Outcomes of a good Phys-Pt. relationship
patient satisfaction, return visits to same phys., compliance w/ treatment, ↓malpractice suits
(1) the seating arrangement, (2) making eye contact, (3) responding verbally or head nodding, (4) tone of voice, and (5) activity level.
One needs to watch for: (1) pt posture and position; (2) gestures; and (3) how the pt speaks (e.g., with a loud voice) or whether there is silence or sighing
general questions in which the student physician asks the patient to describe how he/she is feeling. You may request a specific area of interest, but let the patient choose what is most important in that area; useful when you want to get the pt's description of his or her symptoms. For example, "Can you tell me about your chest pain?"
asks the pt to communicate more about a particular fact or subject; may include such things as when the symptoms started, their duration, and associated symptoms. Such questions can be particularly helpful with rambling patients. Example: "Can you tell me if there has been any pain associated with getting around?"
asks for a specific bit of information; range of possible answers is restricted by the form of the question; useful when you want to know a certain fact or set of facts even if they do not seem important to the pt. "What did your father die of?" or "When did the chest pain begin?"
also called "facilitation", may be either verbal or nonverbal communication which encourages the pt to say more about the subject; a non-focused or open-ended approach encouraging the patient to continue talking about the problem and suggesting its importance. Examples include a simple nod of the head, "You did?", and "Uh-huh."
technique used with the goal of reassuring a patient or putting him/her at ease. There is a danger in over-using it giving a pt. false hope. Example would be, "I'm sure that many people who have gone through what you have would also feel overwhelmed."
Phys. describes to the pt his or her perception of the patient's verbal and nonverbal communication; draws attention to something which the pt. may not be consciously aware of or purposely trying to avoid; often related to affective responses on the part of the patient ("You seem depressed when you talk about that.") or points out that the pt is having difficulty expressing ideas ("It seems hard to talk about what happened.")
communicates acceptance of and respect for the pt's emotional response or experience; lets the patient know that the feelings are understandable and make sense; Examples include: "I can see why you would be upset about this," "Your reactions are perfectly normal," "This would be anxiety provoking for anyone."
difficult technique for beginning interviewers; gives the patient time to respond to a difficult question or ventilate feelings; if too long, pt may feel you are disinterested or disagree with him/her; carefully timed, it promotes closeness and allows pt to continue talking about a difficult subject
technique includes the repetition of the patient's words to encourage expansion regarding details and feelings
tells the patient when he or she is changing directions in the interview; for example, "Now, I'd like to ask you questions about other health problems you may have."
draws together what the pt has said; sometimes it serves to clarify the relationship of information obtained ("It seems you were feeling well until two weeks ago when you first had the chest pain."); also appropriate at the conclusion of the interview to help check understanding of the pt's story and to allow pt to add or restate important information
7 attributes of a symptom
3) Quantity / Severity
4) Timing (Onset/Duration/Frequency)
5) Setting in which it occurs
6) Remitting or exacerbating factors
7) Associated manifestations (symptoms)
Opening the interview
Greeting the patient using proper name
Seated in appropriate position
Beginning to establish rapport
Inviting the Patient's Story [Moving from General to Specific Questions]
Chief Complaint (CC)
History of Present Illness (HPI)
Personal and Social History
Closing the interview
Ask the patient if he/she has questions or anything to add
Tell the patient what will happen next
History of Present Illness (HPI)
Chief Complaint (In pt's own words)
7 Attributes of a Symptom (LQQTSR(E)A)
Inviting the Patient's Perspective
Medications (Dose, method, freq., what for)
Allergies (Med, enviro, food and Rxn)
Substance Use (Alcohol, tobacco, illicit drugs; what type, how often, since when)
Adult illnesses: Medical, Surgical, Obstetric/gynecologic, Psychiatric
Effects on life
Patient's unique experience
Increases patient comfort and trust, Provides clues to additional symptoms, Reveals psychosocial problems, Prevents premature hypotheses and chasing down blind allies, Hear both disease and illness, Not having to think of the next question (which blocks listening)
Rapport, Non-judgmental acceptance, Responding to emotions, Facilitate, Summarize, Clarify, Collaboration, Empathy, Confronting versus acknowledging; use of this can greatly enhance "what the pt. means" → "what the physician understands"
Clinical Framework Over time
Experience-based Medicine → Knowledge-based Medicine → Evidence-based Medicine → Value-based Medicine
Set of learned and shared beliefs and values, that are applied to social interactions and applied to interpretation of experiences; Framework that shapes and directs how we behave and manner in which we interpret behaviors of others; Influences how we experience illness and how we express illness, pain and our own health care decisions
Multiple dimensions of culture
Beliefs explaining health and illness
Approach used in making decisions
Healing traditions (and individuals involved in those traditions)
Immigration / citizenship status
Theoretical construct, or abstraction, by which we attempt to explain an individual's problems
Defined in terms of structure and/or function of body organs and systems
Individual's personal experience of ill health
Aspects of cultural identity
Ethnicity, Race, Country of origin, Language, Gender, Age, Marital status, Sexual orientation, Religious or Spiritual beliefs, Socioeconomic status, Education, Migration history, Level of acculturation, Other identified groups
Subjective, Self-defined, Relates to each individual's identity with a group sharing nationality, history, religion and cultural patterns
Objective, Refers to genetic relationships (Between individuals or Among populations); Considered to be more accurate in determining biologic risk factors than is race alone
Race and geographic ancestry
Race might co-vary with different environmental or genetic factors that underlie risk for disease; Race often used to make inferences about individual's genetic ancestry and to predict specific genetic risk factors; Genetic ancestry highly correlated with geographic ancestry, but correlation with race is modest
population-specific differences related to: Access to care, Utilization of resources, Health outcomes, General health, Barriers to optimal health, Race plays a role in creation and maintenance
Milton Bennett's Developmental Model of Intercultural Sensitivity
(INSENSITIVE) Denial → Defense → Minimization → Acceptance → Adaptation → Integration (SENSITIVE)
Values variety of cultures; integrates aspects of own culture w/ others; defines behaviors and values in contrast to and in accordance w/ other cultures
Results in active application of awareness, knowledge and skills to mental health care and support of recovery; Doesn't come naturally; Moves us to the other end of the continuum, away from ethnocentricity (in which we use our own cultural rules to make judgments about people different from us)
Terry Cross's Organizational Cultural Competency Model
(ETHNOCENTRIC) Cultural destructiveness → Cultural incapacity → Cultural Blindness → Cultural Pre-Competence → Basic competence → Advanced competence
Actively educated less informed; seeks to interact w/ diverse groups and learn from individuals w/ different cultural backgrounds
Ending point; No attempt is made to learn if individual "fits"
Starting point; More information needed to check "fit" with individual
Individual's sense of the transcendent; Sense that there is something bigger than self; Many components
Adherence to a faith tradition in practice, belief or both; Constructed by a community of believers; Many components, but cannot assume inclusion of spirituality
Kleinman's Questions (Eliciting an Individual's Explanatory Model)
1) What do you call the problem?
2) What do you think has caused the problem?
3) Why do you think it started when it did?
4) What do you think your sickness does? How does it work?
5) How severe is your sickness? Will it have a short or long course?
6) What kind of treatment do you think you should receive?
7) What are the most important results you hope to receive from this treatment?
8) What are the chief problems the sickness has caused?
9) What do you fear most about the sickness?
Listen with sympathy and understanding to the individual's perception of the problem
Explain your perception of the problem
Acknowledge and discuss the differences and similarities
Recommend treatment / solution
Negotiate and agreement
Cultural Competence in Medical Practice
Includes knowledge, skills and attitudes
Enhances physician's: Understanding/respect for patient's values, beliefs and expectations, Awareness of own assumptions and values, Awareness of assumptions and values embedded in the U.S. system of health care delivery, Ability to adapt care to meet needs of individual patient
Advantages to Cultural Identity Assessment
Identification of potential strengths and support, Identification of potential vulnerabilities, Identification of potential areas of cultural conflict, Better appreciation for patient's perspective, Assistance in building rapport with patient
Ethical Principles in Medicine
Respect for Autonomy
Do no harm
Avoid acting in ways that cause needless harm or injury.
Do not injure through carelessness, malice or avoidable ignorance.
Avoid exposing patients to unnecessary risk
When risk is inevitable: minimize those risks
Follow the standards of due care
Duty to do Good
We should act in a way that promotes the interest of others.
The nature of the relationship between a physician and a patient imposes a duty to promote the welfare of the patient.
We expect reasonable sacrifices of the physician's interest for the sake of their patients
People are free from interference and control by others; includes notions of self-determination, independence and freedom; patients have the right to choose actions, and make decisions that are consistent with their own values, goals and life plan, even if their family and physician disagree; decision should be free of coercion (voluntary) and informed.
The Distribution of Social Benefits and Burdens; req. ppl who are situated equally to be treated equally, act consistently in cases that are similar in ethically relevant ways
Formal principle: Everyone should get what they deserve.
ABC's of ethics
Bioethical Principles and Values
Gather information about the case; Obtain information about the background, clinical information, and expected outcomes of various courses of action; Communicate with the patient regarding goals and values, and objectives of medical care in this clinical scenario; Discuss patient preferences; If the patient is unable to communicate, obtain information regarding advance directives, previous conversations, or family opinions regarding patient preferences; Communicate with family and friends regarding their opinions, goals, and values (if the patient consents to this step); Consider the involvement of additional parties, such as pastoral care, social work, or an ethics committee
Bioethical Principles and Values
Identify bioethical principles applicable to the case. Principles may include: Respect for patient autonomy, Beneficence, Nonmaleficence, Justice
Identify values applicable to the case. Values may include: Honesty, Integrity, Altruism, Respect for life, Freedom, and others.
Assess the decisional capacity of the patient; If the patient does not possess decisional capacity, identify any advance directives or other communications of patient wishes; If necessary, identify a surrogate decisionmaker to speak on the patient's behalf; often defined by state law, and may include a hierarchy such as spouse, adult children, parents, etc; If no surrogate can be identified, a court appointed surrogate may be named.
Identify possible courses of action; Weigh positive and negative ramifications of each possible course of action; Select the course of action that best adheres to ethical principles and values of the patient and the physician; Make the decision in a timely fashion to allow for the best possible outcome.
Review the clinical outcome; Assess the opinions of the patient, family, and health care providers; Analyze in retrospect whether other options may have been preferable
Ability to receive information, to deliberate, to make an authentic choice, and to communicate that choice
Factors affecting pt. capacity
Mental illness, Delirium, Pain, Anxiety, Confusion, Depression, Pharmaceutical/illicit drugs
Means of determining capacity
Routine communications and interactions
Standardized tests (example: MMSE)
DSM-IV Criteria for Diagnosing Depression
5 or more of the following for at least 2 weeks:
SIG E CAMPS
*Interest dimished (anhedonia)*
Guilt or worthlessness
Appetite (or weight) change
*Mood (depressed or irritable)*
Impact of depression
The Global Burden of Disease Study found MDD ranks second behind only ischemic heart disease in lost years of healthy life
Estimated cost over 75 Billion dollars per year
Major Depressive Disorder is highly treatable by a number of modalities: Up to 60-70% response rate to first line treatment; Proper treatment reduces adverse outcomes, duration of episodes, and recurrence
Why we should screen for MDD
It is a common, important disorder
There are effective treatment modalities
Early treatment improves outcomes
Validated screening tools/techniques
The U.S. Preventative Services Task Force recommended screening in adults in clinical practices that have systems in place for diagnosis, treatment and follow-up.
2-question Depression Screen
"Over the past two weeks, have you felt down, depressed or hopeless?"
"Over the past two weeks, have you felt little interest or pleasure in doing things?"
A positive answer to one or both of these two questions 83-87% sensitive and specific
1-question Depression Screen
"Are you depressed?"
Used in Geriatric settings
Approximately 70% sensitive/specific
Depression risk factors
Female Gender, History of depressive illness or alcoholism in first degree relative, Prior episode of MDD, Post partum, More remote family history of depressive illness, lack of social support, significant stressful life events, current alcohol or substance abuse, nicotine dependence or multiple failed attempts at tobacco cessation
Indications to screen for MDD
First degree relative with depression, 2+ Chronic diseases, Obesity, Chronic pain, Financial Strain, Major Life Changes, Pregnancy/postpartum, Multiple vague symptoms, Fatigue/sleep disturbance, Substance abuse, Elderly
Red Flags for PCPs to check for Depression
Frequent, often unrelated, use of medical resources without serious illness, Several unexplained somatic complaints, Persistent failure to adhere to management strategies, Failure to improve despite "adequate" management
How to diagnose depression
History and physical with review of systems
Closed-ended questions about nine diagnostic criteria
Assess suicide risk
Ask about history of manic episodes
Ask about alcohol/drug use
Ask about recent losses or social stressors
Ask about new medications
Ask about previous depressive episodes
Ask about seasonal mood variation
Ask about Family History of depression/ bipolar disorder
Ask about anxiety
Ask about intrusive thoughts/compulsions
Exclude other causes with testing only if indicated by history and physical/RoS
Uses for a pt. note
Assess quality of care
Characteristics of a good note
Comprehensive, Complete, Clear, Descriptive, Concise, Discrete, Respectful, Timely, Legible, Accurate, Organized
3 Rules of Charting
1. No Record = Didn't Happen
2. Illegible = Worthless
3. Unorganized = No Value
"Do not use" Abbreviations
U - Write "unit"
Q.D., Q.O.D. - Write "daily", "every other day"
Trailing zero (X.0 mg), Lack of leading zero (.X mg) - Write "X mg", "0.X mg")
Penalties for altering/falsifying records
Jeopardize malpractice defense
Liability insurer could cancel coverage
Criminal charges for fraud and perjury (Fine / imprisonment?)
Medical license revocation - unprofessional conduct
How to correct an error
1. Single strike-through line
5. Identified as "Error"
Subjective component of SOAP note
Information obtained from patient or family; Includes chief complaint (CC), history of present illness (HPI), and pertinent portions of past, family, and personal/social histories and review of systems (ROS); What the patient tells you
Objective component of SOAP note
Information from your observations (e.g., physical exam findings or vital signs); Includes laboratory results and other diagnostic study results (e.g., x-rays); What you observe / detect on examination
Assessment component of SOAP note
Describes your impression of the current medical problems; Includes differential diagnosis and/or your reasoning behind your medical impressions
Plan component of SOAP note
Plan for treatment and follow-up; May include medications or additional diagnostic studies and therapies
Requirements for our pt. note
1. Patient Name (Last Name, First Name)
2. Medical Record Number
4. Chief Complaint (in patient's own words)
5. Attributes of a Symptom (7)
6. Patient's Perspective (what's causing it?)
7. Medications (dose, form, freq., what for?)
8. Allergies (Agent and rxn)
9. Substance Use (Tobacco, Alcohol, Illicit Drugs)
10. Signature, Printed Name
Proper Procedure Used to Correct Errors
Narrative / Paragraph Format
Interpersonal Violence Stats
One in every four women will experience domestic violence in her lifetime
An estimated 1.3 million women are victims of physical assault by an intimate partner each year
The majority (85%) of family violence victims are female. Females were 84% of spousal abuse victims and 86% of abuse victims at the hands of a boyfriend
Historically, females have been most often victimized by someone they knew
Females who are 20-24 years of age are at the greatest risk for nonfatal intimate partner violence.
Most cases of IPV are not reported to police
Children who witness vilence
Witnessed IPV is strongest risk factor for transmitting violent behavior to next generation; Boys who witness IPV are 2x as likely to beat their own kids and partners; 30%-60% of perpetrators of IPV also abuse children in the home
Sexual Assault and Stalking
40-45% of relationships reporting IPV also report sexual assault/forced sex; 1 in 12 women and 1 in 45 men have been stalked in their lifetime; 81% of women stalked by a current or former partner are also physically assaulted, 31% are raped
Perpetrator risk factors
Young age, Low self-esteem, Low income, Low academic achievement, Aggressive/delinquent behavior as youth, Alcohol/drug abuse, *Witnessing violence as a child, Experiencing violence as a child*, Social isolation, Unemployment
Roles of the Medical Community in IPV
Intervention and Prevention
Physician interventions in IPV
Just ask (Even if denied, victim will often appreciate being asked and remember, making you/your office a potential safe place for future help); Simple, direct and neutral/gentle questioning best; Ask when patient alone; Rates of detection in one study of ER universal screening went from 1 to 18%.
Physician response to identifying IPV
Give validating messages, Break through denial, Plant seeds for change, Listen non-judgmentally, Document statements, injuries and photograph if possible, Refer/Give resources, Safety Plan/Escape Plan
Do's and Don't of IPV
Don't encourage confrontation
Don't tell patient what to do
Don't encourage couples counseling
Do assess level of danger and professionally inform patient of same
Do schedule follow-up
Do hospitalize if needed for safety
Questions to ask once IPV is identified
Are children present?
Is violence escalating?
Are there weapons in the house?
Limited English Proficient
Individuals who do not speak English as their primary language and who have a limited ability to read, write, speak, or understand English
Pt. outcomes in LEP scenarios
↓ patient satisfaction
↓ patient compliance
↓ patient outcomes (health)
↓ rates of return office visits
↑ hospitalization rates
Title VI of the Civil Rights Act of 1964
To avoid discrimination based on national origin, this require recipients of federal financial assistance to take reasonable steps to provide meaningful access to LEP persons
CLAS Standards (Office of Minority Affairs, 2001)
National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care
14 standards, 3 themes:
- Culturally competent care
- Language access services (LAS) [ Mandates ]
- Organizational supports for cultural competence
LAS CLAS Standards [ Mandates ]
4. Language assistance services must be offered at no cost to the patient
5. Patients and consumers must be informed of their right to language assistance services
6. Health care organizations must assure the competence of language assistance provided by interpreters / bilingual staff
7. Availability of easily understood patient materials and appropriate signage
Section 504 of the Rehabilitation Act of 1973
Protects from discrimination based on disability; Requires that federal fund recipients provide sign language interpreters for people who have hearing impairments
Hiring bilingual staff
Hiring staff interpreters
Contracting for professional interpreters
Using telephonic interpreter lines
Using community volunteers
Use of family members or friends as interpreters
Techniques to facilitate Communication w/ an interpreter
Arrange seating so interpreter is "in the background"
Guide interpreter in his/her role
Make eye contact with patient
Use first person
Speak directly to patient
Use short sentences
Ask one question at a time
Avoid slang / technical jargon
Correct interpreter when needed / gently remind him/her of role
Avoid side conversations with interpreter
physician does what he or she believes best for
patient - even if it overrides patient's choices
If the pt's is impaired or in doubt, or if the pt's decision are not informed or voluntary, the physician may intervene temporarily
A pt's autonomous choice is overridden; eg. withholding a diagnosis or test result requested by a pt. b/c the physician believes the info will greatly upset the pt.
Especially vulnerable pts.
Pts w/ mental disabilities, communication problems (Deaf, illiterate, non-english speaking), minorities, some who hold particular religious or spiritual beliefs, pts w/o insurance or with limited financial means, Children, Pt. on a vent w/ restrainers on!
How to minimize pt. vulnerability
Recognize it, Take steps to assure communication, Understand a patient's beliefs, expectations and concerns, Respect the patient and avoid personal judgments
Guidelines for Sexuality in the Phys-Pt. relationship
Sexual relationships with current patients are unethical.
* Sexual relationships with former patients may be unethical.
* Before becoming involved with a former patient, consider the possibility of undue influence, and psychological impact upon pt.
* An extended interval (eg, 2 years) should elapse before becoming involved with a former patient [In mental health it may be forever].
* If unsure about a relationship's impact on a former patient, consult with a colleague.
Health care disparities
differences that remain after taking into account patient needs and preferences and the availability of health care
People commonly affected by health care disparities
Patients with chronic illnesses
Ppl. of minority racial and ethnic groups
Goals of Increasing Education and Awareness of Disparities Among Providers
Don't Make Assumptions
Eliminate Fear (makes you more apt to do the right thing)
Quality failure (in Healthcare Disparities)
The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge
4 elements of Stigma
- Lead to marginalized care
process of applying beliefs and expectations about a group to a person from that group.
a preference or an inclination, especially one that inhibits impartial judgment
unjustified negative attitude based on a person's group membership
Alcohol and mental health
Sexually transmitted infections
A Patient-Based Approach toCross Cultural Care
Assure effective communication, Beware of stereotyping, Build trust
As patient advocates, physicians are expected to act in the patient's best interest and "do no harm"
This relationship is different than the strictly business relationship which are mostly profit oriented.
Conflict of interest
exists when a person entrusted with the interests of a client, dependent or the public violates that trust.
Examples: Personal interest, Third Party interest, Financial, Personal or Professional Role
Results of conflicts of interest in medicine
Patients might suffer physical harm
The integrity of medical judgment may be compromised
Patients may lose trust that clinicians are acting on their behalf
3 traditional means for avoiding or resolving conflicts of interest
Reducing the opportunities for conflicts of interest
Codes or other formal guidelines
mutations associated with increased risk of breast, ovarian, colon, Fallopian tube, and prostate cancer
mutations associated with breast cancer, ovarian cancer, prostate cancer, and pancreatic cancer
BRCA1 and BRCA2
Tumor Suppressor Genes; The protein products are involved in DNA damage repair and other functions; Most known mutations lead to premature termination of protein and loss of tumor suppression
A laboratory test of a person's genes or chromosomes for abnormalities, defects or deficiencies, including carrier status, that are linked to physical or mental disorders or impairments, or that indicate susceptibility to illness, disease or other disorder, whether physical or mental, which test is direct test and not an indirect manifestation of genetic disorders
Types of Genetic Testing
Diagnostic: Determine cause of a disease
Predictive: Determine risk for a disorder
Predictive genetic testing
Analyze chromosomes and patterns of base pairs
Some examples: Cystic Fibrosis, Breast cancer,
Breast cancer risk
Lifetime risk for breast cancer in general population is 12%.
Lifetime risk is 60% for BRCA-1 or BRCA-2
Ovarian cancer risk
Lifetime risk for ovarian cancer in general population is 1.4%
Lifetime risk is 15 - 40% for BRCA-1 or BRCA-2
Pros of genetic testing
Advance medicine and public health
Correlate diseases to genes
Allow individuals and families to make lifestyle, fertility and planning decisions.
May be reassured by a negative result.
Cons of genetic testing
Payment (costs money)
May lose health insurance*
Not enough people to offer genetic counseling
Is your sense of belonging to an ethnic community based upon your genes?
Many argue that these ethical issues must be resolved before it should be done extensively.
Nondiscrimination Information Act (2008)
Prohibits group health insurance plans and issuers of coverage from basing eligibility or adjusting premiums on the basis of genetic information. Ins. companies cannot require or purchase results of genetic tests. Prohibits employers from firing, refusing to hire or otherwise discriminating against (potential) employees.
Slippery Slope argument
Not a good argument, but a very common argument nonetheless
Testing for Down Syndrome and other chromosomal abnormalities may lead, as technology develops, to aborting fetuses disposed to:
Violence? Criminality? Low IQ? Homosexuality?
Pluripotent: can differentiate into all cell types of the body; Have capacity for self-renewal; Goal is to identify mechanisms that govern cell differentiation and turn HESCs into cell types to treat disease and injury
Somatic gene therapy
Insertion of a normally functioning gene (via a viral vector) into the nuclei of cultured stem cells.
The engineered cells are injected back into the patient where the added gene will restore normal function.
Germline Gene Therapy (inheritable genetic modification--IGM)
Eliminate "bad" genes from the individual and from his descendants; Has not yet been attempted on humans
"GloFish" contain a transgene for a fluorescent protein
Transgenic rhesus monkey (ANDi)
Formation of a human stem cell
Derived in vitro at day 5 of embryonic development
Embryo consists of 200-250 cells
Most are trophoblast cells (Outermost layer of blastocyst)
HESCs are harvested from inner cell mass of blastocyst (30-34 cells)
Induced pluripotent stem cells
Converting adult human skin cells into cells with the properties of HESCs, Activate 4 genes in the adult cells to reprogram into pluripotent cells
Could eliminate need for HESCs (Not there yet, so we don't know if it will work)
Unknown: if iPSCs have the same potential as HESCs, safety of iPSCs for transplantation in to humans
Argument against destroying human embryos (classic argument)
1. It is morally impermissible to kill human beings intentionally.
2. The human embryo is an innocent human being.
3. Therefore it is morally impermissible to kill human embryos intentionally.
Rebuttal to classic argument
Does not suffice to show that most HESC research is impermissible. Most investigators engaged in HESC research do not derive the HESCs themselves. They use cell lines that have been provided to them by other researchers. For a lot of ppl, this distinction is important.
Moral argument against using HESCs
Must establish complicity in the destruction of embryos.
To avoid charge of complicity:
Those who derived the HESCs would have done so, absent the demand for the cells.
Other arguments against using HESCs (1)
Current research will result in future destruction of the embryos.
Problem: This criticism is too sweeping. Would affect research with adult stem cells and non-human animal stem cells (which are freely given by adults for this purpose). Current HESC research could reduce or eliminate demand for HESCs by enabling the use of alternative sources of cells.
Other arguments against using HESCs (2)
If it's wrong to destroy human embryos, even if a researcher does not destroy them, himself, he is morally complicit: He symbolically aligns himself with a wrongful act.
Problem: There may be a duty to avoid moral taint, but this can be overridden for the sake of a noble cause.
Standard view of those opposed to HESC research
"Genetic" view: you become a human being with the emergence of the one-cell zygote at fertilization
Problem: Twinning is possible until days 14-15. Identical (monozygotic) twins are not "identical" people. An individual who is an identical twin can't be numerically identical to the one-cell zygote. (Numerical identity must satisfy transitivity)
You become a human being at gastrulation
Rebuttal to embryologic view
Some reject that the early human embryo is a human being. Cells that comprise the early embryo are homogeneous. The cells do not function in a coordinated way to regulate and preserve a single life.
Each cell is alive, but they only become parts of a human organism around day 16. So, disaggregating the cells at day 5 to derive HESCs does not destroy a human being.
Problem: There is some intercellular coordination in the zygote. Some cells become part of the trophoblast and others part of the inner cell mass. Without coordination, all could differentiate in the same direction.
you become a human being when the human EEG pattern is acquired, After week 24 of gestation
a fetus should be considered human when it can survive on its own; In the past: 28 weeks (lung maturity), but w/ advances in technology: 25 week fetuses survive (High risk from physical and/or mental disabilities); at birth, when cord is cut
Possibilities for spare embryos after fertility treatment
Stored for future reproductive use
Donated to other infertile couples
Donated to research
Some argue it is OK to use them in HESC research, once the decision has been made to discard them
Argument in favor of using doomed embryos
It is morally permissible to kill embryos (at the end of a research project) that were about to be killed by someone else (simply discarded), where killing that individual will help others; The decision to discard the embryos causes their death; research just causes the manner of death.
Arguments against using doomed embryos
The decision to discard may have been made as a precondition for donation to research; They may have been inclined to donate to another couple if research had not been available; A researcher who receives embryos could choose to rescue them (But this is illegal).
CAGE questions (for suspected alcohol or substance abuse)
Have you ever thought ab CUTTING back?
Do you get ANNOYED by criticism of your behavior?
Have you ever felt GUILTY ab use, or ab actions while using?
Do you ever feel the need for an "EYE OPENER"?
2 affirmative answers suggest alcohol misuse
Questions to ask suspected abuse victim
"Have you been hit, kicked punched or otherwise hurt by someone w/in the last year?"
"Do you feel safe in your relationship now?"
"Is there a partner from a previous relationship making you feel unsafe now?"
Questions to ask when eliciting sexual history
"When was the last time you had intimate physical contact w/ someone? Did that include sexual intercourse?"
"Do you have sex w/ men, women, or both?"
"How many sexual partners have you had in the last 6 mo./5 years/your lifetime?"
"Do you always use condoms?"
"Do you have any concerns ab HIV or AIDS?"
"Do you have oral or anal sex?"
"Are you satisfied w/ you sex life?"
"How is your libido or desire for sex?"
Pts. who are at increased risk for STDs
pts w/ multiple partners, is homosexual, uses illicit drugs, or has a prior history of STDs
Inquire ab sores or growths on the penis, or any pain or swelling in the scrotal area. Also ask ab discharge from the penis.
Tips for taking sexual history
-Explain why you are taking the sexual history
-note that you realize this info is highly personal, and encourage the pt. to be open and direct
-relate that you gather this info from everyone
-affirm that the convo is confidential
Effective interventions to reduce alcohol misuse
an initial counseling session of about 15 minutes, feedback, advice, and goal-setting. Most also include further assistance and follow-up.
Behavioral counseling (5 A's)
1) assess alcohol consumption
2) advise patients to reduce alcohol consumption to moderate levels
3) agree on individual goals for reducing alcohol use or abstinence
4) assist patients with acquiring the motivations, self- help skills, or supports needed for behavior change
5) arrange follow-up support and repeated counseling, including referring dependent drinkers for specialty treatment