临床实习的法律规范问题调查及对策

通过问卷对来自四川大学华西医院等6所不同层次医疗机构的475名实习医生进行调查,发现身份不合法、患者不配合、义务履行不充分、管理不规范是目前实习中的主要问题.提出在优化实习资源、加强实习生教育的基础上,通过建立《实习医师资格考试制度》、成立“临床实习管理规范委员会”,确立实习规范化的法律依据和制度框架,促进我国医学教育和卫生事业的良性发展.     

论现代临床护理决策的“非语言性”道德语境

现代临床护理决策的“非语言性”道德语境包括道德多元化、患者中心化和责任独立化三个主要方面.对“非语言性”道德语境的忽视导致了护理决策缺乏公信力.临床护理决策伦理模式的建构能使护理决策主体充分考虑“非语言性”道德语境,有利于道德争议的有效解决.     

妇产科临床见习教学中融入人文素质教育的探讨

妇产科由于涉及到患者较多的隐私而经常出现患者不愿配合教学的情形,使妇产科临床教学工作及实习质量受到影响.本文采用标准化病人教学来解决这一妇产科临床见习教学中的矛盾,并探讨妇产科临床见习教学中融入人文素质教育的意义.将100名临床见习医学本科生随机分为试验组和对照组(各50人),分别对两组病史采集、实践操作和病历书写能力进行比较,并对所在组教学模式提升人文素质的效果进行评价.结果显示试验组OSCE考核成绩显著高于对照组(P＜0.01),且该组学生的人文素质也得到很大提高(P＜0.01).妇产科临床见习教学中融入人文素质教育,将理论知识与临床实践有机结合,既培养了学生的专业技能,又提高了人文素质.     

医学生妇产科临床见习渗透伦理学教学的意义

现代医生应是专业技能与人文素养兼备的形象,医学伦理学素质是医学生理应具备的品格.实践证明,医学伦理学临床见习是培养医学生医学伦理学素质的必要环节.医学伦理学的临床见习,能固化医学生的知识体系,有利于医学生医学伦理学素质的养成,帮助提高医学生分析和解决医学临床实践中面临的伦理困境.而妇产科室由于其特殊性,在临床见习中渗透伦理学教学的意义尤为重大,通过妇产科医学伦理学临床见习的设计与实施,科学合理地选择见习的内容,寻找最佳的见习方式和方法,完善见习的评定体系和考核形式,医学伦理学的教学效果立竿见影.     

全科医学临床诊疗中的决策

临床诊疗的每个步骤,几乎都涉及如何决策的问题.医生应该将患者的利益放在首位,告诉患者拟采取的这些步骤其效果、风险及花费,让患者作出最终的决定.全科医学的精髓是“以人为本”,全科医师更应该帮助患者决策、让患者决策.而全科医疗的特点也决定了必须如此和可能如此.     

Ethics in Academia: Students' Vies of Professors' Actions

Although psychologist impairment has received attention from researchers, there is a paucity of empirical data aimed at determining the point at which such impairment necessitates action. The purpose of this study was to provide such empirical data. Members of Division 42 (n = 285) responded to vignettes describing a psychologist whose symptoms of either depression or substance abuse varied across five levels of severity. Results identified specific levels of impairment at which psychologists were deemed too impaired to practice psychotherapy, as well as significant differences between ratings of increasingly severe impairment. Practical and ethical implications of these results are discussed.     

By-Person Factor Analysis in Clinical Ethical Decision Making: Q Methodology in End-of-Life Care Decisions

Objective: To determine the usefulness of Q methodology to locate and describe shared subjective influences on clinical decision making among participant physicians using hypothetical cases containing common ethical issues.

Design: Qualitative study using by-person factor analysis of subjective Q sort data matrix.

Setting: University medical center.

Participants: Convenience sample of internal medicine attending physicians and house staff (n = 35) at one midwestern academic health sciences center.

Interventions: Presented with four hypothetical cases involving urgent decision making near the end of life, participants selected one of three specific clinical actions offered for each case. Immediately afterward and while considering their decision, each respondent sorted twenty-five subjective self-referent items in terms of the influence of each statement on their decision-making process. By-person factor analysis, where participants are defined as variates, yielded information about the attitudinal background the physicians brought to their consideration of each hypothetical case. We performed a second-order factor analysis on all of the subjective viewpoints to determine if a smaller core of shared attitudes existed across some or all of the four case vignettes. Factor scores for each item and post-sort comments from interviews conducted individually with each respondent guided the interpretation of ethical perspective used by these respondents in making clinical decisions about the cases.

Measurements and Main Results: Second-order factor analysis on seventeen viewpoints used by physicians in the four hypothetical urgent decision cases revealed three moderately correlated (r ² < 40%) subjective core attitudinal guides used broadly among all the cases and among sixteen of the seventeen original factors. Across all the cases, our participants were guided in general by: (1) patient-focused beneficence, (2) a patient- and surrogate-focused perspective that includes risk avoidance, and (3) best interest of the patient guided by ethical values. Economic impact on the physician, expediency in resolution of the situation, and the expense of medical treatment were not found to be influential determinants in this study.

Conclusions: Q sorting and by-person factor analysis are useful qualitative methodological tools to study the complex structure of subjective attitudes that influence physicians in making medical decisions. This study revealed the subjective viewpoints used by our physician participants as they made ethically challenging treatment decisions. The three second-order factors identified here are grounded in current bioethical values as well as the personal traits of physicians. The participants' decision methods appear to resemble casuistry more than principle-based decision making. Generalizability of results will require further studies.     

Ferenczi's “Confusion of Tongues” Theory and the Analysis of the Incest Trauma

Abstract

The tender-mother transference of Ferenczi's humanistic analytic orientation was as important an advance in pioneering times as was Kohut's selfobject transference in contemporary psychoanalysis. Ferenczi's clinical theory and method began a focus on pre-oedipal experiences, which eventually became an alternate to the oedipal theory. Freud was critical of Ferenczi's formulation, leading a successful attempt to suppress his work and remove it from mainstream psychoanalysis because he believed it was “regressive.” In actuality, Ferenczi's “Confusion of Tongues” theory and “Relaxation Therapy” were prophetic and pioneering attempts to understand and treat the incest trauma (ironically the clinical data upon which Freud founded psychoanalysis 100 years ago). In the case of Miss T., Ferenczi's ideas are applied to the contemporary analysis of the incest trauma.     

Reply to Letter to the Editor

The current policy of the National Institute of Health designed to increase the participation of women and minorities is radically different from previous policies designed to protect minorities from abuses in research studies. The principal arguments to support this policy are twofold: 1) Increased representation of minorities and women in research would increase the generalizability of research data and allow for valid analyses of differences in subpopulations; and 2) being in a clinical research study is advantageous to participants regardless of the final research study results. It remains unclear whether minorities find these arguments compelling. Instead of telling minorities that participation in research is good for them, the research community should focus on understanding what minority communities want from clinical research and then tailoring the message to meet this need. Persuasive arguments to promote long-term increased representation of minorities in clinical research must come from within minority communities.     

Compounding Vulnerability: Pregnancy and Schizophrenia

The predominant ethical framework for addressing reproductive decisions in the maternal–fetal relationship is respect for the woman's autonomy. However, when a pregnant schizophrenic woman lacks such autonomy, healthcare providers try to both protect her and respect her preferences. By delineating etic (objective) and emic (subjective) perspectives on vulnerability, I argue that options which balance both perspectives are preferable and that acting on etic perspectives to the exclusion of emic considerations is rarely justified. In negotiating perspectives, we balance the etic commitment to protect the vulnerable patient and her fetus from harm with the emic concern to empower a decisionally incapacitated woman. Equilibrium is best achieved by nurturing interdependent relationships that empower and protect the vulnerable woman. The analysis points to the need for better social support for mentally ill patients.