整合循证医学与叙事医学的可能与不可能

基于整合循证医学与叙事医学的假定目标提出三点思考,其一是重视研究循证医学与叙事医学的不可通约性,将前者定义为视觉(证据)优势的医学,后者定义为听觉(共情)优势的医学,并予以价值分野的阐释;其二是从思想史的角度考察循证医学与叙事医学的精神发育,从中捕捉两种医学认知路径的类型意义;其三建议将肿瘤这一涉及身心灵不同境遇的临床领域作为整合循证医学与叙事医学思维路径的试验田。     

Saints-protectors from Snake Bite: A Short Overview and a Tentative Analysis

A short overview of several saints, including Peter, Paul, John, George, Hilarius, Hubert, and Gaudentius, venerated in Christian tradition as protectors from snake bite, is offered as an introduction to a more substantial debate on the factors determining the choice of protectors in folk medicine, as well as on the possible adjuvant effect of (auto)suggestive therapy obtained by the invocation of saints.     

The Role of Religion and Spirituality in Medical Patients in Germany

Using the new developed SpREUK questionnaire (version 1.0b), we examined how German patients (n = 129) with cancer, multiple sclerosis and other diseases view the impact of spirituality and religiosity (SpR) on their health and how they cope with illness. Patients with both a religious and spiritual attitude (32%) had significantly higher values in the sub-scales dealing with the search for meaningful support, and the stabilizing effects of SpR than patients without such attitudes (20%), while patients with a non-spiritual religious attitude (35%) had lower perception of the beneficial effects of their SpR and had significantly lower scores in the search for meaningful support sub-scale. Just half of the non-spiritual religious group and 42% of religious patients are convinced that finding an access to a spiritual source has a positive influence on their illness.     

Spiritual Beliefs and Barriers Among Managed Care Practitioners

Purpose: Ninety percent of American adults believe in God and 82% pray weekly. A majority wants their physicians to address spirituality during their health care visit. However, clinicians incorporate spiritual discussion in less than 20% of visits. Our objectives were to measure clinician beliefs and identify perceived barriers to integrating spirituality into patient care in a statewide, primary care, managed care group. Methods: Practitioners completed a 30-item survey including demographics and religious involvement (DUREL), spirituality in patient care (SPC), and barriers (BAR). We analyzed data using frequencies, means, standard deviations, and ANOVA. Findings: Clinicians had a range of religious denominations (67% Christian, 14% Jewish, 11% Muslim, Hindu or Buddhist, 8% agnostic), were 57% female and 24% had training in spirituality. Sixty-six percent reported experiencing the divine. Ninety-five percent felt that a patients spiritual outlook was important to handling health difficulties and 68% percent agreed that addressing spirituality was part of the physicians role. Ninety-five percent of our managed care group noted 8lack of time as an important barrier, lack of training was indicated by 69%, and 21% cited fear of response from administration. Conclusions: Managed care practitioners in a time constrained setting were spiritual themselves and believed this to be important to patients. Respondents indicated barriers of time and training to implementing these beliefs. Comparing responses from our group to those in other published surveys on clinician spirituality, we find similar concerns. Clinician education may overcome these barriers and improve ability to more fully meet their patients expressed needs regarding spirituality and beliefs.*This material has previously been presented as an abstract at the Culture and End of Life Conference, Association of Medical Colleges Spirituality, Kansas City, MO, September 12–14, 2002.Project supported by the Foundation for Spirituality in Medicine, Baltimore, MD     

The trauma triangle

Recent research supports the hypothesis that more active engagement of the patient in occurring illnesses improves quality of life and probably even life expectancy.In this study experience and theoretical knowledge from psychotherapy is transplanted to clinical practice in order to improve the physician's engagement in the patient-disease relationship. By defining severe and long-term illnesses as a psychotrauma, the transfer of the psychotherapeutical model leads to the creation of a new triangular relationship: patient-illness-doctor. Practical examples are used as illustrations for the conceptual differences between psychotherapy and clinical medicine. Options for dialogue show the difference between adaptation (learning to live with) and adjustment (active coping strategies and controlling). The hypothesis is that a better dialogue will reduce illness-related stress, giving the patient better and more effective access to personal psychic and physical support systems.     

Involvement of cardiac,respiratory and gastrointestinal functions in neural responses to stressful events

In the stress concept, fight and flight situations as well as other CNS-controlled reaction patterns for alertness to danger have to be followed by or integrated with a restorative “build-up” process in order to maintain homeostasis. The “build-up” process can be studied physiologically for example after regular exercise or training. Under these conditions there is a decrease in resting sympathetic adrenergic activity and an increase in the parasympathetic vagal activity. A theoretical model for the “build-up” process in psychosomatic gastroenterology has previously been presented. The present paper deals with the “build-up” process in cardiovascular and respiratory tract diseases seen in athletes. Anorexia nervosa related to excess physical training is also discussed as well as the “build-up” process in severe obesity and psychosomatic gastroenterological disorders.     

BEHAVIORAL RESEARCH IN PREVENTIVE DENTISTRY: EDUCATIONAL AND CONTINGENCY MANAGEMENT APPROACHES TO THE PROBLEM OF PATIENT COMPLIANCE

This study examined the effects of reinforcement on compliance with an oral hygiene education program. Patients 18 years of age or older who enrolled in an ongoing program at a periodontal practice received 3–5 sessions of instruction in preventive dental care. Using a between-subjects design, patients who entered the program during alternating months also had a portion of their fees refunded contingent upon improvements in their dental plaque scores. Pre- and posttreatment data showed that all subjects exhibited lower plaque levels following the program, but that greater improvements were seen in patients who were exposed to the fee reduction contingency. Plaque scores taken at a 6-month follow-up revealed some relapse for the Fee Reduction subjects. However, their scores were still substantially better than pretreatment, and better than those of the Education only subjects, whose data differed little from untreated Controls. Methodological and practical issues related to behavioral research in preventive dentistry are discussed.     

Psychological aspects of scuba diving injuries: Suggestions for short-term treatment from a psychodynamic perspective

Dive medicine is described as an area of practice in which psychologists may choose to expand their clinical service and research activities. The author argues that most research studying risk behavior and sports take into account biological, behavioral or cognitive approaches, while ignoring unconscious conflict in risk-taking and injury management. The present paper uses a psychodynamically-oriented, interview-based approach to studying psychological reactions to decompression sickness in three experienced scuba divers. Brief interventions and their outcomes are described.     

冠状动脉搭桥术后再狭窄研究的思考

冠状动脉搭桥术(CABG)是目前外科治疗冠心病的成熟、定型的手术方法,但术后再狭窄影响了病人的远期疗效,其研究也越来越受到人们重视。随着生物医学模式向生物心理社会医学模式的转变,研究者对CABG术后再狭窄也有了更深入的认识,更加注重整体性、动态化和系统最优化。试用系统论方法探讨CABG术后再狭窄的防治。     

“比较治疗学”与“循证医学”之比较

对比较治疗学与循证医学兴起的历史背景、基本内涵的差异以及在临床决策方法方面的关系进行了较为细致的比较。循证医学与比较治疗学分属于临床决策的两个不同的阶段,比较治疗学的内涵范围要大于循证医学,同时循证医学为比较治疗学提供主要的基础性决策依据,比较治疗学的决策方法是循证医学在临床决策方法上的新发展。两者对促进临床科学决策都具有重要意义。