Doctor's Expertise and Managing Discrepant Information from Other Sources in Genetic Counseling: A Conversation Analytic Perspective

The study examines a recurrent interactional pattern in genetic counseling. It describes clinical geneticists' responses in situations in which clients have presented information from other sources that is potentially discrepant with information given by the doctor. The data consists of 12 video-recorded sessions of genetic counseling in Finland, and the method is conversation analysis. There are two primary ways the doctors respond: either they accept the client's information as such, but show that it is not discrepant with the doctor's information, or they reject the client's information. In the latter case they mitigate the ‘wrongness’ of the client's information. The clinical geneticists seem to be working with a dilemma: they need to find a balance between ensuring correct understanding of the information and showing respect for the expertise of others. A particularly complex case is also analyzed and reflected on.     

Care of the Self and Patient Participation in Genetic Discourse: A Foucauldian Reading of the Surgeon General's “My Family Health Portrait” Program

Critics of genetic discourse are concerned that deterministic and discriminatory views of genetics are increasingly becoming adopted. These views argue that current genetic discourse becomes a source of power whereby powerful institutions harm people with so-called “bad” genes. This essay argues that current analyses of the power of genetics discourse are grounded in an improper reading that disempowers patients. Deploying Michel Foucault's concept “care of the self,” this essay claims that genetics discourse is better understood as a way that patients take on power through rhetoric rather than a force that has power over patients. Through a close reading of the “My Family Health Portrait” program, this paper argues that patients experience a process of “subjection” wherein they become agents of and objects of genetics discourse both. This alternative mode of analyzing the power of genetics discourse has implications for our collective understanding of the operations of the care of the self and the uses of genetic information that we propose.     

Differences in Individual Approaches: Communication in the Familial Breast Cancer Consultation and the Effect on Patient Outcomes

This multicenter study aimed to assess (i) whether individual clinical geneticists and genetic counselors vary in their communication skills and (ii) whether this variation in communication impacts on patient outcomes, such as anxiety, depression, genetics knowledge, and satisfaction. One hundred and fifty women from high-risk breast cancer families attending their first genetic counseling consultation completed pre and post-consultation self-report questionnaires. The consultations were audiotaped and transcribed verbatim. Univariate analyses showed highly significant differences between individual clinical geneticists and genetic counselors in: facilitating understanding (p 0.001); facilitating active involvement (p 0.001); facilitating partnership building (p = 0.003); addressing emotional concerns (p 0.001); and discussing prophylactic mastectomy (p = 0.017). Multivariate linear regressions showed that this variation in communication resulted in a greater change in patients depression 4 weeks after the counseling session (p = 0.017). These findings suggest clinical geneticists and genetic counselors have achieved some standardization in communicating information, but showed diversity in their facilitation skills. Communication skills may be a useful area to explore further in this field.     

A call to restructure the drug development process: Government over-regulation and non-innovative late stage (Phase III) clinical trials are major obstacles to advances in health care

The history of drug/vaccine development has included major advances guided primarily by risk/benefit analyses concerning the innovative agent, not by evidence-based clinical trials (Phase I–IV). Because the approval for new drugs is hindered under the present process, the system requires restructuring. The Phase I/II study period should be more flexible, using the “environment of knowledge” about the new agent, plus risk/benefit assessments. Phase III, as presently constructed, does not add new adverse events data, it provides a narrower profile of drug efficacy than properly done Phase II studies, and placebo-controlled trials continue to raise unresolved ethical and social issues. Phase III studies should be abandoned for most drugs, and substituted with properly powered Phase II doseranging studies plus careful post-marketing surveillance. Phase III should be a penalty for poor drug development, not a regulatory requirement. To accomplish efficient drug development, greater cooperation between pharmaceutical companies and governments in developing clinical trials is needed rather than over-regulation. These changes will synchronize the drug development and regulatory process with the current rapid drug discovery process, reduce drug development time and cost, and improve patient care. The author is Adjunct Professor of Medicine, Weill Medical College of Cornell University, New York, New York, USA.     

Bottlenose dolphin (Tursiops truncatus) calves appear to model their signature whistles on the signature whistles of community members

Bottlenose dolphins are unusual among non-human mammals in their ability to learn new sounds. This study investigates the importance of vocal learning in the development of dolphin signature whistles and the influence of social interactions on that process. We used focal animal behavioral follows to observe six calves in Sarasota Bay, Fla., recording their social associations during their first summer, and their signature whistles during their second. The signature whistles of five calves were determined. Using dynamic time warping (DTW) of frequency contours, the calves signature whistles were compared to the signature whistles of several sets of dolphins: their own associates, the other calves associates, Tampa Bay dolphins, and captive dolphins. Whistles were considered similar if their DTW similarity score was greater than those of 95% of the whistle comparisons. Association was defined primarily in terms of time within 50 m of the mother/calf pair. On average, there were six dolphins with signature whistles similar to the signature whistles of each of the calves. These were significantly more likely to be Sarasota Bay resident dolphins than non-Sarasota dolphins, and (though not significantly) more likely to be dolphins that were within 50 m of the mother and calf less than 5% of the time. These results suggest that calves may model their signature whistles on the signature whistles of members of their community, possibly community members with whom they associate only rarely.     

Tool-use learning in Tonkean macaques (Macaca tonkeana)

The transmission of tool use is a rare event in monkeys. Such an event arose in a group of semi-free-ranging Tonkean macaques (Macaca tonkeana) in which leaning a pole against the parks fence (branch leaning) appeared and spread to several males. This prompted us to test individual and social learning of this behavior in seven young males. In the first experiment, three males learned individually to obtain a food reward using a wooden pole as a climbing tool. They began using the pole to retrieve the reward only when they could alternatively experience acting on the object and reaching the target. In a second experiment, we first tested whether four other subjects could learn branch leaning after having observed a group-mate performing the task. Despite repeated opportunities to observe the demonstrator, they did not learn to use the pole as a tool. Hence we exposed the latter subjects to individual learning trials and they succeeded in the task. Tool use was not transmitted in the experimental situation, which contrasts with observations in the park. We can conclude that the subjects were not able to recognize the target as such. It is possible that they recognized it and learned the task individually when we alternated the opportunity to act upon the object and to reach the reward. This suggests that these macaques could then have associated the action they exercised upon the pole and the use of the pole as a means to reach the reward.     

“Hands up Who Wants to Die?”: Primoratz on Responsibility and Civilian Immunity in Wartime

The question of the morality of war is something of an embarrassment to liberal political thinkers. A philosophical tradition which aspires to found its preferred institutions in respect for individual autonomy, contract, and voluntary association, is naturally confronted by a phenomenon that is almost exclusively explained and justified in the language of States, force and territory. But the apparent difficulties involved in providing a convincing account of nature and ethics of war in terms of relations between individuals has not prevented liberal theorists from attempting this task. This paper examines a recent attempt by Igor Primoratz to sketch out the implications of a consistent liberalism for just war doctrine and, in particular, as regards the question of who may be a legitimate target of attack in wartime. Primoratz’s paper itself is a critique of Michael Waltzer’s authoritative exposition of just war theory for failing to be sufficiently and consistently liberal. The debate between these two authors is a productive site for investigating the potential and limitations of liberal theories of just war.     

2003年诺贝尔医学奖给科学界的多重启示(上)

2003年诺贝尔医学奖授予了两位美英物理学家,劳特布尔和曼斯菲尔德,表彰他们在磁共振成像方面的发现.这些发现导致现代磁共振技术的开发,这一技术标志着医学诊断学和科学研究中的一项突破.该项发现建筑在核磁和核磁共振现象被发现的基础之上.核磁现象的发现及其应用导致了1943、1944和1952年诺贝尔物理学奖的获得.核磁共振现象的发现及其应用导致了1991年和2002年诺贝尔化学奖的获得.这意味着,2003年诺贝尔医学奖是该系列发现中第六个诺贝尔科学奖.     

Something from nothing: exploring dimensions of children's knowing through the repeated reading of favourite books

Witte‐Townsend and DiGiulio explore some of the dimensions of knowing that children, teachers and parents may engage together during story‐time. They reflect on some of their own long‐term relationships with children and children's books, especially Phoebe Gilman's Gilman P 1992 Something from nothing (New York, NY, Scholastic Inc)  [Google Scholar] Something from nothing (published in 1992) and Simms Taback's Taback S 1999 Joseph had a little overcoat (New York, NY, Viking‐Penguin)  [Google Scholar] Joseph had a little overcoat, published in 1999. The authors probe issues such as why children ask to hear a favourite story over and over and why they suddenly abandon all interest and move on to a new book. They explore the meaning of the silences that sometimes arise during story‐time, pooling around the young listeners as the last words of the book are read. Witte‐Townsend and DiGiulio remind us of the value of literature in the lives of children and they affirm that the reading and re‐reading of favourite stories enables the understanding of complex human issues and contributes significantly to social, emotional and spiritual growth.     

Swimming against the mainstream: the early years from chilly tributary to transformative mainstream

This article traces the transformative paradigm shift in the theory and practice of personal change. Within a decade, new conceptual models, analytic methodologies and modes of treatment were created. Treatments were altered in the content, locus, and agents of change. This enterprising period also witnessed a sweeping shift in the public acceptance of behaviorally oriented treatments. The present article also analyzes the evolving theorizing and applications of social cognitive theory rooted in modeling, self-regulatory, and self-efficacy mechanisms of psychosocial change. This model of change is implemented from an agentic perspective to promote personal, institutional, and society-wide changes that address some of the most urgent global problems.