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1.  A future like ours revisited 
Journal of Medical Ethics  2002;28(3):192-195.
It is claimed by the future like ours anti-abortion argument that since killing adult humans is wrong because it deprives them of a future of value and the fetus has a future of value, killing fetuses is wrong in the same way that killing adult human beings is wrong. In The morality of abortion and the deprivation of futures (this journal, April 2000) I argued that the persuasive power of this argument rests upon an equivocation on the term "future of value". If the expression means "a potential future of value" then the moral claim is implausible because people do not in general have rights to what they need to fulfill their potential; if the expression means "self-represented future of value" then the argument fails because the fetus does not represent its future. Under no interpretation is the argument sound. In Deprivations, futures and the wrongness of killing (this journal, December 2001) Donald Marquis, author of the future like ours argument, responds at length to this objection. In the present essay the focus of the debate shifts to the proper interpretation of the right not to be killed. Donald Marquis argues that this liberty right entails the welfare right to the means necessary to sustain life; I argue that the right not to be killed does not entail unlimited welfare rights. On Marquis's view, the right not to be killed confers upon the fetus the right to whatever it takes to sustain life; on the view I defend, the right not to be killed does not confer upon the fetus or anyone else the right to another person's body. On Marquis's view, abortion is almost never permissible; on my view abortion is almost always permissible.
PMCID: PMC1733571  PMID: 12042408
2.  Expectations and experience of people who consult in a training practice 
All the patients (348) seen in one week in a training practice in Exeter were asked to complete a pair of questionnaires, one before and one after consulting, about the content of that consultation. Seventy-one per cent responded. Ninety-two per cent of respondents expected to be told what was wrong with them, although 72 per cent had a “pretty good idea” of what was wrong beforehand. In the event, 76 per cent felt they had actually been told what was wrong. Sixty-one per cent sought advice or suggestions for self-help. Fifty-four per cent expected to receive, and 57 per cent received a prescription, including 14 per cent who had not expected one. Ninety-three per cent were satisfied with what took place.
The nine patients who were dissatisfied had expectations which differed little from those of the rest, but their experience in the consultation differed significantly, particularly in relation to discussion, comprehension and the exchange of information. It is concluded that the need for explanatory information greatly exceeded the need for medication in this sample of people.
Some special problems and differences were identified among people who consulted the trainee: in particular, their consultations were less likely to be relaxed and they expected to be, and were, followed up less often than those who saw a principal.
PMCID: PMC1972118  PMID: 7320987
3.  On the morality of deception--does method matter? A reply to David Bakhurst. 
Journal of Medical Ethics  1993;19(3):183-187.
Does it signify morally whether a deception is achieved by a lie or some other way? David Bakhurst has challenged my view that it can signify. Here I counter his criticisms--firstly, by clarifying the terminology: What counts as a lie? Secondly, by exploring further what makes lying wrong. Bakhurst maintains that lying is wrong in that it infringes autonomy--and other deceiving stratagems, he says, do so equally. I maintain that lying is wrong in that it endangers trust--and other types of deceiving stratagems do not do so equally. Lying to patients, I contend, is an abuse of their trust. Other forms of their intentional deception need not be so, although, in our autonomy-minded culture, they are likely to be so.
PMCID: PMC1376288  PMID: 8230152
4.  Deprivations, futures and the wrongness of killing 
Journal of Medical Ethics  2001;27(6):363-369.
In my essay, Why abortion is immoral, I criticised discussions of the morality of abortion in which the crucial issue is whether fetuses are human beings or whether fetuses are persons. Both argument strategies are inadequate because they rely on indefensible assumptions. Why should being a human being or being a person make a moral difference? I argued that the correct account of the morality of abortion should be based upon a defensible account of why killing children and adults is wrong. I claimed that what makes killing us wrong is that our premature deaths deprive us of our futures of value, that is, the goods of life we would have experienced had we survived. This account of the wrongness of killing explains why killing is one of the worst of crimes and how killing greatly harms the victim. It coheres with the attitudes of those with cancer or HIV facing premature death. It explains why we believe it is wrong to kill infants (as personhood theories do not). It does not entail that it wrongs a human being to end her life if she is in persistent vegetative state or if her future must consist only of unbearable physical suffering and she wants to die (as sanctity of human life theories do not). This account of the wrongness of killing implies (with some defensible additional assumptions) that abortion is immoral because we were fetuses once and we know those fetuses had futures of value.
Mark Brown claims that this potential future of value account is unsound because it implies that we have welfare rights to what we need to stay alive that most people would reject. I argue that Brown is incorrect in two ways: a welfare right to what we need to stay alive is not directly implied by my account and, in addition, most of us do believe that dependent human beings have substantial welfare rights to what they need to stay alive. Brown argues that depriving us of a future of value of which we have mental representations both is a better explanation of the wrongness of killing and does not imply that abortion is immoral. I reply that (a) if Brown's arguments against my view were sound, those arguments could be easily adapted to show that his view is unsound as well and (b) Brown's view is both ambiguous and unsound on any interpretation.
The most popular class of pro-choice argument strategies appeals to the view that some or all fetuses lack either a mental state or function or a capacity for a mental state or function necessary for possession of the right to life. Desires, interests, sentience, various concepts, moral agency, and rationality have all been suggested as candidates for this crucial mental role. Brown's analysis is one member of this class of strategies. I believe that it is possible to show that none of these strategies is reasonable. However, there are so many of these strategies that the required argument demands something more like a book and less like a short essay. The argument of the following essay is a piece of this larger argument.
Key Words: Abortion • future of value • Mark Brown • Don Marquis • the right to life • welfare rights
PMCID: PMC1733477  PMID: 11731597
5.  Can Psychopathic Offenders Discern Moral Wrongs? A New Look at the Moral/Conventional Distinction 
Journal of Abnormal Psychology  2011;121(2):484-497.
A prominent view of psychopathic moral reasoning suggests that psychopathic individuals cannot properly distinguish between moral wrongs and other types of wrongs. The present study evaluated this view by examining the extent to which 109 incarcerated offenders with varying degrees of psychopathy could distinguish between moral and conventional transgressions relative to each other and to non-incarcerated healthy controls. Using a modified version of the classic Moral/Conventional Transgressions task (Nucci & Turiel, 1978) that employs a forced-choice format to minimize strategic responding, the present study found that total psychopathy score did not predict performance on the task. Task performance was explained by some individual sub-facets of psychopathy and by other variables unrelated to psychopathy, such as IQ. The authors conclude that, contrary to earlier claims, insufficient data exist to infer that psychopathic individuals cannot know what is morally wrong.
PMCID: PMC3397660  PMID: 21842959
moral reasoning; moral/conventional transgressions distinction; psychopathy; insanity
Surgical confusions have been rarely studied, especially in ophthalmology. The author hypothesized that such confusions occur rarely but are unacceptable in the public, legal, and regulatory arenas; often occur in circumstances presenting predictable risk; more often involve wrong lens implant than wrong eye, procedure, or patient; and can be prevented by following the Universal Protocol.
A retrospective series of 106 cases occurring between 1982 and 2005 included 42 closed files from the Ophthalmic Mutual Insurance Company and 64 cases reported to the New York State Health Department. Records were grouped by procedure planned and analyzed to answer these questions: How did the error occur? By whom and when was the error recognized? Who was responsible? Was the patient informed? What was done to the patient? What was the outcome? What liability payments were made? What policy changes or sanctions resulted? Was the error preventable by following the Universal Protocol?
The most common confusion was wrong lens implant, accounting for 67 (63%) of the 106 cases. Wrong eye surgery occurred in 15 cases, wrong eye blocks in 14, wrong patient/procedure in 8, and wrong corneal transplant in 2. In 16 cases, the Universal Protocol would have been unlikely to prevent the confusion.
Surgical confusions occur infrequently and usually cause little or no permanent injury, but they may be devastating to the patient, the physician, and the profession. Measures to prevent such confusions, including the Universal Protocol and related checklists, deserve the acceptance, support, and active participation of ophthalmologists.
PMCID: PMC2258113  PMID: 18427628
7.  Persons and their copies. 
Journal of Medical Ethics  1999;25(2):98-104.
Is cloning human beings morally wrong? The basis for the one serious objection to cloning is that, because of what a clone is, clones would have much worse lives than non-clones. I sketch a fragment of moral theory to make sense of the objection. I then outline several ways in which it might be claimed that, because of what a clone is, clones would have much worse lives than non-clones. In particular, I look at various ideas connected with autonomy. I conclude that there is no basis to the claim that, because of what a clone is, clones would have much worse lives than non-clones. I therefore reject the claim that cloning human beings is morally wrong.
PMCID: PMC479190  PMID: 10226912
8.  Physicians’ Beliefs About Conscience in Medicine: A National Survey 
To explore physicians’ beliefs about whether physicians sometimes have a professional obligation to provide medical services even if doing so goes against their conscience, and to examine associations between physicians’ opinions and their religious and ethical commitments.
A survey was mailed in 2007 to a stratified random sample of 1,000 U.S. primary care physicians, selected from the American Medical Association Physician Masterfile. Participants were classified into three groups according to agreement or disagreement with two statements: “A physician should never do what he or she believes is morally wrong, no matter what experts say,” and “Sometimes physicians have a professional ethical obligation to provide medical services even if they personally believe it would be morally wrong to do so.”
The response rate was 51% (446/879 delivered questionnaires). Forty-two percent and 22% believed they are never and sometimes, respectively, obligated to do what they personally believe is wrong, and 36% agreed with both statements. Physicians who are more religious are more likely to believe that physicians are never obligated to do what they believe is wrong (58% and 31% of those with high and low intrinsic religiosity, respectively; multivariate odds ratio, 2.9; 95% CI, 1.2–7.2). Those with moral objections to any of three controversial practices were more likely to hold that physicians should never do what they believe is wrong.
A substantial minority of physicians do not believe there is ever a professional obligation to do something they personally believe is wrong.
PMCID: PMC2859045  PMID: 19707071
9.  Angelika Amon: Conquering the divide 
The Journal of Cell Biology  2011;193(2):254-255.
Amon studies how cells segregate their chromosomes and what happens when they get it wrong.
Amon studies how cells segregate their chromosomes and what happens when they get it wrong.
PMCID: PMC3080264  PMID: 21502356
10.  Respectful encounters and return to work: empirical study of long-term sick-listed patients' experiences of Swedish healthcare 
BMJ Open  2011;1(2):e000246.
To study long-term sick-listed patients' self-estimated ability to return to work after experiences of healthcare encounters that made them feel either respected or wronged.
A cross-sectional and questionnaire-based survey was used to study a sample of long-term sick-listed patients (n=5802 respondents). The survey included questions about positive and negative encounters as well as reactions to these encounters, such as ‘feeling respected’ and ‘feeling wronged’. The questionnaire also included questions about the effects of these encounters on the patients' ability to return to work.
Among patients who had experienced positive encounters, those who also felt respected (n=3327) demonstrated significantly improved self-estimated ability to return to work compared to those who did not feel respected (n=79) (62% (95% CI 60% to 64%) vs 34% (95% CI 28% to 40%)). Among patients with experiences of negative encounters, those who in addition felt wronged (n=993) claimed to be significantly more impeded from returning to work compared to those who did not feel wronged (n=410) (50% (95% CI 47% to 53%) vs 31% (95% CI 27% to 35%)).
The study indicates that positive encounters in healthcare combined with feeling respected significantly facilitate sickness absentees' self-estimated ability to return to work, while negative encounters combined with feeling wronged significantly impair it.
Article summary
Article focus
To what extent can positive and perceived respectful healthcare encounters influence long-term sick-listed patients' ability to return to work?
To what extent can negative and perceived unfair healthcare encounters influence long-term sick-listed patients' ability to return to work?
Key messages
Long-term sick-listed patients' self-estimated ability to return to work is significantly facilitated if healthcare encounters are perceived as respectful.
Long-term sick-listed patients' self-estimated ability to return to work is significantly impeded if healthcare encounters are perceived as unfair.
The net effect of feeling respected was highest among patients with somatic disorders, while the net effect of feeling wronged was highest among patients with psychiatric disorders.
Strengths and limitation of this study
The study sample was large and we obtained quite a high response rate.
The outcome measure was the respondents' self-estimated ability to return to work, not their actual ability.
The findings are based on the views of long-term sick-listed patients and so generalisation may not be possible.
PMCID: PMC3211048  PMID: 22021890
11.  Legal Consciousness and Responses to Sexual Harassment* 
Law & society review  2009;43(3):631-668.
Studies of legal mobilization often focus on people who have perceived some wrong, but rarely consider the process that selects them into the pool of potential “mobilizers.” Similarly, studies of victimization or targeting rarely go on to consider what people do about the wrong, or why some targets come forward and others remain silent. We here integrate sociolegal, feminist, and criminological theories in a conceptual model that treats experiencing sexual harassment and mobilizing in response to it as interrelated processes. We then link these two processes by modeling them as jointly determined outcomes and examine their connections using interviews with a subset of our survey respondents. Our results suggest that targets of harassment are selected, in part, because they are least likely to tell others about the experience. Strategies that workers employ to cope with and confront harassment are also discussed. We find that traditional formal/informal dichotomies of mobilization responses may not fully account for the range of ways individuals respond to harassment, and we propose a preliminary typology of responses.
PMCID: PMC2840650  PMID: 20300446
12.  Wrong-level surgery: A unique problem in spine surgery 
Even though a lot of effort has gone into preventing operating at the wrong site and wrong patient, wrong-level surgery is a unique problem in spine surgery.
The current method to prevent wrong level spine surgery performed is mainly relied on intra-operative X-ray. Unfortunately, because of the unique features and anatomy of the spinal column, wrong level spine surgery still happens. There are situations that even with intraoperative X-ray, correct level still cannot be reliably identified.
Examples of patient whose surgery can easily be performed on the wrong level are illustrated. A protocol to prevent wrong-level spine surgery preformed is developed.
The consequence of wrong-level spine surgery not only generates another surgery of the intended level; it is usually also associated with lawsuit. Strictly following this protocol can prevent wrong-level spine surgery.
PMCID: PMC3108446  PMID: 21660270
Spine surgery; wrong-level surgery; wrong-sided surgery
13.  Experience of wrong-site tooth extraction among Nigerian dentists 
The Saudi Dental Journal  2011;23(3):153-156.
To report the experience of wrong-site tooth extraction among Nigerian dentists.
Study design
A self-administered questionnaire was distributed among a cross-section of Nigerian dentists. Information requested included personal experience on wrong-site tooth/teeth extraction and its after-effect, possible reasons for wrong-site tooth extraction and documentation of the event in patients’ case. Respondents were also asked if they were aware of any colleagues who had previously experienced wrong-site tooth extraction and possible legal implication of the event, and if they aware of the universal protocol for preventing wrong site, wrong procedure, and wrong person surgery.
Twenty-two (13%) of the respondents reported having extracted a wrong tooth. The event occurred within 5 years after graduation in most cases. Most respondents (53.6%) informed the patient immediately after the event. Only 68% of the respondents documented the event in patient’s case record. Most common reasons for wrong-site tooth extraction were heavy workload, presence of multiple condemned teeth and miscommunication between dentists. Fifty-five percent of respondents were aware of a colleague who had extracted a wrong tooth. The most probable legal implication of wrong-site tooth extraction according to the respondents was litigation by the patient. Only 25% of dentists were aware of a universal protocol for preventing wrong-site surgery.
Wrong tooth/teeth extraction is not an uncommon event in the studied environment. The need to be familiar with universal protocol on wrong-site surgery and its legal implications are highlighted.
PMCID: PMC3723253  PMID: 23960510
Wrong-site; Tooth; Extraction; Dentists
14.  On telling the truth to patients with dementia 
Western Journal of Medicine  2000;173(5):318-323.
Objectives To discover what dementia sufferers think is wrong with them, what they have been told and by whom, and what they wish to know about their illness. Background Ethical guidelines regarding telling truth appear to be equivocal. Declarations of cognitively intact subjects, attitudes of family members, and current psychiatric practice all vary, but no previous research has been published concerning what patients with dementia would like to know about their diagnosis and prognosis. Design Questionnaire study of patients' opinions. Setting Old Age Psychiatry Service in Worcester, United Kingdom. Participants Thirty consecutive patients with dementia. Results The quality of information received has been poor, and many patients have no opportunity to discuss their illness with anybody. Despite that, almost half of the participants in this study had adequate insight, and most declared that they would like to know more about their predicament. Conclusions Although many patients would like to know the truth, the rights of those who do not want to know should also be respected. Therefore, the diagnosis of dementia should not be routinely disclosed, but just as in other disorders, health care professionals should seek to understand their patients' preferences and act appropriately according to their choice.
PMCID: PMC1071151  PMID: 11069866
15.  Would you like to know what is wrong with you? On telling the truth to patients with dementia 
Journal of Medical Ethics  2000;26(2):108-113.
Objectives—To discover what dementia sufferers feel is wrong with them; what they have been told and by whom, and what they wish to know about their illness.
Background—Ethical guidelines regarding telling truth appear to be equivocal. Declarations of cognitively intact subjects, attitudes of family members and current psychiatric practice all vary, but no previous research has been published concerning what patients with dementia would in fact like to know about their diagnosis and prognosis.
Design—Questionnaire study of the patients' opinions.
Setting—Old Age Psychiatry Service in Worcester.
Participants—30 consecutive patients with dementia.
Results—The quality of information received has been poor and many patients have no opportunity to discuss their illness with anybody. Despite that almost half of the participants in this study had adequate insight and a majority declared that they would like to know more about their predicament.
Conclusions—Although many patients would like to know the truth, the rights of those who do not want to know should also be respected. Therefore the diagnosis of dementia should not be routinely disclosed but (just as in other disorders) health care professionals should seek to understand their patients' preferences and act appropriately according to their choice.
Key Words: Dementia • telling truth • patients' perspectives
PMCID: PMC1733205  PMID: 10786321
16.  What should we say? 
Journal of Medical Ethics  2006;32(1):7-12.
Abstract ethics mostly focuses on what we do. One form of action is a speech act. What we say can have profound effects. We can and should choose our words and how we speak wisely. When someone close to us suffers an injury or serious illness, a duty of beneficence requires that we support that person through beneficial words or actions. Though our intentions are most often benign, by what we say we often make the unfortunate person feel worse. Beginning with two personal accounts, this article explains what can go wrong in the compassionate speech of wellwishers, and uncovers some of the reasons why people say things that are hurtful or harmful. Despite a large body of clinical evidence, there is no perfect strategy for comforting a friend or relative who is ill, and sometimes even the best thing to say can still be perceived as insensitive and hurtful. In some cases, we may have good reason to knowingly say a hurtful or insensitive thing. Saying these 'wrong' things can sometimes be the best way to help a person in the long term. To complicate matters, there can be moral reasons for overriding what is good for the patient. What kind of admonishments should we make to a badly behaved patient? What is the value of authenticity in our communication with the people we love? These questions demand an ethical defence of those speech acts which are painful to hear but which need to be said, and of those which go wrong despite the best efforts of the wellwisher. We offer an ethical account, identifying permissible and impermissible justifications for the things we say to a person with a serious injury or illness.
PMCID: PMC2563280  PMID: 16373515
compassion; equity; misfortune; moral luck
17.  Risk of obesity in immigrants compared with Swedes in two deprived neighbourhoods 
BMC Public Health  2009;9:304.
Despite a strong social gradient in the prevalence of obesity, there is little scientific understanding of obesity in people settled in deprived neighbourhoods. Few studies are actually based on objectively measured data using random sampling of residents in deprived neighbourhoods. In addition, most studies use a crude measure, the body mass index, to estimate obesity. This is of concern because it may cause inaccurate estimations of the true prevalence and give the wrong picture of the factors associated with obesity. The aim of this study was to estimate the prevalence of, and analyse the sociodemographic factors associated with, three indices of obesity in different ethnic groups settled in two deprived neighbourhoods in Sweden.
Height and weight, waist circumference and body fat percentage were objectively measured in a random sample (n = 289). Sociodemographic data were obtained through a survey. Established cut-offs were used to determine obesity. Country of birth was categorized as Swedish, Other European, and Middle Eastern. Odds ratios were estimated by unconditional logistic regression.
One third of the sample was classified as obese overall, with 39.0% of women being abdominally obese. After adjusting for age, we found higher odds of obesity in Middle Eastern women than in Swedish women regardless of outcome with odds ratios ranging between 2.74 and 5.53. Men of other European origin had higher odds of BMI obesity than Swedish men. Most associations between country of birth and obesity remained in the full model.
This study demonstrates the magnitude of the obesity problem and the need for prevention programmes targeting native and immigrant adults in deprived neighbourhoods in Sweden. The initiatives should also focus on particular groups, e.g. immigrant women and those experiencing economic difficulties. Further studies are needed on behavioural and environmental factors influencing the risk of obesity in residents settled in deprived neighbourhoods.
PMCID: PMC2748077  PMID: 19698119
18.  Anterior temporal involvement in semantic word retrieval: voxel-based lesion-symptom mapping evidence from aphasia 
Brain  2009;132(12):3411-3427.
Analysis of error types provides useful information about the stages and processes involved in normal and aphasic word production. In picture naming, semantic errors (horse for goat) generally result from something having gone awry in lexical access such that the right concept was mapped to the wrong word. This study used the new lesion analysis technique known as voxel-based lesion-symptom mapping to investigate the locus of lesions that give rise to semantic naming errors. Semantic errors were obtained from 64 individuals with post-stroke aphasia, who also underwent high-resolution structural brain scans. Whole brain voxel-based lesion-symptom mapping was carried out to determine where lesion status predicted semantic error rate. The strongest associations were found in the left anterior to mid middle temporal gyrus. This area also showed strong and significant effects in further analyses that statistically controlled for deficits in pre-lexical, conceptualization processes that might have contributed to semantic error production. This study is the first to demonstrate a specific and necessary role for the left anterior temporal lobe in mapping concepts to words in production. We hypothesize that this role consists in the conveyance of fine-grained semantic distinctions to the lexical system. Our results line up with evidence from semantic dementia, the convergence zone framework and meta-analyses of neuroimaging studies on word production. At the same time, they cast doubt on the classical linkage of semantic error production to lesions in and around Wernicke's area.
PMCID: PMC2792374  PMID: 19942676
aphasia; voxel-based lesion-symptom mapping; naming; semantic; errors
19.  Image Retake Analysis in Digital Radiography Using DICOM Header Information 
A methodology to automatically detect potential retakes in digital imaging, using the Digital Imaging and Communications in Medicine (DICOM) header information, is presented. In our hospital, neither the computed radiography workstations nor the picture archiving and communication system itself are designed to support reject analysis. A system called QCOnline, initially developed to help in the management of images and patient doses in a digital radiology department, has been used to identify those images with the same patient identification number, same modality, description, projection, date, cassette orientation, and image comments. The pilot experience lead to 6.6% and 1.9% repetition rates for abdomen and chest images. A thorough analysis has shown that the real repetitions were 3.3% and 0.9% for abdomen and chest images being the main cause of the discrepancy being the wrong image identification. The presented methodology to automatically detect potential retakes in digital imaging using DICOM header information is feasible and allows to detect deficiencies in the department performance like wrong identifications, positioning errors, wrong radiographic technique, bad image processing, equipment malfunctions, artefacts, etc. In addition, retake images automatically collected can be used for continuous training of the staff.
PMCID: PMC3043704  PMID: 18592314
Diagnostic image quality; Digital Imaging and Communications in Medicine (DICOM); image analysis
20.  To err is human: Quality management practices in surgical oral pathology, a safety net for medico-legal complications 
Reading a slide and rendering a diagnosis is not only a science but also requires us to appreciate the constant artifact that is introduced in a controlled manner by tissue processing and obtaining a stained tissue section. There are a number of steps involved in getting the final stained tissue section and all these procedures if not performed properly have the potential to give rise to erroneous picture on the slide. Simple errors in judgments can lead to wrong diagnosis and unwarranted treatment. Such mistakes can put us at risk for Medico-Legal problems. The subject of Medico-Legal issues and practice of pathology has been neglected and amount of information available to the practicing professional in India is scarce. This paper focuses on standardized procedures for the various histopathology laboratory exercises. The paper highlights the importance of proper record maintenance with reporting protocols. A list of do's and don’ts for an Oral Pathologist is provided to help him/her in reducing the probable Medico-Legal issues. It does not in any way address the issue of individual competence and diagnostic abilities: That is an aspect for each individual to introspect upon and take remedial action.
PMCID: PMC3830233  PMID: 24250085
Medico-Legal issues; Surgical Pathology and Oral Pathology
21.  What do patients want from doctors? Content analysis of written patient agendas for the consultation. 
BACKGROUND: Although much has been written about what patients want when they contact their general practitioner (GP), there are no published data from large cohort studies of what patients expect. AIM: To describe the expectations of a large group of patients who consulted with their GPs. METHOD: A GP and a social sciences graduate carried out a content analysis of written agenda forms completed by 819 patients who consulted 46 randomly selected GPs. Inter- and intra-rater reliabilities were confirmed. RESULTS: A total of 756 (92%) agenda forms were returned. Inter-rater reliability was satisfactory (kappa > 0.6 for all but two main themes). Almost all patients had requests they wished to make of their doctor, 60% had their own ideas about what was wrong, and 38% had considered explanations about why they were unwell. Forty-two per cent and 24% of patients had consulted because they had reached the limit of their anxiety or tolerance respectively. Seven per cent, 4%, and 2% had comments, which were usually negative, to make about previous management, communication with doctors, or time in the consultation. CONCLUSION: These data demonstrate that most patients come to the consultation with a particular agenda. Failure to address this agenda is likely to adversely affect the outcome of many consultations.
PMCID: PMC1313530  PMID: 10885083
22.  Evolving dimensions in medical case reporting 
Medical case reports (MCRs) have been undervalued in the literature to date. It seems that while case series emphasize what is probable, case reports describe what is possible and what can go wrong. MCRs transfer medical knowledge and act as educational tools. We outline evolving aspects of the MCR in current practice.
PMCID: PMC3094294  PMID: 21524284
23.  Gist-based conceptual processing of pictures remains intact in patients with amnestic mild cognitive impairment 
Neuropsychology  2012;26(2):202-208.
The picture superiority effect, better memory for pictures compared to words, has been found in young adults, healthy older adults, and, most recently, in patients with Alzheimer’s disease and mild cognitive impairment. Although the picture superiority effect is widely found, there is still debate over what drives this effect. One main question is whether it is enhanced perceptual or conceptual information that leads to the advantage for pictures over words. In this experiment, we examined the picture superiority effect in healthy older adults and patients with amnestic mild cognitive impairment (MCI) to better understand the role of gist-based conceptual processing.
We had participants study three exemplars of categories as either words or pictures. In the test phase, participants were again shown pictures or words and were asked to determine whether the item was in the same category as something they had studied earlier or whether it was from a new category.
We found that all participants demonstrated a robust picture superiority effect, better performance for pictures than for words.
These results suggest that the gist-based conceptual processing of pictures is preserved in patients with MCI. While in healthy older adults preserved recollection for pictures could lead to the picture superiority effect, in patients with MCI it is most likely that the picture superiority effect is a result of spared conceptually-based familiarity for pictures, perhaps combined with their intact ability to extract and use gist information.
PMCID: PMC3295863  PMID: 22229341
picture superiority effect; mild cognitive impairment; Alzheimer’s disease; familiarity; recollection
24.  Patients' unvoiced agendas in general practice consultations: qualitative study 
BMJ : British Medical Journal  2000;320(7244):1246-1250.
To investigate patients' agendas before consultation and to assess which aspects of agendas are voiced in the consultation and the effects of unvoiced agendas on outcomes.
Qualitative study.
20 general practices in south east England and the West Midlands.
35 patients consulting 20 general practitioners in appointment and emergency surgeries.
Patients' agendas are complex and multifarious. Only four of 35 patients voiced all their agendas in consultation. Agenda items most commonly voiced were symptoms and requests for diagnoses and prescriptions. The most common unvoiced agenda items were: worries about possible diagnosis and what the future holds; patients' ideas about what is wrong; side effects; not wanting a prescription; and information relating to social context. Agenda items that were not raised in the consultation often led to specific problem outcomes (for example, major misunderstandings), unwanted prescriptions, non-use of prescriptions, and non-adherence to treatment. In all of the 14 consultations with problem outcomes at least one of the problems was related to an unvoiced agenda item.
Patients have many needs and when these are not voiced they can not be addressed. Some of the poor outcomes in the case studies were related to unvoiced agenda items. This suggests that when patients and their needs are more fully articulated in the consultation better health care may be effected. Steps should be taken in both daily clinical practice and research to encourage the voicing of patients' agendas.
PMCID: PMC27368  PMID: 10797036
25.  Making the internal market work: a case for managed change. 
BMJ : British Medical Journal  1993;307(6914):1270-1272.
The internal market in the NHS is meant to ensure that provider units compete on the basis of price and quality and that money follows patients into efficient units. But the example of what happened to one local ophthalmology unit suggests what may go wrong when entrepreneurial activity is applied in a market that does not work perfectly. In 1991-2 the unit had a high workload but also comparatively high prices (because of crude pricing in the local hospital); because of pressure of work the waiting times lengthened and general practitioners increasingly complained about the service. The staff in the unit reopened a longstanding debate about the need for a third consultant ophthalmologist, but neither the purchasers (including fundholders) nor the provider unit were able to fund the post. Fundholders in a neighbouring district, however, together with that district health authority, decided to place their contracts elsewhere for the following year. Although the withdrawal of contracts jeopardised the clinical and financial viability of the ophthalmic unit, patients continued to use the service. When general practitioners in the district realised that their local service might collapse they pressed to keep the service open. The fundholders and the host purchaser finally agreed to fund a third consultant and drew up standards for the service. As a result the waiting times fell and the service is now described as "excellent." Short term market decisions may have unforseen long term implications for services to patients. This needs to be addressed as part of the evolution of the reformed NHS.
PMCID: PMC1679343  PMID: 8281064

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