Medical hermeneutics: Where is the “text” we are interpreting?

The present paper is a commentary on an article by Drew Leder [1]. Leder identifies a series of texts in the clinical encounter, emphasizes the central role of interpretation in making sense of each of these texts, and articulates ordering principles to guide the interpretive work.The metaphor of clinical work as textual explication, however, creates the expectation that there is a text somewhere to be found. Such an expectation invites doctors and patients to search for the text and runs the risk of conceptualizing patients as more static than they are. If one is to use the textual metaphor, one must appreciate the radical extent to which the clinical encounter is a mutually produced and shifting entity. The qualities of mutuality and indeterminacy are not those one usually associates with texts. One might ultimately be better served by a different metaphor based more directly on uncertainty.     

Medicine as business and profession

This paper analyzes one dimension of the frequently alleged contradiction between treating medicine as a business and as a profession, namely the incompatibility between viewing the physician patient relationship in economic and moral terms. The paper explores the utilitarian foundations of economics and the deontological foundations of professional medical ethics as one source for the business/medicine conflict that influences beliefs about the proper understanding of the therapeutic relationship. It, then, focuses on the contrast and distinction between medicine as business and profession by critically analyzing the classic economic view of the moral status of medicine articulated by Kenneth Arrow. The paper concludes with a discussion of some advantages associated with regarding medicine as a business.     

The effects of family composition,family health,parenting behavior and environmental stress on children's divorce adjustment

The traditional family composition model of children's divorce adjustment was compared to a family competence model. Subjects included 81 children whose parents remained married, were divorced, or were divorced and subsequently remarried. Divorced families had been separated for between 24 and 48 months. Custodial parents completed questionnaires regarding family functioning, occurrence of stressful life events, and child's psychosocial adjustment. Children completed questionnaires regarding parenting behaviors and self-esteem. A trained examiner conducted a structured diagnostic interview of the child. Multivariate analysis of covariance showed that family composition had a significant effect on the occurrence of stressful events and change in income but not children's adjustment. Hierarchical multiple regression correlations indicated the most powerful predictors of child adjustment were family competence variables which accounted for 21% of the variance in child adjustment scores. In contrast, family composition accounted for only 8% of variance in child adjustment scores. Further, hierarchical multiple regression correlations indicated that higher levels of family functioning were associated with families where parental hostility was low and parents displayed few rejecting behaviors while practicing consistent and appropriate discipline.     

Building and Maintaining Clinical Programs

This paper describes the basic elements of practice development and management within the academic medical setting. These include assessment of the market environment, both in the community and within the medical setting, product development, marketing, budget basics, quality, managed care negotiations, and finding time to do research in a financially-driven health care system.     

Latinas with Arthritis: Effects of Illness, Role Identity, and Competence on Psychological Well-Being

Tested a theoretical model on the effects of social role identity, illness intrusion, and competence on psychological well-being among 109 low-income Latinas with arthritis. All six roles studied were rated as highly important identities. Sex-role nontraditionalism was associated with less importance of the homemaker, mother, and grandmother roles. Negative affect increased as a function of intrusions into valued identities. Having important role identities contributed to feelings of competence (i.e., self-esteem and self-efficacy), which in turn, contributed to psychological well-being. Competence also mediated the effects of pain, identity, and illness intrusions on psychological well-being. Results suggest competence processes play an important role in well-being.     

Effects of Self-Correction on the Acquisition, Maintenance, and Generalization of the Written Spelling of Elementary School Children

We examined the effect of self-correction on the acquisition, maintenance, and generalization of written spelling of elementary school students attending an after-school clinic. Six students registered for remedial tutoring participated. During self-correction, students initially learned four proofreading marks and a procedure for using them that were subsequently applied as the students compared their spelling to a model. Results showed a functional effect between self-correction and improved student performance on target words. Using the self-correction procedure, the students spelled at least 98% of the target words accurately, maintained at least 85% of the correctly spelled words, and generalized at least 70% of the words at home, in context, and with word variations. Questionnaires administered to the students, their parents, and teachers indicated that students preferred self-correction. Parents noticed academic improvements in their child's spelling performance as well as positive changes in attitude toward school. Most teachers did not notice changes in spelling performance or attitude.     

Reflections on segregating and assessing areas of competence

Various complexities that arise in the application of legal and/or clinical criteria to the actual assessment of competence/capacity are discussed, and a particular way of understanding the nature of such criteria is recommended.     

Effects of diagnostic classification systems on clinical hypothesis-generation

In this study it was determined whether (a) classification as opposed to absence of classification has an effect on the quality of clinical hypotheses (b) the DSM-III-R and the CBCL have a different effect on the quality of clinical hypotheses, and (c) the potential difference between the DSM-III-R and the CBCL is moderated by the different number of syndromes identified by these systems. To investigate these questions, an experiment was conducted in which 86 clinicians generated hypotheses for six cases. The clinicians were divided into a DSM-III-R, a CBCL, and a control group. Of the six cases, two were classified by both classification systems as one syndrome, two were classified as one syndrome by the DSM-III-R but as two syndromes by the CBCL, and two were classified as two syndromes by the DSM-III-R but as one syndrome by the CBCL. The quality of the hypotheses was determined by means of four dependent variables selected from an overview of qualitative criteria: explanatory value, redundancy, possibility of operationalization, and specificity. No differences between the CBCL and the control groups were found. The DSM group performed better than the control group regarding explanatory value and redundancy. The DSM-III-R group also scored better than the CBCL group regarding explanatory value, particularly when the number of identified syndromes was two for the CBCL and one for the DSM-III-R.     

Competing interests: The need to control conflict of interests in biomedical research

Individual and institutional conflict of interests in biomedical research have becomes matters of increasing concern in recent years. In the United States, the growth in relationships — sponsored research agreements, consultancies, memberships on boards, licensing agreements, and equity ownership — between for-profit corporations and research universities and their scientists has made the problem of conflicts, particularly financial conflicts, more acute. Conflicts can interfere with or compromise important principles and obligations of researchers and their institutions, e.g., adherence to accepted research norms, duty of care to patients, and open exchange of information. Disclosure is a key component of a successful conflict policy. Commitments which conflict with a faculty member's primary obligations to teaching, research, administrative responsibilities, or patient care also need attention. Institutional conflict of interests present different problems, some of which are discussed in an analysis of an actual problem posed by two proposed clinical trials. This paper is adapted from a lecture presented to a Symposium on Scientific Integrity, Warsaw, Poland, 23 November 1995. Daniel Steiner was Vice-President and General Counsel of Harvard University (1972–92) and in that capacity became familiar with conflict of interest issues. He is currently Counsel to the Boston law firm. Ropes and Gray, and is Adjunct Lecturer in Public Policy at the John F. Kennedy School of Government. Harvard University.