Howard F. Stein

The cascade effect in the clinical care of patients.

IN biology, the term cascade refers to a process that, once started, proceeds stepwise to its full, seemingly inevitable, conclusion. Common examples are the clotting cascade and the complement cascade. Processes that occur in molecular systems often have correlates in larger systems. It is our contention that cascade effects are frequently operative in the clinical care of patients, and that recognition of this fact gives us a better understanding of the clinical decision-making process. The cascade effect that we will describe generally consists of an initiating factor or factors, followed by a series of events that seem to be a .xa0.xa0.

The Role of the Student-Teacher Relationship in the Formation of Physicians: The Hidden Curriculum as Process

Relationship-Centered Care acknowledges the central importance of relationships in medical care. In a similar fashion, relationships hold a central position in medical education, and are critical for achieving favorable learning outcomes. However, there is little empirical work in the medical literature that explores the development and meaning of relationships in medical education. In this essay, we explore the growing body of work on the culture of medical school, often termed the “hidden curriculum.” We suggest that relationships are a critical mediating factor in the hidden curriculum. We explore evidence from the educational literature with respect to the student-teacher relationship, and the relevance that these studies hold for medical education. We conclude with suggestions for future research on student-teacher relationships in medical education settings.

The role of relationships in the professional formation of physicians: Case report and illustration of an elicitation technique

OBJECTIVEnStudies of physicians professional development highlight the important effect that the learning environment has in shaping student attitudes, behaviors, and values. The objective of this study was to better understand the interplay among relationships and experiences in mediating the effects of the learning environment.nnnMETHODSnWe randomly recruited 2nd- and 4th-year students from among volunteers at each of five medical schools. One interviewer at each school conducted a face-to-face, open-ended, semi-structured interview with each student. The interviewers used a method called life-circle diagramming to direct the student to draw a picture of all of the relationships in his/her life that had an influence on the sort of doctor that each student saw him/herself becoming. Interviews lasted between 60 and 120 min. Using a narrative framework that focuses on elements of students stories (e.g., setting, characters, plot), we analyzed transcripts through an iterative process of individual reading and group discussion to derive themes and relationships among themes.nnnRESULTSnTwenty students completed interviews. These students are embedded in complex webs of relationships with colleagues, friends, family, role models, patients, and others. Most students entered medical school with formed notions of what they wanted to be like as physicians. While students generally gravitated toward relationships with like-minded people, their experiences varied, and some students could sense themselves changing as they moved through school. Such changes were often related to important events or issues. The relationships that students found themselves in during the context of these events had an important effect on students beliefs about what kinds of behaviors and attitudes were possible and desirable in their future practice.nnnCONCLUSIONSnStudents proceed through medical school embedded in complex webs of relationships that exert a powerful influence (both positive and negative) on their formation as physicians.nnnPRACTICE IMPLICATIONSnEducational interventions that foster adoption of professional values need to acknowledge the influence of relationships, and assist students to harness and shape relational effects on their growth and development. The life-circle diagramming activity holds potential to promote reflection and self-knowledge, and to provide a foundation for professional growth.

Contingent or universal approaches to patient deficiencies in health numeracy.

Medical decision–related numeracy includes aptitude with numbers, fractions, and ratios. It is an aptitude assumed necessary for complete understanding of the risks of health behaviors and medical treatments, for communicating one’s utilities when the patient’s individual preferences can swing the decision, and for considering costs and cost-effectiveness of alternative treatments. The ability to perform basic arithmetic operations is part, but not all, of health numeracy. It has been established that patients’ health literacy (the ability to read information relevant to health) is related to their health behaviors and health outcomes. We would also expect numeracy to be associated with health outcomes, although there is little evidence yet of its connection to health outcomes that could not be explained as an expression of the effects of health literacy or of general intelligence. It seems reasonable to figure out how physicians and health communicators may compensate for patients’ numeracy deficits by communicating in a way so that they may understand quantitative concepts. In this endeavor, should physicians and health educators routinely assess patients’ health literacy and numeracy and adjust their communication contingent on their patients’ ability to understand? Or should they develop a message that all patients can grasp and use it universally? Articles in this issue of Medical Decision Making provide support for each of these competing approaches. Fagerlin, ZikmundFisher, and colleagues report on the development of a subjective measure of numeracy intended to facilitate its measurement for research. Presumably, an instrument such as this could serve as a basis for sorting patients into groups to receive messages appropriate for different levels of health literacy and numeracy. Schwartz, Woloshin, and Welch, on the other hand, describe a communication tool, a ‘‘Drug Facts Box,’’ that tabulates the efficacy and side effect rates of a treatment. This tool successfully conveyed its key concepts not only to the well educated (health lecture attendees in a university town) but also to the poorly educated (patients and family members in a Veterans Affairs medical center waiting room). Although the tool is proposed as a required component of direct-to-consumer advertisements rather than for patient education, it represents an ideal of communication, accessible for all, that does not oversimplify but rather expresses the concepts essential for evaluating a treatment decision, including the numerical aspects of risk, efficacy, and quality of life.

Poetic License: Writing Poetry as a Way for Medical Students to Examine Their Professional Relational Systems.

Medical educators and researchers have studied poetry by medical students as a potential source of information about the socialization process in medical education and students’ views about salient clinical issues. One previously uninvestigated area is the examination of medical student poetry for insights into how students experience and understand the professional relational systems in which they participate during their training. In this article, the authors examine a series of poems written by medical students for insights into the students’ relationships with patients, patients’ families, and supervisors. Detailed analyses demonstrate how students use various elements of poetry, such as vivid detail, metaphor, point of view, and emotional expression, to explore these relationships. The authors conclude that writing poetry may exert a healing influence on students and appears to be one way students can make emotional sense of the different relational systems they encounter over the course of training.

Adversary symbiosis and complementary group dissociation: An analysis of the U.S./U.S.S.R. conflict

Abstract This paper explores the psychological basis for the reciprocal stereotyping that governs U.S./Soviet perceptions of one another. The primary obstacle to mutuality in the relationship between the U.S. and U.S.S.R. is their use of each other reciprocally as projective targets by which each deals with its unacceptable aggressive impulses. Soviet-American relations are discussed in terms of a model of adversary symbiosis, wherein each member of the pair complements one another to preserve the enmity. The influence of American and Russo-Soviet national psychology and cultural history on present perception, expectation, and attitudes is examined. Repetitive themes from American cinema, music, literature, and automotive design from the late 1970s and early 1980s are adduced to illustrate the unconscious American preparation for hostility. It is further argued that reciprocal provocation paradoxically makes the Soviets more “Russian” and the Americans more “American” than would otherwise occur. It is argued that the principal “reality” governing Soviet-American nations is projective, and that until that process is examined the vicious cycle of anxiety (fueling the armament race) will continue.

Our stories of illness.

In this poem, the author describes three types of stories after healing from his illness: restitution, quest, and chaos. (PsycINFO Database Record