Patients and agents – or why we need a different narrative: a philosophical analysis

Background

The success of medicine in the treatment of patients brings with it new challenges. More people live on to suffer from functional, chronic or multifactorial diseases, and this has led to calls for more complex analyses of the causal determinants of health and illness.

Methods

Philosophical analysis of background assumptions of the current paradigmatic model.

Results

While these factors do not require a radical paradigm shift, they do give us cause to develop a new narrative, to add to existing narratives that frame our thinking about medical care. In this paper we argue that the increased focus on lifestyle and shared decision making requires a new narrative of agency, to supplement the narrative of “the patient”. This narrative is conceptually linked to the developing philosophy of person-centred care.

Conclusions

If patients are seen also as “agents” this will result in a substantial shift in practical decisions: The development and adoption of this narrative will help practitioners work with patients to their mutual benefit, harnessing the patients’ motivation, shifting the focus from treatment to prevention and preventing unnecessary and harmful treatments that can come out of our preoccupation with the patient narrative. It will also help to shift research efforts, conceptual and empirical, from “treating” and “battling” diseases and their purported “mechanisms” to understanding complex contributing factors and their interplay.

     

Extinction of conditioned inhibition through nonreinforced presentation of the inhibitor

In previous studies that have tried to extinguish conditioned inhibition through nonreinforced presentations of the inhibitor, researchers have repeatedly failed to find evidence for such extinction. The present study revealed that extinction can be achieved through nonreinforcement of the inhibitor, depending on properties of the reinforcer. In a human causal learning experiment, we found complete extinction in a scenario in which the reinforcer could take on negative values. Thereby, this scenario reflected the assumed symmetrical continuum on which associative strength can vary, according to the Rescorla-Wagner theory of associative learning. In contrast to this, the inhibitory cue retained its inhibitory potential in another condition, in which the scenario did not allow negative values of the reinforcer. nt]mis|Klaus G. Melchers has previously published under the surname “Lober.” Susann Wolff is now working at the Max Planck Institute for Human Cognitive and Brain Sciences in Leipzig, Germany     

Impairment of single-trial memory formation by oral methylphenidate in the rat

High synaptic concentrations of dopamine and/or norepinephrine can impair the working memory function of the prefrontal cortex and impede attention and learning. Methylphenidate, a dopamine and norepinephrine transporter blocker known to facilitate these cognitive processes at low doses, was hypothesized to interfere with memory storage at doses that may raise concentrations of these neurotransmitters to systemically disruptive levels. In the present experiments, a dose of 10.0mg/kg of this drug was administered to female and male Long-Evans rats using a novel oral administration procedure designed to model the normal mode of delivery to humans. It was found to interfere with single-trial memory acquisition in a delayed object recognition test, a spontaneous learning task that involves no appetitive or aversive motivator. The time that the rats spent in overt exploration of the to-be-remembered objects during the acquisition trial was not affected, suggesting that the drug may have impaired processes of memory formation independently of interference with attention.     

Consensus and normative validity 1

A weak and a strong version of discourse theory can be distinguished. In the strong version the only source of normative validity in the nonspecific sense is rational consensus, where all parties concerned accept a norm for the same reasons, which are rationally convincing in the same way for all. In the weak version both rational and overlapping consensus can be sources of validity in the nonspecific sense. It is argued that the weak version is the more adequate, since it can accommodate cases which the strong version cannot, and which it is unreasonable to view as cases of compromise. Discourse theory needs a weaker general discourse principle and a more flexible notion of normative consensus than is found in Habermas's Between Facts and Norms (1996).     

Posttraumatische Belastungsstörung

There are some problems concerning the concepts of trauma-related disorders and especially the category of posttraumatic stress disorder (PTSD) with respect to classification, diagnosis and epidemiological findings, which can only be understood within the historical framework of the development. Even current diagnostic systems, such as the diagnostic and statistical manual of mental disorders version 4 (DSM-IV) and the international classification of diseases version 10 (ICD-10) differ in the classification of these disorders which led to higher prevalence rates being achieved with ICD-10. The diagnostic algorithms have been opened to included subsyndromal PTSD as well as complex PTSD including more severe psychiatric disorders.     

Individual differences in spatial configuration learning predict the occurrence of intrusive memories

The dual-representation model of posttraumatic stress disorder (PTSD; Brewin, Gregory, Lipton, & Burgess, Psychological Review, 117, 210-232 2010) argues that intrusions occur when people fail to construct context-based representations during adverse experiences. The present study tested a specific prediction flowing from this model. In particular, we investigated whether the efficiency of temporal-lobe-based spatial configuration learning would account for individual differences in intrusive experiences and physiological reactivity in the laboratory. Participants (N = 82) completed the contextual cuing paradigm, which assesses spatial configuration learning that is believed to depend on associative encoding in the parahippocampus. They were then shown a trauma film. Afterward, startle responses were quantified during presentation of trauma reminder pictures versus unrelated neutral and emotional pictures. PTSD symptoms were recorded in the week following participation. Better configuration learning performance was associated with fewer perceptual intrusions, r = ?.33, p < .01, but was unrelated to physiological responses to trauma reminder images (ps > .46) and had no direct effect on intrusion-related distress and overall PTSD symptoms, rs > ?.12, ps > .29. However, configuration learning performance tended to be associated with reduced physiological responses to unrelated negative images, r = ?.20, p = .07. Thus, while spatial configuration learning appears to be unrelated to affective responding to trauma reminders, our overall findings support the idea that the context-based memory system helps to reduce intrusions.     

Current themes in organizational change

Research in leadership effectiveness has paid less attention to the role of leader fairness than probably it should have. More recently, this has started to change. To capture this development, we review the empirical literature in leadership and fairness to define the field of leadership and fairness, to assess the state of the art, and to identify a research agenda for future efforts in the field. The review shows that leader distributive, procedural, and especially interactional fairness are positively associated with criteria of leadership effectiveness. More scarce and scattered evidence also suggests that fairness considerations help explain the effectiveness of other aspects of leadership, and that leader fairness and other aspects of leadership, or the leadership context, may interact in predicting leadership effectiveness. We conclude that future research should especially focus on interaction effects of leader fairness and other aspects of leadership, and on the processes mediating these effects.