Building bridges between doctors and patients: the design and pilot evaluation of a training session in argumentation for chronic pain experts

Shared decision-making requires doctors to be competent in exchanging views with patients to identify the appropriate course of action. In this paper we focus on the potential of a course in argumentation as a promising way to empower doctors in presenting their viewpoints and addressing those of patients. Argumentation is the communication process in which the speaker, through the use of reasons, aims to convince the interlocutor of the acceptability of a viewpoint. The value of argumentation skills for doctors has been addressed in the literature. Yet, there is no research on what a course on argumentation might look like. In this paper, we present the content and format of a training session in argumentation for doctors and discuss some insights gained from a pilot study that examined doctors' perceived strengths and limitations vis-à-vis this training

Implementation of XpertMalTyph: An Expert System for Medical Diagnosis of the Complications of Malaria and Typhoid

The dearth of medical experts in the developing world has subjected a large percentage of its populace to preventable ailments and deaths. Also, because of the predominant rural communities, the few medical experts that are available always opt for practice in the few urban cities. This consequently puts the rural communities at a disadvantage with respect to access to quality health care services. In this work, we designed and implemented XpertMalTyph; a novel medical diagnostic expert system for the various kinds of malaria and typhoid complications. A medical diagnostic expert system uses computer(s) to simulate medical doctor skills in diagnosis of ailments and prescription of treatments, hence can be used to provide the same service in the absence of the experts. XpertMalTyph is based on JESS (Java Expert System Shell) programming because of its robust inference engine and rules for implementing expert system

Distinguishing personal belief from scientific knowledge for the betterment of killer whale welfare – a commentary

We contest publication of Marino et al. regarding captive killer whale (Orcinus orca) welfare because of misrepresentations of available data and the use of citations that do not support assertions. Marino et al. misrepresent stress response concepts and erroneously cite studies, which appear to support Marino et al.’s philosophical beliefs regarding the cetacean hypothalamic–pituitary–adrenal axis. To be clear, these misrepresentations are not differences of scientific opinion, as the authors’ conclusions lack any scientific basis. More extensive review of Marino et al.’s citations reveal a dearth of empirical evidence to support their assertions. Further, Marino et al.’s approach to animal welfare is not consistent with conventional veterinary approaches to animal welfare, including their apparent opposition to use of preventative and therapeutic veterinary interventions. While Marino et al. argue that killer whales’ cognitive and spatial needs preclude management of this species under human care, misrepresentation of the citations used to support this opinion invalidates their arguments. Misleading interpretations of data relative to killer whales’ cognitive and emotional needs and specious and unsubstantiated comparisons with states experienced by humans with posttraumatic stress disorder and other conditions, represent a number of strategies used to misrepresent knowledge regarding killer whale welfare. These misrepresentations and fallacies are inconsistent with scientific ethical standards for credible, peer-reviewed journals (ICMJE, 2018), and are barriers to rigorous discourse and identification of strategies for optimizing killer whale welfare. Assertions in the paper amount to nothing more than a compilation of conclusory, philosophical statements. We would also like to mention that manuscripts such as Marino et al.’s do great damage to the fields of comparative psychology and to behavioral science as a whole

Handbuch Kommunikationsstrategien zur Schärfung des Umweltbewusstseins im Umgang mit Arzneimitteln : Forschungsvorhaben 37 08 61 400 des Umweltbundesamtes

In Germany, as in almost all industrial countries, active pharmaceutical substances can now be found in virtually all water bodies and occasionally also in drinking water. Even though the concentrations in question tend to be very low, there are initial signs of their impact on aquatic life. There is no evidence as yet of any acute consequences for human health. It is, however, impossible to rule out long-term consequences from these minimal concentrations or unexpected effects from the interaction between various active ingredients (cocktail effect). At special risk here are sensitive segments of the population such as children and the chronically ill. There is thus a need for action on precautionary grounds. The main actors in the health system are largely unaware of the problem posed by drug residues in water. Although knowledge cannot be equated with awareness – given the existence of the ‘not wanting to know' phenomenon – the first step is to generate a consolidated knowledge base. Only by creating awareness of the problem can further strategies be implemented to ultimately enlighten and bring about behavioural change. At stake here is the overall everyday handling of medications, including prescription, compliance, and drug-free disease prevention down to the doctor-patient relationship. The latter, namely, is often characterised by misunderstandings and a lack of communication about the – supposed – need to prescribe drugs. The first part of the strategy for the general public involves using various channels and media to address three different target groups. These were identified by ISOE in an empirical survey as reacting differently to the problem under review: · ‘The Deniers/Relativists' · ‘The Truth-Seekers' · ‘The Hypersensitives' The intention is to address each target group in the right tone and using the most suitable line of reasoning via specific media and with the proper degree of differentiation. The ‘Truth-Seekers' play an opinion-leading role here. They can be provided with highly differentiated information through sophisticated media which they then pass on to their dialogue partners in an appropriate form. The second part of the strategy for the general public relates to the communication of proper disposal routes for expired drugs. The goal is to confine disposal to pharmacies so that on no account are they flushed down the sink or toilet. Based on an analysis of typical errors in existing communications media on this topic, ISOE prepared recommendations for drafting proper information materials. In addressing pharmacists, the first priority is to convey hard facts: to this end we propose a PR campaign to place articles in the main specialist media. At the same time, the subject should feature in training and continuing education programmes. Another aim is to strengthen the advisory function of the pharmacies. The environmentally sensitive target group would indeed react positively to having their attention drawn to the issue of drug residues in water. For all other customers, the pharmacists can and should act as consultants: they emphasise how important it is to take medication as instructed (compliance) and use suitable pack sizes, and warn older customers in particular about the potential hazards of improper drug intake. The first stage of the communications strategy for doctors likewise revolves around knowledge. Here, however, it is important to take into account their self-image as scientists while in fact having little grasp of this specific area. The line to take is that of ‘discursive selfenlightenment'. This means that the issue of drug residues in water cannot be conveyed to doctors by laymen but must be taken up and imparted via the major media of the medical profession and by medical association officials (top-down). The second stage, namely that of raising doctors’ awareness of the problem, is likely to encounter strong resistance from some of the medical profession. They may fear a threat of interference in treatment plans from an environmental perspective and feel the need to emphasise that doctors are not responsible for environmental issues. As shown in empirical surveys by ISOE, such a defensive reaction is ultimately down to an underlying taboo: people are loath to discuss the over-prescription taking place in countless doctors' surgeries. And it is a fact that this problem cannot be tackled from the environmental perspective, although the goals of water protection are indeed consistent with the economic objectives of restraint in the deployment of drugs. Any communications measure for this target group has to bear in mind that doctors feel restricted by what they see as a ‘perpetual health reform' no matter which government is in power. On no account are they prepared to tolerate any new form of regulation, in this case for environmental reasons. An entirely different view of the problem is taken by ‘critical doctors' such as specialists in environmental health and those with a naturopathic focus. They are interested in the problem because they see a connection between the quality of our environment and our health. What is more, they have patients keen to be prescribed as few drugs as possible and who are instead interested in ‘talking medicine'. So, any communication strategy intent on tackling the difficult problem of oversubscribing drugs needs to look carefully at the experiences of these medical professionals and also at a ‘bottom-up strategy'. Implementation of strategic communications should be entrusted to an agency with experience in ‘issue management'. Knowledge of social marketing and the influencing of behaviour are further prerequisites. All important decisions should be taken by a consensus committee (‘MeriWa'1 round table), in which the medical profession, pharmacists and consumers are represented.In Deutschland und in fast allen Industrieländern finden sich mittlerweile Medikamentenwirkstoffe in nahezu allen Gewässern und vereinzelt auch im Trinkwasser. Auch wenn die Konzentrationen in der Regel sehr gering sind, lassen sich erste Anzeichen für Auswirkungen auf Wasserlebewesen nachweisen. Akute Folgen für die menschliche Gesundheit sind bisher nicht erwiesen. Es kann allerdings nicht ausgeschlossen werden, dass sich Langzeitfolgen dieser Niedrigstkonzentrationen entwickeln und unerwartete Effekte durch die Wechselwirkung zwischen verschiedenen Wirkstoffen (Cocktaileffekt) entstehen. Besonders gefährdet sind dabei sensible Bevölkerungsgruppen wie Kinder und chronisch Kranke. Es besteht daher nicht zuletzt aus Vorsorgegründen Handlungsbedarf. Das Problem der Medikamentenreste im Wasser ist bei den wichtigsten Akteuren des Gesundheitssystems weitgehend unbekannt. Auch wenn Wissen nicht mit Bewusstsein gleichgesetzt werden kann – denn es gibt auch das Phänomen des Nicht-Wissen-Wollens – geht es in einem ersten Schritt darum, fundiertes Wissen zu erzeugen. Nur auf Basis dieser Sensibilisierung können weitere Strategien umgesetzt und letztendlich Aufklärung und Verhaltensänderungen erreicht werden. Dabei geht es um die gesamte Alltagspraxis im Umgang mit Medikamenten. Diese umfasst Fragen der Verschreibung, der Compliance, der nichtmedikamentösen Krankheitsvorsorge bis hin zum Arzt-Patienten-Verhältnis. Das ist nämlich häufig von Missverständnissen und mangelnder Kommunikation über – vermeintliche – Verschreibungsnotwendigkeiten geprägt. Der erste Teil der Strategie für die Bevölkerung soll über unterschiedliche Kanäle und Medien drei unterschiedliche Zielgruppen ansprechen, die in einer empirischen Untersuchung vom ISOE identifiziert wurden und auf das angesprochene Problem ganz unterschiedlich reagieren: · ‚Die Verleugner/Relativierer‘ · ‚Die Aufklärungsinteressierten‘ · ‚Die Hypersensiblen‘ Jede Zielgruppe soll in der passenden sprachlichen und argumentativen Art und Weise durch spezifische Medien und mit dem richtigen Grad der Differenziertheit angesprochen werden. Dabei spielen „die Aufklärungsinteressierten“ eine Opinionleader-Rolle. Sie können über anspruchsvolle Medien mit sehr differenzierten Informationen versorgt werden und geben dieses Wissen dann in angemessener Form an ihre Gesprächspartner weiter. Der zweite Teil der Strategie für die Bevölkerung bezieht sich auf die Kommunikation richtiger Entsorgungswege für Altmedikamente. Ziel ist es, dass Medikamentenreste nur noch in der Apotheke, keinesfalls aber in der Spüle oder in der Toilette entsorgt werden. Auf Grundlage einer Analyse typischer Fehler in bereits bestehenden Kommunikationsmedien zu diesem Thema hat das ISOE Empfehlungen zur richtigen Konzeption von Infomaterialien erarbeitet. Bei der Ansprache der Apotheker geht es in einem ersten Schritt um die Vermittlung von Faktenwissen: Wir schlagen dazu eine PR-Kampagne vor, die Artikel in den wichtigsten Fachmedien platziert. Gleichzeitig soll das Thema auch Teil der Aus- und Fortbildung werden. Zusätzlich soll die Beraterfunktion der Apotheken gestärkt werden. Die spezielle Zielgruppe der umweltsensiblen Kunden würde durchaus positiv darauf reagieren, wenn sie auf die Problematik der Medikamentenreste im Wasser hingewiesen würde. Bei allen anderen Kunden können und sollen die Apotheker ihre Rolle als Berater wahrnehmen: Sie betonen, wie wichtig die korrekte Einnahme (Compliance) und adäquate Packungsgrößen sind und warnen ihre Kunden, insbesondere die älteren, auch vor potenziellen Fehleinnahmen. Bei der Kommunikationsstrategie für Ärzte geht es im ersten Schritt ebenfalls um Wissen. Dabei muss aber deren Selbstverständnis als Wissenschaftler bei gleichzeitig niedrigem Wissensstand in diesem speziellen Feld berücksichtigt werden. Hier muss der Weg einer ‚diskursiven Selbstaufklärung‘ beschritten werden. Das Thema Medikamentenreste im Wasser kann somit nicht von Laien von außen an die Ärzte herangetragen werden, sondern muss in wichtigen Medien der Ärzteschaft und durch Verbandsfunktionäre angenommen und kommuniziert werden (top-down). Wenn es im zweiten Schritt um eine Problemsensibilisierung geht, muss mit starkem Widerstand eines Teils der Ärzteschaft gerechnet werden. Sie könnten fürchten, dass eine Einmischung in Heilungspläne aus Umweltsicht droht und betonen, dass Ärzte nicht für Umweltfragen zuständig seien. Letztlich steht – das haben empirische Untersuchungen des ISOE gezeigt – hinter dieser Problemabwehr ein Tabu: Es soll nicht darüber gesprochen werden, dass in zahlreichen Praxen zu viel verschrieben wird. Diese Problematik kann tatsächlich nicht aus der Umweltperspektive angegangen werden. Doch decken sich hier die Ziele des Gewässerschutzes mit den ökonomischen Zielen eines sparsamen Umgangs mit Arzneimitteln. Bei jeder Kommunikationsmaßnahme für diese Zielgruppe muss berücksichtigt werden, dass sich die Ärzte von dem, was sie als ‚Dauergesundheitsreform‘ aller Regierungen wahrnehmen, gegängelt fühlen. Sie sind keinesfalls bereit, eine neue Form der Regulierung, diesmal aus Umweltgründen, hinzunehmen. Ganz anders wird das Problem von ‚kritischen Ärzten‘ wie Umweltmedizinern und von Ärzten mit Naturheilschwerpunkt gesehen. Sie interessieren sich für die Problematik, weil sie einen Zusammenhang zwischen Umweltqualität und Gesundheit sehen. Außerdem haben sie Patienten, die an möglichst wenig Medikamentenverschreibungen, dafür aber an einer ‚sprechenden Medizin‘ interessiert sind. Wenn eine Kommunikationsstrategie also auch das schwierige Problem der übermäßigen Verschreibungen angehen will, empfiehlt es sich, die Erfahrungen dieser Mediziner einzubeziehen und zusätzlich auf eine ‚Bottom-up-Strategie‘ abzuzielen. Mit der Umsetzung der strategischen Kommunikation sollte eine Agentur beauftragt werden, die Erfahrungen im ‚Issue Management‘ vorweisen kann. Weiterhin sollte die Agentur Kenntnisse im Social Marketing und der Beeinflussung von Verhalten haben. Alle wichtigen Entscheidungen sollten von einem Konsens-Gremium (Runder Tisch ‚MeriWa‘1) verabschiedet werden, in dem die Ärzteschaft, die Apotheker sowie die Verbraucherinnen und Verbraucher angemessen repräsentiert sind

Palliative Care and Dementia

This paper was commissioned by Alzheimer's Australia to promote discussion by people with dementia, their families and carers of the issues that may be faced as people with terminal dementia move towards death. A palliative care approach will also be appropriate when a person with dementia has another terminal condition

Supporting Special-Purpose Health Care Models via Web Interfaces

The potential of the Web, via both the Internet and intranets, to facilitate development of clinical information systems has been evident for some time. Most Web-based clinical workstations interfaces, however, provide merely a loose collection of access channels. There are numerous examples of systems for access to either patient data or clinical guidelines, but only isolated cases where clinical decision support is presented integrally with the process of patient care, in particular, in the form of active alerts and reminders based on patient data. Moreover, pressures in the health industry are increasing the need for doctors to practice in accordance with ¿best practice¿ guidelines and often to operate under novel health-care arrangements. We present the Care Plan On-Line (CPOL) system, which provides intranet-based support for the SA HealthPlus Coordinated Care model for chronic disease management. We describe the interface design rationale of CPOL and its implementation framework, which is flexible and broadly applicable to support new health care models over intranets or the Internet

Strained mercy : The quality of medical care in Delhi

The quality of medical care is a potentially important determinant of health outcomes. Nevertheless, it remains an understudied area. The limited research that exists defines quality either on the basis of drug availability or facility characteristics, but little is known about how provider quality affects the provision of health care. The authors address this gap through a survey in Delhi with two related components. They evaluate"competence"(what providers know) through vignettes and practice (what providers do) through direct clinical observation. Overall quality as measured by the competence necessary to recognize and handle common and dangerous conditions is quite low, albeit with tremendous variation. While there is some correlation with simple observed characteristics, there is still an enormous amount of variation within such categories. Further, even when providers know what to do they often do not do it in practice. This appears to be true in both the public and private sectors though for very different, and systematic, reasons. In the public sector providers are more likely to commit errors of omission-they are less likely to exert effort compared with their private counterparts. In the private sector, providers are prone to errors of commission-they are more likely to behave according to the patient's expectations, resulting in the inappropriate use of medications, the overuse of antibiotics, and increased expenditures. This has important policy implications for our understanding of how market failures and failures of regulation in the health sector affect the poor.Public Health Promotion,Disease Control&Prevention,Health Monitoring&Evaluation,Health Systems Development&Reform,Educational Sciences,Health Monitoring&Evaluation,Health Systems Development&Reform,Educational Sciences,Health Economics&Finance,Gender and Health