finfish, and exploring the factors that may influence the concepts and practices of aquatic animal welfare. These factors seem to be the foundation of all welfare approaches and include: - ethical and moral concepts of animal welfare and humane treatment - whether animals experience suffering from the potentially adverse practices used in their maintenance, management and use - the public and institutional understandings of these issues and their results. These are discussed with the hope that future developments in, and approaches to, aquatic animal welfare will be of use to society, industries and the public.

Animal Husbandry↗
PubMed2003

Breathlessness in cancer and chronic obstructive pulmonary disease: using a qualitative approach to describe the experience of patients and carers.

OBJECTIVE: To investigate and document the effects of breathlessness on the everyday lives of patients with cancer and COPD and their carers. This subject has been little researched, although dyspnoea is recognized as a disabling, distressing symptom. The number of breathless people is increasing as patients with all types of cardio-respiratory disease live longer. METHODS: Patients with severe COPD and cancer and their carers were interviewed at home using a semistructured format to record their perceptions of the impact of breathlessness, the help they had received from medical and caring services, and their ideas on how these could be improved. RESULTS: 10 patients with COPD (6 male) and 10 with cancer (6 male) and their spouses were interviewed. All patients found breathlessness frightening, disabling, and restricting. Patients developed a stoical, philosophical approach in order to live with dyspnoea and the difficulties it imposed: this was also an important way of reducing the emotional impact of breathlessness. Patients' spouses suffered significantly, experiencing severe anxiety and helplessness as they witnessed their partners' suffering and felt powerless to reduce it. The restrictions imposed by breathlessness affected their lives profoundly. Support of all kinds, practical, medical, and psychosocial was highly valued but was provided inconsistently and sporadically. Where help was given it came most frequently from general practitioners (GPs, family physicians) and specialist respiratory nurses. SIGNIFICANCE OF RESULTS: This study is the first to document the psychosocial needs of carers, which are not adequately recognized or addressed at present. Patients and carers may feel most isolated and need support outside the working hours of most services and future provision needs to reflect this. Patients with cancer experience a more rapid onset of breathlessness. More clinicians need to be educated in the management of chronic breathlessness so known helpful strategies are more widely employed.

Activities of Daily Living↗
PubMed1992

Measuring quality of life in theory and in practice: a dialogue between philosophical and psychological approaches.

Measuring quality of life is of concern to both philosophers and psychologists, yet the two disciplines typically approach the question in very different ways, ways so diverse that it may look as if they are engaged in such disparate activities that no dialogue between them is possible. In this paper we aim to construct the beginnings of a dialogue between the two disciplines which will show how they could serve each other and yet also show how, from the dialogue, difficult and previously unconsidered issues emerge for both sides.

Bioethical Issues↗