En-case-ing the patient: disciplining uncertainty in medical student patient presentations.

The problem-oriented medical record is the widespread, standardized format for presenting and recording information about patients, which is taught to future physicians early in their medical training. Based on our participant observation of medical training, we analyze the ways in which the patient presentation operates in medical training as a disciplinary technology that manages uncertainty in the clinical decision-making process. We uncover various mechanisms at work including the construction of a coherent narrative structure in which chaotic experiences are re-organized and re-interpreted to fit neatly in a linear plot with a predictable ending, the atomization of the patient as a whole into separable "problems," the attempt to solve these "problems" as though they are independent of one another, and the mystification of translations in scale, which give rise to much of the uncertainty in medicine. Operating at the boundary of the chaotic and often ungraspable world of the suffering experience of the patient and the highly structured realm of the medical record, a patient presentation is one medium through which both a disciplined record of experience and disciplined medical practitioners are produced. This process functions to transform the human subject patient into a recognizable, generic clinical case, and the medical student into an identifiable, professional future physician.

Effects of vulvodynia on quality of life.

BACKGROUND: The experiences of women with vulvodynia are poorly understood. OBJECTIVE: We sought to determine the effects of vulvodynia on quality of life. METHODS: We conducted a survey of 280 patients in a university-based vulvar disorders clinic. Skin-related quality of life was measured with a vulvar-specific version of Skindex-29. RESULTS: The response rate was 95%; 101 patients (36%) had vulvodynia, and 179 patients (64%) had other vulvar conditions. Women with vulvodynia had significantly worse quality of life than patients with many other dermatologic conditions, and worse functioning than women with other vulvar conditions (mean functioning scores [+/-SD] of patients with psoriasis, other vulvar conditions, and vulvodynia were 23 +/- 27, 34 +/- 24, and 44 +/- 22, respectively, P = .05). A diagnosis of vulvodynia was the strongest independent correlate of poor quality of life (eg, for poor functioning, odds ratio = 1.8, 95% confidence interval 1.0-3.1). LIMITATIONS: Limitations are single academic medical center and comorbid illnesses determined by self-report. CONCLUSION: Vulvodynia has broad and substantial effects on quality of life.

Insights into the management of emerging infections: regulating variant Creutzfeldt-Jakob disease transfusion risk in the UK and the US.

BACKGROUND: Variant Creutzfeldt-Jakob disease (vCJD) is a human prion disease caused by infection with the agent of bovine spongiform encephalopathy. After the recognition of vCJD in the UK in 1996, many nations implemented policies intended to reduce the hypothetical risk of transfusion transmission of vCJD. This was despite the fact that no cases of transfusion transmission had yet been identified. In December 2003, however, the first case of vCJD in a recipient of blood from a vCJD-infected donor was announced. The aim of this study is to ascertain and compare the factors that influenced the motivation for and the design of regulations to prevent transfusion transmission of vCJD in the UK and US prior to the recognition of this case. METHODS AND FINDINGS: A document search was conducted to identify US and UK governmental policy statements and guidance, transcripts (or minutes when transcripts were not available) of scientific advisory committee meetings, research articles, and editorials published in medical and scientific journals on the topic of vCJD and blood transfusion transmission between March 1996 and December 2003. In addition, 40 interviews were conducted with individuals familiar with the decision-making process and/or the science involved. All documents and transcripts were coded and analyzed according to the methods and principles of grounded theory. Data showed that while resulting policies were based on the available science, social and historical factors played a major role in the motivation for and the design of regulations to protect against transfusion transmission of vCJD. First, recent experience with and collective guilt resulting from the transfusion-transmitted epidemics of HIV/AIDS in both countries served as a major, historically specific impetus for such policies. This history was brought to bear both by hemophilia activists and those charged with regulating blood products in the US and UK. Second, local specificities, such as the recall of blood products for possible vCJD contamination in the UK, contributed to a greater sense of urgency and a speedier implementation of regulations in that country. Third, while the results of scientific studies played a prominent role in the construction of regulations in both nations, this role was shaped by existing social and professional networks. In the UK, early focus on a European study implicating B-lymphocytes as the carrier of prion infectivity in blood led to the introduction of a policy that requires universal leukoreduction of blood components. In the US, early focus on an American study highlighting the ability of plasma to serve as a reservoir of prion infectivity led the FDA and its advisory panel to eschew similar measures. CONCLUSIONS: The results of this study yield three important theoretical insights that pertain to the global management of emerging infectious diseases. First, because the perception and management of disease may be shaped by previous experience with disease, especially catastrophic experience, there is always the possibility for over-management of some possible routes of transmission and relative neglect of others. Second, local specificities within a given nation may influence the temporality of decision making, which in turn may influence the choice of disease management policies. Third, a preference for science-based risk management among nations will not necessarily lead to homogeneous policies. This is because the exposure to and interpretation of scientific results depends on the existing social and professional networks within a given nation. Together, these theoretical insights provide a framework for analyzing and anticipating potential conflicts in the international management of emerging infectious diseases. In addition, this study illustrates the utility of qualitative methods in investigating research questions that are difficult to assess through quantitative means.