The Doctor-Patient Relationship, Partnership Theory, and the Patient as Partner: Finding a Balance Between Domination and Partnership.

It is perhaps most useful to approach the Doctor-Patient relationship (DPR) by admitting that it's complicated. We review some of the strategies that have been employed to mitigate this complexity, zeroing in on one that promises to capture the main features of the DPR without eliminating some of its more important, existential components; pieces of the puzzle that must be retained if we are to avoid oversimplification and the errors that can arise by ignoring important foundational properties. We believe that a useful way to look at the DPR and to capture essential features that must be balanced in the process is provided by Partnership Theory and its definition in terms of the so-called domination and partnership systems. We apply this theory to the DPR and investigate the implications of this application to health care. We see that in the absence of mitigating circumstances, adoption of the patient-as-partner model serves healthcare well and is flexible enough to accommodate circumstances that dictate modifications.

Fishing in a Puddle of Doubt and Disbelief?: A Rejoinder to the Speed et al. Commentary.

In the article "Religiously/Spiritually Involved, but in Doubt or Disbelief-Why? Healthy?", Mrdjenovich (in J Relig Health  https://doi.org/10.1007/s10943-018-0711-2 , 2018) explored the practices of religious attendance and prayer among atheists and agnostic theists. Speed et al. (in J Relig Health https://doi.org/10.1007/s10943-020-01109-1 , 2020) offered a commentary regarding Mrdjenovich's (2018) article with attention to moderators of associations between religious/spiritual constructs and health outcomes. In this rejoinder, I review Speed et al.'s (2020) commentary and I identify a number of concerns, both with their observations and ostensive oversights involving qualitative research methodology, the utility of survey data, the domain of belief, and the impact of calls for a pluralistic approach in the religion-heath research field. I conclude that Mrdjenovich does not misunderstand mechanisms of the (non)religion-health relationship as much as Speed et al. seem to misinterpret Mrdjenovich's (2018) purpose, perspective, and default position on the issues. I reiterate that a concerted effort is required to study health outcomes among religious minorities.

The transition from inquiry to evidence to actionable clinical knowledge: A proposed roadmap.

RATIONALE, AIMS, AND OBJECTIVES: We consider the question "What should we do?" in the context of clinical research/practice. There are several steps along the way to providing a satisfactory answer, many of which have received considerable attention in the literature. We aim to provide a unified summary and explication of these "steps along the way". The result will be an increased appreciation for the meaning and structure of "actionable clinical knowledge". METHODS: We review the literature to identify pertinent works dealing with evidence production and translation into actionable clinical knowledge. We draw from insights in this literature about various aspects of reasoning relevant to clinical questions and integrate these into a unified approach to the processes that lead to actionable clinical knowledge. RESULTS: We collect, collate, and integrate some of the work by Bauer, Carper, Goldman, Haack, McHugh and Walker, and Upshur and colleagues and obtain guidelines to aid in the evidence-to-actionable-clinical- knowledge transition. CONCLUSIONS: Clinical decision-making is not infallible, and the steps we can take to minimize error are context dependent. Medical evidence, produced as it is by human effort, can never be perfect. We will be doing well by assuring that the evidence we use has been produced by a reliable process and is relevant to the question posed.

Authors Disclosing Their Theistic Orientation in Journal Articles on Religion and Health? Infrequent, Informal, and Mostly Inconsistent with Conflict of Interest.

An international survey was conducted of authors (N = 288) in the religion-health (R-H) research field concerning the disclosure of their theistic orientation (T-O) (i.e., whether they believe in God[s], a Higher Power, or a universal spirit) in their journal articles. Most (74%) of the respondents said they never disclose their T-O in this context; e.g., because they feel the information is private (20%), irrelevant (36%), unimportant (56%), and/or likely to make them appear less credible (36%). Atheists were four times less likely than deists and gnostic theists were to disclose their T-O; authors who conducted experimental research and published more frequently were also less likely to disclose their T-O. When disclosure did occur, it was more likely to take place informally within the narrative of manuscripts. Most (66%) of the respondents did not view their T-O as a competing interest (CI). Agnostic theism and the absence of theistic belief were less likely to be experienced as CIs than gnostic theism, deism, and atheism were. The respondents predominantly disagreed both that T-O should be characterized as a CI (48%) and that authors in the R-H field should disclose their T-O as such (59%). Only 18% of the authors in this study who did perceive their T-O as a CI reported that they formally disclose that information to journals or publishers, while the majority (59%) of those authors said they never disclose the information in this context at all. The discussion focuses on reasons as to why authors might choose not to do so. Recommendations are offered for the R-H field.

Scientism recognizes evidence only of the quantitative/general variety.

RATIONALE, AIMS AND OBJECTIVES: McHugh and Walker introduced a model of knowledge to demonstrate that EBM is a form of scientism that ignores important sources of knowledge thereby impairing the practice of medicine. We study the development of this model and explore additional applications. METHODS: Review of the relevant literature and identification of possible areas for fruitful application. RESULTS: We show that the McHugh and Walker model is closely related to the model of evidence considered earlier by Upshur et al. We also indicate that the utility of this model is not limited to showing scientism distorts clinical practice. Several representative applications are identified, including psychotherapy, the Salk polio vaccine trial, and the placebo effect. CONCLUSIONS: Priority should be given to Upshur et al for the development of a model that has far-reaching application to medical epistemology. It is shown that all four of the types of evidence considered-qualitative/personal, qualitative/general, quantitative/general, and quantitative/personal-are required to adequately characterize epistemology in medical research and practice.

Religiously/Spiritually Involved, but in Doubt or Disbelief-Why? Healthy?

The question of why atheists and agnostic theists attend religious services and pray (and what that might mean for their health) is examined through (1) a thematic analysis of commentaries, perspective pieces, and news articles from the popular literature, and (2) a critical review of scholarly research involving comparisons between religious and nonreligious individuals on a variety of health-related outcomes. Findings suggest that atheists and agnostic theists can take pleasure in attending religious services, and they may be driven to pray at times. In many cases, this was explained by their efforts to stay connected and avoid or manage conflict with family members. Despite a pattern of friction between nonbelievers and believers across the dataset, they predominantly agreed on the whys and wherefores of religious service attendance and the prospect that congregants could "bridge the worlds of belief and nonbelief." The themes identified are intended to inform the development of qualitative interview protocols and survey instruments. Although health was not among the most salient themes in the narratives analyzed here, many of the reasons cited for religious service attendance and prayer can be tied to existing literature that has relevance for health. Atheists who experience dissonance between their self-perception and nonbelief in God-and agnostic theists who are prone to existential uncertainty and have only moderate faith-might experience poorer health outcomes. Recommendations focus on the need to (a) supplement secondary analyses of archival survey data with qualitative descriptions of belief systems within groups, and (b) move away from the adversarial stance taken by some of the authors of recently published studies on atheism, nonreligion, and health.

Schemata, CONSORT, and the Salk Polio Vaccine Trial.

In this essay, we defend the design of the Salk polio vaccine trial and try to put some limits on the role schemata should play in designing clinical research studies. Our presentation is structured as a response to de Freitas and Pietrobon (de Freitas, R. S. and R. Pietrobon. 2007. Whoever could get rid of the context of discovery/context of justification dichotomy? A proposal based on recent developments in clinical research. Journal of Medicine and Philosophy 32:25-42.) who identified the CONSORT statement as a schema that would have, had it existed at the time, ruled out the design of the Salk polio vaccine trial of 1954 in favor of a completely randomized controlled clinical trial (RCT). We argue that large-scale public health interventions often require evidence beyond simple efficacy, the limit of what an RCT can provide, and that the design actually adopted for the Salk trial represented a reasonable-albeit imperfect-compromise. This is of more than historical interest in that many contemporary studies are of the scale and scope to require a more pragmatic, rather than explanatory, approach to study design (Kowalski, C. J. 2010. Pragmatic problems with clinical equipoise. Perspectives in Biology and Medicine 53:161-73.).

The Ethics of Clinical Care and the Ethics of Clinical Research: Yin and Yang.

The Belmont Report's distinction between research and the practice of accepted therapy has led various authors to suggest that these purportedly distinct activities should be governed by different ethical principles. We consider some of the ethical consequences of attempts to separate the two and conclude that separation fails along ontological, ethical, and epistemological dimensions. Clinical practice and clinical research, as with yin and yang, can be thought of as complementary forces interacting to form a dynamic system in which the whole exceeds the sum of its parts. Just as effective clinical practice cannot exist without clinical research, meaningful clinical research requires the context of clinical practice. We defend this thesis by triangulation, that is, by outlining how multiple investigators have reached this conclusion on the basis of varied theoretical and applied approaches. More confidence can be placed in a result if different methods/viewpoints have led to that result.

Beware Dichotomies.

This essay combines our thoughts concerning the generally destructive practice of dichotomization with a selective review of the literature supporting our critique. The apparent simplicity of dichotomous thinking encourages its use even when a dyadic representation is totally inadequate to understanding complex situations, and this "simpler is better" mantra continues to stymie our understanding of many of the world's complexities. The identification and naming of two distinct, opposing categories often results in their being seen as in opposition to one another, and that it is somehow incumbent upon us to choose one or the other. This either/or orientation reinforces the original split, confusing explanans and explanandum. We begin by considering dichotomization in general terms, and then turn to brief descriptions of several particular dichotomies. Some of these persist despite what might well be considered sufficient evidence to deny their usefulness, and this often deflects attention away from the more fertile, interesting, and important questions that may be directed to the points at which they intermingle.

Analysis of the Nature of IRB Contingencies Required for Informed Consent Document Approval.

The University of Michigan Human Research Protection Program formed a six-member committee to analyze the nature of Institutional Review Board (IRB) staff and board contingencies for the approval of informed consent documents. Of the 100 studies examined, 87% had one or more informed consent contingencies. "Omissions" in documentation (40%) and "better clarity" (24%) accounted for the majority, while "word-smithing" accounted for only 10%. This is one of the first studies to examine the nature of IRB contingencies as they relate to informed consent documents. Educational efforts targeting completeness in documentation and clarity on the part of study teams, and discouraging "word-smithing" on the part of IRBs, could reduce the number of informed consent contingencies and expedite the IRB approval process.

Providing guidance on the health effects of religious/spiritual involvement: a national assessment of university counseling professionals.

This study assessed the perceptions and practices of a national sample of university counseling professionals (n = 306) regarding their provision of guidance on the health effects of religious/spiritual involvement. Relatively few (21%) discussed the physical health effects of religiosity/spirituality with their clients. The majority (52%) were unsure that such discussions would result in lower health risks; however, nearly half (48%) indicated that these would promote recovery. Almost two-thirds (64%) indicated that discussions of religious/spiritual involvement and health "should occur only with clients who indicate that religion/spirituality is important to them." A plurality (36%) of the respondents had received no formal training on this topic. Implications for clinical training, university counseling centers, and future research are discussed.

Firearm anticipatory guidance training in psychiatric residency programs.

OBJECTIVE: Most suicides (60%) are committed with firearms, and most (80%) of individuals attempting suicide meet diagnostic criteria for mental illness. This study assessed the prevalence of firearm injury prevention training in psychiatric residency programs. METHODS: A three-wave mail survey was sent to the directors of 179 psychiatric residency programs. Outcome measures were the portion of programs offering training in anticipatory guidance for firearms safety, the content of training if offered, and the perceived benefits and barriers to providing such training. RESULTS: A total of 115 directors responded, a response rate of 64%. The vast majority (79%) reported they had not seriously thought about providing firearm injury prevention training. However, more than half (55%) reported that they routinely screened patients for firearm ownership. The directors perceived more benefits than barriers to offering such training. Additionally, the majority (62%) thought APA should provide curriculum guidelines regarding firearm injury prevention training. CONCLUSION: Psychiatrists are uniquely positioned for helping to prevent firearm suicides and homicides among the mentally ill. However, psychiatric residency programs are inadequately training residents and thereby keeping them from maximizing their roles as mental health professionals. Leadership is needed by APA to help reduce firearm violence in the United States.

Reducing firearm-related violence on college campuses-police chiefs' perceptions and practices.

CONTEXT: Firearms are used in the majority of college aged suicides and homicides. With recent efforts by various gun lobbying groups to have firearms more accessible to college students on campuses, there is the potential for more firearm-related morbidity and mortality. OBJECTIVE: This study assessed university police chiefs' perceptions and practices concerning selected issues of firearm violence and its reduction on college campuses. PARTICIPANTS: The Directory of the International Association for College Law Enforcement Administrators was used to identify a national random sample of campus police chiefs (n = 600). The respondents were predominantly males (89%), 40 to 59 years of age (71%), Caucasian (85%), and worked for 21or more years in law enforcement (75%). METHODS: In the fall of 2008, a 2-wave mailing procedure was used to ensure an adequate response rate to a valid and reliable questionnaire. RESULTS: A total of 417 (70%) questionnaires were returned. A firearm incident had occurred in the past year on 25% of campuses and on 35% of campuses within the past 5 years. The majority of campuses (57%) had a plan in place for longer than a year to deal with an "active shooter" on campus. Virtually all (97%) of the campuses had a policy in place that prohibited firearms on campus. The primary barrier (46%) to a highly visible campus plan for preventing firearms violence was the perception that firearms violence was not a problem on their campus. CONCLUSIONS: A greater awareness of the importance of a highly visible campus firearm policy and its potential for reducing firearm trauma on college campuses is needed.

College counselors' perceptions and practices regarding anticipatory guidance on firearms.

OBJECTIVES: This study assessed college counselors' anticipatory guidance on firearms for student clients. PARTICIPANTS: The membership of the Association for University and College Counseling Center Directors was used to identify a national random sample of counseling centers (n = 361). One counselor from each center was selected to survey. METHODS: In the winter of 2008, a 3-wave mailing procedure was used to maximize the response rate. Completed surveys served as consent (as approved by the University Human Subjects Committee). RESULTS: A total of 213 counselors (59%) responded. They were unlikely to provide anticipatory guidance (6%), chart/keep records on client ownership/access to firearms (17%), or to counsel the majority of clients from various diagnostic categories on firearms. CONCLUSIONS: University personnel are likely to refer students with suspected mental health problems to university counseling centers. The findings indicate that few counseling centers will address firearm issues with students.

Prevalence of state firearm mortality and mental health care resources.

A disproportionate share of firearm suicides and homicides are committed by individuals who have a psychiatric diagnosis, many with a history of substance abuse. This study assessed whether selected variables that potentially indicate increased access to mental health care or known demographic risk factors for firearm trauma best predicted state variations in firearm homicide and suicide. Partial correlation coefficients indicated that the proportion of the population within a given state that was African American or Hispanic was significantly associated with increased state firearm homicides. The percent of the population within a given state that had earned a Baccalaureate degree was associated with decreased state firearm homicides. Additionally, increased state firearm ownership rates were significantly associated with firearm suicides, while state educational expenditures were associated with a significant reduction in firearm suicides. The findings suggest that mental health resources within a state have minimal association with firearm homicide and suicide rates. However, state levels of educational achievement and educational expenditures reduce firearm mortality.