The practice of empathy as a prerequisite for informed consent

The patient-physician relationship, as formulated in the traditional biomedical model of medicine, is inherently flawed. In entering this relationship, most patients seek simply to be delivered from illness back to normal psychosocial functioning. The physician, however, almost invariably responds with a purely biologic approach to diagnosis and treatment that often does not effectively address the patient's needs. This precludes the opportunity for a consensus between them, and may in fact lead to the physician manipulating the patient's decisions about the course of therapy. The relationship should be reshaped within a new scientific model of patient care that combines the biomedical analysis of disease with an empathic understanding of the patient's illness experience. Truly informed consent is viewed as a natural outcome of the application of this more comprehensive framework.     

Phenomenology and its application in medicine

Phenomenology is a useful methodology for describing and ordering experience. As such, phenomenology can be specifically applied to the first person experience of illness in order to illuminate this experience and enable health care providers to enhance their understanding of it. However, this approach has been underutilized in the philosophy of medicine as well as in medical training and practice. This paper demonstrates the usefulness of phenomenology to clinical medicine. In order to describe the experience of illness, we need a phenomenological approach that gives the body a central role and acknowledges the primacy of perception. I present such a phenomenological method and show how it could usefully illuminate the experience of illness through a set of concepts taken from Merleau-Ponty. His distinction between the biological body and the body as lived, analysis of the habitual body, and the notions of motor intentionality and intentional arc are used to capture the experience of illness. I then discuss the applications this approach could have in medicine. These include narrowing the gap between objective assessments of well-being in illness and subjective experiences which are varied and diverse; developing a more attuned dialogue between physicians and patients based on a thick understanding of illness; developing research methods that are informed by phenomenology and thus go beyond existing qualitative methods; and providing medical staff with a concrete understanding of the impact of illness on the life-world of patients.     

The impact of job complexity and performance measurement on the temporal consistency, stability, and test-retest reliability of employee job performance ratings

Although research has shown that individual job performance changes over time, the extent of such changes is unknown. In this article, the authors define and distinguish between the concepts of temporal consistency, stability, and test-retest reliability when considering individual job performance ratings over time. Furthermore, the authors examine measurement type (i.e., subjective and objective measures) and job complexity in relation to temporal consistency, stability, and test-retest reliability. On the basis of meta-analytic results, the authors found that the test-retest reliability of these ratings ranged from .83 for subjective measures in low-complexity jobs to .50 for objective measures in high-complexity jobs. The stability of these ratings over a 1-year time lag ranged from .85 to .67. The analyses also reveal that correlations between performance measures decreased as the time interval between performance measurements increased, but the estimates approached values greater than zero.     

Objective risk, subjective risk, and colorectal cancer screening among a clinic sample

Among cancers, colorectal (CRC) is the third most incident and the second most lethal. Although screening for the disease has been shown to be effective in reducing morbidity and mortality, screening rates remain low. Risk of disease has been shown to increase screening uptake, but different types of risk may influence intent to screen, screening in a timely manner, or participating in screening at all. A cross-sectional design was used to select a diverse sample of CRC asymptomatic patients 50 or more years of age (N=104) visiting one of three Midwestern medical clinics. Results showed a positive relationship between receipt of CRC screening and planning to screen for CRC in the future. Objective risk factors (personal/family history and having a primary care physician) were associated with CRC screening uptake and screening within the time intervals recommended by professional screening guidelines, but subjective risk did not obtain significance for screening participation. Both objective (primary care physician) and subjective risk (long-term comparative risk, knowledge) were associated with future plans to screen. Findings suggest that CRC screening behaviors may be differentially influenced by type of risk.     

Discrepancy between subjective autobiographical reliving and objective recall: The past as seen by Alzheimer’s disease patients

This paper investigated whether Alzheimer’s disease (AD) patients may demonstrate a discrepancy between subjective autobiographical reliving and objective recall. To this end, 31 AD patients and 35 controls were asked to retrieve three autobiographical memories. For each memory, participants were asked to rate its subjective characteristics (e.g., reliving, travel in time, visual imagery…). Besides this subjective assessment, we analyzed recall objectively with regard to specificity. Results showed poorer subjective autobiographical reliving and objective recall in AD patients than in controls. A discrepancy (i.e., higher level of subjective reliving than of objective recall) was observed in AD but not in control participants. Despite a compromise in their objective recall, AD patients seemed to attribute a high value to their subjective autobiographical experience. This discrepancy can be attributed to a potential genuine consciousness experience in which mild AD patients can, to some extent, experience some subjective features of the past.     

The relationship between mental toughness and subjective mental illness recovery

Recently there has been an increasing interest in subjective mental illness recovery, and it has been recognised that there is an important role for characteristics such as self-efficacy and locus of control. Mental toughness describes a set of characteristics important for dealing with stress and pressure, and is comprised of challenge, commitment, control of emotion, control of life, confidence in abilities, and interpersonal confidence. The current study explored relationships between mental toughness and subjective mental illness recovery. Seventy-seven participants (nineteen males and fifty-eight females, the majority of which were young adults aged 18–21 years) who had previously recovered from, or were currently recovering from a mental illness (self-reported) completed questionnaire measures of mental toughness and subjective mental illness recovery. Mental toughness had a positive significant relationship to recovery, with particular roles for commitment and confidence in abilities. The findings are discussed in terms of implications for recovery-oriented practice, intervention, and measurement. Further research should examine the role of mental toughness in different aspects of subjective recovery, and also explore relationships with objective measures of recovery.     

Memory for time and place contributes to enhanced confidence in memories for emotional events

Emotion strengthens the subjective sense of remembering. However, these confidently remembered emotional memories have not been found be more accurate for some types of contextual details. We investigated whether the subjective sense of recollecting negative stimuli is coupled with enhanced memory accuracy for three specific types of central contextual details using the remember/know paradigm and confidence ratings. Our results indicate that the subjective sense of remembering is indeed coupled with better recollection of spatial location and temporal context, but not higher memory accuracy for colored dots placed in the conceptual center of negative and neutral scenes. These findings show that the enhanced subjective recollective experience for negative stimuli reliably indicates objective recollection for spatial location and temporal context, but not for other types of details, whereas for neutral stimuli, the subjective sense of remembering is coupled with all the types of details assessed. Translating this finding to flashbulb memories, we found that, over time, more participants correctly remembered the location where they learned about the terrorist attacks on 9/11 than any other canonical feature. Likewise, participants' confidence was higher in their memory for location versus other canonical features. These findings indicate that the strong recollective experience of a negative event corresponds to an accurate memory for some kinds of contextual details but not for other kinds. This discrepancy provides further evidence that the subjective sense of remembering negative events is driven by a different mechanism than the subjective sense of remembering neutral events.     

Time flies when you're having fun: temporal estimation and the experience of boredom

Boredom is a common experience in healthy individuals and may be elevated in various neurological or psychiatric conditions. As yet, very little is known about the cognitive or neural bases of the subjective experience of boredom. We examined temporal perception and the temporal allocation of attention in healthy individuals reporting high- or low-levels of boredom. We found no difference in high- or low-boredom-prone individuals in the temporal allocation of attention, while individuals who experienced low-levels of boredom tended to underestimate time more so than high-boredom-prone individuals. Furthermore, high-boredom-prone individuals demonstrated higher error values when estimating time indicating that the subjective perception of the passage of time may be a critical component to the experience of boredom.     

Die Wiederherstellung der Zeit in der ambulanten Psychotherapie mit Psychosekranken

In psychoanalytic psychotherapy with psychotic patients, a disturbance in time experience quite frequently turns out to be central to the psychotic experience as a whole. These patients experience disruptions in the flow of time that lead to a loss of temporal continuity. This loss of temporal structures causes damage in thinking functions: Relations like causality, finality and others which imply a temporal dimension, cannot be established any more. Parts of treatment histories serve to demonstrate the reconstruction of temporal continuity by the patient in psychotherapy. Object-relation-theory and Piaget’s experimental psychology provide the frame of reference for the understandig of the mental processes involved. At the beginning of the psychotherapy the patient experiences being together with the therapist and being separated from him as two discrete conditions of existing which have no links. The periodical reappearance of being together in combination with the awareness of the therapist’s continuous ongoing care encourages the patient to remember and to envisage the meetings with the therapist. The reliability of the alternation seems to stimulate a specific mental activity which creates connections allowing for transitions between the different conditions — in the sense of Winnicott’s transitional phenomena. Transitional phenomena which sometimes are quite concrete things bridge the gap between presence and future. Narrating serves as a link to the past. Through these creative ego-activities temporal continuity is regained providing the basis for strucured thinking and — very important — for the perception of one’s own personality and its continuity over time, thus generating a sense of identity. This process of reconstructing time is interesting in itself, because it sheds light on the psychodynamics of the restitutional processes after a psychotic illness. Moreover, it allows for hypotheses about the development of the inner time dimension in early childhood.     

Fatigue risk management based on self-reported fatigue: Expanding a biomathematical model of fatigue-related performance deficits to also predict subjective sleepiness

Biomathematical models of fatigue can be used to predict neurobehavioral deficits during sleep/wake or work/rest schedules. Current models make predictions for objective performance deficits and/or subjective sleepiness, but known differences in the temporal dynamics of objective versus subjective outcomes have not been addressed. We expanded a biomathematical model of fatigue previously developed to predict objective performance deficits as measured on the Psychomotor Vigilance Test (PVT) to also predict subjective sleepiness as self-reported on the Karolinska Sleepiness Scale (KSS). Four model parameters were re-estimated to capture the distinct dynamics of the KSS and account for the scale difference between KSS and PVT. Two separate ensembles of datasets – drawn from laboratory studies of sleep deprivation, sleep restriction, simulated night work, napping, and recovery sleep – were used for calibration and subsequent validation of the model for subjective sleepiness. The expanded model was found to exhibit high prediction accuracy for subjective sleepiness, while retaining high prediction accuracy for objective performance deficits. Application of the validated model to an example scenario based on cargo aviation operations revealed divergence between predictions for objective and subjective outcomes, with subjective sleepiness substantially underestimating accumulating objective impairment, which has important real-world implications. In safety-sensitive operations such as commercial aviation, where self-ratings of sleepiness are used as part of fatigue risk management, the systematic differences in the temporal dynamics of objective versus subjective measures of functional impairment point to a potentially significant risk evaluation sensitivity gap. The expanded biomathematical model of fatigue presented here provides a useful quantitative tool to bridge this previously unrecognized gap.     

Emotional reaction to past and future events as a function of temporal distance

In three experiments with 30 Ss, imagined past and future events were used as stimuli. Scales were constructed by the ratio estimation method for (a) subjective temporal distance and (b) emotional reaction to the events. It was found (1) that subjective temporal distance was a power function of chronological distance, (2) that emotional reaction to past events could be described as an exponential function of subjective temporal distance; a simple relation thus exists between the two psychological variables, whereas emotional reaction is related in a more complicated way to the objective variable, and (3) that emotional reaction to future events could be described about as well by a power function as by an exponential function of both subjective and objective temporal distance.     

Attention and the subjective expansion of time

During brief, dangerous events, such as car accidents and robberies, many people report that events seem to pass in slow motion, as if time had slowed down. We have measured a similar, although less dramatic, effect in response to unexpected, nonthreatening events. We attribute the subjective expansion of time to the engagement of attention and its influence on the amount of perceptual information processed. We term the effect time's subjective expansion (TSE) and examine here the objective temporal dynamics of these distortions. When a series of stimuli are shown in succession, the low-probability oddball stimulus in the series tends to last subjectively longer than the high-probability stimulus even when they last the same objective duration. In particular, (1) there is a latency of at least 120 msec between stimulus onset and the onset of TSE, which may be preceded by subjective temporal contraction; (2) there is a peak in TSE at which subjective time is particularly distorted at a latency of 225 msec after stimulus onset; and (3) the temporal dynamics of TSE are approximately the same in the visual and the auditory domains. Two control experiments (in which the methods of magnitude estimation and stimulus reproduction were used) replicated the temporal dynamics of TSE revealed by the method of constant stimuli, although the initial peak was not apparent with these methods. In addition, a third, control experiment (in which the method of single stimuli was used) showed that TSE in the visual domain can occur because of semantic novelty, rather than image novelty per se. Overall, the results support the view that attentional orienting underlies distortions in perceived duration.     

The lower subjective social status of neurotic individuals: multiple pathways through occupational prestige, income, and illness

Subjective social status seems to predict health outcomes, above and beyond the contribution of objective status. The present hypothesis was that neuroticism predicts subjective status and does so via the influence of neuroticism on objective status (i.e., education, occupation, and income), self-perceived illness, and greater negative affect. In turn, lower subjective status would be associated with more severe self-perceived illness. Older adults (N=341) shortly after retirement completed measures of neuroticism, attainment in education, occupation, and salary, and over 2 subsequent years, they completed measures of current subjective status, self-reported illness, and current negative affect. As hypothesized, greater neuroticism was associated with lower subjective status via lower objective status and more severe self-reported illness. However, current negative affect was not associated with subjective status, and subjective status did not predict future poorer subjective health.     

L’observance et certains de ses déterminants dans les maladies inflammatoires chroniques de l’intestin (MICI)

Factors that favor compliance are not constant in researches about IBD patients. The objective of this study is to determine, in a 79 compliant subjects sample, the links between factors themselves which influence observance: depression, alexithymia, causal attributions, health subjective quality of life, the relation with the physician, the health state evaluation and the rapport between therapeutic benefit/side effects (CGI). Results show that patients comprehend independently factors that motivate them to have treatment and seriousness of their health state. If the relationship established with the physician is perceived as fundamental, personal controllability does not seem essential in compliance. So, it seems important to consider more specifically the link between patient's perceived control and physician's perceived control of the disease.     

Subjective health complaints

A variety of subjective illnesses with few or no objective findings have appeared at regular intervals as epidemics in our society under different labels. There are few or no objective findings that might explain the "disease" or the complaints go beyond what is regarded as "reasonable" by the physician. Muscle pain and other types of subjective health complaints are among the most frequent reason for encounters with general practitioners, and one of the major causes for sickness absence. The prevalence of subjective health complaints is very high, with at least 75% of the population reporting one or more subjective health complaints the past 30 days. From a statistical point of view, it is "normal" to have complaints. It is when they become intolerable that assistance is required. The difficult thing is that this threshold is individual and subjective. The psychiatric definitions of these complaints, therefore, refer only to the tip of an iceberg.     

Spécificité des stratégies de coping des patients en rémission de la maladie de Crohn : une étude qualitative

IntroductionCrohn's disease (CD), a chronic inflammatory bowel disease, has strong psychological and social repercussions related to the specificity of the symptomatology. To better understand how patients cope with the disease, coping strategies have been studied but without taking into account the specificity of the CD experience.ObjectiveOur objective is to identify the perceived coping strategies used by patients in relation to their illness experience.MethodUsing a qualitative approach, semi-structured interviews and thematic content analysis with 33 CD patients in remission were conducted.ResultsOur results highlight that some of the coping strategies used are not taken into account by the coping scales frequently used in the literature. Indeed, the illness experience appears to be fundamental in the establishment of new strategies based on the experiential knowledge patients use to reduce the stress induced by a potential relapse. Moreover, coping strategies based on positive emotions are also implemented, and they enable patients to make sense of the disease.ConclusionThe coping strategies, i.e., “experiential knowledge” and “positive emotions”, may shed more light on the complexity of the illness experience of CD patients and allow us to make recommendations concerning the psychological support of patients.     

Validation of the Personal Wellbeing Index for People with End Stage Kidney Disease

The quality of life of people with end stage kidney disease (ESKD) has traditionally been measured using instruments that emphasise objective health status. The present study validates an alternative measure, the Personal Wellbeing Index (PWI), which measures subjective wellbeing. An Australian ESKD sample (N?=?172, Mean age?=?64.04, SD?=?14.82) completed the PWI as well as health-specific quality of life measures. The PWI was subject to confirmatory factor analysis, and a series of regressions and between-group comparisons were performed to reveal that it is a psychometrically appropriate measure for this sample. The PWI and health-specific measures each yield different and complementary results. Thus, the PWI is proposed as a complement to existing health-related quality of life tools, in order to broaden understanding of the patient’s subjective experience. The resulting profile is argued to better inform targeted interventions to improve the quality of life of people with ESKD.     

Objective and subjective socioeconomic status and susceptibility to the common cold.

OBJECTIVE: We ask whether subjective socioeconomic status (SES) predicts who develops a common cold when exposed to a cold virus. DESIGN: 193 healthy men and women ages 21-55 years were assessed for subjective (perceived rank) and objective SES, cognitive, affective and social dispositions, and health practices. Subsequently, they were exposed by nasal drops to a rhinovirus or influenza virus and monitored in quarantine for objective signs of illness and self-reported symptoms. MAIN OUTCOME MEASURES: Infection, signs and symptoms of the common cold, and clinical illness (infection and significant objective signs of illness). RESULTS: Increased subjective SES was associated with decreased risk for developing a cold for both viruses. This association was independent of objective SES and of cognitive, affective and social disposition that might provide alternative spurious (third factor) explanations for the association. Poorer sleep among those with lesser subjective SES may partly mediate the association between subjective SES and colds. CONCLUSIONS: Increased Subjective SES is associated with less susceptibility to upper respiratory infection, and this association is independent of objective SES, suggesting the importance of perceived relative rank to health.