Following in the footnotes of giants: citation analysis and its discontents

Reflecting on his own personal history with bibliometrics, the author places it in the broader context of research with available information and data-mining. In so doing, he considers the utility of bibliometrics for raising new questions and its limitations for guiding decision-making.     

The Patient Perspective as an Integral Part of Diabetes Disease Management

Individuals with diabetes mellitus and their providers view the world from their own perspectives and bring these different perspectives to the clinical encounter. Because individuals with diabetes enact the day-to-day management of their disease, their perspective will, therefore, largely determine their behaviours.A broad interpretation of how to think about individuals in their patient role, their social context and their relationships with providers creates opportunities for providers to assist patients in life-enhancing ways. Steps for providers include examining their own values and attitudes about diabetes and its treatment, contextualising patient responses and incorporating a different set of questions in the clinical encounter. Steps for organisations include involving patients in interdisciplinary meetings, evaluation of system and provider quality, creating a milieu which supports dialogue and relationship development, important elements of a caring environment.     

Following in the Footnotes of Giants

Abstract

Reflecting on his own personal history with bibliometrics, the author places it in the broader context of research with available information and data-mining. In so doing, he considers the utility of bibliometrics for raising new questions and its limitations for guiding decision-making.     

Physician Opportunities

Objective tumor regression in response to therapy invariably results in prolonged patient survival and often improves the quality of remaining life. The author describes criteria for determining, and clinical guidelines for predicting, tumor response. Further, he reviews tactics of cancer chemotherapy with regard to dose-response relationships and kinetics of tumor response.     

The face of cancer

Two voices tell the story of an evolving doctor-patient relationship. Seizures are the first indication of squamous cell lung cancer metastatic to the brain. Both doctor and patient describe the course of the illness, treatment, and remarkable recovery, each from his own perspective. The patient describes how the cancer became a creative as well as a destructive force, expressed in his painting and new approach to life. The essay concludes by discussing limitations of the biomedical model of disease in this case and the complex two-way nature of the healing relationship between doctor and patient.     

Reason, courage, and grace: notes of a death watcher

Dying is strikingly private and personal, and it breaks the interconnectedness of all human life. It is at such a time that the physician's humanity must touch the unique personhood of the afflicted if the death is to be "good". A physician's duty does not rest on the medical profession's code of conduct; it consists of the physician's moral obligation to a specific person in a specific situation. That person's entire identity--not just the physical being--is assaulted by terminal illness; the emotional, familial, and social dimensions of selfhood are ravaged by the disease as surely as is the body. Each individual is involved in his or her suffering in a way that is unique and that cannot be understood or appreciated by anyone else. But the physician must try to bridge the distance that is placed around the sufferer by the dying process. And it is only with his or her own humanity that the care giver can accomplish this. That humanity should inform all decision making, and thus bring with it genuine control and comfort. In this way the patient can truly "own" his or her own death. The patient can thereby attain reason and courage, which together are the quality of grace.     

Houseparents: A vignette

Being with a youngster in crisis means that the adult, too, is involved and may be affected as much as is the youngster himself. The author describes such a situation when a 14-year old has open heart surgery, and its impact on the worker and on the relationship between him and the youngster.The author and his wife are live-in house parents of Torresdale House, a group home for six dependent/neglected adolescent boys operated by St. Francis Vocational School.Clayton, fourteen, came to Torresdale House two years ago. His mother has always had poor health, both physically and mentally. His father left the family when the boy was born. When Clayton contacted his family, he was met with indifference. The boy was raised by a next door neighbor until she had problems of her own and he was placed at Torresdale House.Clayton came with a tendency to magnify everyday life experiences. He also had a habit of turning situations around so that he could derive self-pity—probably in order to reinforce a poor self-image and the idea that he is generally unlucky in life. Clayton has had bad moments at Torresdale House, like stealing 200 dollars from the budget money, but he is generally warm and sensitive. He is small for his age, and has had two medical problems: cysts growing at the tip of his nerve endings, and a heart strain caused by a tight, fleshy substance growing in his subaortic valve which is slowly causing this channel to close. He needed heart surgery.     

Reflections on ASCO (American Society of Clinical Oncologists)

As life expectancy increases and the population ages, people become more susceptible to degenerative diseases such as cancer. This has wide-ranging implications for cancer care, a specialty that has historically been underfunded and under-resourced in the UK. Dr. Martin Duerden, who canvassed the opinions of UK oncologists at the American Society of Clinical Oncologists' conference in Los Angeles earlier this year, focuses on the provision of chemotherapy in the context of the latest evidence and considers the implications for cancer care in a changing NHS.     

Doctor‐patient communication patterns in breast cancer adjuvant therapy discussions

Objective To identify variables within the patient‐oncologist communication pattern that impact overall patient comprehension and satisfaction within the breast cancer adjuvant therapy (AT) setting. Setting and participants Fifty patients were recruited from a number of academic and community‐based oncology practices. Fifteen oncologists participated. Main variables Three communication variables were identified: percentage of total utterances spoken by the patient, percentage of total physician utterances that were coded as affective (i.e. emotional), and total number of questions asked by the patient during the consultation. Knowledge and satisfaction were assessed by a variety of outcome measures, including knowledge items and satisfaction as measured by VASs, the satisfaction with decision scale and the decisional conflict scale. Results The level of patient knowledge about breast cancer and satisfaction with the clinical encounter showed a tendency to correlate with the variables measuring aspects of patient‐physician communication style. Patients who spoke more or asked more questions tended to be more knowledgeable whilst patients whose physicians used more affective language tended to know less but to be more satisfied with their clinical encounter. Conclusions In order to optimize patients’ degree of comprehension and satisfaction with their breast cancer adjuvant therapy, physicians need to increase their affective participation in clinical encounters whilst encouraging patients to ask questions and to actively participate in the decision‐making process.     

Patient advocacy: psychiatrists' perspectives

This paper describes the responses of senior psychiatrists in Wales to a questionnaire exploring their knowledge and beliefs about patient advocacy. The results suggest mainly pro-advocacy attitudes; respondents who had not met advocacy groups involving their own patients holding attitudes almost as positive as those who had. However, despite these findings, further research is required to define the specific benefits of advocacy before further resources are diverted to the development of such services.     

Profile of an adolescent problem drinker

A study was conducted to determine what sociocultural and demographic variables can be used to identify potential problem drinkers among adolescents in middle school and high school. Three thousand seventeen students were administered an in-depth questionnaire regarding their knowledge, attitudes, and behavior toward the use of alcohol. Twenty schools in six school districts in the two-state area of Georgia and South Carolina participated in the study. A number of analyses indicated that the student heavy drinker was most typically male, white, and between the ages of 14 and 15 years with an above average knowledge about alcohol and liberal attitudes toward alcohol use. The adolescent heavy drinker is more likely to have parents and best friends who are heavy drinkers, to have had his first encounter with alcohol at an early age, to drink with friends his own age, and to feel that almost all of his friends drink. Results of this study can be used by family physicians in the management of potential alcohol abusers. Early recognition and intervention by the family physician may help to reduce the alarming number of adolescents who are struggling with problems related to alcohol.     

Alcoholics remaining anonymous: resident diagnosis of alcoholism in a family practice center

Family practice residents rarely detect more than one half of the alcoholic patients they see. This study examines detection rates in terms of the patient's presenting complaint, the clinical encounter, and the resident's attitudes. Over four months 218 patients of the family practice center of a large community hospital completed a survey that included the Short Michigan Alcoholism Screening Test (SMAST). Chart audits of each patient's visit assessed each resident's behavior in recording questions about the patient's use of alcohol. After the first four months, each resident completed a survey of his or her experiences and attitudes concerning alcoholism. Using the SMAST scores and chart audits, 25 of the 218 patients were identified as alcoholic. The residents detected only 12 of the 25 alcoholics. Of 51 patients who presented for physical examinations, the residents recorded asking only 28 about their drinking; of 157 patients who presented for more limited visits, the residents recorded asking only six about their drinking. Residents rated the alcoholic patient as less motivated, more dangerous, less hopeful, and much sicker than the average person. First-year residents rated alcoholics much more negatively than did upper-level residents. The SMAST again proved to be much more effective than clinical interviews in detecting alcoholism in patients.     

A comparison of attitudes towards end-of-life decisions: survey among the Dutch general public and physicians

In The Netherlands, there has been a continuing public debate about the acceptability and regulatory system for medical decision-making concerning the end of life. We studied attitudes of the Dutch general public towards different types of end-of-life decisions in various situations and compared them to attitudes of physicians. Questionnaires were mailed to 1777 members of the Dutch general public (response: 78%). A total of 391 Dutch physicians, including general practitioners, nursing home physicians and clinical specialists, were interviewed in person (response: 81%). In both the survey and physician interviews, questions were asked about attitudes towards active ending of life, terminal sedation, and increasing morphine with premature death as a likely consequence, using hypothetical cases of different patients. By logistic regression analysis, the differences between public and physicians' attitudes were assessed, as well as the associations between attitudes of the general public and their personal characteristics. Acceptance of active ending of life at the request of a terminally ill cancer patient was higher among the general public (85%) than among physicians (64%). For physicians, acceptance decreased to 36% for an incompetent adult, 11% for a patient without a serious disease, and 6% for a patient with dementia. For the general public, these percentages were 63%, 37%, and 62%, respectively. Between both groups, no differences were found in acceptance of terminal sedation and increasing morphine. For the general public, determinants of support for active ending of life were being non-religious, lower education, and having a single household. Acknowledging the observed differences in appreciation of end-of-life decision-making between the general public and physicians is important in doctor-patient communication and in public debate and policymaking. Continued monitoring of practices and informing the general public and policymakers about the clinical and ethical consequences of different types of end-of-life decisions is important.     

“I know I don't have to apologize for crying”: When our history becomes our experience

Professional child and youth care workers in North America can derive strength and inspiration from the lives of many of their European ancestors. Notable among these is Janusz Korczak who, along with his staff, chose to accompany the children of the Warsaw Orphans' Home to their terrible death. Family reunions of those involved in child and youth care work from around the world are now happening with some regularity, and the author illustrates from his own experience how such international involvement can lead to important personal and professional transformations of perspective and attitude.     

Cancer of the colon and rectum: public misconceptions and a gap in doctor-patient communications

What can doctors do to reduce the death rate among the estimated 126,000 persons who will develop colon-rectum cancer in 1983? At present rates, 29,500 females and 27,600 males will die this year from cancers at these sites. One answer to this question may lie in patient-physician communication, and in the capability of doctors to deal with patient attitudes toward colo-rectal examinations and on their knowledge of what people in this country believe in regard to colon-rectum cancer. This article presents findings from an American Cancer Society survey which examined patient attitudes and knowledge in regard to colon-rectum cancer and provides insights on patient attitudes and beliefs useful to the physician in discussing this subject with patients.     

Preserving life and limb on the stage of death: the Dance of Death by Dr Salomon van Rusting

Salomon van Rusting was a medical doctor from Amsterdam who lived and worked around the early 1700 s. He wrote one of the few Dutch Death Dances, naming it 'Het Schouw-Tooneel des Doods'. A Death Dance was an artistic expression of human death popular in the Late Middle Ages. The traditional Death Dance invited acknowledgement of the vanity of worldly existence ('memento mori') by portraying human subjects' encounters with 'Death'. This paper describes the context in which Van Rusting's work arose and briefly characterizes its highly original and, for the most part, rather burlesque nature. In contrast to other Death Dances, Van Rusting's work does not represent medicine as being powerless in the face of death. His work strikes us as having almost modern confidence in our own ability to avoid an untimely death by living sensibly.     

Case study of a chaplain's spiritual care for a patient with advanced metastatic breast cancer

The case study seeks to describe an oncology chaplain's pastoral relationship with a 64-year-old woman with advanced metastatic breast cancer. The patient's distress was complicated by a history of anxiety and other chronic medical conditions. Approximately 16 pastoral encounters occurred during the last year of the patient's life. The patient, chaplain, and the pastoral conversations are presented as well as a retrospective assessment of them. The chaplain's interventions were appropriate for the patient's spiritual needs, particularly in regard to her fear of death, loneliness, grief that her life was "too short" and estrangement from her inherited faith tradition, with observable benefits for the patient. The oncology chaplain has a distinctive role in the healthcare team as one who can meet the patient at the point of their spiritual need, provide appropriate interventions and, thereby, ameliorate the distress, particularly in regard to death anxiety, peace of mind, and issues of meaning.     

Workplace violence prevention education after JCSEA 45

With the release of The Joint Commission's Sentinel Event Alert, Issue 45: Preventing Violence in the Healthcare Setting" in June, 2010, the existence of such violence and the need to provide more effective workplace violence education was officially recognized by the industry's certifying authority. In this article, the author describes a seven-step prevention methodology that has been put in place in his health system.     

Visual hallucinations and unusual pain related to hypomagnesemia in an advanced cancer patient

Hypomagnesemia has been related to high accumulated doses of cisplatin, and its clinical presence is characterized by neuromuscular and cardiovascular alterations. We present the case of an advanced cancer patient who had received successive lines of chemotherapy and who was receiving opioid treatment for cancer pain. During his hospital stay, he experienced visual hallucinations and very intense, unexplained pain in one shoulder. Symptoms reverted with the normalization of his plasma magnesium levels, which were low. We consider that plasma magnesium levels should be monitored in oncology patients with neurological or psychiatric symptoms or with unusual pain.     

The "doctor-customer" relationship: Hippocrates in the modern marketplace

We performed a consecutive survey of 100 people presenting to a hospital injury clinic to ascertain their attitude to terminology currently used to describe them in our own institution and in the international literature. The results of this demonstrated that the subjects significantly preferred the traditional assignation "patient" rather than terms such as client or customer. This finding reflects the need to remember peoples' attitudes and expectations from their consultation with their doctor. Although business models undoubtedly help in the provision of an efficient health care service, remaining at the centre of this encounter is a doctor-patient relationship that involves a more complex interaction than simply a market transaction.