叙事医学本土化的若干思考

叙事医学为人文社会学科介入医学范畴提供了建构性方案,使技术至上的医疗实践逐渐转向重视患者个体的生活价值、痛苦关怀的人文实践,对于医患主体间的鸿沟消弭、理解改善具有独到之处。然而,在中国式现代化的路径视角下,依然需要对西方语境中的叙事医学方法论进行审慎反思,尤其是要考虑国别体制下的文化差异与社会现实,避免造成简单化搬运与应用。在扎根中国本土情境的基础上,探索适应我国的医疗卫生实践、构建和谐医患环境的叙事医学模式。     

临床医学诊断方法对摆脱伦理困境的启示——以决疑术的复兴为线索

人们对以道德原则为起点的演绎推理的坚持是伦理困境存在的重要原因,决疑术作为一种基于案例的推理为人们摆脱伦理困境提供了一种选择但却没有发展出成熟的方法模型。临床诊断与决疑术共为实践推理在方法上存在相似之处,这为决疑术的方法建构提供了模板。以临床诊断方法为参照,决疑术的方法既涉及对待决案件情况的考察、对待决案件进行分类、与范例进行类比等推理过程,同时也关注裁判主体对结论权威性的影响,这分别构成了决疑式推理结论的内在权威和外在权威。

     

医患共同决策何以赋能心身医学实践

医患共同决策以“患病的人”作为临床决策对象,以“知情同意”作为临床决策原则,以“高质量共同参与”作为临床实践方法,契合了心身医学全方位关注患者生理心理社会信息的需要。以医患共同决策赋能心身医学实践,有助于深化患者对心身互动疗法的认知,增强患者战胜疾病的信心,进而促进患者从心理健康走向身体健康。然而,医患共同决策面临的现实难题,制约了心身医学实践发展。有必要基于多元主体共建思路,围绕医者引领共同决策、患者有效参与共同决策和医院完善共同决策制度等内容优化医患共同决策,从而赋能心身医学实践发展。

     

USING PARENTS TO MAINTAIN IMPROVED DENTAL FLOSSING SKILLS IN CHILDREN

An experimenter-administered intervention involving prompts, self-monitoring, permanent product collection, rewards for plaque reduction, and corrective feedback was used to improve the flossing skills of four 7- to 11-year-old children. Parents were subsequently trained in the reward and feedback procedures to facilitate maintenance. In a multiple baseline across subjects design, all four subjects snowed improvement in plaque between teeth during experimenter-administered intervention. Three subjects maintained low plaque levels during the 3- to 4-month parent-administered rewards and feedback follow-up condition. Improved plaque levels on nontargeted tooth surfaces also were observed. Pediatric dentistry applications are discussed.     

Building a primary care discipline: Notes from a psychologist in family medicine

Psychologists of a variety of emphases have actively participated in the growth of family medicine as an academic discipline. Rather than simply collaborate, they have shaped the very nature of the field. This paper describes a number of contributions from psychologists in family systems and educational arenas. In particular, physician-psychologist collaborative work is highlighted.     

The anthropological tradition in the philosophy of medicine

The tradition of anthropological medicine in philosophy of medicine is analyzed in relation to the earlier interest in epistemological issues in medicine around the turn of the century as well as to the current interest in medical ethics. It is argued that there is a continuity between epistemological, anthropological and ethical approaches in philosophy of medicine. Three basic ideas of anthropologically-oriented medicine are discussed: the rejection of Cartesian dualism, the notion of medicine as science of the human person, and the necessity of a comprehensive understanding of disease. Next, it is discussed why the anthropological movement has been superseded by the increasing interest in medical ethics. It is concluded that the present-day moral issues cannot be interpreted and resolved without clarification of the underlying anthropological images.     

OPERANT TREATMENT OF OROFACIAL DYSFUNCTION IN NEUROMUSCULAR DISORDERS

The popularity and reported success of biofeedback treatment for neuromuscular disorders has occurred despite a lack of research identifying the critical variables responsible for therapeutic gain. In this study, we assessed the degree to which severe neurological dysfunction could be improved by using one of the components present in all biofeedback treatment, contingency management. Three cases of orofacial dysfunction were treated by reinforcing specific improvements reliably detectable without the use of biofeedback equipment. The results showed that contingency management procedures alone were sufficient to improve overt motor responses but, unlike biofeedback treatment, did not produce decreases in the hypertonic muscle groups associated with the trained motor behavior. The findings suggest that sophisticated, expensive biofeedback equipment may not be necessary in treating some neuromuscular disorders and that important clinical gains may be achieved by redesigning the patient's daily environment to be contingently therapeutic, rather than only accommodating the disabilities of the physically handicapped.     

BEHAVIORAL ASSESSMENT AND TREATMENT OF CHRONIC FOOD REFUSAL IN HANDICAPPED CHILDREN

In this study, we examined the eating behavior of four handicapped children, none of whom exhibited self-feeding skills. All children had a history of food refusal and were nutritionally at risk; one child received all nourishment by way of a gastrostomy tube. Baseline data taken during mealtimes indicated that all children accepted very little food, expelled food frequently, and engaged in a number of disruptive behaviors. Treatments consisted of one or more of the following contingent events: social praise, access to preferred foods, brief periods of toy play, and forced feeding. Results of multiple-baseline and reversal designs showed marked behavioral improvement for each child and increases in the amount of food consumed. Further improvements were noted at follow-up, which ranged from 7 to 30 months posttreatment.     

A “new rhetoric” for a “new dialectic”: Prolegomena to a responsible public argument

This essay offers, as a counterpart to pragma-dialectical argument, a “new rhetoric” produced in the situated discourse of a public forum when a community addresses matters of common urgency and undertakes informed action. Such a rhetoric takes the principles of discourse ethics as its informing dialectic by identifying an interlocutor as one who is obligatedboth to argue effectively,and also to hold open, even reinforce, norms of communicative reason. Implications concerning the study of fallacies and theethos obligations of communicative reasoning are discussed.     

医学的“死亡”背景与现代医学对死亡的遗忘

人是一种承担着有死性的存在物,一切从人出发并为了人的事业都必须在“人固有一死”的背景中进行。首先阐述了死亡对于医学的背景意义:死亡是人类面临的客观的、必要的限制,关于死亡的立场对于医学具有源始性与优先性,最后从三个方面揭示了当代医学对于死亡的立场:遗忘。