Journal articles on the topic 'Power asymmetry in the physician-patient relationship'

Argumentation theory has much to offer our understanding of the doctor-patient relationship as it plays out in the context of seeking and obtaining consent to treatment. In order to harness the power of argumentation theory in this regard, I argue, it is necessary to take into account insights from the legal and bioethical dimensions of informed consent, and in particular to account for features of the interaction that make it psychologically complex: that there is a fundamental asymmetry of authority, power and expertise between doctor and patient; that, given the potential for coercion, it is a challenge to preserve the interactive balance presumed by the requirement of informed consent; and finally that the necessary condition that patients be ‘competent to consent’ may undermine the requirement of respecting patient autonomy. I argue argumentation theory has the resources to deal with these challenges and expand our knowledge, and appreciation, of the informed consent interaction in health care.

There is a gap between the preferences of immigrant patients and their experiences with intercultural communication. This study aims to explore the experiences and perspectives of long-stay immigrants on intercultural communication in encounters with primary care (PC) nurses. Participants were selected by purposive sampling at the Maresme Primary Care Center. A focus group and five in-depth interviews with long-stay immigrants from eight countries were carried out. Data collection was guided by a script previously validated by a group of experts. We conducted a qualitative analysis following Charmaz’s approach, and data saturation was reached with 11 patients (one focus group and five interviews). Long-stay immigrants would like closer and more personalized communication exchanges with greater humanity, as well as polite and respectful manners as they perceive signs of an asymmetrical care relationship. Those who had negative communication experiences tried to justify some of the behaviors as a result of having free access to public health services. This is one of the few existing studies from the point of view of long-stay immigrants. Achieving effective intercultural communication requires a process of self-reflection, awareness-raising and commitment, both on a personal and institutional level, to eliminate the asymmetry in the nurse-patient relationship. Nurses should be trained in person-centered intercultural communication.

Background: Informal coercion, that is, situations where caregivers use subtle coercive measures to impose their will on patients, is common in adult psychiatric inpatient care. It has been described as ‘a necessary evil’, confronting nurses with an ethical dilemma where they need to balance between a wish to do good, and the risk of violating patients’ dignity and autonomy. Aim: To describe nurses’ experiences of being involved in informal coercion in adult psychiatric inpatient care. Research design: The study has a qualitative, inductive design. Participants and research context: Semi-structured interviews with 10 Swedish psychiatric nurses were analysed with qualitative content analysis. Ethical considerations: The study was performed in accordance with the Declaration of Helsinki. In line with the Swedish Ethical Review Act, it was also subject to ethical procedures at the university. Findings: Four domains comprise informal coercion as a process over time. These domains contain 11 categories focusing on different experiences involved in the process: Striving to connect, involving others, adjusting to the caring culture, dealing with laws, justifying coercion, waiting for the patient, persuading the patient, negotiating with the patient, using professional power, scrutinizing one’s actions and learning together. Discussion: Informal coercion is associated with moral stress as nurses might find themselves torn between a wish to do good for the patient, general practices and ‘house rules’ in the caring culture. In addition, nurses need to be aware of the asymmetry of the caring relationship, in order to avoid compliance becoming a consequence of patients subordinating to nurse power, rather than a result of mutual understanding. Reflections are thus necessary through the process to promote mutual learning and to avoid violations of patients’ dignity and autonomy. Conclusion: If there is a need for coercion, that is, if the coercion is found to be an ‘unpleasant good’, rather than ‘necessary evil’ considering the consequences for the patient, it should be subject to reflecting and learning together with the patient.

Abstract In contrast to medical care, which is focused on the individual patient, public health is focused on collective health. This article argues that, in order to better protect the individual, discussions of public health would benefit from incorporating the insights of virtue ethics. There are three reasons to for this. First, the collective focus may cause neglect of the effects of public health policy on the interests and rights of individuals and minorities. Second, whereas the one-on-one encounters in medical care facilitate a compassionate and caring attitude, public health involves a distance between professionals and the public. Therefore, public health professionals must use imagination and care to evaluate the effects of policies on individuals. Third, the relationship between public health professionals and the people who are affected by the policies they design is characterized by power asymmetry, demanding a high level of responsibility from those who wield them. Against this background, it is argued that public health professionals should develop the virtues of responsibility, compassion and humility. The examples provided, i.e. breastfeeding information and vaccination policy, illustrate the importance of these virtues, which needed for normative as well as instrumental reasons, i.e. as a way to restore trust.

Category: Ankle Arthritis Introduction/Purpose: Total ankle arthroplasty (TAA) outcomes include pain reduction and improved gait speed. Ankle push off power, which requires gastroc-soleus muscle strength, is a critical aspect of healthy gait and increases as gait speed increases. It appears that improvements in pain translate to improved ankle muscle performance. However, ankle power after TAA is surprisingly low. It is possible years of arthritis and latent muscle memory result in reduced gastroc-soleus muscle strength and a gait pattern reliant on proximal joints for power. Evaluating these hypotheses will drive postoperative care. The purpose of this ongoing prospective study is to be the first to evaluate the interplay of pain, gait speed, and ankle muscle performance (strength and power) in people following TAA for end-stage ankle arthritis. Methods: Twelve people [Mean (SD): Age 61 (14.3) years; BMI 30.0 (5.4) Kg/m2; 83% male] with end-stage ankle arthritis who were candidates for TAA participated (12 preoperative and 9 six-month postoperative visits). Performance of adjunct soft tissue procedures and postoperative care were patient specific. A twenty point numeric pain rating scale was used to measure worst pain in the past week. Three dimensional multi-segment foot motion analysis was performed while participants walked barefoot on level ground over a force plate. Ankle peak push-off power (joint torque x segmental velocity) was calculated. Ankle peak isokinetic plantarflexion strength (torque at 60 degrees / second) and ankle sagittal plane passive range of motion were measured with a dynamometer. Participants also completed the six minute walk test. Wilcoxon Signed Rank tests were used to evaluate preoperative to postoperative changes and between limb differences postoperatively. Results: Pain decreased (postoperative mean = 2.8; p = 0.01) and gait speed increased following TAA (p = 0.02). Ankle plantarflexion strength and ankle power during walking were preserved following TAA (both p > 0.8) (Figure 1). Postoperative group mean dorsiflexion was 25.1 degrees and plantarflexion was 18.9 degrees, suggesting sufficient ankle motion was present for plantarflexor muscle performance. However, between limb differences were significant for both strength and power (both p < 0.05) postoperatively. The involved ankle produced 36% less strength and generated 45% less power during walking in comparison to the uninvolved limb. This asymmetry demonstrates that involved limb ankle muscle performance was not normalized at six-month follow up, despite improvements in pain. Conclusion: Study findings provide preliminary evidence that improved pain and gait speed are disconnected from ankle muscle performance following TAA. Postoperative improvements in gait speed were likely driven by more proximal joints (i.e. hip). Without additional targeted postoperative plantarflexion strengthening and gait training to improve ankle muscle involvement, gains in ankle power, a symmetrical gait pattern, and patient tolerance to higher level activity (i.e. stairs) are unlikely to occur long-term. The underpinning mechanisms limiting the necessary strength to drive power generation (i.e. length-tension relationship, atrophy), and the possible cumulative effect of how abnormal gait may influence implant survivorship deserve further attention.

Healing power in the doctor-patient relationship is addressed to physicians in physical health care and to medical students but is of equal importance to dentists, social workers, nurses, and teachers in the field of physical health care. The presentation points up that in the relationship between physician and patient certain phenomena occur that are comparable to responses in the relationship between the psychoanalyst and analysand, such as transference and countertransference. This indicates that the physician in physical health care in effect is involved in some kind of psychotherapy. Aspects of the art of medicine are described. Emphasis is on the potential for patients' physical health improvement—placebo effect—when the providers' perception extends beyond focus on physical symptoms and disorders and includes attention to the patients' psychological and emotional needs.

The following paper deals with the issues of doctor’s image in the doctor-patient relationship in the Internet era and the influence of Internet on patient’s compliance. Both positive and negative standpoints have been discussed briefly, followed by a description of a research model proposed by Laugesen, Hassanein and Yufei (2015) applicable for this type of study. The study examines the impact of patients’ use of Internet health information on various elements of patient-doctor relation (including compliance) through a theoretical model based on principal-agent theory as well as the information asymmetry perspective. A pilot survey and interview study performed on one Polish doctor and a group of his patients, a specialist in Family Medicine has been described. The study carried out by three coworkers: Laugesen, Hassanein and Yufei (2015) revealed that patient-doctor concordance and perceived information asymmetry have relevant effects on patient’s compliance while patient-doctor concordance reveals a stronger relationship. The final conclusions were such that only doctor’s quality had a significant influence on the information asymmetry; the Internet health information gathered by a patient had no impact on perceived information asymmetry; the pilot study performed on the Polish physician confirms the theses presented in this paper but further investigations concerning the formerly discussed issues should be done.

This study focusing on physician-patient interactions aimed to find out whetherphysicians’ gender and experience influence Persian doctor-patient interactions. Sopower strategies in physician-patient interactions were extracted and categorized toexplore the relationship between physicians’ gender and experience and power strategies.Fieldwork was conducted in clinics and hospitals of Rafsanjan city in Iran. One hundredphysician-patient consultations were audiotaped and transcribed during 2011-2012.Woods’ (2006) view was used to examine four strategies of power and knowledge ontheir talk. The findings pointed out the importance of investigating discourse of medicinein order to improve medical consultations, especially physician-patient interactions.Our study confirmed some previous assertions that physician-patient interactionswere asymmetrical. Physicians controlled and dominated the medical consultations byquestioning, interruptions, directive statements and tag questions. The analysis of the datarevealed that all power strategies were applied in Iranian physician-patient interactions.The results of Chi-Square tests indicated that there was a significant relationship betweenpower strategies and physicians’ experience and gender. It was concluded that the femaleand inexperienced physicians tended to control consultations by questioning, interruption,directives and tag questions more than the male and experienced physicians.

Objective: To describe our personal experience of the potential of a rare disease patient organization for fostering patient autonomy and creating a space for the practice of power sharing between physicians and patients.Methods: Using self-reflection and personal autobiographical experience while drawing on the conceptual framework of patient-centredness, we critically reflect on and formulate lessons from our experiences as a patient/researcher and physician/researcher active in a rare disease patient organization for hereditary angioedema established in Japan in 2013. Results: We identified multiple ways in which patient advocacy meetings shifted the patient-physician relationship to one of sharing power and responsibility. Appearing without his or her symbolic white coat, the physician is transformed into a person. In the context of shared group activities, the patient emerges as a person and one who is increasingly an informed and informing actor.Conclusion: A dedicated rare disease patient organization has the potential to function as a catalyst for moving from a paternalistic to a power-sharing model of the patient-physician relationship. It can act as a transformative resource for all key actors.Practice implications: The patient organization potentially reduces formal barriers and allows for the practice of effective patient-physician interactions, even in a cultural setting where paternalism generally shapes relationships. This can build social capital for both patient and physician.

Ethical and legal considerations in pain management typically relate to 2 issues. The first refers to pain management as a human right. The second involves the nature of the patient-physician relationship as it relates to pain management. Although pain physicians often like to think of pain management as a human right, it remains difficult to support this position as a point of law or as a matter of ethics. Medical organizations generally do not define pain management as a specific duty of the physician, apart from the provision of competent medical care. To date, neither law nor ethics creates a duty of care outside of the traditional patient-physician relationship. Absent a universal duty, no universal right exists. Pursuing pain management as a fundamental human right, although laudable, may place the power of the government in the middle of the patient-physician relationship. Despite apparent altruistic motives, attempts to define pain management as a basic human right could have unintended consequences, such as nationalization of medicine to ensure provision of pain management for all patients. Key words: Ethics, law, patient-physician relationship, human right, pain management

Background. Complex dental infections can reach distant areas of the alveolar process, invading the secondary fascial spaces.Objectives. This case report aims to show a misdiagnosis of odontogenic infection and a great need for dentist in the hospital environment.Case Report. A male patient presented facial asymmetry and trismus, while the facial CT examination showed a hyperdense mass involving the left masseteric, pterygomandibular, and superficial temporal regions. The patient was then referred to oral oncology center by emergency physician with cancer suspicion. After 15 days, the patient returned to the same emergency room and was attended by the surgical and maxillofacial trauma team, presenting tachycardia, tachypnea, dysphagia, and trismus. During anamnesis, the patient reported being an uncontrolled diabetic. In intraoral exam, a poor oral condition and generalized periodontitis were observed.Results. Correct diagnosis of odontogenic infection was established and adequately treated.Conclusions. Symptomatology bland may mask the severity of an infection; every increase in volume associated with trismus, poor oral hygiene with or without hyperglycemia should be heavily investigated for the presence of an infectious process. It emphasizes the importance of a dentist working with the physician in emergency room.

ABSTRACTObjective:The relationship between the patient and physician is at the heart of good medical care, and trust is an essential component of this relationship. To enable the oncologist to better form a trusting relationship with the patient, this article describes four factors that influence patient trust.Methods:Thematic literature review and a clinical vignette.Results:The authors discuss four factors that influence patient trust. These factors are whether and how the oncologist (1) minimizes the potential for shame and humiliation during the medical encounter, (2) manages the power imbalance between doctor and patient without abuse or misuse, (3) demonstrates to the patient an appreciation of how he or she is suffering from experience of cancer, and (4) demonstrates to the patient how he or she is suffering from the treatment provided by the oncologist. The authors illustrate these factors with a clinical vignette.Significance of results:The cancer patient is best cared for by an oncologist who can not only understand disease and treat medical problems, but also accompany the patient through the illness experience. This requires an appreciation of the challenges to trust that are inherent in the special characteristics of the patient–physician interaction.

Anthropologists examining the relationship between physician and patient in Western biomedicine have observed an inherent power discrepancy between the physician, assumed to hold scientific knowledge, and the patient, the recipient of this knowledge. COVID-19 presents a unique challenge to that dynamic, as physicians, scientists and medical experts possess limited understanding of the pathophysiology, interventions and treatment of the disease. Drawing on my experience as a resident physician on the frontlines of the COVID-19 pandemic, I contend that the absence of knowledge surrounding COVID-19 fosters a new form of intimacy between physician and patient through greater emphasis on subjective patient experience, increased transparency between physician and patient, and an expanding physician role beyond management of the physical disease state.

The analyzed issue presupposes develo0ment of the new scientific paradigm to implement true communication of physician and patient without formalism or structural power in the process of communication. According to author, to rearrange this type of social interaction of physician and patient from the position of axiological i.e. valueoriented approach that includes eventness and discourse-ethics as modes of its implementation. The overcoming of statistical communication in favor of dynamic one can serve as a base for identification of new theoretical and methodical guideline in this area transforming relationship between physician and patient into system of couching.

AbstractThe purpose of the current study was to analyze brow and ear position, and examine the relationship between these structures in patients presenting for blepharoplasty evaluation. A retrospective chart review was performed, which included all patients presenting to one oculoplastic physician for a blepharoplasty evaluation from November, 2012 to March, 2014. The prevalence of brow ptosis and brow and ear asymmetry was calculated; the proportional distribution was determined, and chi-square analysis and the z-test of proportions were used to calculate the significance. Institutional Review Board approval was obtained for this study. A total of 133 patients met the inclusion criteria. Some degree of brow ptosis was noted in 83% of patients. Brow asymmetry was found in 88% of patients, and ear asymmetry in 77%. Of those patients who had asymmetry, 61% had the right brow lower and 75% had the right ear lower; 73% of all patients had the brow and ear lower on the same side (p < 0.001). In this study, brow ptosis and asymmetry were quite common. In addition, the side of the lower brow correlated strongly with the side of the lower ear, and the right side structures were lower more often than the left. Patients presenting for blepharoplasty evaluation may have an element of generalized facial asymmetry which includes the brows and ears. These observations can be important for preoperative planning and patient counseling.

AbstractThe commonly occurring metaphors and models of the doctor–patient relationship can be divided into three clusters, depending on what distribution of power they represent: in the paternalist cluster, power resides with the physician; in the consumer model, power resides with the patient; in the partnership model, power is distributed equally between doctor and patient. Often, this tripartite division is accepted as an exhaustive typology of doctor–patient relationships. The main objective of this paper is to challenge this idea by introducing a fourth possibility and distribution of power, namely, the distribution in which power resides with neither doctor nor patient. This equality in powerlessness—the hallmark of “the age of bureaucratic parsimony”—is the point of departure for a qualitatively new doctor–patient relationship, which is best described in terms of solidarity between comrades. This paper specifies the characteristics of this specific type of solidarity and illustrates it with a case study of how Swedish doctors and patients interrelate in the sickness certification practice.

In this paper, the author argues that a rights-based culture has unfairly shifted the balance of power away from the physician to the patient with no corresponding shift in the level of responsibilities. After reviewing various Codes of Ethics and the nature of the doctor-patient relationship, the paper then considers, from a philosophical perspective, how this imbalance may be redressed within a communitarian framework. Specific attention is also given to the primary duties owed by patients to their caregivers.

Consumerism, patient rights legislation, and malpractice litigation have created a greater power symmetry between patient and physician. Patients read, question, and insist upon greater participation in decision-making involving treatment. The ideal patient is knowledgeable and an active negotiator in the physician/patient relationship. However, there are some patients who feel so empowered that they are determined to direct and control their treatment. They may request or refuse laboratory tests and attempt to dictate the terms under which diagnosis and treatment should be accomplished. There are as well some physicians who, as a result of conciliatory personal styles, are willing to accommodate to the demands of these patients. In this article, four cases are presented in which physicians have accepted those terms against their better judgment. In two cases malpractice suits followed, ultimately won by the defendant physician. In the last instance a physician patient committed suicide and a malpractice action was settled by mediation. These four case examples establish the principle that physicians, for whatever reason, cannot accommodate the demands of empowered patients that contradict clinical judgment and violate the scientific practice of medicine. Such accommodation may have disastrous results for both patient and physician. Physicians should listen compassionately to patients’ needs and desires, but they may have to refer a patient elsewhere when a negotiated consensus cannot be reached.

A shift in emphasis from deficits to strengths to promote health and well-being in patients with congenital and acquired craniofacial conditions (CFC) is appropriate given the chronic, “incurable” nature of CFC. Personal narratives are a valuable starting point for discovering sources of resilience. This paper explores such a shift by considering two areas of ethical concern suggested by patient narratives: informed consent and the physician-patient relationship. Both areas contain pitfalls and opportunities. The powerful emotions these patients bring with them argue for caution in medical decision making. Attention to the individual's psychosocial adjustment should always supplement surgical evaluations. Because of the inequality of the physician-patient relationship, care should be taken to use this power in positive ways. The relationship between patient and surgeon is particularly charged and may be an important source of support, information, hope, and advice for patients. The changing health care system threatens the physician-patient relationship, but the rise of alternative medicine suggests patients continue to value relationships. Relationships are critical for individuals with CFC, who experience social rejection because of the fundamental importance of face in human interactions. Future research directions should include long-term outcome studies on patients receiving modern craniofacial team care, qualitative research on resilience in patients with positive life adjustment, and development of a conceptual framework and research methodology for understanding quality of life of individuals with CFC. An emphasis upon strengths rather than defects will have implications for the structure of craniofacial teams, the care that is provided, and allocation of resources.

Background Under the Affordable Care Act, patient satisfaction scores are used to determine reimbursements. There are limited data studying the correlation of patient satisfaction with physician adherence to standard of care practice. Objective To examine the correlation between patient satisfaction scores and provider adherence to tuberculosis (TB) monitoring in psoriasis patients on biologic therapy. Methods A multicenter retrospective chart review was conducted evaluating physicians’ compliance with TB testing. TB testing compliance was measured and Press Ganey scores of providers from the same time period were obtained. Results The correlation constant among providers was 0.41, suggesting no linear relationship between compliance and patient satisfaction scores. Conclusions This study did not show a correlation between increased patient satisfaction scores and adherence to appropriate medical standards of care. This contributes to the body of evidence suggesting that these scores are an unsuitable determinant of physician compensation. Further studies controlling multiple variables and with greater power are needed.

Modern medicine has progressed in parallel with the advancement of biochemistry, anatomy, and physiology. By using the tools of modern medicine, the physician today can treat and prevent a number of diseases through pharmacology, genetics, and physical interventions. Besides this materia medica, the patient's mind, cognitions, and emotions play a central part as well in any therapeutic outcome, as investigated by disciplines such as psychoneuroendocrinoimmunology. This review describes recent findings that give scientific evidence to the old tenet that patients must be both cured and cared for. In fact, we are today in a good position to investigate complex psychological factors, like placebo effects and the doctor-patient relationship, by using a physiological and neuroscientific approach. These intricate psychological factors can be approached through biochemistry, anatomy, and physiology, thus eliminating the old dichotomy between biology and psychology. This is both a biomedical and a philosophical enterprise that is changing the way we approach and interpret medicine and human biology. In the first case, curing the disease only is not sufficient, and care of the patient is of tantamount importance. In the second case, the philosophical debate about the mind-body interaction can find some important answers in the study of placebo effects. Therefore, maybe paradoxically, the placebo effect and the doctor-patient relationship can be approached by using the same biochemical, cellular and physiological tools of the materia medica, which represents an epochal transition from general concepts such as suggestibility and power of mind to a true physiology of the doctor-patient interaction.

This article works through about ideology melukat and its role in patient doctor relationship. Ideology grasp is utilized in two different way. First, descriptive purification: as ‘ system thinks ’, ‘trusty system ’, ‘symbolic praktice’ one is engaged social action and politics (neutral conception of ideology). Both of, mendasar's ala ideology is engaged process power relationship justification that asymmetric, in reference to justification process dominates (ideologies critical conception). Its quick is place growths melukat giving room managinging to get affix significant. Melukat also clear away doctor practice room as therapy of alternative complementary.

Background: Medicine has been gaining high technological power, essential for many diagnoses and current treatments. On the other hand, one observes the distancing of the physician from what should be his instrument of work: the person. Bahiana School of Medicine has been implementing actions aimed at integrating the student into the subjective elements of medical practice through such subjects as the Psychodynamics of the Medical Clinic. Objectives: To portray the reality of the teaching of the discipline Psychodynamics in the Bahiana School of Medicine and Public Health; to evaluate the performance of the psychodynamic material taught in the 7th semester of the medical course, as well as the need to teach humanistic fundamentals to the student community of this school. Methods: Case study conducted through documentary analysis, interview with professor of the subject and application of questionnaire. After approval by the Ethics Committee, questionnaires containing sex, age, year of the course, questions related to the subjects developed in the subject were applied, such as doctor-patient relationship, death and dying, medical vocation and humanization etc. Results: The goal of psychodynamics is to provide an integral view of the patient. The questionnaires were answered by 124 students distributed between the 4th, 5th and 6th grades. 88.7% agreed that the subject provided grounds for establishing an effective physician-patient relationship. 91.2% agreed that the subject drew attention to the therapeutic aspect that can have the doctor-patient relationship. 99.2% agree that in order to meet humanity, it is first necessary to humanize. 86.3% of the students agree on the need to teach humanistic fundamentals throughout the course. Conclusions:A Psicodinâmica da Clínica médica vem atingindo os objetivos propostos. Há necessidade do ensino de fundamentos humanísticos durante todo curso de medicina.Background:Medicine has been gaining high technological power, essential for many diagnoses and current treatments. On the other hand, one observes the distancing of the physician from what should be his instrument of work: the person. Bahiana School of Medicine has been implementing actions aimed at integrating the student into the subjective elements of medical practice through such subjects as the Psychodynamics of the Medical Clinic. Objectives:To portray the reality of the teaching of the discipline Psychodynamics in the Bahiana School of Medicine and Public Health; to evaluate the performance of the psychodynamic material taught in the 7th semester of the medical course, as well as the need to teach humanistic fundamentals to the student community of this school. Methods: Case study conducted through documentary analysis, interview with professor of the subject and application of questionnaire. After approval by the Ethics Committee, questionnaires containing sex, age, year of the course, questions related to the subjects developed in the subject were applied, such as doctor-patient relationship, death and dying, medical vocation and humanization etc. Results: The goal of psychodynamics is to provide an integral view of the patient. The questionnaires were answered by 124 students distributed between the 4th, 5th and 6th grades. 88.7% agreed that the subject provided grounds for establishing an effective physician-patient relationship. 91.2% agreed that the subject drew attention to the therapeutic aspect that can have the doctor-patient relationship. 99.2% agree that in order to meet humanity, it is first necessary to humanize. 86.3% of the students agree on the need to teach humanistic fundamentals throughout the course. Conclusions: A Psicodinâmica da Clínica médica vem atingindo os objetivos propostos. Há necessidade do ensino de fundamentos humanísticos durante todo curso de medicina.

Healthcare has long been marked by the authoritative-physician–passive-patient interaction, with patients seeking help and physicians seeking to restore patients back to health. However, globalisation, social movements, and technological advancements are transforming the nature of this relationship. We aim to identify core values that influence the power dynamic between patients and healthcare professionals, and determine how to steer these interactions towards partnership, a more suitable approach to current healthcare needs. Patients with chronic diseases (10 men, 18 women) and healthcare professionals (11 men, 12 women) were interviewed, sessions transcribed, and the framework method used to thematically analyse the data. Validation was done through analyst triangulation and member check recheck. Core values identified as influencing the patient-healthcare professional power dynamic include: (A) values that empower patients (acceptance of diagnosis and autonomy); (B) values unique to healthcare professionals (HCPs) (acknowledging patients experiential knowledge and including patients in the therapeutic process); and (C) shared capitals related to their interactions (communication, information sharing and exchange, collaboration, and mutual commitment). These interdependent core values can be considered prerequisites to the implementation of the patient-as-partner approach in healthcare. Partnership would imply a paradigm shift such that stakeholders systematically examine each other’s perspective, motivations, capabilities, and goals, and then adapt their interactions in this accord, for optimal outcome.

Despite basing its foundation upon the ideals of Hippocrates, Western medicine, especially in the last century, has shifted from a holistic to a more reductionist approach to understanding and treating patients. These changes are primarily a result of widespread acceptance of the biomedical model in modern medicine. Consequently, there are now significant differences in physician and patient explanatory models for the same ailment. Cancer, for example, is interpreted as primarily a physiological process by the medical community, or more simply, as a disease. The patient, on the other hand, interprets cancer as an illness, a more subjective response, covering all aspects of the patient’s life experience, including emotional, psychological, social, and cultural realms, in addition to physiological aspects. These differences in explanatory models result in disparities between physicians and patients when it comes to defining the condition, managing the condition and even defining successful outcomes. These incongruencies must be addressed through effective communication in the clinical encounter, an aspect of patient care that has proven beneficial effects on patient health outcomes. The shared treatment decision-making model best addresses these communication problems. By providing a framework for both the physician and patient to negotiate their respective explanatory models en route to a mutually agreeable treatment decision, this model is a compromise between the two extremes of patient-physician models of communication: paternalism andinformed decision-making. Ultimately, the shared treatment decision-making model establishes a clinical relationship that is no longer characterized by an inabilityto effectively negotiate and consolidate differing values due to unbalanced informational and power dynamics in a social context. By incorporating this model of communication into medical practice, physicians and patients will better understand each other, bridging the disparities apparent in current practice and allow Western medicine to once again approximate the Hippocratic ideal.

The Author of the article summarizes the core aspects and theoretical assumptions of the “Enabling Approach” that has characterized the clinical practice of the ASUGI for years. The model has proved to be effective in positively influencing the quality of life of individuals assisted and in reducing the number of hospitalisations. The model affirms the need to establish relations of a mainly symmetrical nature with the individuals assisted and their caregivers. On the contrary, according to this approach, proposing a “top-down” asymmetric relationship with the patient means responding to an unconscious health professional’s need of power over the patient rather than to the patient’s real needs. This aspect, in the perspective of the Author, lies at the basis of the active involvement (Engagement) of patients in their health care processes.

Even with the passage of time, the misguided motivations of highly educated, physician-participants in the genocide known as the Holocaust remain inexplicable and opaque. Typically, the physician-patient relationship inherent within the practice of medicine, has been rooted in the partnership between individuals. However, under the Third Reich, this covenant between a physician and patient was displaced by a public health agenda that was grounded in the scientific theory of eugenics and which served the needs of a polarized political system that relied on this hypothesis to justify society’s racial hygiene laws. As part of the National Socialist propaganda, Adolf Hitler ominously argued that the cultural decline of Germany after World War I could largely be based on interbreeding and a “resultant drop in the racial level.” This foundational premise defined those who could be ostracized, labeled and persecuted by society, including those who were assimilated. The indoctrination and implementation of this distorted social policy required the early and sustained cooperation and leadership of the medical profession. Because National Socialism promised it could restore Germany’s power, honor and dignity, physicians embraced their special role in the repair of the state. This article will explore the imperative role, moral risks and deliberate actions of physicians who participated in the amplification process from “euthanasia” to systemic murder to medically-sanctioned genocide. A goal of this analysis will be to explore what perils today’s physicians would face if they were to experience the transitional and collective behaviors of a corrupted medical profession, or if they would, instead, have the fortitude and courage necessary to protect themselves against this collaboration. Our premise is that an awareness of history can serve as a safeguard to the conceit of political ascendency and discrimination.

In this paper, I analyze different situations in which the doctor-patient relationship, the knowledge/information produced within this framework, and the practices of medical questioning came to the fore in the work of the state security services, one of the typical institutions of social observation and surveillance of the Hungarian socialist state. I examine work and recruitment dossiers opened from 1956 to the 1980s which document either physicians’ uses in state security observation of information which they gained about their patients during their professional (medical) activities in or in which the physician-patient relationship appears as a context of the physician’s recruitment. I discuss how physicians constructed the patient when the gaze of the state security forces was also arguably part of their medical gaze. I contend that medical knowledge and, more generally, information revealed in the professional (medical) context and used in the framework of network surveillance, taken out of their strict medical context, constituted a gray zone of power. On the one hand, this information was a useful tool with which the regime could exert some measure of effective social and political control beyond the borders of healthcare, while on the other hand, it could help physicians develop a certain degree of social resistance.

In clinical practice, patients can present with many different diseases, often both somatic and mental. Holistic medicine will try to see the diseases as a whole, as symptoms of a more fundamental imbalance in the state of being. The holistic physician must help the patient to recover existence and a good relationship with self. According to the life mission theory, theory of character, and holistic process theory of healing, recovering the purpose of life (the life mission) is essential for the patient to regain life, love, and trust in order to find happiness and realize the true purpose of life. We illustrate the power of the holistic medical approach with a case study of an invalidated female artist, aged 42 years, who suffered from multiple severe health problems, many of which had been chronic for years. She had a combination of neurological disturbances (tinnitus, migraine, minor hallucinations), immunological disturbances (recurrent herpes simplex, phlegm in the throat, fungal infection in the crotch), hormonal disturbances (14 days of menstruation in each cycle), muscle disturbances (neck tensions), mental disturbances (tendency to cry, inferiority feeling, mild depression, desolation, anxiety), abdominal complaints, hemorrhoids, and more. The treatment was a combined strategy of improving the general quality of life, recovering her human character and purpose of life (“renewing the patients life energy”, “balancing her global information system”), and processing the local blockages, thus healing most of her many different diseases in a treatment using 30 h of intense holistic therapy over a period of 18 months.

AbstractObjective:This study sought to better understand the patient s perspective of the experience of recovery from cancer that appeared to defy medical prognoses.Methods:Fourteen cases of medically verified exceptional outcomes were identified. A qualitative approach, employing long narrative interviews was used. Data was analyzed using a cross case thematic analytic approach.Results:The major overarching theme was connections, both internal and external. Internal included connections with God or a higher power and with oneself. The external connections, the focus of this paper, included 1) personal connections with friends and family, 2) connections with the medical system: the physician, nurses and other staff, and 3) connections with other patients. They described the nature of these relationships and the importance of frequent contact with family and friends as providing significant emotional and instrumental support. They expressed confidence in receiving care from a reputable clinic, and with very little probing illustrated the importance of the relationship with their providers. They articulated the significance of the compassionate qualities of the physician and identified communication attributes of their physician that were important in establishing this connection. These attributes were demeanor, availability, honesty, sensitivity in the decision making process. They provided examples of positive connections with nurses and other staff as well as with other patients through their illness process.Significance of results:The importance of connections in these illness narratives was richly illustrated. These issues often are overlooked in clinical settings; yet they are of crucial importance to the health and well-being of the patients.

The purpose of this study is to investigate the relationship between location and specialty of training and practice characteristics such as type of practice (i.e. community versus academic), socio-demographic profile of patients and their complexity, hospital/health facility affiliations and workload/productivity. The analysis required an extraction of registrant data from the University of Toronto Postgraduate Web Evaluation and Registration (POWER) system for a cohort of exiting residents and fellows from 1993 to 2003. The data extract was linked to several administrative databases held by ICES, including physician practice and billing information from the Ontario Health Insurance Plan (OHIP) and anonymized patient demographic data from the Registered Persons Database (RPDB). Results of this study will inform workforce policy issues such as the overall contribution made by Toronto graduates to Ontario, other Canadian provinces and international practice pool of physicians, trends regarding medical career choice, similarities and differences between career choices of International Medical Graduates versus Canadian Medical Graduates, impact of location/program of training, impact of length of training and profile/geography of patients served by graduates of Toronto. The study will aim to create a methodology/template for analysis that can be applied to other medical schools and catchment areas in human health resource planning. Chan B, Willett J. Factors Influencing Participation in Obstetrics by Obstetrician-Gynecologists. 2004; 103(3):493-498. Noble J, Baerlocher MO. Future Practice Profiles of Canadian Medical Trainees. Clinical and Investigative Medicine 2006; 29(4):288-289. Watson DE, Katz A, Reid RJ, Bogdanovic B, Roos N. Family Physician Workloads and Access to Care in Winnipeg: 1991 to 2001. Canadian Family Physician 2004; 171(4):339-342.

According to holistic medical theory, the patient will heal when old painful moments, the traumatic events of life that are often called “gestalts”, are integrated in the present “now”. The advanced holistic physician’s expanded toolbox has many different tools to induce this healing, some that are more dangerous and potentially traumatic than others. The more intense the therapeutic technique, the more emotional energy will be released and contained in the session, but the higher also is the risk for the therapist to lose control of the session and lose the patient to his or her own dark side. To avoid harming the patient must be the highest priority in holistic existential therapy, making sufficient education and training an issue of highest importance. The concept of “stepping up” the therapy by using more and more “dramatic” methods to get access to repressed emotions and events has led us to a “therapeutic staircase” with ten steps: (1) establishing the relationship; (2) establishing intimacy, trust, and confidentiality; (3) giving support and holding; (4) taking the patient into the process of physical, emotional, and mental healing; (5) social healing of being in the family; (6) spiritual healing — returning to the abstract wholeness of the soul; (7) healing the informational layer of the body; (8) healing the three fundamental dimensions of existence: love, power, and sexuality in a direct way using, among other techniques, “controlled violence” and “acupressure through the vagina”; (9) mind-expanding and consciousness-transformative techniques like psychotropic drugs; and (10) techniques transgressing the patient's borders and, therefore, often traumatizing (for instance, the use of force against the will of the patient).We believe that the systematic use of the staircase will greatly improve the power and efficiency of holistic medicine for the patient and we invite a broad cooperation in scientifically testing the efficiency of the advanced holistic medical toolbox on the many chronic patients in need of a cure. The level-8 tools can traumatize the patient if used incorrectly. Some of the level 9 tools and most of the level-10 tools can be severely traumatising for the patient, even when used correctly, so there must be compelling reasons for using them, and the patient must know, understand, and accept the risk before the onset of treatment.

Background: Although much has been written about the potential power of the association between physicians’ personal health practices and those of their patients, we found few objective studies of this relationship. We therefore investigated this association using objectively measured health care indicators. Aim of the study: The aim of the study was to show the association between physicians’ own screening/immunization practices and their patients screening/immunization practices. Material and methods: We assessed 8 indicators of quality of health care (screening and vaccination practices) for primary care physicians (n=1488) and their adult patients (n = 1 886 791) in Israel’s largest health maintenance organization. The physicians were also patients in this health care system Results: For all 8 indicators, patients whose physicians were compliant with the preventive practices were more likely (p < 0.05) to also have undergone these preventive measures than patients with noncompliant physicians. We also found that more similar preventive practices showed somewhat stronger relations. For example, among patients whose physician had received the influenza vaccine, 49.1% of eligible patients received influenza vaccines compared to 43.2% of patients whose physicians did not receive the vaccine (5.9% absolute difference, 13.7% relative difference). This is twice the relative difference (7.2%) shown for pneumococcal vaccine—eligible patients of influenza-vaccinated versus non vaccinated physicians (60.9 vs 56.8%).When we examined the rates of un-related practices, we found that, for example,mammography rates were identical for patients whose physicians did and did not receive the influenza vaccine Conclusions: We found a consistent, positive relation between physicians’ and patients’preventive health practices. Objectively establishing this healthy doctor—healthy patient relationship should encourage preventionoriented health care systems to better support and evaluate the effects on patients of improving the physical health of medical students and physicians.

Background:Patient-reported outcomes (PROs) have become widespread in daily clinical evaluation in patients with rheumatoid arthritis (RA). However, there are few reports for the relationship or discordance between the subjective assessment by the physician and the objective assessment by the patient with RA in surgical treatment.Objectives:We examined the relationship or discordance about the PROs in patients with RA who underwent total elbow arthroplasty (TEA).Methods:We retrospectively identified 53 elbows of 48 patients with RA who underwent TEA at Okayama University Hospital, collected from January 2012 to December 2016.We collected clinical data for the grip strength, range of motion, the Mayo Elbow Performance Scale (MEPS) as objective assessments, and the Patient-Related Elbow Evaluation (PREE), Disability of the Arm, Shoulder, and Hand (DASH) Japanese version and Hand20 as subjective assessments.For statistical analysis, we performed t-tests for pre- and post-operative physical findings and subjective evaluations, and Spearman rank correlation to examine the relationship between objective and subjective assessments.Results:The mean age of the patients at the time of arthroplasty was 63 years, the average disease duration was 23 years, and the average postoperative observation period was 32 months. The average DAS28-CRP was 3.01, and biological uses were 18 cases.The range of motion of the elbow joint and the grip strength was significantly improved postoperatively. All outcome assessments improved significantly except for HAQ (see table1).There was significantly correlated PREE with DASH, Hand20, and MEPS preoperatively. Postoperative PREE showed a significant and robust correlation in postoperative DASH, Hand20, whereas not associated with postoperative MEPS (see table2).To investigate the discordance between PREE and MEPS after TEA, we focused on changes in each item of PREE. Pain- and reach-related items improved postoperatively. But, it was difficult to improve in items affected by hand and finger functions, such as “tie shoelaces.”To explore the effects of finger and hand functions on postoperative assessments, we performed multiple regression analyses. Both preoperative grip strength (unstandardized coefficient [Β] =-0.07; 95%CI -0.148 to -0.006, t value=-2.18, P=0.03) and preoperative Hand20 (B = 0.27, 95%CI 0.029 - 0.518, t=2.25, p=0.02) were significant predictors of postoperative PREE.Conclusion:Surprisingly, the PROs of patients and the surgeon’s evaluations correlated well before surgery but resulted in discordance after TEA. We improved elbow functions by TEA, but since rheumatoid arthritis was a polyarticular disorder, improvement of a single joint function did not improve utterly subjective assessment in patients with RA. We found that the upper limb functions after TEA were significantly affected by preoperative finger and hand function. A rheumatologist should consider the dysfunctions of finger and hand when planning for elbow surgery in patients with RA.Table 1.Pre- and postoperative range of motion of elbow and forearm, grip strength, and measurementCharacteristicPreoperativePostoperativeP valueElbow flexion, degree116 ± 19134 ± 9< 0.001- extension-34 ± 21-25 ± 160.005- total arc82 ± 32109 ± 19< 0.001Grip power, mmHg106 ± 66130 ± 740.007DASH50.5 ± 20.535.8 ± 25.4< 0.001Hand2060.4 ± 19.138.9 ± 29.6< 0.001PREE55.6 ± 18.818.5 ± 17.1< 0.001- pain29.7 ± 11.36.5 ± 7.9< 0.001- function25.9 ± 11.512.0 ± 11.9< 0.001- specific function56.9 ± 25.525.4 ± 25.3< 0.001- usual function20.8 ± 11.310.5 ± 11.3< 0.001HAQ-DI1.06 ± 0.701.07 ± 0.800.607MEPS51.3 ± 16.697.9 ± 3.6< 0.001Table 2.Spearman’s correlation coefficients for pre- and postoperative PREE score*QuestionnairePreoperative Correlation estimateP valuePostoperative Correlation estimateP valueDASH0.56< 0.00010.84< 0.0001Hand200.58< 0.00010.84< 0.0001MEPS- 0.39< 0.01-0.27N.S.Disclosure of Interests:ryozo harada: None declared, Keiichiro Nishida Grant/research support from: K. Nishida has received scholarship donation from CHUGAI PHARMACEUTICAL Co., Eisai Co., Mitsubishi Tanabe Pharma and AbbVie GK., Speakers bureau: K. Nishida has received speaking fees from CHUGAI PHARMACEUTICAL Co., Eli Lilly, Janssen Pharmaceutical K.K., Eisai Co. and AYUMI Pharmaceutical Corporation., Yoshihisa Nasu: None declared, Ryuichi Nakahara: None declared

In 1863, the term “odontoma” was introduced by Paul Broca which he described as a tumor formed by overgrowth of transitory or complete dental tissue. The World Health Organization classified them under mixed benign odontogenic tumors because of their origin from epithelial and mesenchymal cells, exhibiting different structures of dental tissue (enamel, dentin, cementum and pulp).1 There are two distinct types: compound and complex. Compound odontoma is composed of all odontogenic tissue in an orderly fashion resulting in many teeth-like structures but with no morphological resemblance to normal teeth, whereas a complex odontoma appears as an irregular mass with no similarity even to rudimentary teeth.2,3,4 The pathogenesis of odontomas has not been completely established, although the most accepted etiology is related to trauma, infection, growth pressure, and genetic mutations in one or more genes that cause disturbances in the mechanism controlling tooth development.1,5 Patients with compound odontoma are often asymptomatic. It is usually detected on routine radiography upon examination of an unerrupted tooth.6 Odontomas can occur anywhere in the jaws and are usually found associated with or within the alveolar process.7 However, the presence of an odontoma in the maxillary sinus is very rare. We present a female patient with a compound odontoma in the maxillary sinus, initially managed as nasal vestibulitis with maxillary sinusitis. CASE REPORT A 63-year-old woman from Cavite City, Philippines consulted in our institution due to perception of foul odor. Six weeks prior to admission, she experienced right alar pain, facial fullness and swelling with associated undocumented fever. She consulted an ENT specialist and was diagnosed with nasal vestibulitis with maxillary sinusitis. She was given cefixime 200mg, one tablet twice a day and Metronidazole 500mg, one tablet every six hours for seven days. Five weeks prior to admission, despite resolution of the nasal and maxillary swelling and pain, she started to perceive a foul odor. There was no associated nasal congestion and nasal discharge, fever, no nasal itchiness nor frequent sneezing. Her physician requested an orthopantomogram hat revealed a suspicious mass and haziness in the right maxillary sinus and an impacted tooth in the left maxillary sinus. (Figure 1) She was advised surgery but opted for a second opinion. 2 weeks prior to admission, still with perception of foul odor, she consulted another ENT specialist and was given co-amoxiclav 625mg, one tablet every eight hours. A CT scan of the paranasal sinuses revealed mucoperiosteal thickening and calcific density within the opacified right maxillary sinus. (Figure 2 A, B) The patient was advised surgery. The patient had pulmonary tuberculosis in 1983 but was treated for six months. She does not recall having any un-erupted teeth and claimed that her previous dental extractions were unremarkable. She had a family history of bronchial asthma and colon cancer. She did not drink alcoholic beverages but she previously smoked for 1 pack-year. Anterior rhinoscopy revealed scant clear mucoid discharge in both nasal cavities, noncongested and nonhyperemic turbinates, and no intranasal mass. She was edentulous, with no facial mass or swelling. The rest of the examination was unremarkable. With an assessment of a right maxillary mass (odontogenic tumor versus foreign body) with right maxillary sinusitis, and an impacted tooth in the left maxilla she underwent a Caldwell-Luc procedure. Antrotomy was performed through the canine fossa via a gingivolabial incision overlying the anterior maxillary wall. Thick clear mucous was seen oozing out and eventually drained and suctioned out. (Figure 3) A 2 cm x 2 cm x 2.1 cm ovoid, whitish to tan colored hard mass partially covered by black fragments was carefully extracted. (Figure 4) Irrigation of the maxillary sinus was performed using normal saline solution and the natural maxillary ostium was widened. The incision was closed with interrupted mattress sutures using chromic 3.0 and the mass was submitted for histopathological analysis. Microscopic sections revealed misshapen teeth or denticles with a coordinated pattern of calcification such as enamel, dentin and cementum. (Figure 5 A - C) The final histopathologic report was a compound odontoma of the right maxillary sinus. The postoperative follow-up was satisfactory. Our patient developed no oro-antral fistula and showed no signs of maxillary sinusitis and the perception of foul odor resolved. DISCUSSION Odontoma is a generally asymptomatic, slowly progressing tumor that may pass unnoticed. It is usually detected by routine radiograph. This may be associated with un-erupted tooth, mainly the mandibular third molar, followed by the upper canine and upper central incisor. The prevalence of odontoma associated with impacted canine is 1.5 %.8 The maxillary sinus is a frequent site for pathologies of odontogenic origin because of its close anatomical relationship with teeth and periodontal tissues. This makes a frequent but not a common site for inflammatory diseases as well as neoplastic lesions.6 The patient initially presented with right alar pain and right facial swelling. She did not recall having an un-erupted tooth and claimed that her previous dental extractions were unremarkable. After treatment, the pain and swelling resolved but she started to perceive a malodorous smell. Commonly, clinicians arrive at the diagnosis of sinusitis when failure of its resolution despite antibiotic treatment prompts warning bells that warrant further radiographic investigation. The radiographic appearance of odontoma is almost always diagnostic3 as in the presented case. Panoramic and periapical images usually show well-defined borders of a similar density to calcified dental tissue, having a ground-glass appearance, and a radiopaque mass occupying the affected maxillary sinus.9 This was evident in the patient's panoramic radiograph. Additional radiographic evaluation with computed tomography was necessary to determine the extension and features of the lesion because periapical and panoramic images do not provide complete visualization of the maxillofacial complex. CT scans serve as a guide not only for evaluation of the lesion itself, but also for localization of associated pathology and proper treatment planning.10 In this case, the computed tomography scan of the paranasal sinuses revealed mucoperiosteal thickening and calcific density within the opacified right maxillary sinus, suggesting odontogenic origin with concomitant maxillary sinusitis. Due to its asymptomatic course, it can be surmised that the patient might have had the asymptomatic compound odontoma for a long time. The mass in her maxillary sinus was seen freely floating in her CT scan. It may be hypothesized that obstruction by the odontoma could have altered the ventilation and drainage of the maxillary sinus, causing the symptoms of the patient. Cabov, et al. reported that odontomas in the maxillary sinus may also cause pain, facial asymmetry and chronic congestion of the sinus.11 Management for this case was surgical removal of the mass with drainage of trapped mucus as well as medical treatment of the maxillary sinus infection. The Caldwell-Luc procedure was the favored approach to this case because it offered easy access to the mass that could not be extracted trans-nasally because of its size and solid nature. Restoring the drainage of the maxillary sinus was also essential and this was done by widening the natural maxillary sinus ostium. The histological characteristics of the mass extracted from the patient consisted of denticles with a coordinated pattern of calcification such as enamel, dentin and cementum, compatible with a compound odontoma. The rarity of odontomas makes them easy to miss should a radiographic examination not have been done. Despite their being usually asymptomatic, our patient had chronic perception of foul odor that was bothersome and frustrating. A clinician relying on medical history and physical examination alone could not have arrived at the correct diagnosis. In this case, it was shown that radiographic imaging was very crucial in catching a hidden and rare tumor.

OBJECTIVES/SPECIFIC AIMS: If intranasal ketamine can be utilized for pain control in cancer patients, this could provide them with superior analgesia and better quality of life, without the risk of significant respiratory depression associated with opioid medications. We seek to obtain preliminary data via a clinical trial addressing safety, feasibility, and utility of this novel technique for the treatment of persistent uncontrolled cancer pain. These findings would be an important initial step towards testing the effectiveness of intranasal ketamine as a non-opioid medication for cancer pain used as potential maintenance outpatient therapy. These initial findings would be applied to a subsequent trial to determine the effectiveness and associated toxicities of ketamine in a larger sample of cancer patients, and address the compelling need to identify new, successful management therapies for cancer pain. Specific Aims: 1. To evaluate (pharmacodynamic) effects of NAS ketamine on Patient Reported Outcomes (PROs), such as pain scores, side effects, depression, quality of life, and functional status. A clinical trial will be conducted where NAS ketamine will be given to a sample of patients with cancer related pain. Patient Reported Outcomes (PROs), such as pain scores, depression, quality of life, and functional status will be noted on Numerical Pain Rating Scale (NPRS), Montgomery Asberg Depression Rating Scale (MADRS), and Edmonton Symptom Assessment (ESAS), Eastern Cooperative Oncology Group (ECOG) and Patient Reported Outcome Measurement Information System (PROMIS) scales respectively. 1. To measure pharmacokinetics of NAS ketamine through analysis of ketamine and its metabolite norketamine to determine pharmacokinetic properties. During this clinical trial blood samples will be drawn at specified intervals and sent for analysis. 3. To determine opioid sparing effect of NAS ketamine. Opioid use will be measured by documenting use of rescue medications prior to and during the study and by evaluating total opioid consumption prior to and during the study. METHODS/STUDY POPULATION: Study sample: In the search for improved therapies for chronic cancer pain, medications with novel mechanisms of action have been sought. One such promising pharmacologic approach is ketamine. We specifically intend to measure utility of ketamine in patients with pain related to cancer or cancer treatment. Ketamine has shown to reverse central sensitization and opioid tolerance in rat models. Since ketamine is Scheduled III in United States and has abuse potential, we do not intend for ketamine to replace opioids, but use in patients who have failed opioid therapy. Since the investigators of the study practice at Emory, subjects will be from oncology and pain clinics (the supportive oncology clinic, oncology clinics, the pain clinic and Acute Pain Service) at Emory. The trial will be conducted at the Phase 1 Unit of the Winship Cancer Institute (WCI) at Emory. Subjects may be identified and contacted via telephone with information about the study prior to their next clinic appointment in order to allow time for them to consider the study. Eligibility criteria: Patients will be eligible to participate if they are: 1. Adults with uncontrolled cancer related pain a. Male and female subjects at least 18 years of age. b. Patients with uncontrolled pain related to cancer or cancer treatment. c. Uncontrolled pain will be defined as i. pain which persists for more than 7 days and is rated >/=4 on NPRS, and/or ii. use of breakthrough medication more than 4 times in 24 hours d. Failed other pain medications such non-steroidal anti-inflammatories such as ibuprofen, acetaminophen, opioids such as tramadol, hydrocodone, oxycodone etc. and antineuropathics such as gabapentin. 2. Able to provide informed consent a. Patients who are able to understand written and verbal English. Patients will be excluded from the study if they have any of the following: 1. Conditions increasing the risk of side effects from ketamine a. Conditions not safe due to cardiovascular effects of ketamine i. Presence of severe cardiac disease-EF <15% in patients with known history of cardiac disease ii. Uncontrolled Stage 2 hypertension or greater (systolic blood pressure > 160 and/or diastolic blood pressure >100) iii. Baseline tachycardia, HR >100 b. Conditions not safe due to potential effect of ketamine on intracranial and intraocular pressure i. Presence of elevated ICP ii. Uncontrolled glaucoma c. Presence of uncontrolled depression or other psychiatric comorbidity with psychosis 2. Conditions not safe due to potential side effects reported in ketamine abusers a. History of liver disease b. History of interstitial cystitis 3. Conditions where delivery of intranasal medications may be unreliable a. Active allergic or infectious rhinitis b. Patients with lesions of nasal mucosa 4. Conditions where fetus may be exposed to ketamine in utero (ketamine is category C medication) a. Pregnant women, nursing mothers and women of childbearing potential not using contraception known to be highly effective. b. Highly effective contraception methods include combination of any two of the following: Use of oral, injected or implanted hormonal methods of contraception or; Placement of an intrauterine device (IUD) or intrauterine system (IUS); Barrier methods of contraception: condom or occlusive cap (diaphragm or cervical/vault caps) with spermicidal foam/gel/film/cream/ vaginal suppository; Total abstinence; Male/female sterilization. 5. Conditions with medication abuse potential a. Illicit substance abuse within the past 6 months b. Documented history of medication abuse/misuse (e.g. Unsanctioned dose escalation, broken opioid agreement etc.) 6. Conditions where ketamine metabolism may be altered, resulting in erroneous dose response relationship a. Clinical requirement for medications that are concurrent inducers or strong inhibitors of CYP3A4. CYP3A4 substrates are allowed. (Ketamine is metabolized by CYP3A4) Study sample limitations: Subject factors that may affect the final resultant study sample of subjects with full data for analysis. 1. Subjects who may not get pain relief with ketamine may not follow up and resulting incomplete data not eligible for analysis that may erroneously enhance positive effect of ketamine on pain relief. To account for this effort will be made to document the reason for lack of follow-up by contacting patient via telephone or at next scheduled clinic visit within Emory Healthcare. 2. Since patients coming to Emory are typically insured, the study will not adequately capture indigent population. It is not the intention of the current study to investigate differences in pain characteristics or responses of patients with insurance vs indigent population and will need to be addressed via future trials. Since this is a single center trial, the results of this trial might lack external validity required to support widespread changes in practice. This will be a pilot trial to figure out likely most efficacious dose. If this trial is successful, a multi-site randomized clinical trial will be conducted next. Primary Study Measures Primary exposure Intranasal Ketamine for cancer related pain Ketamine is an FDA approved anesthetic with amnesic, analgesic, dissociative, and sedative properties. It is unique among anesthetic agents in that it does not depress cardiovascular and respiratory systems. Ketamine is a noncompetitive, antagonist of N-methyl-D-aspartate (NMDA) receptors that blocks the NMDA channel in the open state by binding to the phencyclidine (PCP) site located within the lumen of the channel. Antagonism of NMDA receptors produces antinociception of persistent or neuropathic pain in animal models and analgesia in pain states in humans. The NMDA receptor is believed to play a role in the development of opioid tolerance and ketamine has been shown in a rat model to prevent fentanyl-induced hyperalgesia and subsequent acute morphine tolerance 5. Ketamine also interacts at a number of other receptor sites to block pain. Some of these sites include voltage-sensitive calcium channels, depression of sodium channels, modulation of cholinergic neurotransmission, and inhibition of uptake of serotonin and norepinephrine. Ketamine also interacts with kappa and mu opioid receptors; however, in humans, naloxone, an opioid antagonist, does not antagonize the analgesic effects of ketamine. Safety and efficacy of ketamine as an anesthetic and analgesic agent is well-documented 2-4. Ketamine is not labeled by the FDA as an analgesic agent. Low (subanesthestic) doses of ketamine have minimal adverse impact upon cardiovascular or respiratory function but produce analgesia and modulate central sensitization, hyperalgesia, and opioid tolerance. Cancer pain, especially in end stages, can be very complicated and is mediated by a variety of pathways: visceral, nociceptive, neuropathic and central. If ketamine can be utilized for pain in end stage cancer patients, this could provide them with superior analgesia and better quality of life, without the risk of significant respiratory depression associated with opioid medications. One of the challenges that we face with ketamine is the route of administration. The most common route is intravascular or intramuscular. Although it has been given orally and rectally, the bioavailability of ketamine when given via these routes is limited to 20-30%. Intranasal (NAS) administration has advantages of being needle free method of administration with potential for outpatient therapy. It lacks hepatic first pass effect resulting in higher bioavailability compared to oral route. Large surface area, uniform temperature, high permeability and extensive vascularity of the nasal mucosa facilitate rapid systemic absorption of intranasal administered drugs 6. In the pilot trial conducted by the study investigators, single dosage of intranasal ketamine has been shown to be feasibility and effective option for temporary pain reduction in patients with cancer related pain. The investigators now seek to obtain feasibility and efficacy data on long-term use of intranasal ketamine for cancer related pain. Ketamine is a scheduled III medication. A physician with a DEA license can order intranasal ketamine from a compounding pharmacy. Primary outcome of interest: Pain scores will be recorded on Numerical Pain Rating Scale (NPRS) at regular intervals throughout the study. NPRS is the most responsive tool to document pain intensity when compared to Visual Analogue Scale (VAS) and Visual Rating Scale (VRS) for measuring pain, 7 showing higher compliance rates, better responsiveness, ease of use, and good applicability relative to VAS/VRS8. Minimal clinically important differences (MCIDs) for pain ratings varies substantially based on patient population and statistical technique used, range of 0.4 to 3.7 points has been reported as a MCID. In general, improvements of pain severity</=1.5 points on NPRS could be seen as clinically irrelevant 9-13. Above that value, the cutoff point for “clinical relevance” depends on patients’ baseline pain severity, and ranges from 2.4 to 5.3 11-13. Higher baseline scores require larger raw changes to represent clinically important differences 14. Primary aim: To determine efficacy of intranasal ketamine in reducing cancer related pain. A clinical trial will be conducted to determine effect of intranasal ketamine on cancer related pain. Pain scores will be recorded on Numerical Pain Rating Scale (NPRS) at regular intervals throughout the study. Minimal clinically important differences (MCIDs) for pain ratings varies substantially based on patient population and statistical technique used, range of 0.4 to 3.7 points has been reported as a MCID. In general, improvements of pain severity</=1.5 points on NPRS could be seen as clinically irrelevant 9-13. Above that value, the cutoff point for “clinical relevance” depends on patients’ baseline pain severity, and ranges from 2.4 to 5.3 11-13. Higher baseline scores require larger raw changes to represent clinically important differences 14. Several clinical trials for pain have reported a reduction of 2 points on NPRS to be clinically important.15-17 Therefore for the purposes of this study, MCID of 2 was used for sample size calculations. A prior research study done by Carr et al. studied effects of intranasal ketamine for breakthrough pain in patients with chronic pain of various etiologies. 18 Total number of subjects in this study was 20 (4 of these had cancer related pain).This study demonstrated a mean reduction of 2.7 units on NPRS (P<0.0001), with standard deviation of 1.87. Since MCID is 2, effect size using this (MCID/SD) = 1.05. Power and sample size table: Assumptions: 1. T-test is the appropriate test (may not be the appropriate test since we have a small sample size and may not be able to assume normality of means based on the central limit theorem) 2. Distribution of reductions in pain score is normal 3. Effect size of 1.05 is clinically meaningful; Sample Size: A sample size of 7 from a population of 20 (in the study done by Carr etal.) achieves 80% power to detect a NPRS difference of −2 between the null hypothesis mean of 0.0 and the alternative hypothesis mean of 2 with an estimated standard deviation (SD) of 1.87 and with a significance level (alpha) of 0.05 using paired t-test assuming that the actual distribution is normal. We will include 10 patients to account for the possibility that the observed pain reduction in the current study may be different than the study done by Carr, as in this study patients were given ketamine for breakthrough pain, as opposed to for baseline pain. We will enroll 25 patients in the study to account for potential dropouts. RESULTS/ANTICIPATED RESULTS: Majority of subjects experienced the largest decrease in their pain with the 10mg IV dose. Side effects included nausea/vomiting and a feeling of unreality. All side effects resolved by the end of each study visit. No severe adverse events occurred. DISCUSSION/SIGNIFICANCE OF IMPACT: Further study is required to elucidate safety of NAS ketamine with long term use for cancer related pain.

This article examines an ethical controversy that has received relatively little attention in public debates about the legalization of medical aid-in-dying (AID): should physicians inform patients that they have the option of hastening death? Drawing on ethnographic research about the implementation of AID in Vermont, I argue that how we understand the moral stakes of this debate depends on divergent views regarding language use in social interactions. Some stakeholders in this debate view a physician’s words as powerful enough to damage the patient-physician relationship or to influence a patient to hasten her death, while others believe that merely informing patients about AID cannot move them to act against their own values and preferences. I illustrate how these divergent perspectives are tied to competing language ideologies regarding clinical disclosure, which I call ‘disclosure ideologies’. My analysis of these two disclosure ideologies surrounding AID highlights disclosure practices in medicine as a rich site for medical anthropological theorizing on linguistic performativity and the social power of clinical language.

Recent studies suggest that culturally divergent explanatory models of illness and treatment practices, differing physician–patient goals and expectations, and mistrust and misunderstandings between refugee patients and health care professionals are associated with lower health care utilization and outcomes among refugees in Western host countries. In our experience working as psychiatrists with persons who are refugees, we have found that attention to the processes that define and redefine boundary relationships has important implications for therapeutic care, as well as for training residents and others in culturally-responsive care. This article examines the manner and micro-processes by which boundaries are established, maintained, or altered between medical provider and person who is a refugee as a key pathway in the development of working relationships that are culturally sensitive. We work from an expanded concept of boundaries in psychiatry, viewing boundaries as a way of describing interactions that play important and even critical roles in advancing, impeding, and redefining significant aspects of the therapeutic relationship between practitioner and patient. The quality of the interactions occurring minute by minute within treatment sessions provides the foundation from which relationships are defined, parameters of openness or closure of communication are conveyed, and the power structure is laid out. We offer Martin Buber’s formulation of the I–Thou relationship as the philosophical grounding of flexible, culturally sensitive boundary behaviors. At its best, boundaries of mutual engagement that are respectful and cognizant of a patient’s individuality and cultural history and values are conveyed to the refugee patient.