Does the philosophy of medicine exist?

There has been a great deal of discussion, in this journal and others, about obstacles hindering the evolution of the philosophy of medicine. Such discussions presuppose that there is widespread agreement about what it is that constitutes the philosophy of medicine.Despite the fact that there is, and has been for decades, a great deal of literature, teaching and professional activity carried out explicitly in the name of the philosophy of medicine, this is not enough to establish that consensus exists as to the definition of the field. And even if consensus can be obtained as to what constitutes the philosophy of medicine, this does not mean that it exists as a field.     

CLINICAL BEHAVIORAL PHARMACOLOGY: METHODS FOR EVALUATING MEDICATIONS AND CONTINGENCY MANAGEMENT

We evaluated methods for comparing the effects of dextroamphetamine (Dexedrine), thioridazine (Mellaril), and contingency management in the control of severe behavior problems. A reversal design was used in which medications were systematically titrated and assessed in unstructured as well as structured settings with three clients. Subsequently, behavioral procedures including timeout, differential reinforcement of other behavior, and visual screening, were used in a multiple-baseline design across settings. The assessment and design methods were useful in comparing the interventions. Dextroamphetamine decreased inappropriate behaviors and improved academic behaviors in one client, but no reliable effects were observed in the other two clients. Thioridazine was variable across clients, settings, behaviors, and dosages. Contingency management produced consistent decreases in inappropriate behaviors and small improvements in academic performance.     

TESTICULAR SELF-EXAMINATION: VALIDATION OF A TRAINING STRATEGY FOR EARLY CANCER DETECTION

Testicular self-examination (TSE) can lead to early diagnosis and treatment of testicular cancer, the third leading cause of death in young men. We evaluated the effectiveness of a brief and specific checklist for teaching TSE skills. Ten men were videotaped while performing testicular self-examinations before and after training. The TSE training resulted in large and significant increases in the number of TSE steps completed and duration of the TSE. Two urological validation measures supported the improvements observed in the mens' self-examinations. Subjects reported continued performance of TSE during a follow-up telephone interview. This pilot study indicates that a brief and specific checklist is an effective strategy for teaching early cancer detection skills.     

THE EFFECT OF INFORMATIONAL FEEDBACK ON FOOD INTAKE OF ADULT BURN PATIENTS

The effect of informational feedback on the protein and caloric consumption of burn patients was investigated using a multiple-baseline across subjects. The patients were four severely burned adult males who failed to consume sufficient foods to achieve prescribed levels of protein or kilocalories via standard burn unit procedures during recovery. Feedback consisted of informing patients of (a) their prescribed levels of protein and kilocalories, (b) the protein and kilocalorie content of hospital foods and beverages, and (c) their actual intake of protein and kilocalories. Following the provision of feedback, there was an increase in protein and kilocalorie intakes and in the number of days during which prescribed levels for protein and kilocalories were achieved. These results suggest that the informational feedback was effective for improving the oral caloric intake of burn patients.     

Implicit States of Connectivity in the Clinical Practice of Jungian Psychoanalysis and Andean Shamanism

This paper will describe the spiritual states of “oneness” experienced by Andean shamans in relation to oceanic states in early infancy and working with trauma in Jungian analysis. The author’s work exploring implicit energetic experience with Andean shamans will be referenced with comparisons made to depth psychology, in both theory and in practice. Definitions of Q’echua terms describing different psychic meditative states that Andean shamans enter into will be provided as Andean medicine people have a much more developed language for conceptualizing these experiences. A clinical vignette will be presented that demonstrates how the spaces of implicit connection that occur between an analyst and analysand in the analytic setting can be a catalyst for healing.     

THEOLOGY AS THE QUEEN (BEE) OF THE DISCIPLINES?

Abstract. Once Queen of the Medieval court of sciences, dethroned theology may be able in our time to play a strategic servant role in rightly humiliating, elevating, and ordering the disciplines, in gadflying like a mutant honeybee, generating surprise and serendipity through the intermediacy of social science, and in offering ethical homing direction to the disciplines in their applied endeavors.     

Clinical interpretation: The hermeneutics of medicine

I argue that clinical medicine can best be understood not as a purified science but as a hermeneutical enterprise: that is, as involved with the interpretation of texts. The literary critic reading a novel, the judge asked to apply a law, must arrive at a coherent reading of their respective texts. Similarly, the physician interprets the text of the ill person: clinical signs and symptoms are read to ferret out their meaning, the underlying disease. However, I suggest that the hermeneutics of medicine is rendered uniquely complex by its wide variety of textual forms. I discuss four in turn: the experiential text of illness as lived out by the patient; the narrative text constituted during history-taking; the physical text of the patient's body as objectively examined; the instrumental text constructed by diagnostic technologies. I further suggest that certain flaws in modern medicine arise from its refusal of a hermeneutic self-understanding. In seeking to escape all interpretive subjectivity, medicine has threatened to expunge its primary subject — the living, experiencing patient.     

Medical education: The training of ethical physicians

This paper suggests that medical education be revised to assist in diffusing potential ethical dilemmas that arise during health care provision. A revised medical education would emphasize the role of the humanities in the training of physicians, especially in light of recent critiques of the canonical scientific model in general, and more specifically in the use of that model for medical training and practice.I wish to thank Dr. Mary Ann Cutter and Melissa M. Amaro for their critical suggestions.     

The Future of Psychology in Family Medicine

Psychology has been integral to the field of family medicine since its inception as a medical specialty in the 1960s. Psychologists and other behavioral scientists contribute to family medicine in teaching clinical skills, in defining research questions, in developing research methodology, and in creating integrated physical/mental health care delivery systems. Future developments in the field of psychology in family medicine are likely to emphasize development and evaluation of screening measures which identify mental health problems in primary care, development of early intervention for those mental health problems, and more precise measurement of process and quality of care and health outcomes. Psychologists have an important role to fulfill in educating physicians on alternatives to pharmacologic and medical interventions for common presenting problems in primary care. However, current economic forces shaping the practice of medicine may work against further enhancing the efficacy of the physician in dealing with psychosocial issues. The future role of psychology in family medicine is not yet delineated, and while the move toward parity of reimbursement for mental and physical health care delivery may enhance this collaboration, there is a need to continue to evaluate how the psychological well-being of patients is influenced in the evolution of new models of care delivery.     

An Application of Brief Therapy to Family Medicine

The Solution-Focused Brief Therapy model has been applied to support families with various problems commonly met at the department of family medicine in a large, urban teaching hospital in Seoul. Korea. Many cases there show a different distribution of problems when compared with a tertiary family therapy center. The majority involve psychosomatic problems, family distress around a chronically-ill member, the loss of a family member, and severe illness, only a few involving drinking problems, family violence, or abuse. The SFBT model meets the seven requirements of Doherty and Baird (1983) for a family therapy model to be useful in a medicine setting.