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.     

Culture wars: American moral divisions across the adult lifespan

Sociologists have argued that the public moral debate in contemporary America is characterized by a “culture war,” pitting “orthodox” and “progressivist” groups against one another (Hunter, 1991). This study addressed whether the culture war is evident in the moral thinking of ordinary Americans, and whether age-related patterns exist. Sixty fundamentalist Baptists (orthodox) and 60 mainline Baptists (progressivist) evaluated and reasoned about moral issues such as divorce and abortion. Each group was divided evenly into three age groups copsisting of young, midlife, and older adults. Moral reasoning was analyzed in terms of Shweder's (1990) ethics of autonomy, community, and divinity. Within all three age groups, progressivists used the ethic of, autonomy more than orthodox participants. Orthodox participants used the ethic of divinity more than progressivists. Orthodox and progressivist groups did not differ much in their use of the ethic, of community. Very few age group differences were found within the orthodox and progressivist groups. It is concluded that morality is conceived of in markedly different wasy by orthodox and progressivist groups, and that these conceptions are consistent across age groups.     

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.     

Use and misuse of metrics in research evaluation

This paper addresses some critical issues in the applicability of quantitative performance measures (including bibliometric, economic, and co-occurrence measures) to the assessment of basic research. The strengths and weaknesses of metrics applied as research performance measures are examined. It is concluded that metrics have a useful role to play in the evaluation of research. Each metric employed, whether bibliometric, economic, co-occurrence, or others, brings a new dimension of potential insight to the complex problem of research assessment. However, when used in a stand-alone mode, metrics can be easily misinterpreted and result in misleading conclusions. Metrics should be an integral part of a more comprehensive approach to research evaluation, in which the leading role is assumed by expert peer review. Under this structure, the reviewers must be broadly constituted, so that the technical correctness of the research approaches being taken (doing the job right) can be evaluated by technical experts and the correctness of the research target (doing the right job) can be evaluated as well. This comprehensive approach insures quality in the implementation of existing research paradigms and allows the introduction of revolutionary new research paradigms as well. The views contained in this paper are solely those of the author and do not represent the views of the Department of the Navy. Ronald Kostoff received a Ph.D. from Princeton University, performed technical and economic research at Bell Laboratories, managed energy programs at U.S. Department of Energy, was Director of Technical Assessment at the Office of Naval Research for many years and presently manages the Navy’s In-House Laboratory Independent Research Program.     

Effects of Different Telephone Intervention Styles with Suicidal Callers at Two Suicide Prevention Centers: An Empirical Investigation

To determine the relative effectiveness of telephone intervention styles with suicidal callers, researchers listened unobtrusively to 617 calls by suicidal persons at two suicide prevention centers and categorized all 66,953 responses by the 110 volunteer helpers according to a reliable 20-category checklist. Outcome measures showed observer evaluations of decreased depressive mood from the beginning to the end in 14% of calls, decreased suicidal urgency ratings from the beginning to the end in 27% of calls, and reaching a contract in 68% of calls, of which 54% of contracts were upheld according to follow-up data. Within the context of relatively directive interventions, a greater proportion of Rogerian nondirective responses was related to significantly more decreases in depression. Reduction in urgency and reaching a contract were related to greater use of Rogerian response categories only with nonchronic callers.     

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.     

内部分配改革的职务评价技术探新

建立工资标准系统的关键是确定职务工资率。职务间可比价值成分变异越大,对确定职务工资率的贡献也越大。根据以上研究设想采用方差分析方法进行职务评价。评价步骤包括：职务描述;对职务要素作主成分分析;对职务样本作聚类分析和判别分析;通过方差分析为可比价值各成分建构权重系数ωｉ。ωｉ‘满足：（１）ωｉ≥０;（２）Σωｉ＝１;（３）ωｉ,间可直接比较;（４）ωｉ的大小与对应的可比价值成分变异一致。最后将职务评价值线性变换为工资率。在线性方程中配一个常数。和调节系数α以适合组织的管理约束条件。配合两个企业内部分配改革的研究结果显示了方差分析法的有效性和实用性。     

Evaluating pediatric psychology consultation services in a medical setting: An example

We examined the nature of referrals to a health center-based pediatric psychology service from 1990 to 1993 and assessed the satisfaction of health professionals with these services. Archival evaluation of 1467 records showed that over half of the consultation requests came from general pediatrics, pediatric neurology, and surgical services and that 70% of the psychological services were delivered on an outpatient basis. The most frequent referrals were for cognitive/neuropsychological evaluation and externalizing behavior problems. Pediatric psychology trainees were involved in 94% of the consultations. Survey of health professionals (n = 143) indicated very high overall satisfaction with the quality of services delivered. Presenting problems yielding the greatest likelihood for future consultation requests were behavior problems, child abuse, coping with illness, and depression/suicide. Results are discussed in the context of previous evaluations of pediatric psychology services and recommendations for future evaluation research.     

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.