What's in a Number?

“I'm a six,” Freddy Lowell says after a thoughtful pause. Seven milligrams of Dilaudid, a potent narcotic pain reliever, is already being pushed into a port in his chest by a visibly busy nurse. She registers his pain score with a grunt. She will be back in two hours to ask for an updated number. At some point during this time, his pain will creep back, so strong it will render him mute. When the nurse next inquires, he will respond with seven fingers, his face buried in his pillow. The Numerical Rating Scale has been a mainstay of clinical care since the late 1990s, when pain came to be referred to as the “fifth vital sign” alongside temperature, blood pressure, heart rate, and respiratory rate. But while the first four are measured with precise objectivity, pain is nuanced, complex, and personal, so much so that Freddy will quickly chastise anyone who tries to empathize with his plight. “Nobody knows what it's like,” he says decisively.     

Human embryos in the original position?

Two different discussions in John Rawls' A Theory of Justice lead naturally to a rather conservative position on the moral status of the human embryo. When discussing paternalism, he claims that the parties in the original position would seek to protect themselves in case they end up as incapacitated or undeveloped human beings when the veil of ignorance is lifted. Since human embryos are examples of such beings, the parties in the original position would seek to protect themselves from their embryonic stages onward. When discussing the basis of equality, Rawls claims that the parties in the original position would guarantee basic rights for all those with the capacity to take part in this original position. To guarantee the basic rights of infants and young children, he goes on to interpret this capacity as a "potentiality that is ordinarily realized in due course." Since human embryos have this potentiality, they too should have basic rights.     

Have changes in the context of doctors' work altered the concept of the professional in medicine?

There is clearly current interest in the subject of doctors as professionals. Many other bodies look towards medicine for a definition of a professional. The term 'professional' is not easy to define but appears to include the concepts of a body of specialized knowledge and skill, autonomy, trust, responsibility and integrity, serving society, direct interaction with clients, duty to speak with authority and a licence to practise. This paper reflects on the changes in doctors' work, looking for any alteration in the concept of a professional. There have been significant recent changes in the context of medical work; medicine has suffered much bad publicity. In addition there have been major changes to the regulatory council and there have also been fundamental registration changes, including the revalidation of registration. The government has made substantial changes involving performance targets and management. In addition, patient power has been enhanced. This paper contends that there has been little change in the professional role of medical practitioners; this lack of change assists with defining the whole concept of a professional. The professional role appears to include elements of specialized knowledge, a service ethic and critical evaluation, but there are traits of personality within the concept. The paper concludes with the realization that a definition of a professional is both difficult and continually changing. There are important implications from this paper for other groups that seek to be professionals. Certainly, any such group needs to convince others that this title should indeed be used.     

Can you keep a secret? Pretences of confidentiality in HIV/AIDS counseling and treatment in Eastern Indonesia

A critical feature of contemporary interventions of HIV is the provision of voluntary counseling and testing. Protecting the confidentiality of the client is a lynchpin of successful counseling. This article explores the teaching and implementation of the concept of confidentiality in highlands Papua, Eastern Indonesia. Results of participant observation and in-depth interviews with clinic staff in 2009 and 2010 show that confidentiality is an ideal poorly taught and systematically violated in practice. Identifying, labeling, and regulating HIV-positive persons appears more important than enacting the humanitarian and moral imperative of protecting client rights. Confidentiality becomes the means to enact dividing practices and to create categories of persons-those who choose to adhere to therapies and those who do not. The implications of this pattern are discussed with reference to wider humanitarian initiatives.     

How strong is the case for the adoption of problem-based learning in physiotherapy education in the United Kingdom?

Despite its use in medical and health education in several countries, problem-based learning (PBL) has to date not been adopted in undergraduate physiotherapy education in the UK. Most of these physiotherapy curricula incorporate many of the educationally desirable features found in PBL. The question is whether the evidence for PBL is strong enough to justify the costs involved in adopting it on such programmes. The strength of the evidence for PBL was reviewed in relation to required graduate attributes and several aspects of learning theory. Overall the findings were equivocal. The evidence suggests that PBL is preferential to traditional curricular design, but does not seem to meet all the requirements of medical and health education. Adoption of PBL would be positive, but its processes and outcomes may be no more successful than those of other curricular designs that incorporate the same sound educational design features. Comparative research in this area is needed.     

Who's in the business of saving lives?

There are individuals, including children, dying needlessly in poverty-stricken third world countries. Many of these deaths could be prevented if pharmaceutical companies provided the drugs needed to save their lives. Some believe that because pharmaceutical companies have the power to save lives, and because they can do so with little effort, they have a special obligation. I argue that there is no distinction, with respect to obligations and responsibilities, between pharmaceutical companies and other types of companies. As a result, to hold pharmaceutical companies especially responsible for saving lives in third world countries is unjustified.     

Does hearing the patient perspective improve consultation skills in examinations? An exploratory randomized controlled trial in medical undergraduate education

Purpose: Medical education increasingly includes patient perspectives, but few studies look at the impact on students’ proficiency in standard examinations. We explored students’ exam performance after viewing video of patients’ experiences.

Methods: Eighty-eight medical students were randomized to one of two e-learning modules. The experimental group saw video clips of patients describing their colposcopy, while the control group viewed a clinician describing the procedure. Students then completed a Multiple Choice Questionnaire (MCQ) and were assessed by a blinded clinical examiner in an Objective Structured Clinical Examination (OSCE) with a blinded simulated patient (SP). The SP scored students using the Doctors’ Interpersonal Skills Questionnaire (DISQ). Students rated the module’s effect on their skills and confidence. Regression analyses were used to compare the effect of the two modules on these outcomes, adjusting for gender and graduate entry.

Results: The experimental group performed better in the OSCE than the control group (odds ratio 2.7 [95%CI 1.2–6.1]; p?=?0.016). They also reported significantly more confidence in key areas, including comfort with patients’ emotions (odds ratio 6.4 [95%CI 2.7–14.9]; p?<?0.0005). There were no other significant differences.

Conclusion: Teaching that included recorded elements of real patient experience significantly improved students’ examination performance and confidence.     

Was the black death in India and China?

Firsthand accounts of the Black Death in Europe and the Middle East and many subsequent historians have assumed that the pandemic originated in Asia and ravaged China and India before reaching the West. One reason for this conviction among modern historians is that the plague in the nineteenth century originated and did its worst damage in these countries. But a close examination of the sources on the Delhi Sultanate and the Yuan Dynasty provides no evidence of any serious epidemic in fourteenth-century India and no specific evidence of plague among the many troubles that afflicted fourteenth-century China.     

Tensions in mentoring medical students toward self-directed and reflective learning in a longitudinal portfolio-based mentoring system – An activity theory analysis

Background: In medical education, students need to acquire skills to self-direct(ed) learning (SDL), to enable their development into self-directing and reflective professionals. This study addressed the mentor perspective on how processes in the mentor–student interaction influenced development of SDL.

Methods: n?=?22 mentors of a graduate-entry medical school with a problem-based curriculum and longitudinal mentoring system were interviewed (n?=?1 recording failed). Using activity theory (AT) as a theoretical framework, thematic analysis was applied to the interview data to identify important themes.

Results: Four themes emerged: centered around the role of the portfolio, guiding of students’ SDL in the context of assessment procedures, mentor-role boundaries and longitudinal development of skills by both the mentor and mentee. Application of AT showed that in the interactions between themes tensions or supportive factors could emerge for activities in the mentoring process.

Conclusion: The mentors’ perspective on coaching and development of reflection and SDL of medical students yielded important insights into factors that can hinder or support students’ SDL, during a longitudinal mentor–student interaction. Coaching skills of the mentor, the interaction with a portfolio and the context of a mentor community are important factors in a longitudinal mentor–student interaction that can translate to students’ SDL skills.