'Acute-on-chronic': Emergency Affect and the One-way Staircase of Pharmaceutical Escalation.

The opioid epidemic in the United States is often portrayed as leading to a "pendulum swing" from indiscriminate prescribing toward appropriate use. This portrayal imagines rational-ethical physicians trying to resist irrational-manipulative patients and pharmaceutical companies. Drawing on an ethnography of pain management in U.S. hospital and clinic settings, I suggest instead that chronic pain generates a constantly renewed "emergency affect," a mutual experience for providers and patients that polarizes decisions toward either medication escalation or patient abandonment. Understanding this "emergency affect" can help provide a path forward through the opioid epidemic to embrace the discomfort of pain management.

"Making Moves" in a Cardiac ICU: An Epistemology of Rhythm, Data Richness, and Process Certainty.

Ethnographers of clinical rationality often assume that the goal of biomedical practice is to eliminate uncertainty to produce definitive diagnoses. In this ethnography of an academic cardiac intensive care unit (CCU) in the United States, bodies are conceived instead as ever-changing constellations of problems that make diagnostic certainty irrelevant and require clinicians to construct and reconstruct temporary models to facilitate action. They suspend their uncertainty to "convince themselves" enough to "make moves" on patients, driven by the relentless tempo of critical illness. This necessitates a practice-oriented model of professional rationality that can account for the flow of time, with implications beyond the biomedical.

The first nationwide survey of MD-PhDs in the social sciences and humanities: training patterns and career choices.

BACKGROUND: While several articles on MD-PhD trainees in the basic sciences have been published in the past several years, very little research exists on physician-investigators in the social sciences and humanities. However, the numbers of MD-PhDs training in these fields and the number of programs offering training in these fields are increasing, particularly within the US. In addition, accountability for the public funding for MD-PhD programs requires knowledge about this growing population of trainees and their career trajectories. The aim of this paper is to describe the first cohorts of MD-PhDs in the social sciences and humanities, to characterize their training and career paths, and to better understand their experiences of training and subsequent research and practice. METHODS: This paper utilizes a multi-pronged recruitment method and novel survey instrument to examine an understudied population of MD-PhD trainees in the social sciences and humanities, many of whom completed both degrees without formal programmatic support. The survey instrument was designed to collect demographic, training and career trajectory data, as well as experiences of and perspectives on training and career. It describes their routes to professional development, characterizes obstacles to and predictors of success, and explores career trends. RESULTS: The average length of time to complete both degrees was 9 years. The vast majority (90%) completed a clinical residency, almost all (98%) were engaged in research, the vast majority (88%) were employed in academic institutions, and several others (9%) held leadership positions in national and international health organizations. Very few (4%) went into private practice. The survey responses supply recommendations for supporting current trainees as well as areas for future research. CONCLUSIONS: In general, MD-PhDs in the social sciences and humanities have careers that fit the goals of agencies providing public funding for training physician-investigators: they are involved in mutually-informative medical research, clinical practice, and teaching - working to improve our responses to the social, cultural, and political determinants of health and health care. These findings provide strong evidence for continued and improved funding and programmatic support for MD-PhD trainees in the social sciences and humanities.

Locating global health in social medicine.

Global health's goal to address health issues across great sociocultural and socioeconomic gradients worldwide requires a sophisticated approach to the social root causes of disease and the social context of interventions. This is especially true today as the focus of global health work is actively broadened from acute to chronic and from infectious to non-communicable diseases. To respond to these complex biosocial problems, we propose the recent expansion of interest in the field of global health should look to the older field of social medicine, a shared domain of social and medical sciences that offers critical analytic and methodological tools to elucidate who gets sick, why and what we can do about it. Social medicine is a rich and relatively untapped resource for understanding the hybrid biological and social basis of global health problems. Global health can learn much from social medicine to help practitioners understand the social behaviour, social structure, social networks, cultural difference and social context of ethical action central to the success or failure of global health's important agendas. This understanding - of global health as global social medicine - can coalesce global health's unclear identity into a coherent framework effective for addressing the world's most pressing health issues.

On ethical locations: the good death in Thailand, where ethics sit in places.

In this article, I use ethnographic data on end-of-life care in Northern Thailand to address the relationship between ethics and place. My analysis is based on fieldwork conducted in 2007-2008, consisting of twenty in-depth oral life-histories of dying patients; ninety-five interviews with patients, family members and caretakers; fifty-four interviews with providers, administrators, civil society leaders and other key informants; as well as participant-observation of care of patients at the deathbed. In Northern Thailand, many feel that it is ethical to withdraw life support in the home, but unethical to withdraw it in the hospital. This is because the place of death is partly responsible for the quality of rebirth. Hospitals, on one hand, are powerful for saving lives; but as places to die, they are amoral, dangerous, devoid of ceremonial history and haunted by spirits. Homes, on the other hand, are optimal for dying because they are imbued with moral power from a history of beneficial ceremony and family living. Hospitalized patients at the edge of death are often rushed home by ambulance to withdraw life support in the more ethical place. I argue that the two places can be considered different ethical locations, because each is inhabited by a unique ethical framework governing withdrawal of life support. This concept has implications for the contemporary globalization of bioethics and for understanding practices that arise around ethically charged decisions.