When Are "Paraphernalia" Critical Medical Supplies?

Evidence of harm reduction interventions' morbidity and mortality benefits is abundant and of high quality, so there are good reasons for regional and national groups to advocate for more widespread distribution of legally regulated "drug paraphernalia," including needles, syringes, and fentanyl test strips. But lack of consistency among states' laws means that patients' interstate travel can subject them to being charged with possession of illegal items. This commentary on a case offers guidance to clinicians looking to help patients understand legal risks of interstate travel with supplies that are prescribed or recommended to reduce harms of their drug use and explores the ethical responsibilities of physicians in jurisdictions that legally prohibit these harm reduction interventions.

Conceptual competence in psychiatric training: building a culture of conceptual inquiry.

Building a culture of conceptual inquiry in psychiatric training requires the development of conceptual competence: the ability to identify and examine assumptions that constitute the philosophical foundations of clinical care and scientific investigation in psychiatry. In this article, we argue for the importance of such competence and illustrate approaches to instilling it through examples drawn from our collective experiences as psychiatric educators.

Decoding Physical and Cognitive Impacts of Particulate Matter Concentrations at Ultra-Fine Scales.

The human body is an incredible and complex sensing system. Environmental factors trigger a wide range of automatic neurophysiological responses. Biometric sensors can capture these responses in real time, providing clues about the underlying biophysical mechanisms. In this prototype study, we demonstrate an experimental paradigm to holistically capture and evaluate the interactions between an environmental context and physiological markers of an individual operating that environment. A cyclist equipped with a biometric sensing suite is followed by an environmental survey vehicle during outdoor bike rides. The interactions between environment and physiology are then evaluated though the development of empirical machine learning models, which estimate particulate matter concentrations from biometric variables alone. Here, we show biometric variables can be used to accurately estimate particulate matter concentrations at ultra-fine spatial scales with high fidelity (r2 = 0.91) and that smaller particles are better estimated than larger ones. Inferring environmental conditions solely from biometric measurements allows us to disentangle key interactions between the environment and the body. This work sets the stage for future investigations of these interactions for a larger number of factors, e.g., black carbon, CO2, NO/NO2/NOx, and ozone. By tapping into our body's 'built-in' sensing abilities, we can gain insights into how our environment influences our physical health and cognitive performance.

How Bodily Integrity Is a Core Ethical Value in Care of Persons Experiencing Homelessness.

Influences of chronic homelessness on patients' conceptions of bodily integrity can conflict with clinicians' recommendations about clinically indicated interventions, such as dialysis or amputations. This article considers such conflict by drawing on a capabilities-based model to reframe health care as shared between a patient and clinical team.

Autonomous Learning of New Environments with a Robotic Team Employing Hyper-Spectral Remote Sensing, Comprehensive In-Situ Sensing and Machine Learning.

This paper describes and demonstrates an autonomous robotic team that can rapidly learn the characteristics of environments that it has never seen before. The flexible paradigm is easily scalable to multi-robot, multi-sensor autonomous teams, and it is relevant to satellite calibration/validation and the creation of new remote sensing data products. A case study is described for the rapid characterisation of the aquatic environment, over a period of just a few minutes we acquired thousands of training data points. This training data allowed for our machine learning algorithms to rapidly learn by example and provide wide area maps of the composition of the environment. Along side these larger autonomous robots two smaller robots that can be deployed by a single individual were also deployed (a walking robot and a robotic hover-board), observing significant small scale spatial variability.

Care in the time of coronavirus: Ethical considerations in head and neck oncology.

As COVID-19 continues to challenge the practice of head and neck oncology, clinicians are forced to make new decisions in the setting of the pandemic that impact the safety of their patients, their institutions, and themselves. The difficulty inherent in these decisions is compounded by potentially serious ramifications to the welfare of patients and health-care staff, amid a scarcity of data on which to base informed choices. This paper explores the risks of COVID-19 incurred while striving to uphold the standard of care in head and neck oncology. The ethical problems are assessed from the perspective of the patient with cancer, health-care provider, and other patients within the health-care system. While no single management algorithm for head and neck cancer can be universally implemented, a detailed examination of these issues is necessary to formulate ethically sound treatment strategies.

"He Bore it Like a Scarlet Letter": Medical Student Reflections on Substance Use Disorders.

OBJECTIVE: Substance abuse in the context of the opioid crisis presents a major public health concern. Despite some evidence that medical students' attitudes towards substance use disorders worsen during medical school, very few studies have examined how students' early clinical experiences with substance use disorders shape their views of this clinical population. This study uses student reflective essays to explore these formative educational experiences. METHODS: Using content analysis, the authors analyzed a collection of 802 medical student reflective essays written during core clerkships (excluding Psychiatry), coding for ethical and professional themes as well as descriptions of substance use disorders. In addition to the qualitative identification of themes, the authors used chi-square analysis to determine which themes had statistically significant associations with substance use disorders. RESULTS: Fifty-three essays described patients with substance use disorders. The most common substances described were opioids (n = 25), alcohol (n = 18), and cocaine (n = 11). There were five themes statistically associated with substance use disorders (p < 0.05): (1) adequate treatment, (2) pain, (3) difficult patient, (4) jumping to conclusions, and (5) malingering. CONCLUSIONS: In the sample, students found the treatment of pain to be a significant ethical challenge related to substance use disorders. In considering a comprehensive educational plan, medical educators may need to consider educational venues outside of the Psychiatry clerkship to address substance use disorders.

Addicts and Admits: Metonymy in Medical Students' Reflective Writing.

Phenomenon: Metonymy refers to the substitution of the name of an attribute or adjunct for the name of the object or person being described. In medical contexts, this may involve referring to a person as a disease, body part, or other health-related noun. In this study, we explore the use of metonymy in medical students' reflective writing. Approach: Using content analysis, we identified all usages of metonymy in a sample of 802 medical student reflective essays. We analyzed them for associated themes and used the Fisher's exact test to compare frequencies of clinical ethics themes that occurred in the essays with metonymy to those without metonymy. Findings: Metonymy was used 60 times in the essays. The uses were grouped into thematic clusters of substance abuse (n = 27), illness (n = 9), body part (n = 4), clinical status (n = 6), reproductive health (n = 5), challenging clinical situations (n = 6), and other thoughts on patients as people (n = 3). Several ethical themes associated with essays using metonymy (p < .05): moral distress, substance abuse, adequate treatment, jumping to conclusions, awakening, and pain. Insights: Metonymy was relatively uncommon, and some students explicitly described the practice as dehumanizing to patients. Even so, metonymy did present in a variety of forms and was used most frequently to describe individuals with substance use disorders. Essays involving metonymy were more likely to describe a scenario that elicited moral distress in the students, which may indicate that metonymy occurs more frequently in some troubling situations.

Moral distress in medical student reflective writing.

PURPOSE: Moral distress occurs when one identifies an ethically appropriate course of action but cannot carry it out. In this conceptualization, medical students may be particularly vulnerable to moral distress, but the literature on moral distress in medical trainees remains sparse. METHOD: Using content analysis of 802 reflective essays written by third-year medical students, the authors analyzed for the presence of moral distress and other ethical themes. The authors then used chi-squared analysis to determine which ethical themes were statistically associated with moral distress. RESULTS: Two hundred and seventy-four (34%) of the essays included student descriptions of moral distress. The most frequent theme in the moral distress essays was "role of the medical student" in the training hierarchy, and this reached a statistically significant association with moral distress (χ2=15.19, p < 0.001). Statistically significant associations (p < 0.05) were also found with moral distress and themes related to an "ethical disagreement with supervisor," "insensitive care," "disputes," "abuse," "poverty," "medical errors," and "transplant ethics." Essays discussing the "doctor-patient relationship" or observations of a "job well done" were statistically less likely to involve moral distress. CONCLUSIONS: Moral distress is a common occurrence in medical students, particularly related to medical students' role in the training hierarchy or other difficult interpersonal and clinical interactions. In our sample, moral distress was described less often in the presence of positive role models.

Medical student reflections on geriatrics: Moral distress, empathy, ethics and end of life.

Medical students' early clinical encounters may influence their perceptions of geriatrics. This study examines reflective essays written by 3rd-year medical students on required clinical rotations. Using content analysis, the authors analyzed the essays' thematic content. The authors then used chi-squared analysis to compare themes with geriatric patients (age 60+) to themes with other age groups. One hundred twenty out of 802 essays described a geriatric patient. The most common geriatric themes were (1) death and dying, (2) decision making, (3) meaningful physician-patient interactions, (4) quality of care, and (5) professional development. Geriatric essays were more likely to discuss death/dying and risk-benefit themes and less likely to discuss abuse. Geriatric essays were more likely to describe students' moral distress. Geriatric essays with moral distress were more likely to include empathy themes compared to geriatric essays without moral distress. Geriatric patients may pose unique ethical challenges for early clinical students.

Confidence of IRB/REC Members in Their Assessments of Human Research Risk: A Study of IRB/REC Decision Making in Action.

Understanding how institutional review boards/research ethics committees (IRBs/RECs) perform risk/benefit assessment is important to help improve their function. In environmental ethics, uncertainty about potential outcomes and the precautionary principle play important roles in regulatory oversight but have received little attention in the context of human research ethics. We carried out an empirical study to gain insight into uncertainty by asking IRB/REC members about confidence in their risk assessments immediately after discussion of new protocols under review. Based on 12 meetings carried out by four IRBs/RECs over a 6-month period, we found a robust, inverse relationship between risk and confidence. As risk increased, confidence decreased. We detected different patterns of consensus between different IRBs/RECs and their members. Our study introduces a novel and relatively easy to implement approach to begin to understand IRB/REC decision making in real time that can be used within or across institutions.

Polarities in Clinical Thinking and Practice.

This analysis of a case of a bereaved patient that poses two treatment options-watchful waiting or medication-focuses on five "polarities" in clinical practice: (1) the normal and the pathological, (2) the individual and the diagnostic collective, (3) the primary care physician and the consultant, (4) the expert and nonexpert, and (5) the moment and the process. These polarities can accentuate ethical problems posed by this case, for example, by creating stark contrasts that mask the complex contexts of care and characteristics of patients. These stark contrasts can create false dilemmas that may obscure simpler, shared decision-making solutions. Alternatives to conceiving cases in terms of polarities are discussed.

Professional identity formation: creating a longitudinal framework through TIME (Transformation in Medical Education).

The University of Texas System established the Transformation in Medical Education (TIME) initiative to reconfigure and shorten medical education from college matriculation through medical school graduation. One of the key changes proposed as part of the TIME initiative was to begin emphasizing professional identity formation (PIF) at the premedical level. The TIME Steering Committee appointed an interdisciplinary task force to explore the fundamentals of PIF and to formulate strategies that would help students develop their professional identity as they transform into physicians. In this article, the authors describe the task force's process for defining PIF and developing a framework, which includes 10 key aspects, 6 domains, and 30 subdomains to characterize the complexity of physician identity. The task force mapped this framework onto three developmental phases of medical education typified by the undergraduate student, the clerkship-level medical student, and the graduating medical student. The task force provided strategies for the promotion and assessment of PIF for each subdomain at each of the three phases, in addition to references and resources. Assessments were suggested for student feedback, curriculum evaluation, and theoretical development. The authors emphasize the importance of longitudinal, formative assessment using a combination of existing assessment methods. Though not unique to the medical profession, PIF is critical to the practice of exemplary medicine and the well-being of patients and physicians.

Building a Central Repository for Research Ethics Consultation Data: A Proposal for a Standard Data Collection Tool.

Clinical research ethics consultation services have been established across academic health centers over the past decade. This paper presents the results of collaboration within the CTSA consortium to develop a standard approach to the collection of research ethics consultation information to serve as a foundation for quality improvement, education, and research efforts. This approach includes categorizing and documenting descriptive information about the requestor, research project, the ethical question, the consult process, and describing the basic structure for a consult note. This paper also explores challenges in determining how to share some of this information between collaborating institutions related to concerns about confidentially, data quality, and informatics. While there is much still to be learned to improve the process of clinical research ethics consultation, these tools can advance these efforts, which, in turn, can facilitate the ethical conduct of research.

Risk factor medicalization, hubris, and the obesity disease.

The essays on obesity in this issue frequently refer to the recent American Medical Association (AMA) declaration of obesity as a disease. In response to these essays, I describe and explore the significance of 'risk-factor medicalization' and how negative unintended consequences with this approach to disease modeling are exemplified in many of the essays. I also relate the essays' content to the issue of physician hubris in the face of their own helplessness in aiding the obese patient.