Clinical psychology in medical settings: Psychology's role in health care

The number of clinical psychologists working in medical settings has grown along with the range of services provided by psychologists to patients with a multitude of medical problems across the lifespan. Medical care cost savings brought about by these psychological interventions is highlighted along with issues of public policy and specialization of training. The opportunity for ongoing development of clinical psychology in medical settings is described as unlimited and the mission of the newJournal of Clinical Psychology in Medical Settings is presented as supporting that growth.     

加速卫生改革迎接入世挑战

中国即将加入WTO。加入WTO后 ,随着中国服务贸易业的对外开放 ,给与健康有关的医疗健康服务带来了前所未有的挑战和机遇。分析我们即将面临的挑战、风险和压力 ,并提出深化卫生改革 ,提高竞争实力的对策。     

Integrating Care for Persons, Not Only Diseases

Integrated care is geared toward enhancing usual care and decision-making for common combinations of medical and mental health conditions, including the behavioral health and behavioral change aspects. Yet even with comprehensive and well-integrated care for health conditions and well-coordinated teamwork in place, some patients do not engage or respond to care in the way clinicians would like or predict. This troubles patients and clinicians alike and may be chalked up informally to things like medical complexity (multiple co-existing conditions), mental health conditions (that complicate care), or simply the case being considered complex or difficult. It also raises the question of how to address person-specific factors that interfere with care of whatever conditions the patient may have, and invites behavioral health clinicians in medical settings to look beyond care of conditions to the care of persons, and to look beyond disease-specific care management protocols to master generic practices of care management across whatever conditions the person may have. This person-centered emphasis is intrinsic to the concept of the “patient-centered medical home” which has burst into animated discussion and demonstration among providers, health plans, government plans, employer purchasers, and professional associations across public and private entities. This represents an opportunity for collaborative care clinicians to help shape the national state of the art in medical home and includes a range of person-oriented (rather than disease-oriented) practices for care management, including working systematically with complex patients and difficult patient–clinician relationships.     

Surrogate medical decision making on behalf of a never-competent, profoundly intellectually disabled patient who is acutely ill

With the improvements in medical care and resultant increase in life expectancy of the intellectually disabled, it will become more common for healthcare providers to be confronted by ethical dilemmas in the care of this patient population. Many of the dilemmas will focus on what is in the best interest of patients who have never been able to express their wishes with regard to medical and end-of-life care and who should be empowered to exercise surrogate medical decision-making authority on their behalf. A case is presented that exemplifies the ethical and legal tensions surrounding surrogate medical decision making for acutely ill, never-competent, profoundly intellectually disabled patients.     

Musiktherapie bei Kindern mit Migräne

Migraine in childhood is a serious health problem with a tendency for chronification. According to the bio-psycho-social model migraine is considered as a disorder generated by multiple factors and requiring an interdisciplinary treatment concept consisting of both medical and psychotherapeutic interventions. Music therapy as a nonverbal, creative arts therapy is especially apt for the treatment of children. A specific treatment concept in music therapy for children with migraine, to be applied within a multidisciplinary framework, and its theoretical background are presented in this article. Music therapy is firmly established within the context of stationary infant psychiatric care. Also, it is presently used as a method of outpatient psychotherapy mainly for children and adolescents. Additionally, music therapy finds frequent use in medical care, special needs education and curative education for children. This article will be limited to the presentation of music therapy as artistic psychotherapy.     

Affirming the Existential within Medicine: Medical Humanities, Governance, and Imaginative Understanding

This paper first distinguishes governance (collective, autonomous self-regulatory processes) from government (externally-imposed mandatory regulation); it proposes that the second of these is essentially incompatible with a conception of the medical humanities that involves imagination and vision on the part of medical practitioners. It next develops that conception of the medical humanities, as having three distinguishable aspects (all of them distinct from the separate phenomena popularly known as "arts-in-health"): first, an intellectual enquiry into the nature of clinical medicine; second, an important dimension of medical education; third, a resource for moral and aesthetic influences upon clinical practice, supporting "humane health care" as the moral inspirations behind organised medicine. Medical humanities sustains these three aspects through paying proper attention to the existential and subjective aspects of medicine. By encouraging authentic imagination among health care practitioners, medical humanities aligns well with both humane health care and governance in the sense of self-regulation. However, it can neither be achieved mechanistically nor well-measured through proxies such as patient satisfaction. Above all, it should not be allowed to supply, through inappropriate qualitative "targets," new forms of management tyranny.     

Providing Pastoral Care Services in a Clinical Setting to Veterans At-Risk of Suicide

The value of enhanced spiritual wellbeing has largely been overlooked as part of suicide prevention efforts in Veterans. The aim of this qualitative study is to examine the clinical pastoral care services provided by VA Chaplains to Veterans at-risk of suicide. This study was conducted using in-depth interviews with five Chaplains affiliated with a medical center located in upstate New York. This study was able to show that some at-risk individuals do actively seek out pastoral care, demonstrating a demand for such services. In conclusion, a pastoral care framework may already exist in some clinical settings, giving at-risk Veterans the opportunity to access spiritual care.     

Reasonable People,Double Jeopardy,and Justice

The equipoise requirement in clinical research demands that, if patients are to be randomly assigned to one of two interventions in a clinical trial, there must be genuine doubt about which is better. This reflects the traditional view that physicians must never knowingly compromise the care of their patients, even for the sake of future patients. Equipoise has proven to be deeply problematic, especially in the Third World. Some recent critics have argued against equipoise on the grounds that clinical research is fundamentally distinct from clinical care, and thus should be governed by different norms. I argue against this “difference position,” and instead take issue with the traditional, exclusively patient-centered account of physicians' obligations that equipoise presupposes. In place of this traditional view, I propose a Kantian test for the reasonable partiality that physicians should show their patients, focusing on its application in clinical research and medical education.     

Genetic Counseling in Southern Iran: Consanguinity and Reason for Referral

Population based genetic counseling that promotes public health goals is an appropriate health care service. The genetic counseling center in Shiraz, southern Iran serves most of the clients in the region. During a 4-year period, 2,686 couples presented for genetic counseling. Data files revealed that 85% had consanguineous relationships (1.5% double first cousin, 74% first cousin, 8% second cousin, 1.5% beyond second cousin). Most prevalent reasons for referral were premarital counseling (80%), with 89% consanguinity, followed by preconception (12%), postnatal (7%), and prenatal counseling (1%). The most common abnormalities in probands or relatives were intellectual and developmental disabilities, hearing loss/impairment, and neuromuscular dystrophies. Family history of medical problem(s) and/or consanguinity was the main indication for referral in nearly every family. Premarital consanguinity poses unique challenges and opportunities. There is considerable opportunity for genetic counseling and education for couples in this population. The tradition of consanguinity, which is likely to persist in Iran, requires multidisciplinary agreement regarding the appropriate process of genetic counseling. Effective genetic counseling in Iran hinges on inclusion of data from genetic counseling services in national genomic and epidemiologic research programs.     

The Importance of Fostering Ownership During Medical Training

There is a need to consider the impact of the new resident-hours regulations on the variety of aspects of medical education and patient care. Most existing literature about this subject has focused on the role of fatigue in resident performance, education, and health care delivery. However, there are other possible consequences of these new regulations, including a negative impact on decision ownership. Our main assumption of is that increased shift work in medicine can decrease ownership of treatment decisions and impact negatively on quality of care. We review some potential components of decision ownership in treatment context and suggest possible ways in which the absence of decision ownership may decrease the quality of medical decision making. The article opens with the definition of decision ownership and the overview of some contextual factors that may contribute to the development of ownership in medical residency. The following section discusses decision ownership in medical care from the perspective of “diffusion of responsibility.” We question the quality of choices made within narrow decisional frames. We also compare isolated and interrelated choices, assuming that residents make more isolated decisions during their shifts. Lastly, we discuss the consequences of decreased decision ownership impacting the delivery of health care.     

Pastoral Care and Medical Education

This essay describes how contemporary medical education and pastoral care share historical roots, confront similar pressures and objectives in the formation of future professionals, and address common concerns in the area of bioethics. The essay concludes with a summary of ideas regarding the present and future relationship between medical education and pastoral care. The essay is dedicated to the memory of David P. Rogers, M.D., whose vision of medical education and medical practice embodied a rare passion for justice.     

Psychology and mind-body segregation: Are we part of the problem?

Despite advances in behavioral medicine and health psychology, the health care system and medical education continue to show resistance to a truly biopsychosocial model of medical practice. Psychologists in medical settings have generally been identified as challenging the concept of mind-body duality and the segregation of biologic and psychosocial sciences in medicine. However, examples are presented of how psychologists contribute to and perpetuate mind-body segregation via exclusive theoretical conceptualizations, arbitrary definitions of professional behavior, and dogmatic constraints on the limits of psychology's field of knowledge.     

循证医学与医学教育改革

循证医学这一新的医疗模式反映了世界医学的发展趋势,代表了现代医学的前进方向。医学教育必须应这一趋势,按照循证医学的基本精神促进观念更新,推进医疗模式、教学内容、教学方法和继续教育等方面的改革,全面提高医学教育质量。     

儒释道与改善癌症患者临终关怀的关系

随着中国肿瘤患病率的不断上升,社会对临终关怀的需求也逐渐增大。由于我国基本国情、文化背景和价值观念与西方不同,援引自西方基督教的临终关怀理念与实践方法在中国的发展出现了许多问题。本文旨在从中国传统的儒释道文化中汲取智慧和经验,针对当前的问题,从死亡教育的开展、医护人员的培训、临终关怀机构的发展与社会支持等方面,提出相应的完善策略,促进我国临终关怀的本土化、体系化、制度化与社会化,希望为构建具有中国特色的临终关怀体系提供新的思路。     

Development of a Substance Abuse Consultation and Referral Service in an Academic Medical Center: Challenges, Achievements and Dissemination

Approximately 25% of US hospital beds are occupied by individuals with active substance use disorders (SUD). Acute medical hospitalization provides an opportunity to address SUDs and provide patient-centered intervention and referral for treatment. Nationally, some hospitals have developed substance abuse consultation departments to improve the care of hospitalized substance users. In this paper we describe the Addiction Psychiatry Service (APS) in a large urban hospital which provides bed-side SUD consultation, screening, intervention and referral to treatment. APS utilizes the multiple disciplines of psychology, social work and medicine to integrate substance abuse services throughout the hospital and educate future generations of medical and psychology trainees. We conclude with how the APS service is informing the development of similar programs in other academic departments within our hospital and best practice recommendations to further disseminate this service model.     

Patient Perspectives on the Learning Health System: The Importance of Trust and Shared Decision Making

We conducted focus groups to assess patient attitudes toward research on medical practices in the context of usual care. We found that patients focus on the implications of this research for their relationship with and trust in their physicians. Patients view research on medical practices as separate from usual care, demanding dissemination of information and in most cases, individual consent. Patients expect information about this research to come through their physician, whom they rely on to identify and filter associated risks. In general, patients support this research, but worry that participation in research involving randomization may undermine individualized care that acknowledges their unique medical histories. These findings suggest the need for public education on variation in practice among physicians and the need for a collaborative approach to the governance of research on medical practices that addresses core values of trust, transparency, and partnership.     

Ethics in medicine: Are we blind? In support of teaching medical ethics at the bedside

The ability to recognize and respond to the ethical dimension of medicine is integral to providing health care that is comprehensive and humane. However, this aspect of medical practice is underemphasized in clinical and academic medicine, despite attempts to devise curricula in this field. This paper examines the origins and consequences of this deficiency through a case history of a Jehovah's Witness who reluctantly accepted a blood transfusion. It emphasizes the ubiquity of the ethical context in medicine and argues that blindness to this context stems from the prevailing scientific and technological paradigm in medicine. Innovations in medical education are called for to enhance health care providers' abilities to appreciate and cope with these complex situations.     

Toward an epistemology of “addictive disease”

This article examines the social perception of disease. Understanding medical perceptions provides an opportunity to gain insight into factors that influence health care seeking behavior patterns, treatment compliance and social policy. This paper views addictive disease models as metaphorical substitutes for moral turpitude models. This conclusion suggests that it is important for health care providers to carefully and instrumentally apply their language to facilitate patient compliance with treatment protocols, in general, and psychotherapy in particular.     

The Future of Psychology in Academic Health Care Centers

A promising opportunity exists to continue psychology's move beyond its traditional mental health emphasis into a general health care discipline. Abundant empirical evidence supports that psychologists treat a wide array of physical disorders as well as psychological components of medical problems. The immediate issues confronting psychology's full emergence into the health care world are discussed and recommendations are offered to assure the success of this initiative. Office of the Senior Vice President and Provost