结节性甲状腺肿手术路径质量管理成效研究

本文通过对比分析临床路径实施前后各项质量相关指标,研究临床路径模式在精细分科部门中结节性甲状腺肿手术患者质量管理的应用成效。结果显示临床路径在质量管理过程中取得显著成效,尤其是在缩短平均住院日方面,但对于费用的控制还有待进一步提高,因此应对实施中的临床路径进行不断地持续改进,为患者提供更优质的服务。     

Why it is difficult to see the anima as a helpful object: critique and clinical relevance of the theory of archetypes

This paper is divided into three parts. The first deals briefly with more general aspects of the theory of archetypes (as conceived by Jung); the second examines the anima archetype in rather more detail, because it is, apart from the self, the main archetype in Jung's thought; and the third discusses the clinical repercussions of the anima theory and of the theory of the archetypes in general. The various references to Jung himself and certain circumstances of his life are included here on the assumption that personal problems in his biography contributed decisively to the constitution of his theory, so that deeper insights accure if they are taken into account.     

Genetic Studies of Autism: From the 1970s into the Millennium

Reviewers in the 1960s and early 1970s were skeptical about any substantial role for genetic factors in the etiology of autism. A realization that the 2% rate of autism in siblings (as estimated at that time) was far above the general population base rate, and that this suggested a possible high genetic liability, led to the first small-scale twin study of autism. The replicated evidence from both twin and family studies undertaken in the 1970s and 1980s indicated both strong genetic influences and the likelihood that they applied to a phenotype that was much broader than the traditional diagnostic category of autism. Medical and chromosomal findings also indicated genetic heterogeneity. Advances in molecular genetics led to genome-wide scans of affected relative pair samples with a positive log of the odds to base 10 score for a location on chromosome 7. The major remaining research challenges and the likely clinical benefits that should derive from genetic research are considered in relation to both current knowledge and that anticipated to emerge from research over the next decade.     

Cognitive Load and the Equality Heuristic: A Two-Stage Model of Resource Overconsumption in Small Groups

Two studies were conducted to test a two-stage model of the psychological mechanisms underlying the overconsumption of scarce resources in small groups. The model proposes that members of groups sharing resources first anchor their consumption choices on an “equal-division” heuristic and then, given sufficient cognitive capacity, adjust their choices in a self-serving direction. The results from both studies support the model. The first study found that when faced with a common resource pool almost all group members expressed thoughts regarding equality; however, individuals with sufficient cognitive capacity requested more from the pool and expressed more task-relevant thoughts than individuals lacking the necessary cognitive resources. The second study provided additional support for the two-stage model by demonstrating that group members' cognitions occur in the order predicted by the model and by demonstrating that an individual difference, social value orientation, affects thought processes only when individuals are not experiencing high cognitive loads. Implications are discussed.     

Evaluation of drug toxicity in clinical trials

An increasing number of drugs removed from the market because of unacceptable toxicity raises concerns regarding preapproval testing of drug safety. In the present paper it is postulated that the non-inferiority type of trial should be abandoned in favor of the superiority trial with active controls and less stringent (p<0.1, both for efficacy and toxicity) statistics. This approach will increase sensitivity of detection of drug-induced adverse effects at the expense of increasing false positive results regarding the difference in efficacy between the tested and reference drug. Such a move will increase the protection of future patients. In addition, the proposed design is far more acceptable from the clinical (e.g. no need to specify the statistically expected “unimportant” number of deaths) and ethical points of view, as well as being favored by the strong incentive of involved parties. In the second part of this paper arguments are presented in favor of the hypothesis that placebo (still used in some superiority trials) does not induce adverse effects. The assertion that placebo may induce adverse effects is probably biased by the nature of the clinical experiment. Such a conclusion is supported by studies indicating that placebo-induced adverse effects are disease — and treatment — specific. The modification of clinical trials according to the proposed changes may increase the trials’ sensitivity at detecting adverse effects of drugs. A lecture on the subject of this paper was presented at the 6th International Bioethics Conference on the subject of ‘The Responsible Conduct of Basic and Clinical Research’, held in Warsaw, Poland, 3–4 June 2005.     

Conducting clinical research in Polish conditions

This paper comments on Polish legal guarantees for diseased persons with reference to the hazards that accompany experimental treatment. While acknowledging that participation in a clinical research program provides patients with additional opportunities for advanced treatment, the paper also points out that systems for monitoring patients participating in experimental treatment require improvement. This paper was presented at the 6th International Bioethics Conference on the subject of ‘The Responsible Conduct of Basic and Clinical Research’, held in Warsaw, Poland, 3–4 June 2005.     

Expressivism, Logic, Consistency, and Moral Dilemmas

On an expressivist view, ethical claims are understood as expressions of our attitudes, desires, and feelings. A famous puzzle for this view concerns the use of logic in ethical reasoning, and two standard treatments try to solve the puzzle by explaining logical inconsistency in terms of conflicting attitudes. I argue, however, that this general strategy fails: because we can reason effectively even in the presence of conflicting moral attitudes – in cases of moral dilemmas – avoiding these conflicts cannot be a ground for correct moral reasoning. The result is a dilemma for expressivists: if they take all kinds of attitudes to be under consideration, then conflict cannot play the required role, since attitudes can fail to be compatible in cases of moral conflict. If they restrict attention to ‘all-in attitudes’ or to intentions or plans, then there is an important notion of obligation, used in standard arguments – one for which conflicts are allowed – that they fail to capture. I explain why expressivists should be especially tolerant of conflicting attitudes, and I conclude that they should pursue a different strategy for grounding logical normativity.

Recognizing Racit Knowledge in Medical Epistemology

The evidence-based medicine movement advocates basing all medical decisions on certain types of quantitative research data and has stimulated protracted controversy and debate since its inception. Evidence-based medicine presupposes an inaccurate and deficient view of medical knowledge. Michael Polanyi’s theory of tacit knowledge both explains this deficiency and suggests remedies for it. Polanyi shows how all explicit human knowledge depends on a wealth of tacit knowledge which accrues from experience and is essential for problem solving. Edmund Pellegrino’s classic treatment of clinical judgment is examined, and a Polanyian critique of this position demonstrates that tacit knowledge is necessary for understanding how clinical judgment and medical decisions involve persons. An adequate medical epistemology requires much more qualitative research relevant to the clinical encounter and medical decision making than is currently being done. This research is necessary for preventing an uncritical application of evidence-based medicine by health care managers that erodes good clinical practice. Polanyi’s epistemology shows the need for this work and provides the structural core for building an adequate and robust medical epistemology that moves beyond evidence-based medicine.An erratum to this article can be found at     

Some Lessons I Have Learned From 25 Years in Clinical Neuropsychology: A Letter to My Grandchildren

The practice and study of clinical neuropsychology is considered an empirical enterprise. However, such an approach may result in missing the more humanistic or phenomenological side of the experience of brain dysfunction. This addresses a personal journey rather than a professional and scientific one. In doing so, the limits of the discipline and the suffering and value of the experience of the illness are presented. An earlier version of this article was presented as the Presidential Address for the Division 40 (Clinical Neuropsychology) of the American Psychological Association in August of 2003.