[When is a doctor a good doctor? An analysis of the contents of statements by representatives of the medical profession ]. / Wann ist ein Arzt ein guter Arzt? Eine inhaltsanalytische Untersuchung von Aussagen medizinischer Professionsvertreter.

BACKGROUND: Several professional bodies have developed influential documents which have tried to describe the essential competences of a good doctor. Such an initiative has not been previously conducted in German-speaking countries. Differences between the published statements point towards the significance of differences in the respective sociocultural setting. METHODS: The first step was to take advantage of a series of standardized written interviews [including the item "What makes a doctor a good doctor?"], conducted with leading German physicians and published serially in the Deutsche Medizinische Wochenschrift. Responses were qualitatively analysed by three assessors in accordance with Grounded Theory. Text fragmentation and assignment of categories was built successively: it was based on the actual material and repeatedly revised. RESULTS: 261 statements were extracted from a total of 83 interviews. It was possible to assign 249 of them to one of the following nine categories: "knowledge", "empathy" and "patient orientation" and, less frequently "practical competence", "genuineness", "helper", "awareness of limits", "life-long learning" and "cooperation". Results were similar for older and younger physicians, or when comparing representatives of clinical and theoretical disciplines. CONCLUSIONS: It will be worthwhile to survey and evaluate the opinion of additional members of the medical profession and of patients and others with a stake in the health system--comparing and delineating results from different countries--so that a more comprehensive picture can be drawn of "the good doctor".

The art of perception: from the life world to the medical gaze and back again.

Perceptions are often merely regarded as the basic elements of knowledge. They have, however, a complex structure of their own and are far from being elementary. My paper will analyze two basic patterns of perception and some of the resulting medical implications. Most basically, all object perception is characterized by a mixture of knowledge and ignorance (Husserl). Perception essentially perceives with inner and outer horizons, brought about by the kinesthetic activity of the perceiving subject (Sartre). This first layer of perceptual reality, the world of "open" perceptions, is the inescapable background for "every rationality, every value, every existence" (Merleau-Ponty). On an epistemological level a characteristic change of perceptual patterns in medicine was introduced by pathological anatomy (Foucault). The reference of medical perception to the dead body created the new possibility of "absolute" perception, allowing for more precise medical interventions, but at the same time coming into conflict with the open structures of "ordinary," non-scientific perception patterns in everyday life. On the basis of these distinctions, an analysis of the different perceptual patterns in medicine becomes possible. Such an analysis would be the task of a sub-field in medical philosophy that could be called "medical aesthetics" having as its goal an "art of perception" understood as a technique of adequately applying different perceptual patterns in medical practice.

Codes and morals: is there a missing link? (The Nuremberg Code revisited).

Codes are a well known and popular but weak form of ethical regulation in medical practice. There is, however, a lack of research on the relations between moral judgments and ethical Codes, or on the possibility of morally justifying these Codes. Our analysis begins by showing, given the Nuremberg Code, how a typical reference to natural law has historically served as moral justification. We then indicate, following the analyses of H. T. Engelhardt, Jr., and A. MacIntyre, why such general moral justifications of codes must necessarily fail in a society of "moral strangers." Going beyond Engelhardt we argue, that after the genealogical suspicion in morals raised by Nietzsche, not even Engelhardt's "principle of permission" can be rationally justified in a strong sense--a problem of transcendental argumentation in morals already realized by I. Kant. Therefore, we propose to abandon the project of providing general justifications for moral judgements and to replace it with a hermeneutical analysis of ethical meanings in real-world situations, starting with the archetypal ethical situation, the encounter with the Other (E. Levinas).

Functional analysis of a rat sodium channel carrying a mutation for insect knock-down resistance (kdr) to pyrethroids.

Pyrethroid insensitivity in resistant (kdr) insects has been correlated with a leucine to phenylalanine replacement in the S6 transmembrane segment of domain II of the axonal sodium channel alpha(para)-subunit. An alpha-subunit of rat brain type II sodium channel containing this mutation has been expressed and its sensitivity to permethrin compared with that of the wild-type channel. The steady-state activation curve of the mutant was shifted 14 mV in the depolarizing direction. We propose that an equivalent shift of the sodium current activation curve in kdr insects could account for their low sensitivity to permethrin toxicity.

Identification of mutations in the housefly para-type sodium channel gene associated with knockdown resistance (kdr) to pyrethroid insecticides.

We report the isolation of cDNA clones containing the full 6.3-kb coding sequence of the para-type sodium channel gene of the housefly, Musca domestica. This gene has been implicated as the site of knockdown resistance (kdr), an important resistance mechanism that confers nerve insensitivity to DDT and pyrethroid insecticides. The cDNAs predict a polypeptide of 2108 amino acids with close sequence homology (92% identity) to the Drosophila para sodium channel, and around 50% homology to vertebrate sodium channels, Only one major splice form of the housefly sodium channel was detected, in contrast to the Drosophila para transcript which has been reported to undergo extensive alternative splicing. Comparative sequence analysis of housefly strains carrying kdr or the more potent super-kdr factor revealed two amino acid mutations that correlate with these resistance phenotypes. Both mutations are located in domain II of the sodium channel. A leucine to phenylalanine replacement in the hydro-phobic IIS6 transmembrane segment was found in two independent kdr strains and six super-kdr strains of diverse geographic origin, while an additional methionine to threonine replacement within the intracellular IIS4-S5 loop was found only in the super-kdr strains. Neither mutation was present in five pyrethroid-sensitive strains. The mutations suggest a binding site for pyrethroids at the intracellular mouth of the channel pore in a region known to be important for channel inactivation.

Changes in the methylation of amplified esterase DNA during loss and reselection of insecticide resistance in peach-potato aphids, Myzus persicae.

Insecticide resistance in peach-potato aphids, Myzus persicae, results from the amplification of genes encoding an esterase that hydrolyses and sequesters insecticides. Resistance is normally stable, but highly resistant aphid clones sometimes lose resistance when insecticidal selection pressure is removed. This loss of resistance, termed reversion, arises from a loss of elevated esterase enzyme through transcriptional control, i.e. without loss of the amplified esterase DNA sequences. We have shown that loss of the elevated enzyme occurred simultaneously with loss of methylation at CCGG sites in the amplified DNA sequences. During reselection of resistance in these revertant clones, enzyme levels increased, but there was no corresponding return of methylation to DNA sequences. Thus, although DNA methylation is closely correlated with expression of the amplified esterase genes during reversion, it may not be a factor in the reverse process.