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.

     

Treating Procrastination Using Cognitive Behavior Therapy: A Pragmatic Randomized Controlled Trial Comparing Treatment Delivered via the Internet or in Groups

Procrastination is a common problem among university students, with at least half of the population reporting great difficulties initiating or completing tasks and assignments. Procrastination can have a negative impact on course grades and the ability to achieve a university degree, but can also lead to psychological distress. Cognitive behavior therapy (CBT) is believed to reduce procrastination, but few studies have investigated its effectiveness in a regular clinical setting. The current study explored its effects using a pragmatic randomized controlled trial comparing treatment delivered during 8 weeks as self-guided CBT via the Internet (ICBT) or as group CBT. In total, 92 university students with severe procrastination were included in the study (registered as a clinical trial on Clinicaltrials.gov: NCT02112383). Outcome measures on procrastination, depression, anxiety, and well-being were distributed at pre- and posttreatment as well as 6-month follow-up. An outcome measure of procrastination was administered weekly. Linear mixed and fixed effects models were calculated, along with improvement and deterioration rates. The results showed large within-group effect sizes on procrastination, Cohen’s d of 1.29 for ICBT, 95% Confidence Interval (CI) [0.81, 1.74], and d of 1.24 for group CBT, 95% CI [0.76, 1.70], and small to moderate benefits for depression, anxiety, and well-being. In total, 33.7% were regarded as improved at posttreatment and 46.7% at follow-up. No differences between conditions were observed after the treatment period, however, participants in group CBT continued or maintained their improvement at follow-up, while participants in self-guided ICBT showed some signs of deterioration. The findings from the current study suggest that CBT might be an effective treatment for those struggling with severe procrastination, but that a group format may be better for some to sustain their benefits over time and that the clinical significance of the results need to be investigated further.     

Do Bettors Correctly Perceive Odds? Three Studies of How Bettors Interpret Betting Odds as Probabilistic Information

This paper reports on three studies investigating how accurately bettors (=people who regularly bet on sports events) interpret the probabilistic information implied by betting odds. All studies were based on data collected by web surveys prompting a total of 186 experienced bettors to convert sets of representative odds into frequency judgments. Bayesian statistical methods were used to analyze the data. From the results, the following conclusions were made: (i) On the whole, the bettors produced well‐calibrated judgments, indicating that they have realistic perceptions of odds. (ii) Bettors were unable to consciously adjust judgments for different margins. (iii) Although their interval judgments often covered the estimates implied by the odds, the bettors tended to overestimate the variation of expected profitable bets between months. The results are consistent with prior research showing that people tend to make accurate probability judgments when faced with tasks characterized by constant and clear feedback. Copyright © 2015 John Wiley & Sons, Ltd.     

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.     

INCREASING THE VARIETY OF FOODS CONSUMED BY A PICKY EATER: GENERALIZATION OF EFFECTS ACROSS CAREGIVERS AND SETTINGS

A multiple baseline across settings was used to evaluate the effects of differential reinforcement of alternative behavior, nonremoval of the fork ( Hoch, Babbitt, Coe, Krell, & Hackbert, 1994 ), and stimulus fading on consumption of food rejected previously. The study was conducted in two separate settings, and caregivers were trained in the intervention technique to increase generalization to natural settings. Food variety increased in both settings.