Causality and Dispositionality in Medical Practice

Pharmacists may be well placed to take up a role in depression care, complementing the role of general practitioners. However, depression care is a relatively new role for pharmacists, and little is known of their attitudes, current practices, and barriers toward it. A random sample of 200 community pharmacists in Belgium was surveyed about the care of patients with depression in comparison with patients with other, physical conditions. The 69 pharmacists who responded to the survey generally endorsed a very positive attitude toward their potential role in depression care. This willingness was, however, not reflected in current practice, and fulfilling this role appeared to be more difficult with patients with depression in comparison with patients with other, physical conditions. A lack of training in mental health issues was the most important barrier reported. Cooperation with general practitioners in depression care was desired, but the current level of cooperation was rather low. For pharmacists to effectively take up depression care, perceived barriers need to be addressed through specific training programs and increased cooperation with general practitioners.

Medical educators: the new generalists identifying the core traditions of the profession to create the next generation of doctors.

Significance. Narrative medicine, which amassed an extensive theoretical foundation through the efforts of medical anthropologists, sociologists, philosophers, and physicians in the 1980s-2000s, began actively permeating the educational and clinical environments in the USA, European countries, and China in the 2010s as a complement to evidence-based medicine. Articles, including reviews, describing the theoretical principles and results of applying this approach in medical training and clinical practice, which demonstrate its benefits, are regularly published in leading scientific journals. However, reviews on the implementation of narrative medicine practices in Russian, as well as descriptions of the organizational solutions, techniques, and tools, are currently virtually absent. This paper attempts to provide such a description. Purpose. To identify the list of countries actively studying and implementing narrative medicine, and to describe the organizational forms and tools through which the approach is being integrated into educational, clinical, and research practice. Material and methods. A selection and analysis of sources from the PubMed, MedEdPortal, Jstor, and Elibrary databases was conducted, which served to identify countries most actively promoting the narrative medicine approach. A subsequent analysis of these materials, combined with searches on the portals of educational institutions, research centers, medical clinics, and public organizations in these countries, enabled the identification and systematization of the organizational solutions and tools used to implement narrative medicine. Results. Based on the results of the study, it can be concluded that narrative medicine is most actively developing in the U.A., Italy, and China. In all these countries, it is noted that the application of this approach positively influences the improvement of quality of medical care provided. The tools, approaches, and methods for implementing narrative medicine into clinical practice, educational settings, and the research environment have been tested, and methodological guidelines have been developed. Narrative medicine is most fully integrated into the educational environment in China, where the approach enjoys a state support and is used in training future doctors, social workers, and nurses. Digital storytelling tools, developed and used in Italy and the U.A., make it easier to work with patient narratives, and the collected data can serve as a basis for targeted changes in the care delivery system. In clinical practice, the positive outcomes of applying the approach are noted in oncology, cardiology, dentistry, chronic disease management, and palliative care. Scope of application. The study results can be useful by health officials, medical education curriculum developers, and healthcare administrators. Keywords: narrative medicine; narrative based medicine; tools of narrative medicine; narrative competence; clinical narrative reasoning; digital narrative diary.

Comprehensive decade-long analysis of point-of-care resources reveals insights into how clinical research makes its way into practice across different medical specialties and through time to enable us to identify potential translational bottlenecks in the pathway from research to practice.

s the authors of "What Does<i>Cruzan</i>Mean to the Practicing Physician?"¹point out, complex court cases have maramifications for clinical practice. This is especially true garding the withholding and withdrawing of fluids and ttrition from incompetent patients. The argument that advance directives ought to be elicited from patients by physicians is essential for the future of clinical practice. Despite reservations some physicians may have regarding such directives, eg, that they might artificially "tie down" their options, patient-directed care not only derives from the law today, but also from good medical ethics and good clinical practice. The objection of those who argued that fluids and nutrition constituted a "special form of care" somehow immune to the patient's judgment about implementation and withdrawal always struck a negative chord in families who had to live with the enthusiasm of health professionals about prolonging the life of their loved ones. The<i>Cruzan</i>

This dissertation deals with knowing in medical practice by focusing on what epistemic agents such scientists, engineers, and medical professionals do when they construct and use knowledge, and what criteria play a role in evaluating the results. Based on experiences as a student and researcher in Technical Medicine, I have learned that current ideas about decision-making in clinical practice – i.e., the epistemology of evidence-based medicine (EBM) – are limited. Instead of deferring (a part of) their responsibility to clinical guidelines, doctors have epistemological responsibility for their clinical decisions. This means that they are responsible for the collection, critical appraisal, interpretation and fitting together of heterogeneous sources of evidence into a ‘picture’ of the patient. Understanding how the epistemological responsibility of doctors can be developed and how it can be assessed requires a more detailed account of (medical) expertise. I argue that this involves an account of the epistemic activities that clinicians should be able to perform and the cognitive skills that allow them to perform these activities. An account of expertise also improves our understanding of interdisciplinary research projects. Through their training, experts develop a disciplinary perspective that shapes how they deal with a target system. In interdisciplinary research aimed at problems in medical practices, multidisciplinary teams consisting of disciplinary experts interact around a problem, each exercising their own disciplinary perspective in dealing with aspects of the target system, rather than integrating theories. An important example of such an interdisciplinary research project is the development of a new medical imaging technology. Medical images do not speak for themselves but need to be interpreted. For this, engineers and clinicians need to enter into a shared search process to establish what an image represents, which requires an understanding of medical practice to establish for what relevant clinical claims they might provide evidence, whereas an understanding of the imaging technology is required to establish the reliability of this evidence. In medical practice, interdisciplinary collaborations are also important. Knowing in current medical practice is distributed over professionals with different expertises who collaborate in the construction of clinical knowledge. This collaborative character of epistemic practices in clinical decision-making leads to complex social practices of trust. Trust in these practices is implicit, in the sense that trusting the expertise of others occurs while the members of a team focus on other tasks, most importantly, building up a framework of common ways of identifying and assessing evidence. It is within this intersubjective framework that trusting or mistrusting becomes meaningful in multidisciplinary clinical teams.

Introduction: To increase, develop or maintain the knowledge and skills; to update the medical approaches necessary for providing an effective healthcare service are aimed through continuing medical education(CME) activities.In this study,we evaluated the factors influencing attendance to CME activities along with the experiences in CME and perceptions of family physicians about the effect of CME on their routine clinical practice. Methods:A questionnaire developed by the researchers was implemented to family physicians during 3 Family Medicine CME activities held in consecutive 6 months.The questionnaire composed of multiple-choice,open-ended,Likert-type questions about sociodemographic characteristics, professional experience concerning CME. An index about perceptions of participants about the effect of CME activities on their daily clinical practice was developed and a score ≥ 20 points was considered as “positive index score”. Results: A total of 247 family physicians, consisting of 112 family medicine residents, 106 specialists and 29 general practitioners,participated in the study.The most frequently mentioned barriers to participate in CME activities were economic reasons and time constraints.Residents stated that CME was useful in the recognition of new medications (p=0.006).General practitioners reported that CME had more impact in early diagnosis and treatment(p=0.0001). There was no difference between the reports of all groups on effects of CME on chronic disease follow-up(p=0.078).Participants who had scores ≥20,which revealed a positive perception on the impact of CME activities on their daily clinical practice were 71%. Conclusions: Our study participant pyhsicians think that scientific activities and meetings improve their daily clinical practice. Time constraint and economic reasons were reported highly as barriers for attendance to CME. “Perceived impact of CME activities on daily clinical practice index” may be used for evaluation in different groups of participants and meetings with variable themes.

Medicine is a sociotechnical system wherein culture manifests itself in all its aspects. Culture, however, is often intangible and is frequently neglected in formal healthcare education, research and practice. This sounding board article attempts to generate interest in making culture a serious component of healthcare systems at different levels, including its founding philosophical underpinnings, educational systems, research activities and clinical practice. It is recommended that a framework of culture-oriented medical philosophy, education, research and practice be implemented. Each component of this framework is briefly discussed in relation to healthcare. Culture should be reflected explicitly in healthcare through research activities, medical humanities, cultural competence, communication and ethics.

Reviewed by: Rationalizing Medical Work: Decision-Support Techniques and Medical Practices* Marcia L. Meldrum (bio) Rationalizing Medical Work: Decision-Support Techniques and Medical Practices. By Marc Berg. Cambridge, Mass.: MIT Press, 1997. Pp. x+238; illustrations, figures, notes, bibliography, index. $30. Marc Berg undertakes in this very interesting volume to analyze the application of decision-support tools—computer-based support systems, protocols, and clinical decision analysis—to medical practice. In doing so he raises several interesting questions about the nature of medical diagnostic and therapeutic practice and about the use of computer-based and other “rationalizing” technologies in contemporary work and culture. Berg begins with an incisive discussion of the post-World War II medical literature, tracing how arguments for the use of decision-support tools were developed, supported, and critiqued. His demonstration that each tool was shaped by a particular concept of what “science-based medicine” is, or should be, is well reasoned and provocative, and prompts the reader to reexamine what we understand by scientific practice. The central section of the book considers the construction and implementation of several decision-support tools: a triage aid to help nurses decide which chest pain patients should be admitted to the coronary care unit, a computer program for the diagnosis of abdominal pain, a research protocol for an experimental breast cancer treatment. Based on these examples, Berg argues that structured, rationalized aids are usually transformed in practice by a variety of logistical, organizational, and value-based factors—staff skills and hierarchies, variations in patient presentation financial criteria, ethical questions, among many others; that where decision-support tools succeed, it is after the practice site is “disciplined to a formalism” (p. 79), that is, where structures are introduced or reinforced to support the tool’s operation; that this mutual transformation of tool and practice site by each other is highly localized in space and scope—and must be replicated and readjusted if the tool is introduced in another setting; finally, that even where the tool is successfully adapted for regular use, doctors and other staff routinely support, adjust, and retransform its operation. The tool and the practice in this way “co-produce” each other to form a new adaptive hybrid. In Berg’s view, both advocates and critics, wedded to prescriptive views of how decision-support tools “are supposed to work” or not to work, fail to understand the nature and potential of the way they actually do work. Berg’s argument is intelligent and well researched through interviews, practice observations, and reading of the literature. It is probably my historian’s bias, but I think the book might have been stronger if he had placed more emphasis on his unique material and slightly less on the theoretical discussion, which, as he notes, complements and extends analyses of scientific [End Page 719] practice and work by contemporary anthropologists and other scholars—Bruno Latour, Donna Haraway, Susan Leigh Star. His many interesting statements about the flow of medical practice, its embedded assumptions, and the work done to incorporate tools are supported with concise observations drawn rather disjointedly from his several cases, supplemented by only a few complete narratives showing us the internal processes. Particularly after the author tells us that very few tools have been introduced in more than a single site, or remained in permanent use, the reader is forced to question whether his model has reality only in localized instances. One tool that might have received more intensive analysis is the use of the problem-oriented medical record introduced by Lawrence Weed, which has been almost universally instituted, at least in the United States, and which Berg discusses in his review of the literature, but to which he fails to return. One of the principal technologies examined is the breast cancer research protocol. As Berg points out, research protocols are widely used and highly structured. But they also present a different rationale from decision tools introduced into established clinical practice. A research protocol carries with it the implication, often the promise, that existing rules and routines will change. This implicit assumption does not invalidate Berg’s model of “co-production,” but its operation will be different than in the other examples...

The book is the result of a belief that the greatest contributions in the field of therapeutic science are made on the borders of areas that were traditionally separate. The book From Molecule to Population is devoted to the light shedding on the most important chain between the design of a drug molecule and its final effect on human populations. This journey of integration we map in four. Our starting point is the molecular basis with the studies of innovative chemical synthesis and bioactive scaffolds. This then becomes personalized therapy in clinical practice, across the translational bridge, under clinical pharmacy and close pharmacovigilance of the safety of individual patients. Lastly, we use the population-level lens and apply the systems of pharmacoepidemiology and the real-world evidence of a drug to gain insights into the extensive use, benefits, and risks of a drug. This book targets students, scholars, clinicians in the field of pharmaceutical sciences, medicinal chemistry, clinical pharmacy, and in the area of public health. It belongs to those who want to have a unified idea of how the properties of the molecules predetermine the clinical practice and how the personal results of the patients influence the overall knowledge of the population health. Our long run objective is to make people more collaborative and holistic minded. With links between chemical structure and population-wide effect, we will be able to help in a future where quality patient care is replicated by a smooth flow between drug development, clinical application, and safety monitoring anywhere.

Medical podcasts are becoming increasingly available; however, it is unclear how these new resources are being used by trainees or whether they influence clinical practice. This study explores the preferences and experiences of otolaryngology residents with otolaryngology-specific podcasts, and the impact of these podcasts on resident education and clinical practice. An 18-question survey was distributed anonymously to a representative junior (up to post-graduate year 3) and senior (post-graduate year 4 or greater) otolaryngology residents at most programs across the US. Along with demographic information, the survey was designed to explore the preferences of educational materials, podcast listening habits and motivations, and influence of podcasts on medical practice. Descriptive statistics and student t-tests were used to analyze the results. The survey was distributed to 198 current otolaryngology residents representing 94% of eligible residency programs and was completed by 73 residents (37% response rate). Nearly 3-quarters of respondents reported previous use of otolaryngology podcasts, among which 83% listen at least monthly. Over half of residents changed their overall clinical (53%) and consult (51%) practice based on podcast use. Residents rank-ordered listening to podcasts last among traditional options for asynchronous learning, including reading textbooks and watching online videos. While other asynchronous learning tools remain popular, most residents responding to this survey use podcasts and report that podcasts influence their clinical practice. This study reveals how podcasts are currently used as a supplement to formal otolaryngology education. Results from the survey may inform how medical podcasts could be implemented into resident education in the future.

This thesis explores how medicine is practiced in a paediatric HIV clinic in outer London. It draws on ethnographic research that took place in the clinic over the course of a year. The significance of the topic is situated in the complexity of the issues presented clinically by children with HIV in London. During practice recurrent associations of confidentiality, stigma, vulnerability, naivety and innocence emerges around the patient cohort that mainly comprises recent African migrants living their lives in complicated urban environments. These associations are contrasted by the uncompromising requirements of antiretroviral medicine which needs almost perfect dosing adherence in order to suppress the virus. The incompatibilities between complex patient lives and medical requirements must be made compatible through clinical practice. Therefore, the thesis emphasises the clinic as the key site where the ‘cultural’ issues presented by patients are consolidated with drug requirements to form a functional medicine. The argument is informed by discussions around Science and Technology Studies (STS), and the Sociology of Childhood (SoC). These discussions highlight practice as ‘enacted’, where objects such as disease, the body or medicine are not ‘given’ but gain their shape through their recurrent enactions (Mol 2002, Mol and Law 2004). I have used these discussions to argue that medicine and protocol do not pre-exist practice but must be enacted by practitioners and (child) patients in the clinic. Clinical practice is shown in the thesis as consolidating protocol, drug requirements, patients, practitioners and representations of HIV in ongoing clinical enactions to make the antiretroviral medicine amongst the paediatric cohort operational. To do this, the research focuses on a set of procedures enacted in the clinic: disclosure, adherence, HIV as chronic illness and transition. These procedures inform practitioners on how to maintain care and make medical requirements explicit to child patients (and their parents), enforcing behaviour that accords with the goals of antiretroviral medicine. In this way practice and protocol are negotiated and renegotiated to ensure their effectiveness between all of the associations involved in participating with the condition, paediatric HIV and the corresponding medicine. Compared to existing STS on the subject of medicine and the clinic, paediatric HIV practice emphasises the clinic’s role to consolidate seemingly incompatible associations around patients such as stigma, vulnerability and innocence into medical requirements. The result is that STS that advertently or inadvertently implies that medical practice is messy or disjointed are questioned in light of two important features of paediatric HIV. Firstly, that practice must necessarily consolidate disparate patient lives into medical requirements if treatment is to be successful, and secondly, that practitioners must employ a logic to generate a coherent, well-organised clinical practice that is flexible and pliable to diverse eventualities. The significance of this argument demonstrates the clinic’s importance in enacting interventions and attuning medicine, displacing a notion of protocol or guidelines as dictating practice without negotiation, or the belief that the ideal course of clinical practice is fully predefined in protocol. Therefore, the implications of this research underline the clinic as a key site in rationalising how medicine is formulated and applied to patients.

Background. At present, the Russian state, medical and educational communities are concerned about the health of the younger generation. In this regard, at the stage of training pediatricians in residency, there is a very acute issue related to the search for approaches, means and methods of training that contribute to the formation of the readiness of such specialists to carry out psychological and pedagogical activities and solve pedagogical problems, in the process of professional medical activity, one of which is the education of the value attitude of children to their own health. From 2022 to 2023 academic year, an experimental study was conducted at the Faculty of Retraining and Continuing Professional Education at the St. Petersburg State Pediatric Medical University, aimed at to studying evaluate the pediatrician's level of psychological and pedagogical knowledge formation and pedagogical skills which are related to their readiness to the psychological and pedagogical type of activity and the solution of pedagogical problems in medical practice. Purpose. To identify changes in the state of psychological and pedagogical knowledge and the motivational orientation of pediatricians to the formation of the value attitude of patients to health during the experimental work, conditioned by the contextual approach to the study of the discipline "Pedagogy". Materials and methods. The study involved 300 first-year pediatricians with an average age of 25.48±2.03 years, including 233 women and 67 men. All respondents were divided into two groups (150 people each) – the main group and the control group – according to the criterion of participation in the experimental work, which involved the use of a contextual approach in the process of studying the discipline of the Pedagogy curriculum. Residents agreed to conduct research procedures. In advance, the authors of the article received permission from the Local Ethics Committee of the St. Petersburg State Pediatric Medical University to organize an experimental study. The methodology of the study consisted of adapted questionnaires and questionnaires. The followingstatistical methods were used: Wilcoxon T-test (for related samples); the analysis of correlations between the studied parameters was carried out using the C. Spearman criterion. The calculation of the results was carried out using the application package of the program "IBM SPSS Statistics 27". Results. Experimental research work has revealed changes in the level of formation of psychological and pedagogical knowledge and pedagogical skills that ensure the readiness of pediatricians to carry out psychological and pedagogical activities in the process of medical practice and to solve the pedagogical problem aimed at educating the value attitude of patients to their own health. Conclusions. The results of the experimental study indicate the need to use a contextual approach in the process of training pediatricians for psychological and pedagogical activities, and as a didactic means of teaching - medical and pedagogical situations recreated or modeled by specialists.

Reconsidering laboratory-based anatomy within the backdrop of digital transformation: Bringing an old practice into a new world.

Organs at risk dose constraints in carbon ion radiotherapy at MedAustron: Translations between LEM and MKM RBE models and preliminary clinical results.