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Eva's stories: recognizing the poverty of the medical case history.

The medical case history is a proven tool for approaching the question "What is wrong with this person?" Its virtues, however, can become vices, in part as a consequence of the dehumanizing flight from sensitive subjectivity to sanitized objectivity, from human interest to "science." The case history, because it is so useful and effective, is not likely to be profoundly altered in the future, but medical educators can make themselves and their students more aware of the serious flaw in this form of discourse, i.e., the erasure of the unique individual from his or her disease. The exercise of asking medical students to abstract case histories from richly written short stories, novels, plays, or operas might heighten students' recognition of the poverty of the medical case history. To illustrate this idea, the story of Eva, a dying woman, is presented initially as a typical medical case history; it is then contrasted with excerpts from a novelist's narrative of Eva's life.

Aged↗

Our compact with tomorrow's doctors.

In recent years, the image of medicine as a caring profession has been badly tarnished by a rash of critical reports in the media. In the face of this negative publicity, do young people still want to be doctors? The author reviews conventional reasons given for the declining applicant pool (e.g., issues of declining income, loss of autonomy, etc.) and posits that an additional reason may be perceptions that doctors no longer command respect and that they are being oppressed by, rather than being guardians of, the health care system. Such views challenge academic medicine to broadcast to the world a realistic picture of the fabulous opportunities and gratifications that lie ahead for the next generation of physicians. However, academic medicine must also address some current realities within medical education, such as the admission process (where at present there is a tendency to overemphasize indices of academic achievement and underemphasize the personal characteristics sought in applicants) and the acculturation process in medical school (which can often dehumanize students and convert idealistic ones into cynics). The author acknowledges that these are tough challenges. He suggests as a first step that leaders of academic medicine prepare and disseminate an explicit statement of their commitments, a kind of compact between teachers and learners of medicine. He outlines these commitments, and states his hope that by fulfilling them, the academic medicine community can make clear that medicine-which at its core is still about the doctor-patient relationship-is a true calling, not just beleaguered occupation.

Acculturation↗

Viewpoint: today's professionalism: engaging the mind but not the heart.

Professionalism is au courant in medicine today, but the movement to teach and evaluate professionalism presents a conundrum to medical educators. Its intent is laudable: to produce humanistic and virtuous physicians who will be better able to cope with and overcome the dehumanizing features of the health care system in the United States. However, its impact on medical education is likely to be small and misleading because current professionalism curricula focus on lists of rules and behaviors. While such curricula usually refer to virtues and personal qualities, these are peripheral because their impacts cannot be specifically assessed. The author argues that today's culture of medicine is hostile to altruism, compassion, integrity, fidelity, self-effacement, and other traditional qualities. Hospital culture and the narratives that support it often embody a set of professional qualities that are diametrically opposed to virtues that are explicitly taught as constituting the "good" doctor. Young physicians experience internal conflict as they try to reconcile the explicit and covert curricula, and they often develop nonreflective professionalism. Additional courses on professionalism are unlikely to alter this process. Instead, the author proposes a more comprehensive approach to changing the culture of medical education to favor an approach he calls narrative-based professionalism and to address the tension between self-interest and altruism. This approach involves four specific catalysts: professionalism role-modeling, self-awareness, narrative competence, and community service.

Curriculum↗

ICU visiting policies.

Head nurses from 78 ICUs in 37 northeast Ohio hospitals were interviewed about visiting policies. There was tremendous variation with regard to frequency and length of visits; 25% of these ICUs allowed only 2 visits/day, and 42% restricted visits to under 20 min. Most units rarely or never allowed children under 12 yr old to visit. Traditional rationales for restricted visiting are not supported by studies in the literature, nor are they consistent with current concepts of patients' rights. In an era where high technology and medicine by-the-numbers threaten to dehumanize patients, open visiting is an important part of the humanization process.

Adult↗

Responding to patient-initiated humor: guidelines for practice.

Over the past few decades, increasing evidence has shown the beneficial effects of humor. The use of caregiver-initiated humor as an intervention in healthcare settings has both physiological and emotional benefits. Little has been written, however, about another very important aspect of humor, patient-initiated humor. When patients use humor to relieve their feelings of stress, uncertainty, or embarrassment, they are trying to communicate with their caregiver. This use of humor by patients is not to "make light" of the situation, but rather a way to reduce their feelings of dehumanization. Humor is an interactive process of sharing and an important aspect of communication. Patients will observe the caregiver for a response. An open, accepting response signals understanding; a negative or null response, however, may serve to isolate the patient. The guidelines discussed in this article for recognizing, interpreting, and responding to patient-initiated humor will help home care and hospice nurses to foster increased open patient/caregiver communication and create a supportive humanistic atmosphere for patient care.

Adaptation, Psychological↗

The ophthalmologist's office: planning and practice. Patient traffic flow and use of paramedical personnel.

In order for the ophthalmologist to achieve the greatest earning power and personal satisfaction, he or she must devise traffic flow techniques that efficiently allow for maximum utilization of all examining areas and paramedical personnel in the office without dehumanizing patients. By delegating as much responsibility as possible to staff, the ophthalmologist will have the opportunity of performing his or her specialized skills to the fullest extent, and therefore will achieve optimal personal gratification. This emotional reward indemnifies the future of private practice, because it can exist only in the presence of a close patient-physician relationship, which is the cornerstone of the private practice of ophthalmology.

Ophthalmic Assistants↗

Women's attitudes toward gynecologic practices.

Seventy-five female students and faculty members at a community college completed a questionnaire exploring their attitudes toward gynecologic procedures, their physicians, and the discussion of sexual concerns. Eighty-five percent reported negative feelings toward the pelvic examination (anxiety, vulnerability-humiliation, and dehumanization). Forty-one percent expressed negative feelings toward their physician's behavior, while 43% reported positive feelings. Seventy-two percent would not discuss sexual concerns with their physicians. A large percentage of recommendations (87%) addressed themselves to the doctor-patient relationship rather than to procedural matters (29%). These findings recommend serious self-scrutiny and behavior change on the part of physicians. Specific recommendations to alleviate the current situation are provided by the authors, and suggestions are made for incorporating the findings into educational environments.

Attitude↗

Titrated intravenous barbiturates in the control of symptoms in patients with terminal cancer.

Patients with terminal cancer may have a series of severe and dehumanizing physical and psychologic symptoms. To improve symptom control in the final days and hours of life, we administer intravenous barbiturates continuously to provide heavy sedation or continuous somnolence. Titrated dosage is then reduced to a minimum, after a desired steady-state has been achieved. Improved symptom control is provided, and the patient's dignity is maintained until death.

Aged↗

An ethical framework for nursing service administration.

Nurses as administrators are responsible for creating an ethical work environment in which nurses' human welfare is promoted. Bureaucratic organizations can dehumanize people, wherein human welfare suffers in the midst of institutional constraints. Amid these conditions nurses' ethical competence cannot develop nor can nurses maintain a sense of personal integrity. Applying concepts from nursing and general ethics to administrative practice provides a basis for developing an ethical framework for management. The proposed framework involves ethical awareness, principled reasoning, moral commitment to the profession and to one another, and primary consideration for human welfare with strategies to promote it. Use of these components when making decisions in daily practice and on a policy level enhances the well-being of nurses working in organizations.

Administrative Personnel↗

Can knowledge be promoted and values ignored? Implications for nursing education.

This paper aims to reflect upon the educational task of the university, to consider whether knowledge can be promoted and values ignored, and thus to explore the implications for nursing education. The university is the cradle which nurtures intellectuals, professionals and scientists as whole human beings. Paced by the spirit and the ideals of paideia, it cannot be limited merely to developing the student's mind. It should also inspire the student with a belief in the higher values of life, as a compass in his profession. (Paideia is an ancient Greek conception of the ideal human education. It includes modern notions such as civilization, culture, tradition, literature, philosophy and education. It means formation of the human being of any age, as an independent, free and virtuous whole person.) Values, when transmitted by all teachers of all subjects within the educational structures of the university, can increase the student's respect for truth, for the worth and the rights of other persons, his appreciation of his own worth, assets and limitations, his love of wisdom and desire to serve humanity, his outlook about man's position in the world and his inquiring mind in order to discover higher perspectives of life. Only in this way does university become a worthy centre of paideia for educating nurses committed and aspiring to provide holistic, personalized, quality nursing care to people, as well as to determine and shape the future of nursing education in the midst of our technological, computerized, and some would say dehumanized era, propelling itself into the twenty-first century.

Attitude of Health Personnel↗

The duality in using information and communication technology in elder care.

AIM: The aim of this paper is to report a study illuminating values and perceptions held by professional carers of older people about the use of information and communication technology applications. BACKGROUND: Various information and communication technology applications have successfully been developed to help solve a variety of problems in elder care. Beside different technical barriers and the assumed negative attitudes among older people, staff values and attitudes have been found to be an important cause of resistance to change and slowness in introduction of information and communication technology in health care of older people. METHODS: An interview study was conducted in 2004 with 10 healthcare personnel with 3-26 years experience of working in home care and nursing homes in Northern Sweden. Qualitative content analysis was used to identify recurring themes in the data. RESULTS: The interpretation of values and perceptions among carers revealed a duality where the carers perceived information and communication technology as a promoter of both inhumane and humane care, a duality that seemed to make them defensive and resistant to change. Within the overall duality, other dualities were embedded that described both perceptions about the care of older people and about being a carer. There was evidence of resistance among professional carers towards an introduction of information and communication technology applications in elder care. Carers considered that the same attributes of information and communication technology that could promote humane care could also lead to dehumanized care. CONCLUSION: There should be an ethical discussion when introducing information and communication technology applications in elder care. The best caring alternative for all those concerned should be considered. It should promote aspects of wellbeing and dignity for frail older people and fears of inhumane care among carers must be recognized and discussed.

Adaptation, Psychological↗

The impact of nurses' opinion of client behaviour and level of social functioning on the amount of time they spend with clients.

The impact of nurses' opinion of client behaviour and level of social functioning on the amount of time they spend with clients For people afflicted with different kinds of psychiatric disorder, suffering is a common denominator. The time the nurses spend with psychiatric clients may mirror their attitudes towards and feelings for these clients. The aim of this study was to investigate the connections between the time spent together and the nurses' opinion of client behaviour and social functioning in community-based psychiatry. In this quantitative study, 29 clients were assessed by 30 nurses, who answered the Global Assessment of Functioning Scale (GAF) and the Positive and Negative Syndrome Scale (PANSS). At the same time, 11,200 non-participant observations of clients were registered using the Patient Activity Classification (PAC) to investigate how they spent their time at two psychiatric group dwellings. The PAC instrument revealed that clients spent an average of 60.8% of time alone, while only 20% of their daily time was spent with the nurses. Based on a factor analysis, indices were made by setting cut-off points for the PANSS and the GAF scores, and four small groups of clients were generated: a relatively high level of social functioning and a low degree of psychiatric symptoms (A); a relatively high level of social functioning and a high degree of psychiatric symptoms (B); a low level of social functioning and a low degree of psychiatric symptoms (C); and, finally, a low level of social functioning and a high degree of psychiatric symptoms (D). The clients judged as having a low level of social functioning in combination with high degrees of psychiatric symptoms, that is, the most vulnerable and dependent individuals, receive less staff attention (18%) and are the clients who spend the most time alone (71.4%). It might be possible to interpret the results of this study in the light of a process of dehumanization.

Adult↗

Student discussion groups on doctor-patient relationships: a critical assessment.

Regular discussion groups for all students were introduced at a new clinical medical school to enable students to discuss freely their responses to patients. The main aim was to prevent the alleged dehumanizing effect of medical education. The groups were monitoring by attendance records, questionnaires and tape-recordings. In fact, the majority of students stopped attending so that only two of the five groups survived longer than 6 months. Despite improvements in organization and styles of conducting the groups, a similar fall in attendance occurred in the next year's intake. paradoxically, in most meeting there was a lively and apparently beneficial discussion on the students' reactions to their contacts with patients, so it was difficult to explain the overall drop in attendance. It was concluded that, while organizational details and inappropriate styles of conducting the groups were partly responsible, the main problem was the apparent conflict in attitudes between the students medical teachers and their group conductors (who were mainly psychiatrists), i.e. between the concepts of modern technological medicine and those of psycho-social medicine. This induced a conflict of motivation in the students, who naturally need to identify with their teachers, which most of them resolved by avoiding the groups. It is suggested that more effective integration between general medical teachers and the organizers of such groups is needed, and that group conductors should include general practitioners and clinical supervisors as well as psychiatrists.

Education, Medical, Undergraduate↗

Innocents abroad: Western fantasies of childhood and the iconography of emergencies.

In this paper I explore the emotional interests maintained by the imagery of children used in Third World emergencies. Boundaries between adult and child are reproduced through relations of paternalism between North and South, such that the infantilisation of the South exemplified in imagery of children works to secure the competence and maturity of the Northern donor. Drawing on both analyses of the cultural origins and meanings of concepts of childhood and psychoanalytic perspectives, I suggest that media coverage of disasters arouses both identification and strategies to ward off and protect from the anxiety this brings. The gendered as well as geographical distribution of qualities of children's innocence and experience are discussed, drawing on both general imagery of children and recent coverage of children and child-saving, particularly in the former Yugoslavia. Developing analyses of 'disaster pornography', the paper explores how children appear as the principal focal objects onto which attention is pinned and as the signifiers of distress. This is at the cost of dehumanizing both children, their families and their cultures, and rendering them passive objects of a western gaze which seeks to confirm its own agency and omnipotence to ward off its own insecurities. While aid organisations and campaigns necessarily engage with, and sometimes collude with, these reactions, the paper ends by suggesting that there may be strategies whereby images of children can function to comment on rather than maintain prevailing colonial and paternalistic relations.

Advertising↗

Detained asylum seekers, health care, and questions of human(e)ness.

This paper contains some personal observations of life inside Woomera Detention Centre and certain aspects of the detained asylum seeker experience. This is from my own reference point as a psychiatric nurse who in 2002 undertook a six-week contract at Woomera, and from my subsequent sociological reflections on this experience. I draw attention to the disintegrative effect of detention on the individual and the bleakness of everyday life symbolically expressed in forms of self-harm. Then, through the example of medication administration, I show the vulnerability of those in detention to bureaucratic procedures that become micropolitical sites, providing the machinery for dehumanizing acts. I conclude by calling for sociologists, health care workers, and the public health community in general to take a more active political stance against a Government and its policies that actively erode spirit, the body and, for some, even life.

Depressive Disorder↗

Vulnerability as a key to authenticity.

PURPOSE: Vulnerability is explored as a human trait that gives nurses an opportunity to engage in authentic nursing. Vulnerability in both nurse and patient is necessary for the practice of nursing with caring as its basic premise. ORGANIZING FRAMEWORK: Philosophic discourse. SCOPE: Vulnerability is explored in terms of its traditional connotation and existential meaning. CONCLUSIONS: To be authentic, nurses must be aware of their own vulnerability, recognize themselves in others, and be willing to enter into mutual vulnerability. If nurses deny the opportunity to be vulnerable, they deny the opportunity to participate in humanness and are more likely to dehumanize others.

Humans↗

Disclosing the details of child sexual abuse: can imaginative literature help ease the suffering?

PROBLEM: Research indicates that full disclosure of the events surrounding child sexual abuse, while therapeutic, is often difficult to achieve. METHODS: A nonconventional research approach was employed in order to examine more closely the lived experience of these children. Two novels were analyzed using close reading. FINDINGS: Details of the events and resultant dehumanization of the children were uncovered, as well as the rescuing role of the ancestor. Writing emerged also as a therapeutic tool that facilitated disclosure and helped to promote healing. CONCLUSIONS: The analysis of imaginative literature enables the reader to examine sensitive topics like sexual abuse and contributes to its treatment.

Adaptation, Psychological↗

Models of job-related stress and personal achievement among consultant doctors.

The antecedents and outcomes of feelings of job-related stress and personal achievement were studied in a large sample of consultant doctors working in Scotland. In a sample of 333 doctors it was found that a tendency to use emotion-oriented coping strategies and negative appraisals of organizational changes in the practice of medicine mediated the effect of the personality dimension of Neuroticism on reported job stress. Job stress levels predicted the degree of 'burnout' experienced by doctors, i.e. their tendencies to be emotionally exhausted by their work and to dehumanize patients. Higher clinical workloads were related to higher levels of stress but also to higher feelings of personal achievement. A substantial proportion of the variance in many of the variables in the stress model was accounted for by a general tendency to experience negative emotions, closely related to Neuroticism; this general factor appeared to be similar to the recently formulated concepts of 'negative affectivity' and 'somatopsychic distress'. The personality factors of Extraversion and Conscientiousness both contributed to positive feelings of personal achievement (N = 344); the effect of Extraversion was direct, whereas the effect of Conscientiousness was mediated by a tendency to use task-oriented coping strategies. Models of the processes of stress and personal achievement were tested for acceptability using the EQS Structural Equations Program. The implications of the models for transactional theories of stress are discussed.

Achievement↗