En partant d’une description des nombreux changements de la pratique médicale depuis quelques décennies, la thèse étudie divers aspects constitutifs du malaise du médecin. L’accroissement de la puissance médicale qu’a permis la technoscience est analysée et remise dans un contexte plus large où les technologies de l’information ont une grande place. L’augmentation considérable des connaissances pose un problème de maîtrise de la science médicale. La multiplicité des observations fait qu’il y a discordance de certaines d’entre elles avec les théories médicales largement acceptées. De cette manière, le gain d’efficacité est associé à une perte de la cohérence du discours médical. Le rôle du médecin disparaît derrière la technique, qui semble pouvoir, seule, rendre tous les progrès accessibles. Le médecin devient alors un simple distributeur de services et, à ce titre, développe parfois des offres de pratiques sans fondement, voire dangereuses.<p>Le pouvoir du médecin est évoqué, et se ramène in fine à la fourniture d’un diagnostic et d’une explication de sa maladie au patient. Le rôle des explications particulières que donne le médecin au malade est exploré à la lumière d’une conception narrative et évolutive de la vie humaine. Le rôle du médecin apparaît alors comme d’aider le patient à réécrire a posteriori le fil d’une histoire qui apparaît initialement comme interrompue par la maladie.<p>Le rôle social de maintien de l’ordre de la pratique médicale est alors évoqué. Ensuite, par une approche descriptive du phénomène religieux, on montre que la médecine du XXIe siècle a les caractéristiques d’un tel phénomène. Entités extrahumaines, mythes, rites, tabous, prétention à bâtir une morale, accompagnement de la vie et de la mort, miracles, promesse de salut, temples, officiants sont identifiés dans la médecine « classique » contemporaine. Seule la fonction de divination de l’avenir d’un homme précis est devenue brumeuse, la technoscience permettant régulièrement du « tout ou rien » là où auparavant un pronostic précis (et souvent défavorable) pouvait être affirmé.<p> L’hypothèse que la médecine est devenue une religion du XXIe siècle est confrontée à des textes de S. Freud, M. Gauchet et P. Boyer. Non seulement ces textes n’invalident pas l’hypothèse, mais la renforcent même. Il apparaît que le fonctionnement de l’esprit humain favorise l’éclosion de religions et donc la prise de voile de la médecine. La dynamique générale de la démocratisation de la société montre que la médecine est une forme de religion non seulement compatible avec une société démocratique, mais est peut-être une des formes accomplies de celle-ci, où chaque individu écrit lui-même sa propre histoire.<p>Le danger qu’il y a, pour le patient comme pour le médecin, si ce dernier accepte de jouer un rôle de prêtre, est ensuite développé. Enfin, la remise dans le cadre plus général de l’existence humaine, l’évocation de la dimension de révolte de la médecine, de son essentielle incomplétude, l’acceptation d’une cohérence imparfaite permettent au médecin de retrouver des sources de joie afin de, peut-être, ne tomber ni dans un désinvestissement blasé, ni dans un cynisme blessant.<p><p>From a description of the many changes medical practice has undergone for a few decades, the work goes on to study many sides of the modern doctor’s malaise. The gain of power made possible by technoscience is put on a larger stage where information technologies play a major role. The abundance of knowledge makes health literacy more difficult. the great number of observations makes discrepancies with general theories more frequent. The gain in power is associated with a loss of coherence of the medical speech. The doctor’s role vanishes behind technology that seems to be the only access to all medical progresses. Doctors becomes mere service providers and go on to offer unvalidated or even harmful services on the market.<p>Modern medical power resumes into the explanations and diagnosis given to the patient. The role of medical explanations is explored through an evolutive and narrative vision of human life. The duty of the doctors then appears to allow a new narration of the self that bridges the gap disease introduced into the patient’s life.<p>The role of medicine in maintaining social order is mentioned. Through a sociological approach of the religious phenomenon, one can see that XXIst century medicine is such a phenomenon. Medicine knows of extrahuman entities, myths, rites, taboos, miracles, temples; priests are present in modern mainstream medicine. Some want to derive objective moral values from medicine, and it brings companionship to man from birth to death. The only departure from old religions was the weakened ability to predict the future of an individual patient: for some diseases for which survival was known to be very poor, the possibilities are now long-term survival with cure, or early death from the treatment. <p>The hypothesis that medicine is a religion is confronted to texts from Freud S. Gauchet M. and Boyer P. Not only do they not invalidate the hypothesis, but they bring enrichment to it. Brain/mind dynamics is such that the appearance of religions is frequent, and makes the transformation of medicine into a religion easier. Society’s democratisation confronted to religion’s history shows that medicine is the most compatible form of religion within a truly democratic society, where each individual writes his own story.<p>To become a priest brings some dangers for the patient, but also for the doctor. These dangers are discussed. This discussion is put into the larger context of human life. The revolt dimension of medicine is discussed, as is its never-ending task. Their acceptance, as that of a lack of total logical coherence can open the possibility for the doctor to enjoy his work, without being neither unfeeling nor cynical.<p> / Doctorat en philosophie et lettres, Orientation bioéthique / info:eu-repo/semantics/nonPublished

Atrial fibrillation (AF), the most common cardiac arrhythmia in persons over age 65, is associated with an increased stroke risk necessitating the need for long-term oral anticoagulation for risk reduction. With the introduction of direct thrombin and factor Xa inhibitors in the US since 2010, these novel oral anticoagulants (NOACs) are increasingly being prescribed, replacing the use of warfarin, a vitamin K antagonist. AF catheter ablation (CA), an elective procedure requiring femoral vascular access is a treatment for drug refractory and persistent AF. Bedrest, limb immobilization, and limited head of bed elevation are nursing measures utilized following femoral venous, and sometimes arterial, sheath removal and hemostasis. Limited research is available on the appropriate duration of bedrest to minimize bleeding complications associated with AF ablation in patients who use NOACs. The purpose of this quality improvement project was to compare and evaluate the effect of bedrest duration on post-procedure bleeding outcomes, urinary complaints, and back pain among patients taking NOACs while undergoing AFCA. Thirty patients undergoing elective AFCA on NOACs were orally consented to participate in the study and placed on shortened (8 hours) or prolonged (>8 hours) bedrest following vascular hemostasis. Outcome measurements included bleeding after ambulation, back pain, and urinary complaints. Fifteen patients (50%) were on shortened bedrest and 15 (50%) were on prolonged bedrest. No statistically significant difference in bleeding, urinary complaints, or back pain were found. Since there is no clear advantage to prolonged bedrest for patients on NOACS after an AFCA procedure, clinicians should consider this when deciding on bedrest duration for their patients.

This thesis examines the validity of exclusionary clauses in medical contracts, more especially, hospital contracts in which the healthcare provider exonerates itself against edictal liability arising from the negligent conduct of its staff, resulting in the patient suffering damages. In assessing whether these types of clauses should be outlawed by our courts, this thesis attempts to synthesize six major traditional areas of law, namely, the law of delict, the law of contract, medical law and ethics, international and foreign law, statutory law and constitutional law into a legal conceptual framework relating specifically to exclusionary clauses in medical contracts in South Africa. This thesis highlights systemic inconsistencies with regard to the central issue, namely, whether these types of clauses are valid or not, especially, given the fact that the practice of exclusionary clauses or waivers in hospital contracts has hitherto traditionally been assessed within the framework of the law of contract. The alignment of the various pre-existing areas of statutory and common law with the Constitution highlights that an inter-disciplinary and purposive approach under the value-driven Constitution, brings about a less fragmented picture in assessing the validity of these types of clauses. This approach accords with the new solicitude of the executive, the judiciary, the legislature and academia to transform the South African legal system not only in terms of procedural law but also substantive law. This has resulted in the alignment with constitutional principles and the underlying values to test the validity of these types of clauses, alternatively, contracts. Whereas pre-constitutionally the assessment of disclaimers in hospital contracts was done against the stratum of antiquated principles, namely, freedom of contract and the sanctity of contract, ignoring values such as reasonableness, fairness and conscionability, post-constitutionally, because the values that underlie the Bill of Rights and which affects all spheres of law, including the law of contract, concepts such as fairness, equity, reasonableness should weigh heavily with the decision-maker. In this regard, broader medico-legal considerations, normative medical ethics and the common law principles of good faith, fairness and reasonableness play a fundamental role in the assessment of contractual provisions, including the practice of disclaimers or exclusionary clauses in hospital contracts. This thesis critically examines how these types of clauses or contracts ought to be adjudicated eventually against the background of such alignment. It concludes that the entering into a hospital contract, in which the patient exonerates a hospital and its staff from liability flowing from the hospital or its staff's negligence causing damages to the patient, would be inconsistent with the Constitution and invalid. In the old order in which traditional divisions of law have been encouraged, a fragmented approach resulted in legal in congruencies which, in turn, created turbulence and a lot of uncertainty. This approach is apposite to that which the new constitutionally based legal system, aims to achieve. The rights in the Bill of Rights which are interconnected and which influences all spheres of law, including contract law, offers a fairer basis upon which, the validity of contracts, or contractual provisions, can be measured than, the pure contract approach. In this regard, although contracts or contractual provisions in the past may have been unfair and unreasonable, the courts, however, refused to strike them down purely on this basis. The law of contract, as a legal vehicle for adjudicating the validity of exclusionary clauses or waivers in hospital contracts, is therefore not ideal. This is primarily due to the antiquated approach the South African courts have always taken in this area of law. The law of delict, statutory law and medical law, standing alone, also does not provide a satisfactory answer. What is needed is an integrated approach in which the traditional areas of law are united and wherein constitutional principles and values, give much guidance and direction. Alternatively, should the unification of the traditional areas of law not be possible in bringing about fair and equitable results, the introduction of legislative measures may very well be indicated. / Thesis (LLD)--University of Pretoria, 2009. / Public Law / unrestricted

Pre-diabetes is a serious health problem in the United States. Distinguished by plasma glucose levels that are above the normal threshold, patients with pre-diabetes are 10 times more likely to develop type 2 diabetes. Patients with pre-diabetes suffer the same complications as patients with diabetes including diabetic retinopathy, nephropathy, and microalbuminuria. There is considerable evidence to support the idea that early identification and aggressive treatment of pre-diabetes has the potential to delay disease progression. The American Diabetes Association’s clinical practice guideline recommends management of with lifestyle modification and metformin for patients who are at risk for developing type 2 diabetes. The purpose of this project was to evaluate the implementation of the 2012 ADA clinical practice guidelines regarding the management of patients with pre-diabetes by the health care providers at a volunteer-run clinic located in a large metropolitan area in the southeastern United States. This study, even with a small sample size (n=26) revealed that the providers at the clinic had not implemented the 2012 ADA clinical practice guidelines. Clinical practice guidelines promote health care interventions that have proven benefits and improve the consistency of care provided to patients. The greatest benefits of implementing clinical practice guidelines for patients with pre-diabetes are early diagnosis and aggressive disease management. This would improve patient outcomes and in the long run, decrease the cost of medical care.

Performance of hand hygiene is among the most effective means of preventing healthcare associated infections (HAI) among patients. Deaths resulting from HAIs are one of the top ten leading causes of death in the United States. Any improvement in the frequency of hand hygiene among healthcare professionals may have a direct impact on patient mortality and associated costs. While anesthesia professionals have been found to have low rates of hand hygiene adherence, few targeted studies seeking to improve hand hygiene adherence among this group exist. Studies conducted to improve hand hygiene among health care professionals have reported limited improvement, with overall inconclusive recommendations for improving prolonged hand hygiene adherence rates. The purpose of this project was to improve anesthesia professionals’ hand hygiene through encouragement of performance and education on the current state of research in the area of anesthesia associated HAIs. Hand hygiene rates were evaluated through measuring the amount of hand sanitizer used at eleven anesthesia workstations in the main operating room of a hospital. Measurements were taken at baseline and continued for three months after the educational program was implemented.

The purpose of the present correlational, ex post facto study was to evaluate the predictive ability and academic achievement criterion outcomes of two district-developed interim mathematics assessment programs for a sample of 5,801 grade 6 students in a large urban school district. Average scores for both interim assessment types were statistically significantly more related to 2013 FCAT 2.0 scores (r = .75 and .72; p < .001) than all other predictors (i.e., student demographics, Florida school grade, and student course GPA) except for 2012 FCAT 2.0 scores (r = .78; p < .001). Further, the newer interim assessment program with an instructional purpose and curriculum-based sequencing had slightly stronger overall predictive power (rs = .88) and a higher criterion mean score (M = 218.08) than the older, state-test mirror interim assessment program (rs = .85; M = 215.47). Regression models by prior year FCAT 2.0 Achievement Level yielded some predictor ranking discrepancies by prior achievement level. Although not statistically significant at the .01 level, groups of students with a more moderate total number of interim assessments outperformed groups with all or nothing. Overall, the two types of interim assessment programs evaluated in the present study were good predictors of the state high-stakes test, 2012 Grade 6 Mathematics FCAT 2.0. However, more research must be done to identify with certainty whether or not the act of taking the interim tests and receiving feedback contributes to improved student learning.

This dissertation seeks to understand the conjunction of faculty roles as teachers and as researchers. This understanding is pursued through philosophical analysis. Discourse ethics, in particular, is used as a framework by which to best understand the roles played by faculty and if the roles of teacher and researcher are, in fact, commensurable. The purpose of the work is two-fold: 1) to develop a construct that may be used by future researchers to better understand the roles played by faculty, and 2) to suggest a best-construct that enables future researchers to propose how actual lived roles should be instantiated in the world. The dissertation reviews a series of university handbooks, professional association ethical guidelines, and philosophical arguments to establish how the roles of faculty are best understood. The investigation illuminates the tensions at the heart of faculty roles. This tension is not definitionally embedded in the roles of faculty as teacher and researcher. Rather, the tension emerges from the failure of institutions to fully actualize faculty roles as normatively grounded in human communicative interaction. As a result, the work suggests that in order to best resolve the cognitive dissonance that may be experienced as a result of role ambiguity, faculty should engage in a process of self-reflection and community dialectic in order to best determine how “faculty” can be actualized in a way that best benefits all stakeholders.

The present study employed a quantitative, non-experimental, multivariate correlational research design to test a hypothesized model examining associative paths of influence between ecological factors and weight status of urban, African-American adolescent females. Anthropometric and self-report survey data of 182 urban, African- American adolescent females were collected during after-school programs, health and physical education classes, and community events in an urban area in northeast Florida. Descriptive analyses were conducted to characterize the study participants based upon their age, study setting, and weight status. A scale reliability analysis was conducted to assess the internal consistency reliability of the sample data using selected measures within the context of the study’s specific population and subsequently guided the structural equation model (SEM) analyses. The SEM path analysis was used to develop two measurement models to control for observed error variance for variables demonstrating poor internal consistency reliability (diet behaviors and nutrition selfefficacy) and a final structural model to test the associative paths of influence between latent (diet behaviors and nutrition self-efficacy) and manifest variables (teacher social support and friend social support) on weight status. The results of the path analysis indicated that both teacher social support and friend social support demonstrated a positive, indirect influence on child weight status through nutrition self-efficacy and diet behaviors following two different and specific paths of influence. Diet behaviors, in turn, demonstrated a positive, direct effect on child weight status. These findings provide clear implications for educational leaders that call for the integration of health behavior change theory into traditional education and leadership practice and actively addressing the childhood obesity epidemic in the school environment by implementing health behavior change strategies at various ecological environmental levels.

The purpose of this project was to evaluate the effectiveness of an educational lifestyle modification (LM) intervention on blood pressure (BP) among adults with prehypertension. Prehypertension is a precursor to hypertension (HTN) and is a public epidemic in the United States. Approximately 68 million (31%) U.S. adult’s aged ≥18 years have hypertension. Hypertension can cause significant target organ damage, lead to coronary heart disease, heart failure, stroke, and kidney failure. Early identification and the primary treatment of persons with prehypertension with LM have the potential to minimize the progression and delay the onset of comorbidities associated with hypertension. This quality improvement project retrospectively reviewed changes in blood pressure for a small sample (n=5) of patients diagnosed with prehypertension who received education about modifying lifestyle behaviors according to nationally accepted clinical practice guidelines. Blood pressure measurements were extracted from the medical record beginning at the time of the education through a three month period. Descriptive data indicates that all five patients had a decrease in systolic and diastolic blood pressure. The median systolic blood pressure at baseline was 129 mmHg decreasing to 121 mmHg at end of study period. The median diastolic blood pressure was 86 mmHg decreasing to 76 mmHg. Integration of lifestyle modification education and subsequent blood pressure monitoring during a routine primary care visit is feasible and may help motivate patients to implement changes and subsequently reduce blood pressure. Future studies should include identifying strategies for improving patient participation.

Academically failing schools are under scrutiny from government education administrators, policymakers, and the general public, due to chronic inabilities to lower dropout rates and to educate students who can pass high-stakes graduation assessments. States’ efforts to adhere to the No Child Left Behind (NCLB) Act have led to the development of accountability systems to determine adequate yearly progress (AYP) and to assign schools grades, as well as wholesale reassessment of current educational programs, which are often replaced with more rigorous curricula. Among curricular programs that have been sought as reform measures for academically failing schools is the International Baccalaureate Program (IBP). The IBP’s exacting curriculum has attracted many schools to adopt it as an alternative course of study for advanced students, as well as a rigorous option to build academic capacity among students who have failed to make AYP. This case study examined teachers’ perceptions of the effect the International Baccalaureate Diploma Programme (IBDP) had on the culture of an academically underperforming high school in Valdosta, Georgia. Teacher volunteers from within the IBDP, in addition to teachers who taught standard classes, participated in a series of three semistructured interviews over 1.5 years, during which time the school made its initial application to the International Baccalaureate Organisation and subsequently began implementing the program with the school’s first cohort of students. Additionally, documents relating to the IB application process were examined, and observations of the IBDP teachers with students in their classrooms were conducted. Data analysis utilized the frameworks of educational criticism and narrative analysis. Teachers within the IBDP reported feelings of increased self-efficacy resulting from their work with both students and community stakeholders. Participant teachers in both IB courses and other programs described an overall improvement in the school’s culture.