USING PARENTS TO MAINTAIN IMPROVED DENTAL FLOSSING SKILLS IN CHILDREN

An experimenter-administered intervention involving prompts, self-monitoring, permanent product collection, rewards for plaque reduction, and corrective feedback was used to improve the flossing skills of four 7- to 11-year-old children. Parents were subsequently trained in the reward and feedback procedures to facilitate maintenance. In a multiple baseline across subjects design, all four subjects snowed improvement in plaque between teeth during experimenter-administered intervention. Three subjects maintained low plaque levels during the 3- to 4-month parent-administered rewards and feedback follow-up condition. Improved plaque levels on nontargeted tooth surfaces also were observed. Pediatric dentistry applications are discussed.     

Psychological aspects of scuba diving injuries: Suggestions for short-term treatment from a psychodynamic perspective

Dive medicine is described as an area of practice in which psychologists may choose to expand their clinical service and research activities. The author argues that most research studying risk behavior and sports take into account biological, behavioral or cognitive approaches, while ignoring unconscious conflict in risk-taking and injury management. The present paper uses a psychodynamically-oriented, interview-based approach to studying psychological reactions to decompression sickness in three experienced scuba divers. Brief interventions and their outcomes are described.     

Building a primary care discipline: Notes from a psychologist in family medicine

Psychologists of a variety of emphases have actively participated in the growth of family medicine as an academic discipline. Rather than simply collaborate, they have shaped the very nature of the field. This paper describes a number of contributions from psychologists in family systems and educational arenas. In particular, physician-psychologist collaborative work is highlighted.     

The anthropological tradition in the philosophy of medicine

The tradition of anthropological medicine in philosophy of medicine is analyzed in relation to the earlier interest in epistemological issues in medicine around the turn of the century as well as to the current interest in medical ethics. It is argued that there is a continuity between epistemological, anthropological and ethical approaches in philosophy of medicine. Three basic ideas of anthropologically-oriented medicine are discussed: the rejection of Cartesian dualism, the notion of medicine as science of the human person, and the necessity of a comprehensive understanding of disease. Next, it is discussed why the anthropological movement has been superseded by the increasing interest in medical ethics. It is concluded that the present-day moral issues cannot be interpreted and resolved without clarification of the underlying anthropological images.     

OPERANT TREATMENT OF OROFACIAL DYSFUNCTION IN NEUROMUSCULAR DISORDERS

The popularity and reported success of biofeedback treatment for neuromuscular disorders has occurred despite a lack of research identifying the critical variables responsible for therapeutic gain. In this study, we assessed the degree to which severe neurological dysfunction could be improved by using one of the components present in all biofeedback treatment, contingency management. Three cases of orofacial dysfunction were treated by reinforcing specific improvements reliably detectable without the use of biofeedback equipment. The results showed that contingency management procedures alone were sufficient to improve overt motor responses but, unlike biofeedback treatment, did not produce decreases in the hypertonic muscle groups associated with the trained motor behavior. The findings suggest that sophisticated, expensive biofeedback equipment may not be necessary in treating some neuromuscular disorders and that important clinical gains may be achieved by redesigning the patient's daily environment to be contingently therapeutic, rather than only accommodating the disabilities of the physically handicapped.     

BEHAVIORAL ASSESSMENT AND TREATMENT OF CHRONIC FOOD REFUSAL IN HANDICAPPED CHILDREN

In this study, we examined the eating behavior of four handicapped children, none of whom exhibited self-feeding skills. All children had a history of food refusal and were nutritionally at risk; one child received all nourishment by way of a gastrostomy tube. Baseline data taken during mealtimes indicated that all children accepted very little food, expelled food frequently, and engaged in a number of disruptive behaviors. Treatments consisted of one or more of the following contingent events: social praise, access to preferred foods, brief periods of toy play, and forced feeding. Results of multiple-baseline and reversal designs showed marked behavioral improvement for each child and increases in the amount of food consumed. Further improvements were noted at follow-up, which ranged from 7 to 30 months posttreatment.     

AN EXPERIMENTAL COMPARISON OF A CONTINGENCY MANAGED COURSE WITH LARGE LECTURE METHOD1

Contingency management procedures resembling the Personalized System of Instruction (PSI) were compared with a conventional lecture method in teaching an introductory psychology course. The use of a within-subjects design in which half of the students experienced both teaching conditions made it possible to examine the reliability of test-score differences over time when subjects were balanced over conditions. In the contingency management course, material was broken down into 14 small units, each unit covering about 30 pages of text. Students were assigned to an undergraduate teaching assistant who was encouraged to develop a close working relationship with each of his/her 13 assigned students. Specifically, this meant that the assistant was to call each student by his/her first name, show an interest in the student's quiz performance, help the student understand difficult concepts, and discuss various topics of interest to the student. Each week, the teaching assistant administered up to four different 10-item multiple-choice quizzes over the week's chapter. A modified “Doomsday Contingency” required each student either to achieve a score of 80% on one of the four quizzes or drop the course. Most students passed the quiz during the first session of the week; those not passing were tutored on special areas of weakness. No student was actually forced to leave the course under the Doomsday Contingency. Although quizzes were administered on a group basis, they were scored individually while the student stood near by. In addition to the weekly quiz assignment, students under the contingency management procedures were asked to attend one lecture per week. The contingency management method departed from traditional PSI in that (1) self pacing was minimal, such that students were required to master one unit per week or drop the course, (2) teaching assistants met with students in small groups, and usually gave individual tutoring only to those students who did not pass the quiz on the first attempt, and (3) students were asked to attend one lecture per week. However, it was similar to PSI in that small units of subject matter were assigned and unit mastery was assessed through use of undergraduate assistants who delivered immediate feedback. Students in the conventional lecture group attended three 50-min lectures each week; two of these lectures followed textbook material closely, while the third, which was attended by all students, concerned material only indirectly related to the text. As a result, students in both conditions were exposed to essentially identical material. Students in the lecture condition could also obtain copies of the unit quizzes, although few did so. Course grades were determined by scores on two 45-item multiple-choice hourly exams, each covering half of the semester material (each worth 25%), and by a 90-item final exam over the entire course (worth 50%). These measures also served as the dependent variables. The experimental design employed a crossover technique in which one fourth of the students began with the contingency management method and then switched to lecture method at midsemester, while another fourth began with the lecture method and switched to contingency management. The other students stayed in the same condition throughout the semester, half under contingency management and half under the lecture method. On the last day of class, all students filled out an extensive questionnaire that assessed their opinions and attitudes about the teaching techniques. In addition to allowing for assessment of any progressive effects that the contingency management procedures might have had over time, the crossover design also permitted students to make meaningful comparisons of the two teaching methods, since half of the students experienced both methods in the same course. Although average test performance was only slightly higher under the contingency management condition, this difference occurred on each exam and was statistically reliable in each case. Further, the method did not interact with time, as it produced about a three-item advantage per half semester. On each of the three exams, teaching method accounted for between 5 and 8% of the total variance in test scores. Finally, attitude measures indicated that students experiencing half a semester of the contingency management procedures preferred them to the lecture technique, but that only those students with a full semester of contingency management rated the course significantly better than students in the full semester lecture course.     

Beyond Consent: Building Trusting Relationships With Diverse Populations in Precision Medicine Research

With the growth of precision medicine research on health data and biospecimens, research institutions will need to build and maintain long-term, trusting relationships with patient-participants. While trust is important for all research relationships, the longitudinal nature of precision medicine research raises particular challenges for facilitating trust when the specifics of future studies are unknown. Based on focus groups with racially and ethnically diverse patients, we describe several factors that influence patient trust and potential institutional approaches to building trustworthiness. Drawing on these findings, we suggest several considerations for research institutions seeking to cultivate long-term, trusting relationships with patients: (1) Address the role of history and experience on trust, (2) engage concerns about potential group harm, (3) address cultural values and communication barriers, and (4) integrate patient values and expectations into oversight and governance structures.     

The Ethics of Smart Pills and Self-Acting Devices: Autonomy,Truth-Telling,and Trust at the Dawn of Digital Medicine

Digital medicine is a medical treatment that combines technology with drug delivery. The promises of this combination are continuous and remote monitoring, better disease management, self-tracking, self-management of diseases, and improved treatment adherence. These devices pose ethical challenges for patients, providers, and the social practice of medicine. For patients, having both informed consent and a user agreement raises questions of understanding for autonomy and informed consent, therapeutic misconception, external influences on decision making, confidentiality and privacy, and device dependability. For providers, digital medicine changes the relationship where trust can be verified, clinicians can be monitored, expectations must be managed, and new liability risks may be assumed. Other ethical questions include direct third-party monitoring of health treatment, affordability, and planning for adverse events in the case of device malfunction. This article seeks to lay out the ethical landscape for the implementation of such devices in patient care.     

医疗文书签字扩大化失去意义的原因分析

随着近年医患关系的紧张,越来越多的医疗工作需要履行签字手续,呈现了签字扩大化的态势。签字扩大化是防御性医疗的一种表现形式,但并未带来医疗纠纷减少,也不是医疗纠纷产生的主要原因,又给医疗工作增加了繁琐程度,而且并未达到知情同意的内涵。所以,签字扩大化失去了其应有的意义。