Health Equity Is No Spectator Sport: The Radical Rooting of a Post-Pandemic Bioethics.

The relationship between equality and equity has been theorized and described in many ways. Recently, this relationship has been popularly illustrated via a meme depicting three people watching a baseball game while standing on boxes. The meme's analogy, that achieving health equity is the ability to view a spectator sport, is a neoliberal account of health. The analogy defines equality at the expense of equity, characterizes health as individualistic, describes health equity as a static outcome, and implies that the bioethical questions for achieving health equity are about the distribution and redistribution of resources. As the SARS CoV-2 pandemic vividly reminded us, health equity is no spectator sport. Health equity is the intentional removal of obstacles to health and the enabling of human flourishing to assure that everyone has fair and just opportunities for health. That relational and radical account of health equity requires different analogies. This article reimagines and re-illustrates the relationship between equality and equity using an organic analogy of three plants. The analogy calls for bioethics to nurture communal relationships and engage community leaders in pursuit of communal flourishing.

The Wayback Machine.

We suffer from a radical autonomy which too often collapses the therapeutic alliance between patient and physician into a health-care transaction between consumer and provider, a fee-for-service exchange for something far short of true health. Some ethicists and physicians are seeking a better way, by employing a virtue ethics approach in which health is seen as a distinct good and the proper end of a medical encounter. Curlin and Tollefsen's The Way of Medicine (2021) synthesizes this material into a heuristic contrasting what they characterize as the Provider Services Model and the Way of Medicine. The authors believe physicians must choose between the two models and serve, respectively, either the well-being or the health of the people they meet as patients. Between the authors' dichotomous choices, many physicians will find a middle way in virtue ethics approaches, which instead characterize health as a communal foundation to human flourishing and autonomy as serving communal as well as individual goods.

The triple helix of clinical, research, and education missions in academic health centers: A qualitative study of diverse stakeholder perspectives.

INTRODUCTION: Academic health centers are poised to improve health through their clinical, education, and research missions. However, these missions often operate in silos. The authors explored stakeholder perspectives at diverse institutions to understand challenges and identify alignment strategies. METHODS: Authors used an exploratory qualitative design and thematic analysis approach with data obtained from electronic surveys sent to participants at five U.S. academic health centers (2017-18), with four different types of medical school/health system partnerships. Participants included educators, researchers, system leaders, administrators, clinical providers, resident/fellow physicians, and students. Investigators coded data using constant comparative analysis, met regularly to reconcile uncertainties, and collapsed/combined categories. RESULTS: Of 175 participants invited, 113 completed the survey (65%). Three results categories were identified. First, five higher-order themes emerged related to aligning missions, including (a) shared vision and strategies, (b) alignment of strategy with community needs, (c) tension of economic drivers, (d) coproduction of knowledge, and (e) unifying set of concepts spanning all missions. Second, strategies for each mission were identified, including education (new competencies, instructional methods, recruitment), research (shifting agenda, developing partnerships, operations), and clinical operations (delivery models, focus on patient factors/needs, value-based care, well-being). Lastly, strategies for integrating each dyadic mission pair, including research-education, clinical operations education, and research-clinical operations, were identified. CONCLUSIONS: Academic health centers are at a crossroads in regard to identity and alignment across the tripartite missions. The study's results provide pragmatic strategies to advance the tripartite missions and lead necessary change for improved patient health.

Combating Contagion and Injustice: The Shared Work for Public Health and Faith Communities During COVID-19.

Faith communities are uniquely positioned for essential public health work to combat the COVID-19 pandemic and address the chronic pre-existing health disparities that have been exacerbated by COVID-19. Specifically, faith communities can (1) dialogue with public health communities, developing internal policies and meeting guidelines consistent with evidence-based recommendations and their own faith traditions, (2) bolster religious daycare and parochial school immunization policies, and (3) partner with faith-based organizations through financial support and volunteer hours. This essential work will complement governmental public health approaches and ensure faith communities can assist with future pandemics.

Questionable Agreement: The Experience of Depression and DSM-5 Major Depressive Disorder Criteria.

Immediately before the release of DSM-5, a group of psychiatric thought leaders published the results of field tests of DSM-5 diagnostic criteria. They characterized the interrater reliability for diagnosing major depressive disorder by two trained mental health practitioners as of "questionable agreement." These field tests confirmed an open secret among psychiatrists that our current diagnostic criteria for diagnosing major depressive disorder are unreliable and neglect essential experiences of persons in depressive episodes. Alternative diagnostic criteria exist, but psychiatrists rarely encounter them, forestalling the discipline's epistemological crisis. In Alsadair MacIntyre's classic essay, such crises occur in science when a person encounters a rival schemata that is incompatible with their current schemata and subsequently constructs a narrative that allows them to reconstruct their own tradition. In search of rival schemata that are in conversation with their own tradition, psychiatric practitioners can utilize alternative diagnostic criteria like the Cultural Formulation Interview, embrace an epistemologically humble psychiatry, and attend to the narrative experience of a person experiencing a depressive episode.

Held Against Our Wills: Reimagining Involuntary Commitment.

Involuntary psychiatric treatment for people with serious mental illness should focus on returning to health instead of reducing danger.

Alternatives to War Within Medicine: From Conscientious Objection to Nonviolent Conflict About Contested Medical Practices.

When we figure medical practice as warfare, an individual clinician may be either a dutiful combatant or a conscientious objector. The rhetorical structure of this choice means that clinicians may exercise their consciences by loyally joining or disloyally exiting the medical ranks' battle against disease. But there are alternatives to loyalty and exit, and within psychiatry, these alternatives have transformed clinical services. In the 1970s, gay activists successfully resisted the American Psychiatric Association's characterization of homosexuality as a mental illness. In the 1940s, Mennonite nonresisters created the Mennonite mental health movement as a noncoercive alternative to standard psychiatric care. These gay activists and Mennonite volunteers opened communal alternatives to violence. When clinicians pursue nonviolent conflict about contested medical practices, they practice with the integrity that develops out of engaging in moral dialogue. Medicine becomes something more than a war in which individuals serve or to which they object: instead, it becomes a prudential set of practices that advance through principled disagreements and that expand the imagination of clinicians as they respond to the vulnerability of the people they meet as patients.

The worthless remains of a physician's calling: Max Weber, William Osler, and the last virtue of physicians.

On the centenary of Max Weber's "Science as a Vocation," his essay still performs interpretative work. In it, Weber argues that the vocation of a scientist is to produce specialized, rationalized knowledge that will be superseded. Weber says this vocation is a rationalized version of the Protestant conception of calling or vocation (Beruf), tragically disenchanting the world and leaving the idea of calling as a worthless remains (caput mortuum). A similar trajectory can be seen in the physician William Osler's writings, especially his essay "Internal Medicine as a Vocation," in which the calling of a physician is described as both rational and noble. While Osler's conception of the physician's vocation has been formative for contemporary medicine, physicians are reporting burnout and leaving medical practice at escalating rates. As physicians abandon their noble vocations, an alternative conception of a physician's vocation is needed. From the worthless remains of the physician's rational and noble vocation, the labor of a physician can find grounding in humility.

Review of serum prolactin levels as an antipsychotic-response biomarker.

Antipsychotics acting as antagonists at dopamine D2 receptors concentrated in the striatum are the cornerstone of effective treatment of psychosis. Substantial progress in treating persons with schizophrenia could be achieved by the identification of biomarkers which reliably determine the lowest efficacious dose of antipsychotics. Prolactin levels have been considered a promising treatment-response biomarker due to dopamine's regulation of serum prolactin levels through D2 receptors in the hypothalamic-pituitary pathway. Prolactin secretion in response antipsychotic administration is associated with the antipsychotics affinity for D2 receptors. This review assesses the available literature on the use of serum prolactin levels as an antipsychotic-response biomarker. Articles were identified through PubMed as well as the reference lists of full text articles available online. Relevant publications were summarized briefly to define the limitations and utility of serum prolactin levels as a tool for improving antipsychotic dosing. Serum prolactin levels in combination with prolactin-inducing potencies for each antipsychotic may help identify the lowest effective dose of antipsychotic medications. , In addition to the fact that prolactin secretion is dependent on serum antipsychotic levels and not brain levels, recent findings show that prolactin release is independent of the ß-arrestin-2 pathway and GSK3ß regulation, one branch of the pathway that has been implicated in antipsychotic efficacy. Therefore, serum prolactin is an indirect biomarker for treatment response. Further investigations are warranted to characterize prolactin-antipsychotic dose-response curves and systematically test the utility of measuring prolactin levels in patients to identify a person's lowest efficacious dose.

Risk Factors for Readmission on an Adult Inpatient Psychiatric Unit.

OBJECTIVE: Readmission rates have been proposed as a possible quality metric for inpatient psychiatry. Little is known about predicting readmissions and identifying modifiable factors that may reduce early readmissions in these settings. METHODS: We reviewed 693 medical records from our adult inpatient psychiatric unit to identify factors associated with patients' readmission within 90 days of discharge. RESULTS: After adjusting for all variables, and including interactions between identified factors, we found several demographic features predicting readmission, including male gender with suicidal ideation on admission (odds ratio [OR] = 13.2; 95% confidence interval [CI], 3.4-51.9), a diagnosis of a psychotic disorder with a prior medical admission (OR = 5.7; 95% CI, 1.7-20.6), and suicidal ideation with comorbid personality disorder (OR = 5.3; 95% CI, 1.4-20.6). Demographic features decreasing the odds of readmission included being non-white with homeless living situation (OR = 0.18; 95% CI, 0.04-0.82), medication changes made within 48 hours of discharge (OR = 0.44; 95% CI, 0.23-0.84), and the number of medications dispensed without documented follow-up plan or appointment (OR = 0.88; 95% CI, 0.81-0.96). CONCLUSION: Future prospective studies utilizing qualitative and quantitative methods are required to more precisely define a wider array of metrics. Improved identification of demographic features associated with early readmissions may suggest areas to target as we seek to the quality of inpatient psychiatric care.

Trains Departing from Different Stations: Being Mortal and Dying in the 21st Century.

While physician-writers and medical humanists both characterize contemporary deaths as train wrecks, they sometimes disagree about what causes such consistent wreckage. In Being Mortal (2014), the surgeon-writer Atul Gawande attributes the wreckage to forces that so reduce aging and dying persons' autonomy that they prevent those persons from being themselves. For the leading medical humanists in Dying in the Twenty-First Century (2015), edited by Lydia Dugdale, it is our emphasis on autonomy over interdependence that causes contemporary death and dying to go off the rails. To understand the gap between these two accounts, their implicit conversation is compared to the explicit dialogue between a previous generation's leading surgeon-writer and medical humanists: How We Die (1993) by Sherwin Nuland and Facing Death (1996), edited by Howard Spiro and colleagues.

"I am the Author and Must Take Full Responsibility": Abraham Verghese, Physicians as the Storytellers of the Body, and the Renewal of Medicine.

Abraham Verghese proposes to renew medicine by training physicians to read the right texts-literary fiction and patients' bodies-with skilled attention. Analyzing Verghese's proposal with reference to Foucault's idea of the "clinical gaze," I find that Verghese conceives of patients as texts that only physicians can read, meaning that physicians become the storytellers of the bodies, lives, and deaths of the people they meet as patients. I conclude that Verghese's project is unsustainable and alternatively propose thinking analogically of physicians as ship captains who maintain therapeutic distance to reopen interpretative spaces for communities outside of medicine.

Use and diversion of medical marijuana among adults admitted to inpatient psychiatry.

BACKGROUND: Marijuana use is associated with anxiety, depressive, psychotic, neurocognitive, and substance use disorders. Many US states are legalizing marijuana for medical uses. OBJECTIVE: To determine the prevalence of medical marijuana use and diversion among psychiatric inpatients in Colorado. METHODS: Some 623 participants (54.6% male) responded to an anonymous 15-item discharge survey that assessed age, gender, marijuana use, possession of a medical marijuana card, diversion of medical marijuana, perceived substance use problems, and effects of marijuana use. Univariate statistics were used to characterize participants and their responses. Chi-square tests assessed factors associated with medical marijuana registration. RESULTS: Of the total number of respondents, 282 (47.6%) reported using marijuana in the last 12 months and 60 (15.1%) reported having a marijuana card. In comparison to survey respondents who denied having a medical marijuana card, those respondents with a medical marijuana card were more likely to have initiated use before the age of 25, to be male, to have used marijuana in the last 12 months, and to have used at least 20 days in the past month. 133 (24.1%) respondents reported that someone with a medical marijuana card had shared or sold medical marijuana to them; 24 (41.4%) of respondents with a medical marijuana card reported ever having shared or sold their medical marijuana. CONCLUSION: Medical marijuana use is much more prevalent among adults hospitalized with a psychiatric emergency than in the general population; diversion is common. Further studies which correlate amount, dose, duration, and strain of use with particular psychiatric disorders are needed.