History's Toolbox in Health Professions Education: One Skill-Based Session on Social Determinants of Health.

Aimed at clinical educators, this article reports on the use of a single skill-based session that introduces learners in Health Professions Education (HPE) to basic techniques from the discipline of history. The premise of the teaching method is a correspondence between medicine's social determinants of health (SDH) and categories of analysis commonly used by historians. At the center are eight categories, or "tools": social, cultural, intellectual, technological, political, economic, racial/ethnic, and gendered. Like the direct and specific implications of many diagnostic signs, each of these adjectives indicate to historians specific types of factors, or determinants. The intervention employs the demonstration-performance teaching method (explanation, demonstration, supervised practice, and evaluation). After the session, learners are able to: use "history's toolbox" as a systematic method for evaluating socio-cultural phenomena inherent in SDH; differentiate eight types of determinants in a historical case study that represents socio-cultural complexity; recognize how categorization simultaneously enhances some determinants while obscuring others, and how the use of constructed social categories in medicine can function to help and harm patients and populations. The intervention described is rooted in scholarship and theoretical questions belonging to the discipline of history, but these are not discussed. Neither the historical content nor the teaching method described here is appropriate for research or teaching in the discipline of history.

"Everything has been tried and his heart can't recover ": A Descriptive Review of "Do Everything!" in the Archive of Ontario Consent and Capacity Board.

BACKGROUND: In end-of-life situations, the phrase "do everything" is sometimes invoked by physicians, patients, or substitute decision-makers (SDM), though its meaning is ambiguous. We examined instances of the phrase "do everything" in the archive of the Ontario Consent and Capacity Board (CCB) in Canada, a tribunal with judicial authority to adjudicate physician-patient conflicts in order to explore its potential meanings. METHODS: We systematically searched the CCB's online public archive from its inception to 2018 for any references to "do everything" in the context of critical care medicine and end-of-life care. Two independent assessors reviewed decisions, collected characteristics, and identified key themes. RESULTS: Of 598 cases in the archive, 41 referred to "do everything" in end-of-life situations. The phrase was overwhelmingly invoked by SDMs (38/41, 93%), typically to advocate for life-prolonging measures that contradicted physician advice. Physicians generally related "doing everything" to describe the interventions they had already performed (3/41, 7%), using it to recommend focusing on patients' quality of life. SDMs were generally reluctant to accept death, whereas physicians found prolonging life at all costs to be morally distressing. The CCB did not interpret appeals to "do everything" legally but followed existing laws by deferring to patients' prior wishes whenever known, or to concepts of "best interests" when not. The CCB generally recommended against life-prolonging measures in these cases (26/41, 63%), focusing on patients' "well-being" and "best interests." CONCLUSIONS: In this unique sample of cases involving conflict surrounding resuscitation and end-of-life care, references to "do everything" highlighted conflicts over quantity versus quality of life. These appeals were associated with signs of cognitive distress on the behalf of SDMs who were facing the prospect of a patient's death, whereas physicians identified moral distress related to the prolongation of patients' suffering through their use of life-sustaining interventions. This divergence in perspectives on death versus suffering was consistently the locus of conflict. These findings support the importance of tools such as the Serious Illness Conversation Guide that can be used by physicians to direct conversations on the patients' goals, wishes, trade-offs, and to recommend a treatment plan that may include palliative care. TRIAL REGISTRATION: Not applicable.

Goods, causes and intentions: problems with applying the doctrine of double effect to palliative sedation.

BACKGROUND: Palliative sedation and analgesia are employed in patients with refractory and intractable symptoms at the end of life to reduce their suffering by lowering their level of consciousness. The doctrine of double effect, a philosophical principle that justifies doing a "good action" with a potentially "bad effect," is frequently employed to provide an ethical justification for this practice. MAIN TEXT: We argue that palliative sedation and analgesia do not fulfill the conditions required to apply the doctrine of double effect, and therefore its use in this domain is inappropriate. Furthermore, we argue that the frequent application of the doctrine of double effect to palliative sedation and analgesia reflects physicians' discomfort with the complex moral, intentional, and causal aspects of end-of-life care. CONCLUSIONS: We are concerned that this misapplication of the doctrine of double effect can consequently impair physicians' ethical reasoning and relationships with patients at the end of life.

"MY RESISTING GETTING WELL": NEURASTHENIA AND SUBCONSCIOUS CONFLICT IN PATIENT-PSYCHIATRIST INTERACTIONS IN PREWAR AMERICA.

This study examines experiences of individual patients and psychiatrists in the Henry Phipps Psychiatric Clinic at Johns Hopkins between 1913 and 1917. The dynamics of these patient-psychiatrist interactions elucidate the well-known conceptual shift in explanations of mental illness during the twentieth century, from somatic models rooted in the logic of "neurasthenia" and damaged nerves to psychodynamic models based on the notion of "subconscious conflict." A qualitative analysis of 336 cases categorized as functional disorders (a catchall term in this period for illnesses that could not be confirmed as organic diseases), shows that patients explained their symptoms and suffering in terms of bodily malfunctions, and, particularly, as a "breakdown" of their nervous apparatus. Psychiatrists at the Phipps Clinic, on the other hand, working under the direction of its prominent director, Adolf Meyer, did not focus their examinations and therapies on the body's nervous system, as patients expected. They theorized that the characteristic symptoms of functional disorders-chronic exhaustion, indigestion, headaches and pain, as well as strange obsessive and compulsive behaviors-resulted from a distinct pathological mechanism: a subconscious conflict between powerful primal and social impulses. Phipps patients were often perplexed when told their physical symptoms were byproducts of an inner psychological struggle; some rejected the notion, while others integrated it with older explanations to reconceptualize their experiences of illness. The new concept also had the potential to alter psychiatrists' perceptions of disorders commonly diagnosed as hysteria, neurasthenia, or psychoneuroses. The Phipps records contain examples of Meyer and his staff transcending the frustration experienced by many doctors who had observed troubling but common behaviors in such cases: morbid introspection, hypochondria, emotionalism, pity-seeking, or malingering. Subconscious conflict recast these behaviors as products of "self-deception," which both absolved the sufferer and established an objective clinical marker by which a trained specialist could recognize functional disorder. Using individual case studies to elucidate the disjunction between patients' and psychiatrists' perspectives on what all agreed were debilitating illnesses, this analysis helps to illuminate the origins of a radical transformation in psychiatric knowledge and popular culture in the twentieth century-from somatic to psychodynamic explanations of mental illness.

Social Skills: Adolf Meyer's Revision of Clinical Skill for the New Psychiatry of the Twentieth Century.

Adolf Meyer (1866-1950) exercised considerable influence over the development of Anglo-American psychiatry during the first half of the twentieth century. The concepts and techniques he implemented at his prominent Phipps Psychiatric Clinic at Johns Hopkins remain important to psychiatric practice and neuro-scientific research today. In the 1890s, Meyer revised scientific medicine's traditional notion of clinical skill to serve what he called the 'New Psychiatry', a clinical discipline that embodied social and scientific ideals shared with other 'new' progressive reform movements in the United States. This revision conformed to his concept of psychobiology - his biological theory of mind and mental disorders - and accorded with his definition of scientific medicine as a unity of clinical-pathological methods and therapeutics. Combining insights from evolutionary biology, neuron theory and American pragmatist philosophy, Meyer concluded that subjective experience and social behaviour were functions of human biology. In addition to the time-honoured techniques devised to exploit the material data of the diseased body - observing and recording in the clinic, dissecting in the morgue and conducting histological experiments in the laboratory - he insisted that psychiatrists must also be skilled at wielding social interaction and interpersonal relationships as investigative and therapeutic tools in order to conceptualise, collect, analyse and apply the ephemeral data of 'social adaptation'. An examination of his clinical practices and teaching at Johns Hopkins between 1913 and 1917 shows how particular historical and intellectual contexts shaped Meyer's conceptualisation of social behaviour as a biological function and, subsequently, his new vision of clinical skill for twentieth-century psychiatry.

Knowledge regarding hymens and the sex education of parents.

The objective of this study was to ascertain beliefs and knowledge of pediatricians and parents regarding the hymen and to evaluate parental and pediatrician attitudes regarding sex education by pediatricians. Surveys were distributed anonymously to parents and pediatricians. Survey questions included knowledge of the female hymen and questions regarding attitudes toward sexual health education. There was a statistically significant difference in mean knowledge scores between pediatricians and parents regarding the hymen (3.7 versus 1.3; p < 0.0001). Almost two-thirds of pediatricians (63%) felt comfortable providing sexual health education directly to their patients, but only 41% felt comfortable educating parents. Pediatricians and parents demonstrate knowledge gaps about the hymen.

"The most important professorship in the English-speaking domain": Adolf Meyer and the beginnings of clinical psychiatry in the United States.

Historians recognize Adolf Meyer (1866-1950), first psychiatrist-in-chief at Johns Hopkins Hospital, as one of the principal architects of clinical psychiatry in the United States. This wholesale influence on the fledgling discipline had much to do with the authority he wielded as a Hopkins chief, but an important question remains: why was Meyer the obvious candidate to establish a department of psychiatry at the nation's foremost institution for medical research and teaching? Taking examples from Meyer's employment in three large American asylums before his appointment to Johns Hopkins in 1908, this article explores how he transformed an improvised set of practices into a clinical system for psychiatry that he implemented on a widespread scale, something that garnered him a reputation as a modernizer of outdated asylums and pegged him, in the minds of Hopkins authorities, as a psychiatric exemplar of commitment to pathological research and clinical teaching.

Social, Motivational, and Symptomatic Diversity: An Analysis of the Patient Population of the Phipps Psychiatric Clinic at Johns Hopkins Hospital, 1913-1917.

In the five years after the Phipps Psychiatric Clinic opened in 1913 at Johns Hopkins, its 88 beds were consistently in high demand. Exploiting the biographical information and the particularly descriptive medical narratives in the hospital records of Phipps patients, this study explores the social composition of the patient population, the various avenues by which patients were admitted, and the decision-making processes of families and communities confronting the vicissitudes of mental illness. Quantitative and qualitative analyses of all admissions between 1913 and 1917 reveal that, contrary to scholarly myth, this population was highly diverse socially, motivationally, and symptomatically.