Patients' non-adherence to treatment is a widespread phenomenon in healthcare. Time preferences (how individuals value outcomes over time) are one cause for non-adherence. Using quasi-hyperbolic discounting, two options in the future are weighted consistently. However, when the early option becomes available the weighting changes. This creates the potential for non-adherence. The agency relationship that exists between patients and doctors implies hidden information. When the patient's time preferences are hidden from the doctor, the doctor must choose how to recommend treatments. Exploring how doctors make treatment decisions when time preferences are hidden from them, and how this impacts adherence, is therefore important. The first contribution of the thesis is to outline a model of the patient-doctor interaction incorporating quasi-hyperbolic discounting and hidden information. This shows that doctors should adapt to non-adherence when the probability a patient is present-biased is large enough. Secondly, a national survey of Scottish GPs explores whether doctors have different time preferences for themselves or their patients. Doctors do have the same private and professional time preferences, but value the health state differently between frames. Lastly, a laboratory experiment tests whether students in the role of a doctor adapt to non-adherence in the way predicted by the model. Students find the socially optimal level of treatment on average. Adaptation is stronger when using a performance payment, and results did not vary along demographic characteristics. The thesis highlights the importance of the patient-doctor interaction for generating nonadherence, not just patient preferences. It also shows that GPs' private time preferences may suitably substitute their preferences for patients. Finally, it points towards potential incentives for doctors to improve patient outcomes.

Effective communication is essential for both a satisfying and productive patient-provider relationship. Ineffective communication can lead to many detrimental patient outcomes including a lack of access to care, an inability to navigate the healthcare environment, a decreased adherence to treatment recommendations, and a lack of patient understanding about disease risk factors, prevention, and management. The Healthy People 2010 initiative recognized the importance of communication by including several health communication-related goals in its objectives. A goal of one of these objectives included increasing the percentage of patients who reported that their care providers have satisfactory communication skills. Researchers can gain insight about those barriers that prevent providers from experiencing effective communication by examining the patients' perspectives about communication. The primary aim of this pilot study was to explore urban African American women's perspectives about the communication utilized during clinical encounters with providers via the use of semi-structured interviews. The semi-structured interviews collected data about a variety of topics including participants' breast cancer-related knowledge, attitudes, beliefs, and practices. Data was also collected about participants' clinical encounter experiences, including their comprehension of health information and their communication experiences with medical providers and other types of health care professionals. Any responses that discussed participants' communication experiences with providers, comprehension of health information, or perspectives about factors that could impede or facilitate communication were selected for analysis. In addition to the semi-structured interviews, participants also completed two health literacy assessments in order to gauge their health literacy levels. Women were administered the Rapid Estimate of Adult Literacy in Medicine (REALM), a word recognition assessment, and the Short Test of Functional Health Literacy in Adults (STOFHLA), a comprehension assessment. Eligibility criteria included women who: (1) were aged 50 and older, (2) were English-speaking, (3) able to respond to interview questions without assistance, (4) of African descent, (5) were Harlem residents, and (6) had never received a diagnosis of breast cancer. One hundred women participated in the study. Data about the effectiveness of providers' communication skills, patients' abilities to comprehend health information, patients' communication experiences with various types of health care providers, and preferred sources of health information were collected from the interviews. Open-ended questions were utilized to gather information about factors that women deemed as either impediments or facilitators to effective communication with providers. Collected data from interviews were analyzed qualitatively. In addition to information about participants' health literacy scores from the literacy assessments, final results included demographic information, preferred sources of health information, and information about those factors that women viewed as either impediments or facilitators to effective communication with doctors and with other health care providers both in and outside of the medical appointment. Additionally, findings from the qualitative analysis results were utilized in order to inform the creation of health communication recommendations for providers who treat urban African American female patients.

Este trabalho volta-se ao estudo das diretivas antecipadas sobre o fim da vida na relação médica no Brasil. Pretende-se verificar a legitimidade bioética e a legitimidade e possibilidade jurídicas da prática das diretivas antecipadas sobre o fim da vida como objetivo central. Busca-se aferir a adequação, bioética e jurídica, das diretivas antecipadas como veículo próprio de autodeterminação da pessoa diante de suas possibilidades existenciais e da formulação de seu projeto de vida e de morte digna. Ademais, especificamente, procura-se determinar a possibilidade jurídica das diretivas antecipadas no Ordenamento brasileiro: a coerência com as garantias constitucionais e a existência de institutos aptos a tal prática. Propõe-se sustentar a legitimação jurídica das diretivas antecipadas no Brasil, indicando possíveis caminhos às soluções interpretativas no plano jurídico, e os efeitos na relação médica a partir, também, das considerações bioéticas. Com essa finalidade, pretende-se averiguar a compatibilidade entre as normas deontológicas de origem bioética e as normas jurídicas de status constitucional de proteção à pessoa humana. A tese também propõe a análise do contexto em que as diretivas antecipadas são utilizadas para (i) problematizar as ideias de capacidade e competência para a prática desse ato de autonomia pessoal, (ii) problematizar sobre como a perspectiva familiar, a perspectiva técnica dos profissionais da saúde e a perspectiva do Poder Judiciário contingenciam a liberdade desse ato e (iii) aferir a eficácia desses atos no espaço clínico e familiar. Para tanto, será empreendido estudo teórico mediante pesquisa bibliográfica e de referências, que levantará as publicações, nacionais e internacionais, sobre os temas da tese. O levantamento bibliográfico compreenderá, preferencialmente, obras sobre filosofia, ética, bioética e direito, que permitam a análise das questões teóricas envolvidas no estudo. O desenvolvimento do trabalho estrutura-se em três capítulos. O primeiro pretende estabelecer as bases conceituais e os fundamentos legais das diretivas antecipadas. O segundo capítulo apresentará a sistematização entre os valores bioéticos e jurídicos que se relacionam a tal prática. O capítulo três apresentará as questões fundamentais pertinentes à validade e eficácia da prática das diretivas antecipadas no Brasil. A partir das premissas construídas ao longo do desenvolvimento, o desfecho da pesquisa pretende reforçar seu argumento central demonstrando, então, a legitimação bioética e a legitimidade e a possibilidade jurídicas das diretivas antecipadas sobre o fim da vida no atual contexto brasileiro.

A atenção primária à saúde constitui hoje área prioritária nas políticas de saúde em diversas partes do mundo, constituindo, no Brasil, elemento estratégico para a organização dos sistemas de atenção. A complexidade e especificidade das demandas e características do cuidado em saúde na atenção primária exige, contudo, renovados esforços conceituais e práticos no sentido da construção de processos comunicacionais e interativos entre médicos e pacientes que caminhem para além da anamnese tradicional, pautada por uma racionalidade estritamente biomédica Objetivo: identificar e compreender fundamentos e contribuições de quatro influentes correntes teóricas que, a partir da década de 90, vêm problematizando as interações e a comunicação entre médicos e pacientes na atenção primária à saúde: Medicina Centrada no Paciente, Medicina Baseada em Narrativa, Abordagem Integral (Comprehensive Care) e Integralidade da Atenção à Saúde. Metodologia: Levantamento e estudo interpretativo, apoiado na filosofia hermenêutica de Hans-Georg Gadamer e Paul Ricoeur, de produção bibliográfica indexada nas bases MEDLINE e LILACS de 1990 a 1999. Resultados: A Medicina Centrada no Paciente orienta-se, fundamentalmente, para a identificação de domínios específicos que devem ser integrados à anamnese médica tradicional para ampliar seu escopo prático, utiliza metodologia de pesquisa quantitativa como modo predominante de fundamentação de suas proposições e propõe inúmeras metodologias ativas de ensino-aprendizado. A Medicina Baseada em Narrativa detém-se no como construir narrativas ao longo do diálogo entre médicos e pacientes, utiliza a metodologia qualitativa como principal recurso de pesquisa e fundamentação de suas proposições e desenvolve diversas estratégias de ensino-aprendizado com utilização de textos literários e narrativos. A Abordagem Integral (Comprehensive Care) utiliza como referencial teórico o modelo biopsicossocial de abordagem do processo saúde-doença e busca desenvolver propostas de assistência integral à saúde de grupos populacionais prioritários do ponto de vista médico-sanitário. A integralidade privilegia a transformação da organização dos serviços e dos processos de trabalho em saúde como primeira instância para a qualificação dos processos comunicacionais entre médicos e pacientes. Não foram identificados nas tradições da Abordagem Integral (Comprehensive Care) e da Integralidade a discussão de estratégias de ensino-aprendizado de abordagens comunicacionais, o que é bastante enfatizado nas outras duas. Conclusão: As quatro tradições estudadas apresentam inovações e pressupostos teórico-práticos que se complementam. Mostra-se imprescindível estabelecer uma fusão de horizontes entre tais proposições de forma a qualificar os diálogos e processos de comunicação-interação estabelecidos entre médicos e pacientes no nível da atenção primária à saúde / The primary health care is currently a priority area in health policies in different parts of the world, being a strategic element to the care systems organization in Brazil. Nevertheless, the complexity and the specificity of demands and characteristics of healthcare in primary health care require conceptual and practical renewed efforts with respect to the construction of interactive and communicational processes between doctors and patients that go beyond the traditional anamnesis, regulated by a rationality strictly biomedics. Objective: identify and understand fundaments and contributions of four theoretical perspectives of relevance which have been problematizing, since the 90s, the interactions and the communication between doctors and patients in primary health care: Patient-Centered Medicine, Narrative Based Medicine, Comprehensive Care and Integrality in Healthcare. Methodology: Survey and interpretive study based on Hans-Georg Gadamers and Paul Ricoeurs philosophical hermeneutics of indexed bibliography in MEDLINE and LILACS from 1990 to 1999. Results: Patient-Centered Medicine is fundamentally guided towards the identification of specific domains that must be integrated with traditional medical anamnesis in order to broaden its practical scope. It uses quantitative research methodology as a predominant way of laying the foundations of its propositions, recommending various active teaching-learning methodologies. The Narrative Based Medicine withholds on \"how\" to construct narratives throughout the dialogue between doctors and patients. It applies a qualitative methodology as the major resource of research and of fundamenting its propositions, besides developing various teaching-learning strategies using literary and narrative texts. The Comprehensive Care uses the biopsychosocial model of addressing the health-disease process as a theoretical approach and aims at developing proposals for Integrality in Healthcare for population groups who have priority in terms of medical health care. Comprehensiveness privileges the transformation of services organization and of work processes in health as the first instance to the quality of communication processes between doctors and patients. In the traditions of Comprehensive Care and of Integrality in Healthcare, the discussion of teaching-learning strategies of communication approaches, which is quite emphasized in the other two approaches, was not identified. Conclusion: The four theoretical perspectives studied present innovations and theoretical-practical propositions that complement themselves. It is imperative to establish a \"fusion of horizons\" between such propositions for qualifying the dialogue and the communication-interaction processes established between doctors and patients at the primary health care level

Este estudo analisa o processo terapêutico da Medicina Homeopática, destacando a relevância de seus componentes na construção de um espaço interativo entre médicos e pacientes, capaz de propiciar novos sentidos para a compreensão do adoecimento e para a perspectiva da cura. As questões que motivaram o trabalho surgiram a partir de preocupações a respeito da insuficiência do tecnicismo da medicina atual para atender às expectativas dos sujeitos participantes das práticas de saúde. Discutimos que a centralidade da pessoa, no paradigma da Medicina Homeopática. ao privilegiar a situação de adoecimento dos pacientes, confere características específicas à sua abordagem, capazes de resgatar a dimensão do cuidado na ação terapêutica. Tomamos, como base empírica, duas unidades de saúde da cidade de São Paulo, onde foram realizadas entrevistas com médicos e pacientes, e colhidos depoimentos espontâneos que surgiram durante o atendimento clínico da autora. O material obtido foi trabalhado qualitativamente e permitiu identificar certos núcleos de sentidos, tais como, St~jeito, Pessoa, E-;cuta, Ver. Vinculo, Tempo, Cura e Medicamento, capazes de refletirem as dimensões essenciais, que traduzem a especificidade do processo terapêutico da Homeopatia. Através das narrativas de sujeitos da prática homeopática, pudemos evidenciar que a construção de um espaço de intersubjetividade, em que pacientes e médicos possam compartilhar a experiência do adoecer, permite introduzir a perspectiva do cuidado e a possibilidade de um projeto de recuperação da saúde. Tais aspectos foram considerados, ao buscarmos compreender a efetividade da Homeopatia, como prática terapêutica. Um desdobramento relevante deste estudo pode ser a análise dos fundamentos da legitimidade da Medicina Homeopática nas práticas de saúde, segundo critérios que preservem a identidade de sua episteme. / This study analyses the therapeutic process of Homeopathic Medicine. It highlights the relevance o f the components o f homeopathy in the construction o f an interactive setting between doctors and patients capable of providing the process o f becoming ill and the perspective o f cure with new meanings. Concems with respect to the insufficiencies of contemporary technological medicine in attending to the expectations and demands of subjects participating in health practices were the issues that motivated this research. The central position occupied by the person in the paradigm of Homeopathic Medicine is discussed. By granting a privileged position to the situation of becoming ill, specific characteristics are conferred to the approach in question, which enable it to redeem the dimension o f care to therapeutic action. Two health units in Sao Paulo City constitute the empírica! basis for the present study. Interviews with doctors and patients were carried out there, as well as clinicai consultations conducted by the author during the course of which spontaneous statements also emerged and were recorded. The material obtained was submitted to a qualitative analysis which led to the identification of certain nuclei of meaning such as, Subject, Person, Hearing, Looking, Bond, Time, Cure, Medication, capable of reflecting essential dimensions which translate the specificity ofthe homeopathic therapeutic process. The narratives of the subjects involved in homeopathic practice document the construction of an intersubjective setting, where patients and doctors may share the experience of becoming ill. Within this setting, it is possible to introduce the perspective of care and the possibility o f a project o f health recuperation. These aspects were taken into consideration when we strove to comprehend the effectiveness of homeopathy as a therapeutic practice. One of the relevant extensions of this project may be the analysis of the basis of legitimacy of Homeopathic Medicine on health care practices through criteria that preserve the identity of its epistemic.

Este trabalho apresenta um estudo exploratório do tipo transversal sobre a relação das doenças crônicas e o uso da tecnologia nuclear. O aumento na prevalência das doenças crônicas nos países em desenvolvimento é preocupante e devem ser avaliados cuidadosamente dentro das sociedades, organizações e seus indivíduos. Os avanços tecnológicos vivenciados nas últimas décadas, em especial, na área da tecnologia nuclear criam expectativas para lidar com o desafio das doenças de modo mais eficiente. Entretanto, pouco foi explorado sobre esse tema por um prisma dos agentes médicos que compõem esse sistema de relações entre a doença e a tecnologia. A necessidade de planejamentos públicos e privados para lidar com essa problemática podem se beneficiar de uma avaliação inicial sobre um tema ainda emergente, mas que deverá compor a agenda de planejamento em saúde e tecnologia nos próximos anos. Por meio de uma metodologia mista, composta por abordagem qualitativa e quantitativa buscou-se configurar e revelar as importantes dimensões sobre o tema dessa pesquisa. A pesquisa de campo foi composta tanto de entrevistas analisadas através de técnicas da teoria fundamentada e também de questionários enviados via web analisados estatisticamente através da análise fatorial exploratória. Tais empreendimentos permitiram revelar dimensões que compõem a percepção entre a doença crônica e o uso da tecnologia nuclear. Essas dimensões apresentadas na forma de um constructo teórico foram então discutidas de um ponto de vista da teoria social e de inovação tecnológica. / This research is an exploratory cross-sectional study about the relationship of chronic disease and the use of nuclear technology. There is a concern over the increase of the prevalence of chronic disease in developing countries and it should hence be carefully evaluated in the context of societies, organizations and individuals. The technological advances experienced in the last decades especially in the nuclear technology area have created expectations to deal more efficiently with the challenge of chronic diseases. However little has been explored in this area under the point-of-view of medical doctors as agents who make this system of relations between disease and technology. The necessity for public and private planning to deal with this set of problems can benefit through an initial evaluation about the forthcoming theme, but should incorporate the agenda of health and technology planning for the following years. Using mixed methodology, made up of qualitative and quantitative approach, this research sought to reveal and configure important dimensions around the theme of this study. The field research was made up of interviews analyzed using techniques of fundamental theory and also of questionnaires sent by web analyzed statistically using exploratory factor analysis. These ventures allowed dimensions to be revealed that make up the perception of chronic disease and the use of nuclear technology. These dimensions presented in a form of a theoretical construct that were then discussed under the point of view of social theory and technological innovation.

A atenção primária à saúde constitui hoje área prioritária nas políticas de saúde em diversas partes do mundo, constituindo, no Brasil, elemento estratégico para a organização dos sistemas de atenção. A complexidade e especificidade das demandas e características do cuidado em saúde na atenção primária exige, contudo, renovados esforços conceituais e práticos no sentido da construção de processos comunicacionais e interativos entre médicos e pacientes que caminhem para além da anamnese tradicional, pautada por uma racionalidade estritamente biomédica Objetivo: identificar e compreender fundamentos e contribuições de quatro influentes correntes teóricas que, a partir da década de 90, vêm problematizando as interações e a comunicação entre médicos e pacientes na atenção primária à saúde: Medicina Centrada no Paciente, Medicina Baseada em Narrativa, Abordagem Integral (Comprehensive Care) e Integralidade da Atenção à Saúde. Metodologia: Levantamento e estudo interpretativo, apoiado na filosofia hermenêutica de Hans-Georg Gadamer e Paul Ricoeur, de produção bibliográfica indexada nas bases MEDLINE e LILACS de 1990 a 1999. Resultados: A Medicina Centrada no Paciente orienta-se, fundamentalmente, para a identificação de domínios específicos que devem ser integrados à anamnese médica tradicional para ampliar seu escopo prático, utiliza metodologia de pesquisa quantitativa como modo predominante de fundamentação de suas proposições e propõe inúmeras metodologias ativas de ensino-aprendizado. A Medicina Baseada em Narrativa detém-se no como construir narrativas ao longo do diálogo entre médicos e pacientes, utiliza a metodologia qualitativa como principal recurso de pesquisa e fundamentação de suas proposições e desenvolve diversas estratégias de ensino-aprendizado com utilização de textos literários e narrativos. A Abordagem Integral (Comprehensive Care) utiliza como referencial teórico o modelo biopsicossocial de abordagem do processo saúde-doença e busca desenvolver propostas de assistência integral à saúde de grupos populacionais prioritários do ponto de vista médico-sanitário. A integralidade privilegia a transformação da organização dos serviços e dos processos de trabalho em saúde como primeira instância para a qualificação dos processos comunicacionais entre médicos e pacientes. Não foram identificados nas tradições da Abordagem Integral (Comprehensive Care) e da Integralidade a discussão de estratégias de ensino-aprendizado de abordagens comunicacionais, o que é bastante enfatizado nas outras duas. Conclusão: As quatro tradições estudadas apresentam inovações e pressupostos teórico-práticos que se complementam. Mostra-se imprescindível estabelecer uma fusão de horizontes entre tais proposições de forma a qualificar os diálogos e processos de comunicação-interação estabelecidos entre médicos e pacientes no nível da atenção primária à saúde / The primary health care is currently a priority area in health policies in different parts of the world, being a strategic element to the care systems organization in Brazil. Nevertheless, the complexity and the specificity of demands and characteristics of healthcare in primary health care require conceptual and practical renewed efforts with respect to the construction of interactive and communicational processes between doctors and patients that go beyond the traditional anamnesis, regulated by a rationality strictly biomedics. Objective: identify and understand fundaments and contributions of four theoretical perspectives of relevance which have been problematizing, since the 90s, the interactions and the communication between doctors and patients in primary health care: Patient-Centered Medicine, Narrative Based Medicine, Comprehensive Care and Integrality in Healthcare. Methodology: Survey and interpretive study based on Hans-Georg Gadamers and Paul Ricoeurs philosophical hermeneutics of indexed bibliography in MEDLINE and LILACS from 1990 to 1999. Results: Patient-Centered Medicine is fundamentally guided towards the identification of specific domains that must be integrated with traditional medical anamnesis in order to broaden its practical scope. It uses quantitative research methodology as a predominant way of laying the foundations of its propositions, recommending various active teaching-learning methodologies. The Narrative Based Medicine withholds on \"how\" to construct narratives throughout the dialogue between doctors and patients. It applies a qualitative methodology as the major resource of research and of fundamenting its propositions, besides developing various teaching-learning strategies using literary and narrative texts. The Comprehensive Care uses the biopsychosocial model of addressing the health-disease process as a theoretical approach and aims at developing proposals for Integrality in Healthcare for population groups who have priority in terms of medical health care. Comprehensiveness privileges the transformation of services organization and of work processes in health as the first instance to the quality of communication processes between doctors and patients. In the traditions of Comprehensive Care and of Integrality in Healthcare, the discussion of teaching-learning strategies of communication approaches, which is quite emphasized in the other two approaches, was not identified. Conclusion: The four theoretical perspectives studied present innovations and theoretical-practical propositions that complement themselves. It is imperative to establish a \"fusion of horizons\" between such propositions for qualifying the dialogue and the communication-interaction processes established between doctors and patients at the primary health care level

No description available.

The purpose of this thesis is to identify common themes presented in several illness narratives with specific attention paid to the relationship between patients and their physicians and patients and their families. Only illness narratives written in America and Western Europe were used for this thesis so the topic could be narrowed to the experience within the western biomedical field. While most research on illness narratives focuses on defining illness and illustrating the importance of introspective work, this thesis identifies patterns in a way that can shape the future treatment of chronically ill patients. This thesis also allows me to creatively explore a personal illness narrative, reinforcing these themes and contributing to the discussion of what physicians and families can do to make the illness experience more bearable for the patient.

This study focuses on the characterization of Cushman’s healers in her three medieval novels The Midwife’s Apprentice; Catherine, Called Birdy; and Matilda Bone. I specifically look at the physical descriptions, medical practices, and the healer’s role within the community as an accepted medical authority. Cushman’s portrayals illuminate the different locations and situations in which women practiced medicine during the Middle Ages, thus she presents more historically accurate portrayals of female healers. The significance of this project is that Cushman challenges the stereotype of the isolated and disfigured old crone that has been, perhaps inadvertently, perpetuated by authors and focuses on the historical accuracies of female healers. Many young readers learn about history through novels and it is important that authors present accurate historical representations of the past they are trying to describe to their audiences. In addition, this project will bring multiple disciplines together such as medieval studies, young adult literature, medical history, and folklore in order to illuminate the historical accuracies and representations of female healers.