Understanding the dynamics of the patient-physician relationship: balancing the fiduciary and stewardship roles of physicians

There has been growing concern about the effects on the patient–physician relationship of the increasing demands on physicians to balance their fiduciary and stewardship responsibilities, what has been called double agency. Various authors have proposed ways to restore patient centeredness to the patient–physician interaction. We have previously discussed the need to establish a patient–physician alliance to achieve this aim and to facilitate achieving this balance in mutual understanding. In this essay, we examine six concepts derived by Michael Balint from research seminars with primary care physicians. These six concepts are (a) the basic fault; (b) the physician's apostolic function; (c) the mutual investment company; (d) the drug doctor; (e) the deeper diagnosis; and (f) the conspiracy of anonymity. We believe these six concepts describe basic forces that shape the patient–physician relationship and allow for the development of an alliance between patients and physicians that can help preserve the essentials of the relationship.     

Ethical issues in the publication of clinical material

Some of the ethical issues involved in publishing clinical material are considered. These include the 'ownership' of such material, the responsibilities of the analyst towards patients and professional colleagues, the keeping and status of records, the nature of trust and confidentiality and its place in analysis, the question of obtaining consent for publication, the nature of consent, and its consequences for treatment. The issues of disguise, of authenticity, and of accuracy are also touched on, as is the potential role of the author's anonymity in protecting the anonymity of the patient.     

Desires in Palliative Medicine. Five Models of the Physician‐Patient Interaction on Palliative Treatment Related to Hellenistic Therapies of Desire

In this paper, we explore the desires that play a role at the palliative stage and relate them to various approaches to patient autonomy. What attitude can physicians and other caregivers take to the desires of patients at the palliative stage? We examine this question by introducing five physicians who are consulted by Jackie, an imaginary patient with metastatic lung carcinoma. By combining the models of the physician-patient relationship developed by Emanuel and Emanuel (1992) and the Hellenistic approaches to desires analyzed by Nussbaum (1994), five different ways of dealing with desires in the context of palliative care are sketched. The story of Jackie shows that desires are to a certain extent responsive to reasoning. In the palliative process, that can be a reason to devote attention to the desires of patients and caregivers and to determine which desires need to be fulfilled, which are less important, and how they are linked to emotions the patient has.     

对SARS病人及相关人员实施隔离等强制措施的思考

对SARS病人及相关人员采取隔离等强制措施是有效控制疫情扩展的重要和主要手段,但同时也是剥夺公民人身自由的一种行为。SARS防治的要求与现行法律存在着一定的冲突;紧急特殊情况下的行政应急措施应属必要。对相关法律进行完善,严格依照法定的条件符合法定程序实施强制措施,才能既有利于控制疫情又充分保障被隔离者的合法权益。     

The classification of neuropsychological deficit

The study involves classification of neuropsychiatric patients on the basis of neuropsychological and intelligence test performance. One hundred twenty-five hospitalized male neuropsychiatric patients with various diagnoses were administered the Halstead-Reitan and Luria-Nebraska neuropsychological test batteries, as well as the Wechsler Adult Intelligence Scale. A cluster analysis was performed for each of those three procedures utilizing Ward's method. It was found in all cases that clusters were determined on the basis of level rather than pattern of performance. Relationships were found between cluster membership and age, education, and presence or absence of structural brain damage but were not found for diagnoses of schizophrenia or alcoholism. Schizophrenic and alcoholic patients were found in all clusters in the case of all three test procedures. Differences in clustering among the three test procedures were noted, with the WAIS being relatively more sensitive to educational differences while the Halstead-Reitan was more sensitive to age differences. The clinical utility of classifying patients on the basis of neuropsychological and cognitive test performance was discussed.Acknowledgement is made to the Veterans Administration for support of this research.     

The death of an analysand: transference, countertransference and desire

This paper is offered as an exploration of transference and countertransference issues when, in the process of analysis, the analysand becomes terminally ill. Written from the point of view of the analyst, eros and boundary issues are discussed. It is proposed that those who are about to die may form particularly intense erotic attachments and that this is characteristic of a speeded up individuation process. The paper is based on the case of a suicidally depressed man who formed an immediate, dependent and erotic transference. After three months, he was diagnosed as having an inoperable lung cancer. From then on the analytic frame was challenged by pressures to act out in a number of different ways. It is argued that gender difference and the heterosexual pairing facilitated the differentiation of adult, sexual and Oedipal feelings from infantile, pre-Oedipal ones. Maintenance of the analytic frame enabled the individuation process to continue to the end.     

Re-Evaluating Professional Autonomy in Health Care

Professional autonomy, as the symbol of the traditional freedom ofdecision-making of medical professionals is criticized. This essayexamines the critique. It analyses the underlying assumption that theautonomy of health professionals is incompatible with the need fororganisation and management in order to control rising health carecosts. It is argued that the concept of professional autonomy should beredefined, not through restricting the decision-making freedom ofindividual health professionals, but through expanding the concept intothe sphere of management, so that managers will take responsibility forpatient care.