Backround Education in ethics and professionalism should reflect the realities medical students encounter in the hospital and clinic. Method We performed content analyses on Case Observation and Assessments (COAs) written by third-year medical students about ethical and professional issues encountered during their internal medicine and paediatrics clinical clerkships. Results A cohort of 141 third-year medical students wrote 272 COAs. Content analyses identified 35 subcategories of ethical and professional issues within 7 major domains: decisions regarding treatment (31.4%), communication (21.4%), professional duties (...) (18.4%), justice (9.8%), student-specific issues (5.4%), quality of care (3.8%), and miscellaneous (9.8%). Conclusions Students encountered a wide variety of ethical and professional issues that can be used to guide pre-clinical and clinical education. Comparison of our findings with results from similar studies suggests that the wording of an assignment (specifying “ethical” issues, “professional” issues, or both) may influence the kinds of issues students identify in their experience-based clinical narratives. (shrink)

Background: Discussions about medical errors facilitate professional learning for physicians and may provide emotional support after an error, but little is known about physicians’ attitudes and practices regarding error discussions with colleagues.Methods: Survey of faculty and resident physicians in generalist specialties in Midwest, Mid-Atlantic and Northeast regions of the US to investigate attitudes and practices regarding error discussions, likelihood of discussing hypothetical errors, experience role-modelling error discussions and demographic variables.Results: Responses were received from 338 participants . In all, 73% of (...) respondents indicated they usually discuss their mistakes with colleagues, 70% believed discussing mistakes strengthens professional relationships and 89% knew at least one colleague who would be a supportive listener. Motivations for error discussions included wanting to learn whether a colleague would have made the same decision , wanting colleagues to learn from the mistake and wanting to receive support . Given hypothetical scenarios, most respondents indicated they would likely discuss an error resulting in no harm , minor harm or major harm . Fifty-seven percent of physicians had tried to serve as a role model by discussing an error and role-modelling was more likely among those who had previously observed an error discussion .Conclusions: Most generalist physicians in teaching hospitals report that they usually discuss their errors with colleagues, and more than half have tried to role-model discussions. However, a significant number of these physicians report that they do not usually discuss their errors and some do not know colleagues who would be supportive listeners. (shrink)

Background and objective: Code status discussions may fail to address patients’ treatment-related goals and their knowledge of cardiopulmonary resuscitation (CPR). This study aimed to investigate patients’ resuscitation preferences, knowledge of CPR and goals of care. Design, setting, patients and measurements: 135 adults were interviewed within 48 h of admission to a general medical service in an academic medical centre, querying code status preferences, knowledge about CPR and its outcome probabilities and goals of care. Medical records were reviewed for clinical information (...) and code status documentation. Results: 41 (30.4%) patients had discussed CPR with their doctor, 116 (85.9%) patients preferred full code status and 11 (8.1%) patients expressed code status preferences different from the code status documented in their medical record. When queried about seven possible goals of care, patients affirmed an average of 4.9 goals; their single most important goals were broadly distributed, ranging from being cured (n = 36; 26.7%) to being comfortable (n = 8; 5.9%). Patients’ mean estimate of survival to discharge after CPR was 60.4%. Most patients believed it was helpful to discuss goals of care (n = 95; 70.4%) and the chances of surviving inhospital CPR (n = 112; 83.0%). Some patients expressed a desire to change their code status after receiving information about survival following inhospital CPR (n = 11; 8.1%) or after discussing goals of care (n = 2; 1.5%). Conclusions: Doctors need to address patients’ knowledge about CPR and take steps to avoid discrepancies between treatment orders and patients’ preferences. Addressing CPR outcome probabilities and goals of care during code status discussions may improve patients’ knowledge and influence their preferences. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:A Reconception of Performance Study in the Philosophy of Music EducationValerie L. TrollingerThe actual place of performance in music education has been the subject of numerous debates over the years. Most debates have revolved within the paradigm of the performance ability of the teacher and consequently the performance ability of the students. Is the level to be attained that of a winning concert band/marching band/choir? Or, is the level (...) to be attained the level at which the students and teacher feel the most comfortable and pleased? Most of this debate, along with the development of various assessments (including the Watkins-Farnum Test) and various rubrics to score music performance competitions, has emphasized characteristics of performance pertaining to accuracy of notes, precision of rhythm, and attendance to musicianship, style, and interpretation. On the other hand, the aesthetic value of performance has also been questioned in that the value of music in the schools should not be assessed solely by the importance placed on the attainment of performance skills by the students, suggesting that it is only through performance that one may know music. For example, in a recent article in the Music Educator's Journal,1 Bennett Reimer promotes the [End Page 193] position that time spent in either performance studies and active performance in music education (both at the K-12 and college teacher training levels) is not vital to the reconception of the National Standards (USA) for music education and, by extension, the field of music education itself. In the MEJ article, Reimer wrote:there is no reason to believe that highly developed performers make the best general music teachers, just as there is no reason to believe the reverse. We must get over the outdated and unrealistic assumption that performance is the one, singular, royal road to being musical and being an effective music educator.... [T]eachers cannot be expected to do what performance specialists do, and their teacher education curriculum must reflect that fact.2This position has also been recently supported by sociological publications3 and the following statement—echoed by several colleagues of mine—by a music teacher-training specialist,There is one big misconception among many music education students. Many graduates view themselves as musicians who are going into teaching. I attribute my own success to the realization that I am a teacher at heart. My first responsibility is teaching children. The vehicle through which I connect to them is music.4It is likely within the previous paradigm in which these respected authors positioned their arguments for the place of performance in the music curriculum and in that regard these assertions are unquestionably valid. What this particular paradigm concerns is the quantity and quality of performance based on purely musical attributes. The omission is that it does not include the quality of performance in relationship to health-based music education, a growing area of concern in the performing arts medicine field and, by extension, music educators who are concerned about this particular aspect of performance.5 The reason for the concern and hence this paper calling to the philosophical community to re-think the place and quality of performance in music education is that these viewpoints have had a great impact upon the validity of music education, in that they ignore a growing body of research from the performance and medical fields. While it must be made clear for the purposes of this paper that the writers of the above quotes have framed their ideas gracefully within their individual philosophical structures of music education, it must be pointed out that current research and knowledge in performance arts, in its conception as a physical human activity, needs to be incorporated into a revised philosophy of music education and curriculum. Music performance in music education has traditionally been viewed as a cognitive and emotional experience. However, it [End Page 194] is also a psychomotor experience, involving all sorts of soft body tissues, bones, and cartilages, which can enhance or detract from the total musical experience. Many music educators do not get enough instruction in college on how to teach voice or instruments healthfully and this is the reason for the concern... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:A Reconception of Performance Study in the Philosophy of Music EducationValerie L. TrollingerThe actual place of performance in music education has been the subject of numerous debates over the years. Most debates have revolved within the paradigm of the performance ability of the teacher and consequently the performance ability of the students. Is the level to be attained that of a winning concert band/marching band/choir? Or, is the level (...) to be attained the level at which the students and teacher feel the most comfortable and pleased? Most of this debate, along with the development of various assessments (including the Watkins-Farnum Test) and various rubrics to score music performance competitions, has emphasized characteristics of performance pertaining to accuracy of notes, precision of rhythm, and attendance to musicianship, style, and interpretation. On the other hand, the aesthetic value of performance has also been questioned in that the value of music in the schools should not be assessed solely by the importance placed on the attainment of performance skills by the students, suggesting that it is only through performance that one may know music. For example, in a recent article in the Music Educator's Journal,1 Bennett Reimer promotes the [End Page 193] position that time spent in either performance studies and active performance in music education (both at the K-12 and college teacher training levels) is not vital to the reconception of the National Standards (USA) for music education and, by extension, the field of music education itself. In the MEJ article, Reimer wrote:there is no reason to believe that highly developed performers make the best general music teachers, just as there is no reason to believe the reverse. We must get over the outdated and unrealistic assumption that performance is the one, singular, royal road to being musical and being an effective music educator.... [T]eachers cannot be expected to do what performance specialists do, and their teacher education curriculum must reflect that fact.2This position has also been recently supported by sociological publications3 and the following statement—echoed by several colleagues of mine—by a music teacher-training specialist,There is one big misconception among many music education students. Many graduates view themselves as musicians who are going into teaching. I attribute my own success to the realization that I am a teacher at heart. My first responsibility is teaching children. The vehicle through which I connect to them is music.4It is likely within the previous paradigm in which these respected authors positioned their arguments for the place of performance in the music curriculum and in that regard these assertions are unquestionably valid. What this particular paradigm concerns is the quantity and quality of performance based on purely musical attributes. The omission is that it does not include the quality of performance in relationship to health-based music education, a growing area of concern in the performing arts medicine field and, by extension, music educators who are concerned about this particular aspect of performance.5 The reason for the concern and hence this paper calling to the philosophical community to re-think the place and quality of performance in music education is that these viewpoints have had a great impact upon the validity of music education, in that they ignore a growing body of research from the performance and medical fields. While it must be made clear for the purposes of this paper that the writers of the above quotes have framed their ideas gracefully within their individual philosophical structures of music education, it must be pointed out that current research and knowledge in performance arts, in its conception as a physical human activity, needs to be incorporated into a revised philosophy of music education and curriculum. Music performance in music education has traditionally been viewed as a cognitive and emotional experience. However, it [End Page 194] is also a psychomotor experience, involving all sorts of soft body tissues, bones, and cartilages, which can enhance or detract from the total musical experience. Many music educators do not get enough instruction in college on how to teach voice or instruments healthfully and this is the reason for the concern... (shrink)

Many studies have observed modulation of the amplitude of the neural index mismatch negativity (MMN) related to which member of a phoneme contrast [phoneme A, phoneme B] serves as the frequent (standard) and which serves as the infrequent (deviant) stimulus (i.e., AAAB vs. BBBA) in an oddball paradigm. Explanations for this amplitude modulation range from acoustic to linguistic factors. We tested whether exchanging the role of the mid vowel /ε/ vs. high vowel /ɪ/ of English modulated MMN amplitude and whether (...) the pattern of modulation was compatible with an underspecification account, in which the underspecified height values are [−high] and [−low]. MMN was larger for /ε/ as the deviant, but only when compared across conditions to itself as the standard. For the within-condition comparison, MMN was larger to /ɪ/ deviant minus /ε/ standard than to the reverse. A condition order effect was also observed. MMN amplitude was smaller to the deviant stimulus if it had previously served as the standard. In addition, the amplitudes of late discriminative negativity (LDN) showed similar asymmetry. LDN was larger for deviant /ε/ than deviant /ɪ/ when compared to themselves as the standard. These findings were compatible with an underspecification account, but also with other accounts, such as the Natural Referent Vowel model and a prototype model; we also suggest that non-linguistic factors need to be carefully considered as additional sources of speech processing asymmetries. (shrink)

In an adaptive clinical trial , key trial characteristics may be altered during the course of the trial according to predefined rules in response to information that accumulates within the trial itself. In addition to having distinguishing scientific features, adaptive trials also may involve ethical considerations that differ from more traditional randomized trials. Better understanding of clinical trial experts’ views about the ethical aspects of adaptive designs could assist those planning ACTs. Our aim was to elucidate the opinions of clinical (...) trial experts regarding their beliefs about ethical aspects of ACTs. (shrink)

Lateral temporal measures of the auditory evoked potential including the T-complex, as well as an earlier negative peak index maturation of auditory/speech processing. Previous studies have shown that these measures distinguish neural processing in children with typical language development from those with disorders and monolingual from bilingual children. In this study, bilingual children with Turkish as L1 and German as L2 were compared with monolingual German-speaking children with developmental language disorder and monolingual German-speaking children with TD in order to disentangle (...) effects of limited language input vs. reduced perceptual abilities in the processing of speech and non-speech stimuli. Sensory processing reflected by the T-complex was compared in response to a German vowel and a sine-wave tone in the three groups of children, ages 5 through 6 years. Stimuli were presented while children watched a muted video. Auditory evoked potentials were time-locked to the vowels and tones. AEPs to the frequent stimuli within an oddball paradigm were analyzed at the left and right temporal electrode sites.The results revealed language status, stimulus, and language test measures all influenced the T-complex amplitudes. Particularly, the peak amplitude of Ta was modulated by language status and stimulus type. Bilingual children had significantly more negative Ta responses than the monolingual children with TD for both vowels and tones while DLD children differed from TD children only for the vowel stimulus. The amplitude of the T-complex was overall more negative at the left than at the right site. The Na peak latency was longer for the bilingual group than that observed for the two monolingual groups. The Tb latency was shorter for DLD and bilingual groups than that for TD children in the vowel condition, but no such latency difference between DLD and bilingual children was found. We suggest that the attenuated T-complex for bilingual children indicates continued plasticity of the auditory cortex to allow for learning of novel, second-language speech sounds. (shrink)

Recent magnetic resonance imaging and pathological studies have indicated that axonal loss is a major contributor to disease progression in multiple sclerosis. 1 H magnetic resonance spectroscopy, through measurement of N -acetyl aspartate, a neuronal marker, provides a unique tool to investigate this. Patients with primary progressive multiple sclerosis have few lesions on conventional MRI, suggesting that changes in normal appearing white matter, such as axonal loss, may be particularly relevant to disease progression in this group. To test this hypothesis (...) NAWM was studied with MRS, measuring the concentration of N -acetyl derived groups. Single-voxel MRS using a water-suppressed PRESS sequence was carried out in 24 patients with primary progressive multiple sclerosis and in 16 age-matched controls. Ratios of metabolite to creatine concentration were calculated in all subjects, and absolute concentrations were measured in 18 patients and all controls. NA/Cr was significantly lower in NAWM in patients than in controls, as was the absolute concentration of NA. There was no significant difference in the absolute concentration of creatine between the groups. This study supports the hypothesis that axonal loss occurs in NAWM in primary progressive multiple sclerosis and may well be a mechanism for disease progression in this group. (shrink)

How did the events of the early modern period affect the way gender and the self were represented? This collection of essays attempts to respond to this question by analysing a wide spectrum of cultural concerns - humanism, technology, science, law, anatomy, literacy, domesticity, colonialism, erotic practices, and the theatre - in order to delineate the history of subjectivity and its relationship with the postmodern fragmented subject. The scope of this analysis expands the terrain explored by feminist theory, while its (...) feminist focus reveals that the subject is always gendered - although the terms in which gender is conceived and represented change across history. Feminist Readings of Early Modern Culture not only explores the representation of gendered subjects, but in its commitment to balancing the productive tensions of methodological diversity, also speaks to contemporary challenges facing feminism. (shrink)

Body and World is the definitive edition of a book that shouldnow take its place as a major contribution to contemporary existentialphenomenology. Samuel Todes goes beyond Martin Heidegger and MauriceMerleau-Ponty in his description of how independent physical natureand experience are united in our bodily action. His account allows himto preserve the authority of experience while avoiding the tendencytoward idealism that threatens both Heidegger and Merleau-Ponty.Todes emphasizes the complex structure of the human body ;front/back asymmetry, the need to balance in a (...) gravitational field, and so forth ;and the role that structure plays in producing the spatiotemporal field of experience and in making possible objective knowledge of the objects in it. He shows that perception involves nonconceptual, but nonetheless objective forms of judgment. One can think of Body and World as fleshing out Merleau-Ponty's project while presciently relating it to the current interest in embodiment, not only in philosophy but also in psychology, linguistics, cognitive science, artificial intelligence, neuroscience, and anthropology. Todes's work opens new ways of thinking about problems such as the relation of perception to thought and the possibility of knowing an independent reality ;problems that have occupied philosophers since Kant and still concern analytic and continental philosophy. (shrink)

From 1998 to 2005, six elections took place in postcommunist Europe that had the surprising outcome of empowering the opposition and defeating authoritarian incumbents or their designated successors. Valerie J. Bunce and Sharon L. Wolchik compare these unexpected electoral breakthroughs. They draw three conclusions. First, the opposition was victorious because of the hard and creative work of a transnational network composed of local opposition and civil society groups, members of the international democracy assistance community and graduates of successful electoral (...) challenges to authoritarian rule in other countries. Second, the remarkable run of these upset elections reflected the ability of this network to diffuse an ensemble of innovative electoral strategies across state boundaries. Finally, elections can serve as a powerful mechanism for democratic change. This is especially the case when civil society is strong, the transfer of political power is through constitutional means, and opposition leaders win with small mandates. (shrink)

Although both EU policy makers and researchers acknowledge that public or stakeholder engagement is important for responsible innovation (RI), empirical evidence in this field is still scarce. In this article, we explore to what extent companies with a disposition to innovate in a more responsible way are moving towards the ideal of mutual responsiveness among stakeholders, as it is presented in the RI literature. Based on interviews with companies and non-economic stakeholders in the Dutch Food industry, it can be concluded (...) that innovative food companies are still far from implementing the ideal of mutual responsiveness in a significant way. The tension between the call for the active involvement of stakeholders in the literature and actual stakeholder engagement practices is explained by identifying a number of critical issues regarding stakeholder engagement, which are specific to actors involved in RI in the private sector. Finally, management practices designed to deal with these critical issues regarding stakeholder engagement are identified. (shrink)

"Effective Weight Loss presents 25 detailed sessions of an empirically supported, cognitive-behavioral treatment package called Acceptance-Based Behavioral Treatment. The Clinician Guide is geared towards helping administer treatment, and the companion Workbook provides summaries of session content, exercises, worksheets, handouts, and assignments for patients and clients receiving the treatment"--.

The obesity epidemic is one of the most serious public health threats confronting the nation and the world. The majority of overweight individuals want to lose weight, but the overall success of self-administered diets and commercial weight loss programs is very poor. Scientific findings suggest that the problem boils down to adherence. The dietary and physical activity recommendations that weight loss programs promote are effective; however, people have difficulty initiating and maintaining changes. Effective Weight Loss presents 25 detailed sessions of (...) an empirically supported, cognitive-behavioral treatment package called Acceptance-Based Behavioral Treatment. The foundation of this approach is comprised of the nutritional, physical activity, and behavioral components of the most successful, gold-standard behavioral weight loss programs. These components are synthesized with acceptance, willingness, behavioral commitment, motivation, and relapse prevention strategies drawn from a range of therapies. ABT is based on the idea that specialized self-control skills are necessary for weight control, given our innate desire to consume delicious foods and to conserve energy by avoiding physical activity. These self-control skills revolve around a willingness to choose behaviors that may be perceived as uncomfortable, for the sake of a more valuable objective. The Clinician Guide is geared towards helping administer treatment, and the companion Workbook provides summaries of session content, exercises, worksheets, handouts, and assignments for patients and clients receiving the treatment. The books will appeal to psychologists, primary care physicians, nutritionists, dieticians, and other clinicians who counsel the overweight. (shrink)

BackgroundThe outbreak of COVID-19 has been a major interrupting event, challenging how societies and individuals deal with risk. An essential determinant of the virus’ spread is a series of individual decisions, such as wearing face masks in public space. Those decisions depend on trade-offs between costs and risks, and beliefs are key to explain these.MethodsWe elicit beliefs about the COVID-19 pandemic during lockdown in France by means of surveys asking French citizens about their belief of the infection fatality ratio for (...) COVID-19, own risk to catch the disease, risk as perceived by others, and expected prevalence rate. Those self-assessments were measured twice during lockdown: about 2 weeks after lockdown started and about 2 weeks before lockdown ended. We also measured the quality of these beliefs with respect to available evidence at the time of the surveys, allowing us to assess the calibration of beliefs based on risk-related socio-demographics. Finally, comparing own risk to expected prevalence rates in the two successive surveys provides a dynamic view of comparative optimism with respect to the disease.ResultsThe risk perceptions are rather high in absolute terms and they increased between the two surveys. We found no evidence for an impact of personal experience with COVID-19 on beliefs and lower risk perceptions of the IFR when someone in the respondent’s family has been diagnosed with a disease. Answers to survey 1 confirmed this pattern with a clear indication that respondents were optimistic about their chances to catch COVID-19. However, in survey 2, respondents revealed comparative pessimism.ConclusionThe results show that respondents overestimated the probabilities to catch or die from COVID-19, which is not unusual and does not necessarily reflect a strong deviation from rational behavior. While a rational model explains why the own risk to catch COVID-19 rose between the two surveys, it does not explain why the subjective assessment of the IFR remained stable. The comparative pessimism in survey 2 was likely due to a concomitant increase in the respondents’ perceived chances to catch the disease and a decreased expected prevalence rate. (shrink)

Patients have received experimental pharmaceuticals outside of clinical trials for decades. There are no industry-wide best practices, and many companies that have granted compassionate use, or ‘preapproval’, access to their investigational products have done so without fanfare and without divulging the process or grounds on which decisions were made. The number of compassionate use requests has increased over time. Driving the demand are new treatments for serious unmet medical needs; patient advocacy groups pressing for access to emerging treatments; internet platforms (...) enabling broad awareness of compelling cases or novel drugs and a lack of trust among some that the pharmaceutical industry and/or the FDA have patients’ best interests in mind. High-profile cases in the media have highlighted the gap between patient expectations for compassionate use and company utilisation of fair processes to adjudicate requests. With many pharmaceutical manufacturers, patient groups, healthcare providers and policy analysts unhappy with the inequities of the status quo, fairer and more ethical management of compassionate use requests was needed. This paper reports on a novel collaboration between a pharmaceutical company and an academic medical ethics department that led to the formation of the Compassionate Use Advisory Committee. Comprising medical experts, bioethicists and patient representatives, CompAC established an ethical framework for the allocation of a scarce investigational oncology agent to single patients requesting non-trial access. This is the first account of how the committee was formed and how it built an ethical framework and put it into practice. (shrink)

The claim that empathy is both automatic and representational is criticized as follows: (a) five empathy-arousing processes ranging from conditioning and mimicry to prospective-taking show that empathy can be either automatic or representational, and only under certain circumstances, both; (b) although automaticity decreases, empathy increases with age and cognitive development; (c) observers' causal attributions can shift rapidly and produce more complex empathic responses than the theory allows.

The stories we tell of psychiatric disability1 and gender play a crucial role not only in the experience of psychiatric disorders, but in who disordered individuals are in the most literal sense. Recent theories of the self—so-called narrative self-constitution views, or “narrative theories”—contend that the self is, fundamentally, constituted by a narrative one tells about oneself. Furthermore, this narrative almost certainly absorbs elements from surrounding cultural scripts. Thus, narrative self-constitution views can shed light on some of the ways in which (...) cultural... (shrink)

Lack of health insurance coverage is a large and growing problem for millions of American families. Rising health care costs and economic insecurity continue to threaten the bedrock of the health insurance system - employer-sponsored coverage - while states’ fiscal situations and the escalating federal deficit complicate any efforts at reform. Providing health insurance coverage to the millions of uninsured remains a major health care challenge for the nation and understanding the current health insurance environment, who the uninsured are, and (...) why they are uninsured is critical when considering health care reform. This paper aims to define the problem of the uninsured, providing an overview of the uninsured in America and the roles and limits of private and public insurance. Following this discussion, the paper describes the current health insurance environment and examines the prospects for improving coverage. (shrink)