Situating Standards in Practices: Multi Drug-Resistant Tuberculosis Treatment in India

Public health care needs to cope with a basic dilemma between providing standardized care within public programmes across entire and at times resource-constrained countries and adapting this care locally when responding to individual needs. This tension between standardization and local adaptation becomes particularly obvious for the prolonged and complicated treatment of multidrug-resistant tuberculosis (MDR-TB). Situated standardization, as introduced by Zuiderent-Jerak [2007a, 2007b] offers a way out of this dilemma. It helps to focus on how standards need to be situated in practice rather than viewing standardization and local adaptation as mutually exclusive practices. How do actors relate standardization and individual care in their practices of treating MDR-TB? Results from qualitative fieldwork at the first MDR-TB treatment sites of the Indian TB programme show that actors situate standards in a particular way. They assess the role of guidelines in a particular situation and on that basis recognize the core recommendations of guidelines or go beyond the guidelines. This allows actors to negotiate how standards should be situated and reconciles the dilemma between local adaptation and standardization. Having guidelines internalized, as is common for Indian TB control, bears both promises and pitfalls for engaging in standardization processes in a situated manner. The results contribute to science and technology study scholarship on guideline development. They highlight how actors coordinate the situating of standards and how this depends upon cultures of control. This illustrates the potential of qualitative studies on local adaptation for guideline developers by revealing existing practices of relating and negotiating local adaptation and standardization.     

Identification of Individuals at Risk for Lynch Syndrome Using Targeted Evaluations and Genetic Testing: National Society of Genetic Counselors and the Collaborative Group of the Americas on Inherited Colorectal Cancer Joint Practice Guideline

Identifying individuals who have Lynch syndrome (LS) involves a complex diagnostic work up that includes taking a detailed family history and a combination of various genetic and immunohistochemical tests. The National Society of Genetic Counselors (NSGC) and the Collaborative Group of the Americas on Inherited Colorectal Cancer (CGA-ICC) have come together to publish this clinical practice testing guideline for the evaluation of LS. The purpose of this practice guideline is to provide guidance and a testing algorithm for LS as well as recommendations on when to offer testing. This guideline does not replace a consultation with a genetics professional. This guideline includes explanations in support of this and a summary of background data. While this guideline is not intended to serve as a review of LS, it includes a discussion of background information on LS, and cites a number of key publications which should be reviewed for a more in-depth understanding of LS. These guidelines are intended for genetic counselors, geneticists, gastroenterologists, surgeons, medical oncologists, obstetricians and gynecologists, nurses and other healthcare providers who evaluate patients for LS.     

Developing evidence-based guidance – implications for systemic interventions

This article provides a brief review of the history and current approaches to the development of clinical guidelines, particularly as applied to systemic and more generally psychological therapies. Some commonly identified problems associated with guideline development in mental health are reviewed and their implications for guideline development considered. The challenges this work presents for systemic therapies are considered, along with likely future development in clinical guidelines.     

Pediatric and Adult Recommendations Vary for Sibling Testing in Cystic Fibrosis

Four to 5 % of cystic fibrosis (CF) patients are diagnosed as adults and often have subtler symptoms. Their siblings are at genetic risk to also have a subtler disease state. Diagnostic testing is recommended for siblings of newly diagnosed infants, but recommendations are less clear for later diagnoses. This study explored sibling testing recommendations in pediatric and adult practice using a survey that was emailed to CF clinicians. There were 58 respondents. Results revealed that 82.5% of pediatric and 36.4% of adult care respondents reported always recommending diagnostic testing for siblings of a newly diagnosed patient. In adult care, another 33.3% reported recommending diagnostic testing if the sibling has symptoms. In pediatric care, whether the sibling had newborn screening was most influential. Most pediatric respondents prefer the sweat chloride test, while 40% in adult practice prefer familial mutation analysis. Perceived barriers included cost, insurance coverage and logistical concerns in both settings, parental emotional state in pediatrics, and concern making recommendations for someone who is not the patient in adult care. Genetic counselors may be able to meet familial needs in CF care, including sibling testing. Many newly diagnosed patients/families do not see a genetic counselor, especially in adult care. These data reveal opportunities for practice guidelines and standardization.     

Children’s mental health: Time to stop using psychiatric diagnosis

Hegemonic mental health service approaches stress the need for ‘accurate’ diagnosis in order to understand what the correct ‘treatment’ should be. I review the evidence on how far diagnosis in psychiatry has helped advance scientific knowledge and clinical practice and conclude that it hasn’t. I then examine how National Institute for Health and Care Excellence (NICE) guidelines in relation to children’s behaviour problems reflects the lack of progress that results from adopting a diagnostic approach. Taking mental health practice beyond reliance on narrow non-evidence-based diagnostic algorithms can be developed by adopting existing projects such as the Partners for Change Outcome Management Systems project.     

Measuring the impact of informal caring

A factor-analysis of caregiving impact appraisals amongst a community-derived sample of informal carers of elderly people revealed two negative (care work strain and relationship dissatisfaction) and two positive (care work satisfaction and care lifestyle satisfaction) scales. Validity was assessed by means of concurrent correlations with levels of assistance with daily living tasks provided by carers and levels of behaviour problems exhibited by elderly dependents. Criterion validity was considered in relation to two important carer outcomes; willingness to care and a standardized measure of strain. Each of the four scales was significantly associated with concurrently assessed willingness to care. Care work strain and relationship dissatisfaction were associated with concurrently measured strain symptomology. Evidence of 6-month predictive validity was obtained for the care work strain scale.     

Being, Doing, and Knowing: Developing Ethical Competence in Health Care

There is a growing interest in ethical competence-building within nursing and health care practising. This tendency is accompanied by a remarkable growth of ethical guidelines. Ethical demands have also been laid down in laws. Present-day practitioners and researchers in health care are thereby left in a virtual cross-fire of various legislations, codes, and recommendations, all intended to guide behaviour. The aim of this paper was to investigate the role of ethical guidelines in the process of ethical competence-building within health care practice and medical research. A conceptual and critical philosophical analysis of some paragraphs of the Helsinki Declaration and of relevant literature was performed. Three major problems related to ethical guidelines were identified, namely, the interpretation problem (there is always a gap between the rule and the practice, which implies that ethical competence is needed for those who are to implement the guidelines); the multiplicity problem (the great number of codes, declarations, and laws might pull in different directions, which may confuse the health care providers who are to follow them); and the legalisation problem (ethics concerns may take on a legal form, where ethical reflection is replaced by a procedure of legal interpretations). Virtue ethics might be an alternative to a rule based approach. This position, however, can turn ethics into a tacit knowledge, leading to poorly reflected and inconsistent ethical decisions. Ethical competence must consist of both being (virtues) and doing (rules and principles), but also of knowing (critical reflection), and therefore a communicative based model is suggested.     

Situating interventions to bridge the intention–behaviour gap: A framework for recruiting nonconscious processes for behaviour change

This paper presents a situated cognition framework for creating social psychological interventions to bridge the intention–behaviour gap and illustrates this framework by reviewing examples from the domains of health behaviour, environmental behaviour, stereotyping, and aggression. A recurrent problem in behaviour change is the fact that often, intentions are not translated into behaviour, causing the so‐called intention–behaviour gap. Here, it is argued that this happens when situational cues trigger situated conceptualizations, such as habits, impulses, hedonic goals, or stereotypical associations, which can then guide behaviour automatically. To be effective in changing such automatic effects, behaviour change interventions can attempt to change situational cues through cueing interventions such as priming, nudging, upstream policy interventions, or reminders of social norms. Alternatively, behaviour change interventions can attempt to change the underlying situated conceptualizations through training interventions, such as behavioural inhibition training, mindfulness training, or implementation intentions. Examples of situated behaviour change interventions of both types will be discussed across domains, along with recommendations to situate interventions more strongly and thus enhance their effectiveness to change automatic behaviour. Finally, the discussion addresses the difference between tailoring and situating interventions, issues of generalization and long‐term effectiveness, and avenues for further research.     

Institutional corruption in psychiatry: Case analyses and solutions for reform

Researchers have documented psychiatry's crisis of credibility and called for transparency and reform, yet current solutions do not go beyond timid acceptance. The conceptual and normative framework of institutional corruption highlights the various economies of influence (e.g., industry's capture of regulatory bodies and medical journals) that need to be mitigated. Case analyses of (a) the process by which the latest antidepressant, vortioxetine, came to market, and (b) the promotion of a heavily conflicted guideline for “mixed depression” illustrate how industry is shaping the scientific evidence base and practice in psychiatry, and why systemic, policy‐oriented solutions are needed. We offer solutions for reform that intend to go beyond simple transparency and address the root causes and systemic nature of the problems in the field. These include developing rating systems for clinical practice guidelines and medical journals, a stepped‐care, contextual approach to diagnosis and treatment, addressing perverse incentive structures within universities, and a shift towards a rights‐based paradigm of care with genuine stakeholder involvement.     

How Managed Care Can Help Couples Cope

ABSTRACT

This article traces how managed care became a quick fix to curb out-of-control healthcare costs rather than a real effective approach to managing care. To date, the impact has been not only a negative experience, but impediment to treating couples facing relationship and related problems. The author is optimistic about how managed care will evolve to recognize the importance of couples and family treatment as we enter the future with integrated systems of healthcare. ? The future will also require significant shifts in the thinking and practice patterns of providers and an emphasis on quality and outcomes.     

Ethical Challenges for Jewish Long Term Care Providers

ABSTRACT

This article discusses the particular ethical challenges and opportunities facing Jewish long term care providers. The discussion begins with background on Jewish healthcare ethics generally and then notes several problems in applying traditional principles in concrete situations today. Specific ethical dilemmas characterizing long term care are described, and their implications for practice within Jewish facilities are explicated. Finally, suggestions are offered regarding special contributions that can be made to both the Jewish community and the larger society by bringing the perspective of Jewish healthcare ethics to the arena of long term care provision and policy-making for aging citizens.     

Diagnostischer Prozess und Voreingenommenheit in der forensischen Psychiatrie

This article analyses the problem of bias and confirmatory bias in the diagnostic process. The analysis is situated mainly within the context of the legal system in the United States but also with consideration of the situation in Germany. Special attention is given to the conceptual history and the development of modern operational classifications, particularly the Diagnostic and Statistical Manual of Mental Disorders (DSM) system.     

Gouvernance et éthique cliniques : deux outils complémentaires pour une meilleure coordination des soins et des traitements

“Governance”, “ethics” and “clinical” three words for a same goal: protect the human health. “Corporate governance” must be associated with the new theory of the firm, for which the theory of asymmetric information provides the foundations. Indeed problems of information represent a fundamental change in the prevailing paradigm within economics; they are central to understanding political economy. “Clinical governance”, promoted by the UK government, constitutes an overarching mechanism designed to improve clinical quality in the National Health Service. To the medical establishment, it is a means to improve the quality of medical practice through clinical guidelines. To make a significant impact on the improvement of healthcare quality, the principles of clinical governance must produce synergy by involving professionals in the modernization of the organization. To obtain excellence in heath care, collective actions and shared decision making were essential. In this context, Clinical ethics consultations could provide a structured approach to decision making that could assist heath professional to resolve conflicts or ethical problems that arise in the care of particular patients.     

Agential Conversations: Interviewing Postdoctoral Life Scientists and the Politics of Mundane Research Practices

Science and Technology Studies (STS) projects often aim at understanding social problems and epistemic challenges in science and, more generally, in the technoscientific worlds we inhabit. However, it is often unclear if and how these projects can help address the problems they identify. Scholars such as Donna Haraway, John Law, and Karen Barad have argued that STS methods always interfere with the contexts they study. Combining this insight with recent feminist scholarship on the politics of care in technoscience suggests that a better understanding of how our research practices already interfere can help us attune our methods in order to promote care as part our research practices. One avenue to investigate this hypothesis is to return to a completed study and reconstruct how its research methods have created interference effects that promoted or could promote care for the problems the study identified. In the case at hand, the methods investigated are interviews with life scientists in Austria and the USA. The problem they defined is that current career rationales in the life sciences, which foreground individualism, mobility, and competition hinder collaboration, teamwork, and mentoring, strain group cohesion, and tend to exclude certain groups. Reframing the research interviews as ‘agential conversations’ that interfered with the contexts they sought to understand shows how the interviews also created situated moments of reflection, connection, and disruption that could serve as a basis for responding to these problematic conditions affecting researchers in the life sciences and beyond.     

It’s NOT FAIR! Or is it? The promise and the tyranny of evidence-based performance assessment

Evidence-based medicine (EBM), by its ability to decrease irrational variations in health care, was expected to improve healthcare quality and outcomes. The utility of EBM principles evolved from individual clinical decision-making to wider foundational clinical practice guideline applications, cost containment measures, and clinical quality performance measures. At this evolutionary juncture one can ask the following questions. Given the time-limited exigencies of daily clinical practice, is it tenable for clinicians to follow guidelines? Whose or what interests are served by applying performance assessments? Does such application improve medical care quality? What happens when the best interests of vested parties conflict? Mindful of the constellation of socially and clinically relevant variables influencing health outcomes, is it fair to apply evidence-based performance assessment tools to judge the merits of clinical decision-making? Finally, is it fair and just to incentivize clinicians in ways that might sway clinical judgment? To address these questions, we consider various clinical applications of performance assessment strategies, examining what performance measures purport to measure, how they are measured and whether such applications demonstrably improve quality. With attention to the merits and frailties associated with such applications, we devise and defend criteria that distinguish between justice-sustaining and justice-threatening performance-based clinical protocols.     

Report writing: Legislative,ethical, and professional challenges

Report writing continues to be one of the most serious and underestimated problem areas facing school psychologists. Current guidelines have not been generally responsive to changes in professional practice stemming from recent legal and legislative mandates, changing professional roles, and contemporary theory and practice. This article reviews various approaches to assessment and their potential influence on psychological report writing. A contemporary approach to report writing is then discussed.     

Managing stress or enhancing wellbeing? Positive psychology's contributions to clinical supervision

One of the key functions of clinical supervision as practised by health professionals such as psychologists includes the restoration of wellbeing, but there are few guidelines in the supervision literature on how to go about this. Research into concepts from the field of positive psychology such as work engagement, sense of coherence, self‐efficacy, flow and resilience has begun to provide detailed understanding of workers' happiness, health and betterment. These findings provide possible directions for supervision interventions that go beyond traditional review of self‐care and stress‐management strategies and seek to extend the wellbeing of the supervisee. This article explores the application of positive psychology to enhance the wellbeing of practitioners such as psychologists, who often work in inherently difficult work environments such as the mental health field. Specifically, a narrative approach is proposed as one possible method and practical examples are offered to demonstrate how positive psychology may be applied in the practice of clinical supervision.     

AN ISLAMIC APPRAISAL OF MINDING THE GAP

The neglect of psycho‐spiritual needs of patients as they traverse the modern healthcare system has been a featured theme in medical literature over the past decade. This literature, which often highlights in‐patient palliative care, as well as acute and critical care settings, influences practice guidelines and protocols of doctors and nurses. In this essay, I review some of the pertinent issues raised in the literature and examine the validity of placing an ethical perspective on this issue. I also compare Islamic theocentric perspectives with secular, non‐theistic perspectives on restoring psycho‐spiritual care for patients. I then develop a framework for pastoral intervention based on aspects of the Islamic tradition and elaborate this framework by addressing clinical contexts and cases. The essay is an exposition based upon a review of the modern medical literature, an analysis of some of the traditional Islamic written sources, and the observations of the investigator, a practicing physician and an American Muslim.     

Three Conceptual Models of Patient and Public Involvement in Standard-setting: From Abstract Principles to Complex Practice

Clinical practice guidelines have been critiqued for prescribing standardized care that neglects patients’ personal circumstances and knowledge in health care decisions. To make care more patient centred, standard-setters are urged to involve patients and the public in guideline development and use. Despite widespread principled support for such Patient and Public Involvement (PPI), the underlying principles guiding PPI in standardization of care are mired on confusion and contradiction. Based on the PPI literature in general, and informed by empirical research on guideline development, it is possible to identify three rationales that justify PPI in clinical standard setting. Each rationale gives rise to a conceptual model which outlines a distinct purpose of participation, who is to be included, and what they are expected to contribute. The Consumer Choice model aims to involve autonomous consumers to personalize clinical care. The Democratic Voice model aims for health care recommendations to better reflect collective values of citizens. The Lay Expertise model aims to re-contextualize universal evidence by including experiential patient knowledge. However, these models can and should not function as ‘Gold Standards’ to be consistently followed in practice. First, the models rely on two distinct types of representation, resulting in contradictory notions of how to be a good representative. Second, imposing models on practice requires a top-down control that is practically and politically problematic. Not only is control difficult to achieve, it may compromise the participatory ideal of participants co-determine practice, and may result in excluding the values and views of ‘real’ patients and public entirely.     

Empirical evaluation of the MCMI-III personality disorder scales

The MCMI-III personality disorder scales were empirically validated with a sample of 870 clinical patients and inmates. Prevalence rates of personality disorders were in general lower on the MCMI-III than clinical ratings, but trait prevalence was generally higher; thus a base rate of 75 on the MCMI-III could be a guideline in the screening of trait prevalence. However, the sensitivity of some MCMI-III scales was very low. Moreover, the correlations of most personality disorder scales of the MCMI-III were significant and positive with corresponding measures on clinical ratings and MMPI-2 personality disorder scales, but these were, in general, not significantly higher than some other correlations. As a consequence the discriminant validity seems to be questionable. The MCMI-III alone cannot be used as a diagnostic inventory, but the test could be useful as a screening device as a part of a multimethod approach that allows aggregation over measures in making diagnostic decisions.