Integrating patient management, reflective practice, and ethical decision-making in an emergency medicine intern boot camp.

BACKGROUND: Integration of clinical skills, ethical decision-making, and reflection skills have emerged as cornerstones of clinical teaching in medical schools. This study aimed to detect whether a multimodal learning environment approach consisting of lectures, a drill, post-drill video debriefing, and written reflection in an emergency medicine rotation boot camp improves interns' patient management skills, ethical decision-making, and reflection skills. METHODS: A multimodal learning environment was created by the collaboration of emergency medicine, ethics, and medical education specialists. Multiple educational techniques involving lectures, case discussions, and role-playing a crisis scenario were applied. Pre-test and post-test, debriefing on performances on video records, video-recorded performance assessment, and reflective essays about their own and group's performances were used to assess various aspects of the student performances. Additionally, a meeting was organized with the presence of the authors to create qualitative data obtained through the program evaluation meeting conducted on three themes: influences of teaching methods, students' performances, and common achievements and mistakes of students. RESULTS: 133 students participated. Post-test multiple-choice question (MCQ) test scores were slightly higher than pre-test. A low and medium correlation was detected among pre-test and post-test patient management problem (PMP) and reflection scores, which was more prominent for female students. Multiple linear regression showed that pre-test and post-test PMP scores significantly contributed to reflection scores. These results might support that better patient management predicts more robust reflective practice. Teachers observed that students appreciated being inspired by well-performing peers, particularly noting the empathic needs of patients, companions, and other health professionals. However, students overlooked summoning forensic or social services and were inhibited by the pressure of the contextual traits of the drill. CONCLUSION: The multimodal learning environment created by multidisciplinary collaboration contributed to the improvement of components of situational awareness of the interns: patient management skills, ethical decision-making, and reflective practice. During this research, we created a toolbox better to capture the richness and diversity of student interactions. Considering the scarcity of context-specific assessment methods and widespread use of MCQs or generic scales for higher-order thinking skills in medicine, this study might be regarded as a step forward in that context.

'My story is like a magic wand': a qualitative study of personal storytelling and activism to stop violence against women in Turkey.

Background: Telling personal stories of violence has been central to recent advocacy efforts to prevent violence against women around the world. In this paper, we explore the use of personal storytelling as a form of activism to prevent femicide in Turkey. This study is part of a broader storytelling initiative called SHAER (Storytelling for Health: Acknowledgement, Expression and Recovery) to alleviate the psychological and emotional suffering of women who have experienced gender-based violence in high-prevalence settings.Objectives: We conceptually explore personal stories of violence as a form of both distributed agency and activism. This conceptual framework is used to answer the following research question in the Turkish context: How do women use their personal stories of interpersonal violence for their own benefit (support) and that of others (activism)?Methods: Our study is based on 20 in-depth semi-structured interviews with women who have experienced violence and were purposefully recruited by the 'We Will End Femicide' Platform in Istanbul. Interviews were conducted between March and August 2019. We used inductive and deductive thematic analysis to identify instances of personal storytelling at three levels: intrapersonal, relational and collective.Results: Our results show how the use of personal storytelling can provide a means of healing from experiences of violence. However, this process is not linear and is often influenced by the surrounding context including: the listener of the story, their reaction, and what social networks the woman has to support her. In supportive social contexts, personal storytelling can be an effective support for activism against violence: personal stories can provide opportunities for individuals to shape broader discourses about violence against women and the right of women to share their stories.Conclusions: Telling one's personal story of violence can both support women's agency and contribute to the collective struggle against violence against women more broadly.

Lived experiences of people living with HIV: a descriptive qualitative analysis of their perceptions of themselves, their social spheres, healthcare professionals and the challenges they face daily.

BACKGROUND: Human immunodeficiency virus (HIV) infection rates have been gradually increasing in Istanbul, Turkey. Many people living with HIV (PLWH) here encounter difficulties, for example, in adapting to the chronic disease and obtaining continuous access to healthcare services. In this study, we aimed to explore the challenges PLWH face in their daily lives and understand their perceptions of themselves, healthcare professionals and services, and their social spheres via their expressed lived experiences in the healthcare setting. METHOD: Individual semi-structured in-depth interviews were conducted face-to-face with 20 PLWH in Istanbul. All the interviews were voice-recorded and transcribed verbatim except one, upon participant request, for which the interviewer took notes. These logs and the interviewer's notes were analyzed thematically using the inductive content analysis method. RESULTS: The themes concerned experiences in three distinct contexts: 1) Interactions with healthcare providers; 2) Participants' responses to their HIV diagnosis; and 3) Interactions with their social networks. Firstly, the results highlighted that the participants perceived that healthcare professionals did not inform them about the diagnosis properly, failed to protect patients' confidentiality and exhibited discriminative behaviors towards them. Secondly, after the diagnosis the participants had difficulty in coping with their unsettled emotional state. While many ceased sexual activities and isolated themselves, some sought support. Lastly, living with HIV affected their relationships with their families and friends either positively or negatively. Moreover, they had to face the difficulties concerning spouse/partner notification issues about which many needed professional support. CONCLUSION: Healthcare professionals' discriminative or inappropriate attitudes and customs in healthcare institutions are perceived to impair PLWH's utilization of healthcare services. Structural factors such as social pressure, societal ignorance about HIV, limited access to HIV prevention, and regulatory barriers might contribute to these challenges. The results suggest that it is necessary to raise healthcare professionals' and society's awareness about HIV and develop national policies to establish a well-functioning referral system and appropriate spouse/partner notification services.

The state of ethics education at medical schools in Turkey: taking stock and looking forward.

BACKGROUND: Ethics teaching is globally considered an essential part of medical education fostering professionalism. It does not only provide knowledge for good clinical conduct, but also trains medical students as virtuous practitioners. Although Turkey has had a considerable experience in ethics education of healthcare professionals, the general state of ethics curricula at medical schools in Turkey is unknown. METHODS: The purpose of this study was to collect comprehensive data about the ethics education programs at medical schools in Turkey. To this aim, we designed a cross-sectional descriptive questionnaire survey which focuses on the content, teaching years, teaching, assessment and evaluation methodologies, workforce and infrastructure. We delivered the questionnaire to all medical schools in Turkey. Seventy-nine medical schools participated in this study (response rate: 78%). RESULTS: Although most institutions had an undergraduate ethics curriculum (91.1%), the findings suggest deficiency of teaching personnel (34.2% had no instructors). Furthermore, the distribution and composition of the workforce was imbalanced. The content varies largely among institutions. Medical schools with an ethics department were more likely to diversify teaching topics. However, ethics education was largely based on the four-principle approach. The content was usually conveyed to students theoretically. Around 90% of schools had classroom lectures. It is the only method used at one-third of them. Clinical ethics education was mostly lacking. Multiple-choice tests were widely used to assess and evaluate student attainments (86.1%). CONCLUSIONS: Staff qualified to teach ethics and ethics education integrated into the six-year medical curriculum given by a multidisciplinary team are urgent necessities. Considering teaching, assessment and evaluation methodologies used, most medical schools seem to fall short of fostering students to develop ethical attitudes. Endeavors aiming for modern topics should be encouraged. As the organization ethics education change continuously, we think that a platform for monitoring ethics education at medical schools in Turkey should be established. Such a body would help ethics instructors to network and find solutions to current problems and build shared wisdom.

Breaking the silence of the lambs: integrating medical staff in prevention of human trafficking / Rompiendo el silencio de los corderos: integrar el personal médico en la prevención de tráfico humano / Quebrando o silêncio dos cordeiros: integrando o pessoal médico na prevenção do tráfico de seres humanos

Introduction: Human trafficking, including forced prostitution, is a form of human rights violation regarding right to life and respect for human dignity. The Physician-patient relationship may serve as a process for victim identification on the basis of physicians’ responsibilities to detect human trafficking. Method: This empirical study was based on a survey among physicians who may have been in contact with foreign sex workers. Almost eighty physicians in three health facilities were selected according to their high potentiality for coming into contact with foreign sex workers as patients. 228 physicians selected to that aim. 82 of them responded to the questionnaire which was performed in order to evaluate their perception and knowledge human trafficking and their attitudes towards sex work. Results: All physicians think that some women among the sex workers are exploited, exposed to violence and coerced to work against their will (100%). Almost all of them know that it is compulsory for the healthcare professionals to inform the security forces of the women who are exploited (80.0%). Nearly half of them have given medical care to a sex worker (46.9%) and 39.0 percent have thought that it may be related to human trafficking. The ones who have informed the police of a human trafficking case are only 10 per cent. Conclusions: We think that the professional should be equipped with ethical values encompassing both a patient’s dignity and general welfare. This may include the professional’s responsibility to make an assessment as to whether the patient is a victim or a sex worker. Furthermore human trafficking in sex work and sexual health are public health issues therefore it should be covered under standards of practice and ethical codes of conduct.

Introducción: El tráfico humano, incluyendo prostitución forzada, es una forma de violación de derechos humanos relacionada con el derecho a la vida y el respeto a la dignidad humana. La relación médico-paciente puede servir como un proceso para identificar víctimas, con base en la responsabilidad del médico de detectar tráfico humano. Método: Este estudio empírico se basó en un cuestionario aplicado a médicos que podían haber estado en contacto con trabajadores sexuales extranjeros. Se seleccionaron unos 80 médicos de tres centros de salud, de acuerdo con su alta probabilidad de entrar en contacto con trabajadores sexuales extranjeros como pacientes. Se seleccionaron 228 médicos para ese objetivo. De estos, 82 respondieron al cuestionario desarrollado para evaluar su percepción y conocimiento del tráfico humano y sus actitudes hacia el trabajo sexual. Resultados: Todos los médicos piensan que algunas mujeres trabajadoras sexuales son explotadas, expuestas a violencia y forzadas a trabajar en contra de su voluntad (100%). Casi todos saben que es obligatorio para el profesional de la salud el informar a las fuerzas de seguridad sobre las mujeres que son explotadas (80,0%). Casi la mitad han proporcionado cuidado médico a un trabajador sexual (46,9%) y 39,0% ha pensado que puede estar relacionado con el tráfico humano. Solo un 10% ha informado a la policía sobre un caso de tráfico humano. Conclusiones: Pensamos que los profesionales deberían formarse en valores éticos incluyendo tanto la dignidad del paciente como su bienestar general. Esto puede incluir la responsabilidad profesional de evaluar si el paciente es una víctima o un trabajador sexual. Además, el tráfico humano en el trabajo sexual y la salud sexual son temas de salud pública, por lo tanto debieran cubrirse de acuerdo con los estándares de la práctica y códigos éticos de conducta.

Introdução: O tráfico de pessoas, incluindo a prostituição forçada, é uma forma de violação dos direitos humanos sobre o direito à vida e o respeito pela dignidade humana. A relação médico-paciente pode servir como um processo para a identificação das vítimas, com base em responsabilidades dos médicos para detectar o tráfico de seres humanos. Método: Este estudo empírico foi baseado numa pesquisa entre os médicos que possam ter estado em contacto com os trabalhadores do sexo estrangeiros. Quase oitenta médicos em três unidades de saúde foram selecionados de acordo com sua alta potencialidade para entrar em contato com profissionais do sexo estrangeiros como pacientes. 228 médicos foram selecionados para esse objetivo. 82 deles responderam ao questionário que foi realizado com a finalidade de avaliar a sua percepção e o seu conhecimento sobre o tráfico de seres humanos e as suas atitudes em relação ao trabalho sexual. Resultados: Todos os médicos pensam que algumas mulheres entre os trabalhadores do sexo são exploradas, expostas à violência e coagidas a trabalhar contra a sua vontade (100%). A maioria deles sabe da obrigação dos profissionais de saúde de informar às forças de segurança sobre mulheres que são exploradas (80,0%). Quase metade deles tem dado assistência médica a trabalhadora do sexo (46,9%) e 39,0 por cento pensaram que isto pode estar relacionado ao tráfico de seres humanos. Os que informaram à polícia de um caso de tráfico de seres humanos são apenas 10 por cento. Conclusões: Nós pensamos que o profissional deve estar incorporado de valores éticos que abrangem tanto a dignidade do paciente como o bem-estar geral. Isso deve incluir a responsabilidade do profissional em avaliar se o paciente é uma vítima ou um profissional do sexo. Além disso o tráfico humano no trabalho do sexo e saúde sexual são questões de saúde pública, por isso, devem ser cobertos pelos padrões de prática e códigos éticos de conduta.

Ethical Issues in Neuromarketing: "I Consume, Therefore I am!".

Neuromarketing is a recent interdisciplinary field which crosses traditional boundaries between neuroscience, neuroeconomics and marketing research. Since this nascent field is primarily concerned with improving marketing strategies and promoting sales, there has been an increasing public aversion and protest against it. These protests can be exemplified by the reactions observed lately in Baylor School of Medicine and Emory University in the United States. The most recent attempt to stop ongoing neuromarketing research in France is also remarkable. The pertaining ethical issues have been continuously attracting much attention, especially since the number of neuromarketing companies has exceeded 300 world-wide. This paper begins with a brief introduction to the field of neurotechnology by presenting its current capabilities and limitations. Then, it will focus on the ethical issues and debates most related with the recent applications of this technology. The French Parliament's revision of rules on bioethics in 2004 has an exemplary role in our discussion. The proposal by Murphy et al. (2008) has attracted attention to the necessity of ethical codes structuring this field. A code has recently been declared by the Neuromarketing Science and Business Association. In this paper, it is argued that these technologies should be sufficiently discussed in public spheres and its use on humans should be fully carried out according to the ethical principles and legal regulations designed in line with human rights and human dignity. There is an urgent need in the interdisciplinary scientific bodies like ethics committees monitoring the research regarding the scientific and ethical values of nonmaleficence, beneficence, autonomy, confidentiality, right to privacy and protection of vulnerable groups.

[Coronary artery disease from a perspective of genomic risk score, ethical approaches and suggestions]. / Genomik risk skorlamasi perspektifinden koroner arter hastaligi, etik yaklasim ve öneriler.

As a leading cause of mortality, coronary artery disease is on the focus of genetic research as a complex trait. Although predictive genetic testing for cardiovascular diseases is on the counter, it is still hard to aggregate information from multiple genetic variants, environmental factors and family history into a single score. Every susceptibility allele provides small contribution to disease formation. Biomarkers play a role in various metabolic pathways. Genetic information and data depend heavily on probabilities. This should be clearly explained by genetic counselor to the patient and relatives who are looking for certain answers. Presence of susceptibility alleles can be a source of anxiety and it may result as a reduced self-confidence in ability to change health behavior. Complex diseases set a new stage to study novel techniques that can elucidate interactions among genetic, environmental and ethnic factors. The cookbook approach to treat a complex disease can often be misleading. Future studies may provide personalized information, which can improve the outcome of standardized treatments. As knowing one's own genetic risk is becoming a task for the responsible individual, it surely will add new challenges to ethical framework. Publicly marketing genetic tests for complex diseases raises ethical concerns. To avoid discriminatory use of genetic information; genetic risk scoring, therapeutic process, ethical policies must have a multifaceted progress. In this review, we summarized the attempts to resolve ethical issues related to genetic testing in complex diseases to resolve patient autonomy with individual responsibility and to aim the patient beneficence and confidentiality.

The introduction of variolation 'A La Turca' to the West by Lady Mary Montagu and Turkey's contribution to this.

AIMS: This study deals with the history of variolation as the oldest immunization method to be transferred from East to West, with emphasis on Turkey's role in this transmission. SCOPE: The technique of variolation was used by various ancient civilizations such as those in India, Tibet and many other parts of Asia. It was based on the subcutaneous inoculation of attenuated pustule material in patients. The method was brought to Anatolia by the Seljuks through the Caucasus and was widely used by the Ottomans for a long period of time. The West learned of this method for the first time mainly through the writings of Dr. Timoni and Lady Mary W. Montagu in the 18th century. Lady Montagu not only wrote letters explaining this method, but also worked actively to introduce it in Europe. CONCLUSION: Since variolation carried the risk of infection, it was replaced by a safer method called vaccination discovered by Jenner (1789), which led to the eradication of smallpox from the world. Despite the fact that vaccination ultimately superseded variolation in Western medical practice, Turkey played a key role as a bridge between civilizations in the transfer of this earlier treatment method to the West.

The pioneering steps of radiology in Turkey (1896-1923).

The discovery of X-rays (1895) by W.C. Roentgen has been a very important step of the modern civilization as a revolutionary technique for scientists all around the world and it has immediately been applied in medical field. The aim of this study is to search the start of radiology in Turkey on the basis of archival and first hand sources. This study shows that Roentgen apparatus was first installed in Turkey by an intern doctor Esad Feyzi who took the first radiographies at the Imperial Medical School (Istanbul) in 1896. He made use of X-ray method for medical diagnosis later on when Turkish-Greek war broke out in 1897. Esad Feyzi worked in the clinical team led by professor Salih Effendi, MD, at the Yildiz Temporary Military Hospital in Istanbul to take radiographies of soldiers wounded at war in cooperation with the German Red Cross medical delegation. This event is most probably the earliest examples of the application of X-ray technique into military surgery all over the world. Researches have also proven that medical radiography technique was also applied in Greece by Greek and English doctors during that war. This war gave the opportunity to German and British medical teams to use X-ray as a radiographic imaging technique at the two confronting sides that was used in consequent wars in other parts of the world, later on. The paper deals with the progress of clinical radiology in Turkey until the foundation of the Turkish Republic in 1923.

The early steps of chloroform anaesthesia in Turkey during the Ottoman Empire in the 19th century.

OBJECTIVE: The aim of this study was to research the pioneering steps for the employment of chloroform in Turkey in comparison with the developments in the West i.e. in the United States and in Europe. The development of anaesthesiology in the West started in the first half of the 19th century. As an anaesthetic substance, ether was first employed in a medical operation by R. Liston in December 1846. But taking into consideration of its bronchially irritant effect, British gynaecologist Dr. J.Y. Simpson preferred to utilize chloroform in obstetrical operations in 1847. The paper aims at shedding light on the earlier steps for modern anaesthesiology in Turkey in that sense. METHODS: The survey used evaluation of archival documents, first hand-original sources such as the annual medical reports of the Medical School, books, official journals, and newspapers of the time, and also secondary sources concerned with the subject. RESULTS: In view of the findings of the survey, chloroform, as an anaesthetic material, began to be administered surgically in Turkey much earlier than it was already known. It was experienced and used in operations at the surgical clinic of the Imperial School of Medicine at the Capital city, Istanbul in 1848. The Crimean War (1853-1855) induced to the prevalent surgical use of chloroform in Istanbul on the soldiers back from the front. In other words, it was evidenced that surgeons started to make use of this anaesthetic substance in the Ottoman Empire, shortly after it was put into medical practice in Europe. CONCLUSION: This study deals with that phenomenal progress of chloroform anaesthesia in the medical history in Turkey during the second half of the 19th century.

[The portrait of an elite, during the transformation from the Ottoman Empire to the Turkish Republic (1861-1940)]. / Osmanli'dan cumhuriyet'e geçis sürecinde bir aydinin portresi Dr. Besim Omer Akalin (1861-1940).

Having spent the first half of his lifetime during declining years of the Ottoman Empire and the other half, at the first reformative, energetic decades of the Turkish Republic, Besim Omer Akalin, M.D. exemplifies very well of a new urban elite at the turn of the 20th century, regarding his education, formation, professional and administrative roles in the society He is known of his remarkable contributions in obstetrics, in pediatrics; and also of his fundamental works for the education of midwifery and nursing in Turkey. He carried out several duties at the same time, such as professor at the Istanbul medical School (Mekteb-i Tibbiye-i Sahane - Darülfünun Tip Fakültesi), head of the first Obstetrical clinic (Viladethane) in Turkey, leader of several associations such as the Red Crescent Society (Hilal-i Ahmer Cemiyeti), the Society for the Protection of Children (Himaye-i Etfal Cemiyeti), Anti-Tuberculosis Society (Verem Savas Dernegi), member of several commissions concerning the public sanitation and health affairs, rector of the Istanbul University, Turkish delegate of the international medical congresses and associations, member of Parliament. Among all those responsibilities, the accomplished to write numerous books, yearbooks and articles on the above mentioned topics. He was also famous for his initiative supporting women to educate at the university and also to come up at the public and socialarena. This study deals with his activities and works on the basis of his biography studied on archival and bibliographical sources. The list of his complete works is annexed to the text.