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Laws or practices that harm particular racial groups must be eliminated unless they “are objectively justified by a legitimate aim and the means of achieving that aim are appropriate and necessary” (United Nations Committee on the Elimination of Racial Discrimination 2008 cheap lisinopril online visa blood pressure pulse, paragraph 10) discount lisinopril 17.5 mg on-line arteria buccalis. The operational and political convenience of making arrests in low-income minority neighborhoods rather than white middle-class ones may be an explanation but certainly not a justification lisinopril 17.5mg sale arteria buccinatoria. Even assuming the legitimacy of the goal of protecting minority neighborhoods from addiction and drug gang violence, the means chosen to achieve that goal—massive arrests of low-level offenders and high rates of incarceration—are hardly a proportionate or necessary response. No independent and objective observer believes the United States can arrest and incarcerate its way out of its “drug problem. Subscriber: Univ of Minnesota - Twin Cities; date: 23 October 2013 Race and Drugs Criminology 44:105–37. National Corrections Reporting Program: Most Serious Offense of State Prisoners, by Offense, Admission Type, Age, Sex, Race, and Hispanic Origin, 2009. Imprisoning Communities: How Mass Incarceration Makes Disadvantaged Neighborhoods Worse. The Rest of their Lives: Life Without Parole for Child Offenders in the United States. Subscriber: Univ of Minnesota - Twin Cities; date: 23 October 2013 Race and Drugs Husak, Douglas N. Marijuana Arrest Crusade: Racial Bias and Police Policy in New York City 1997-2007. Racial Disparity in Criminal Court Processing in the United States: Submitted to the United Nations Committee on the Elimination of Racial Discrimination. Black Arrests for Drug Abuse Violations, 1980 to 2009, generated using the Arrest Data Analysis Tool. Subscriber: Univ of Minnesota - Twin Cities; date: 23 October 2013 Race and Drugs Spohn, Cassia, and Jeffrey Spears. Substance Abuse in States and Metropolitan Areas: Model Based Estimates from the 1991-1993 National Household Survey on Drug Abuse. Administration of Justice, Rule of Law, and Democracy: Discrimination in the Criminal Justice System. Notes: (*) Includes some persons of Hispanic origin; however, there are additional persons of Hispanic origin who are new court commitments who were not categorized as to race and who are not included in these figures. Capacity to other ethnic1 disparities is limited by national arrest and imprisonment data, which either do not or only inadequately indicate the ethnicity of those arrested, sentenced, held in prison, and released from prison. Subscriber: Univ of Minnesota - Twin Cities; date: 23 October 2013 Race and Drugs No. Human rights treaties are binding both on the federal and state governments (Human Rights Watch and Amnesty International 2005, p. When scientists began to study addictive behavior in the 1930s, people addicted to drugs were thought to be Fmorally flawed and lacking in willpower. Those views shaped society’s responses to drug abuse, treating it as a moral failing rather than a health problem, which led to an emphasis on punishment rather than prevention and treatment. Today, thanks to science, our views and our responses to addiction and other substance use disorders have changed dramatically. Groundbreaking discoveries about the brain have revolutionized our understanding of compulsive drug use, enabling us to respond effectively to the problem. As a result of scientific research, we know that addiction is a disease that affects both the brain and behavior. We have identified many of the biological and environmental factors and are beginning to search for the genetic variations that contribute to the development and progression of the disease. Scientists use this knowledge to develop effective prevention and treatment approaches that reduce the toll drug abuse takes on individuals, families, and communities. Despite these advances, many people today do not understand why people become addicted to drugs or how drugs change the brain to foster compulsive drug use. This booklet aims to fill that knowledge gap by providing scientific information about the disease of drug addiction, including the many harmful consequences of drug abuse and the basic approaches that have been developed to prevent and treat substance use disorders. Every year, illicit and prescription drugs and alcohol contribute to the 4,5 A death of more than 90,000 Americans, while tobacco is linked to an estimated 480,000 deaths per year. This exposure can slow the child’s intellectual 6 development and affect behavior later in life. They often develop poor social behaviors as a result of their drug abuse, and their work performance and personal relationships suffer. Such conditions harm the well- being and development of children in the home and may set the stage for drug abuse in the next generation. Scientists study the effects that drugs have on the brain and on people’s behavior. They use this information to develop programs for preventing drug abuse and for helping people recover from addiction. These brain changes can be long-lasting, and can lead to the harmful behaviors seen in people who abuse drugs. Both disrupt the normal, healthy functioning of the underlying organ, have serious harmful consequences, and are preventable and treatable, but if left untreated, can last a lifetime. This initial sensation of euphoria is followed by other effects, which differ with the type of drug used. For example, with stimulants such as cocaine, the “high” is followed by feelings of power, self-confidence, and increased energy. In contrast, the euphoria caused by opiates such as heroin is followed by feelings of relaxation and satisfaction. Some people who suffer from social anxiety, stress-related disorders, and depression begin abusing drugs in an attempt to lessen feelings of distress. Stress can play a major role in beginning drug use, continuing drug abuse, or relapse in patients recovering from addiction. Some people feel pressure to chemically enhance or improve their cognitive or athletic performance, which can play a role in initial experimentation and continued abuse of drugs such as prescription stimulants or anabolic/androgenic steroids. Teens are more likely than adults to engage in risky or daring behaviors to impress their friends and express their independence from parental and social rules. Scientists believe that these changes alter When they first use a drug, people may perceive what seem to the way the brain works and may help explain the compulsive be positive effects; they also may believe that they can control and destructive behaviors of addiction. Why do some people become addicted to Over time, if drug use continues, other pleasurable activities drugs, while others do not? In general, the more risk start to feel the need to take higher or more frequent doses, factors a person has, the greater the chance that taking drugs even in the early stages of their drug use. Consider how Risk Factors Protective Factors a social drinker can become intoxicated, get behind the wheel of a car, and quickly turn a pleasurable activity into a tragedy Aggressive behavior Good self-control in childhood that affects many lives. Lack of parental Parental monitoring supervision and support Is continued drug abuse a voluntary Poor social skills Positive relationships behavior? Drug experimentation Academic competence The initial decision to take drugs is typically voluntary. However, Availability of drugs School anti-drug with continued use, a person’s ability to exert self-control can at school policies become seriously impaired; this impairment in self-control is Community poverty Neighborhood pride the hallmark of addiction. Brain imaging studies of people with Children’s earliest interactions within the family are crucial to their healthy development and 8 risk for drug abuse. Risk and protective factors may be either envi- ronmental (such as conditions at home, at school, and in the neighborhood) or biological (for instance, a person’s genes, their stage of development, and even their gender n Genetics n Chaotic home and abuse n Gender n Parent’s use and attitudes or ethnicity).
Nevertheless purchase lisinopril with visa arrhythmia high blood pressure, the Trotula proved an attractive locus in which to insert additional recipes on gy- necology order lisinopril 17.5 mg without prescription prehypertension que es, obstetrics order lisinopril 17.5mg online blood pressure control chart, or, most commonly, cosmetic concerns. This ‘‘magnet eﬀect’’ suggests not a lack of concern for the integrity of the texts but, rather, recognition of the encyclopedic wealth they were seen to possess. T T E As with so many aspects of the history of the Trotula texts, the creation of the original Trotula ensemble can be neither precisely dated nor attributed to an identiﬁable individual. The three individual texts had gone through several stages of independent revision by the end of the twelfth century (ﬁg. These were both abbreviated versions of the texts: Conditions of Women omit- ted the contraceptives and the following paragraph on the development of the fetus (¶¶–); Women’s Cosmetics abbreviated the text throughout, mostly by omission of the detailed instructions for preparations. The Trotula ensemble proper was probably ﬁrst created in the late twelfth century, for we ﬁnd manuscripts of it from the turn of the thirteenth cen- tury. The compiler of this proto-ensemble, whoever he or she was, combined the already-paired Conditions of Women and Women’s Cosmetics with a copy of Treatments for Women . Although this editor made no major revisions of the texts, s/he did introduce several substantive additions and rearrangements that transformed the ensemble into something more than a simple linking of the three original Salernitan texts. This compiler ﬁrst compared Conditions of Women with a copy of Conditions of Women in order to check certain read- ings and ﬁll in lacunae, particularly the deleted contraceptive section. First was ¶, which describes the month-by-month development of the fetus; this was excerpted from an embryological work attributed to the late-fourth-century North African writer Vindician. Paragraphs –, on the care of the new- born and choice of a wet nurse, were drawn out of The Book for al-Mansur (Liber ad Almansorem), a large medical compendium by the Persian physician Abū Bakr Muḥammad ibn Zakarīyā’ ar-Rāzī (d. The Book for al-Mansur had only re- cently been translated from Arabic into Latin in Spain, and its use by the Tro- tula compiler is one of the ﬁrst witnesses to its circulation. The last three sections of the expanded Conditions of Women, ¶¶– on male and female infertility, were drawn from the work of the Salernitan writer Co- pho. Though theydid not contradict the other material in Conditions of Women, these new chapters slightly shifted the emphasis of the original, from the dis- eases of women (women’s suﬀerings being the chief concern) to procreation (the successful production and rearing of children). With Treatments for Women, the compiler of the proto-ensemble excised chapters on hair and skin care and placed them instead within the third, cos- metic section of the newly constructed text (in the present edition, ¶¶, , –, –, –, –, and ). The surviving manuscripts show Introduction that the proto-ensemble was left incomplete: the compiler never ﬁnished what was apparently a planned integration of all the cosmetic chapters from Treat- ments for Women with those of Women’s Cosmetics. Perhaps the most important feature of this ﬁrst version of the ensemble is that it was here that ‘‘Trotula’’ ﬁrst came into being. Tro(c)ta, as I have already noted, was a popular woman’s name in late-eleventh- and twelfth- century southern Italy; ‘‘Trotula’’ (which literally means ‘‘little Trota’’) has thus far been documented only twice, and in one case it is clearly used as a child’s name. Both Conditions of Women and Women’s Cosmetics,aswe have seen,were anonymous,while Treatments forWomen was regularlyascribed to Trota. The compilerof the proto-ensemble probably thus had only the name of Trota to associate with the three works. Thus we ﬁnd early forms of the ensemble with the title ‘‘The Trotula of Women’’ (Trotula mulierum) or ‘‘The Book Which Is Called the Trotula’’ (Liber qui dici- tur Trotula or Summa que dicitur Trotula). Already by the early thirteenth cen- tury, however, the title ‘‘Trotula’’ was misunderstood as the author’s name— an author who, moreover, was responsible not just for one text but for the whole ensemble. From this point on, even though many scribes continued to diﬀerentiate between the Trotula major (i. The internal reference to Trota in ¶ was also changed to ‘‘Trotula,’’ very few scribes or readers bothering to puzzle through why the work’s author should describe one of her own successful cures in a distant third person rather than with the proud ‘‘I’’ of the ﬁrst person. In the ‘‘transitional’’ ensemble, an editor went back to Women’s Cosmetics and incorporated it in full (together with his/her own substantive revisions), thus ﬁnally completing the third section of the ensemble. This editoralso inserted some new material, such as two cosmetic practices that the early-thirteenth-century author Bernard of Provence had attributed to the Salernitan women. This, then, is the magnet eﬀect of the Trotula, attracting all manner of miscellaneous recipes on women’s medicine. Some time before the middle of the thirteenth century, yet another form of the ensemble emerged. Using copies of both the transitional and the inter- mediate ensembles as a base, the editor of this ‘‘revised ensemble’’ went back to manuscripts of the three original independent treatises in order to establish a purer form of the texts. In Conditions of Women, for example, the editor noticed that a group of recipes (here ¶¶–) had been omitted from the section on aids for diﬃcult birth. The editor of the revised ensemble copied the abbrevi- ated section as s/he found it, then added the missing recipes from Conditions of Women . In the opening sentence (¶), for example, s/he clariﬁed that the subsequent test was for diﬀerentiating ‘‘hot’’ women from ‘‘cold’’ in order that they might be properly aided in conception. The editor of the revised ensemble also suppressed several recipes, such as the treatments for impetigo (a skin condition), worms in infants, and snake- bite in Treatments for Women, as well as many of the cosmetics and obstetrical chapters that had closed Women’s Cosmetics in the intermediate ensemble (in- cluding the chapter on sexual hygiene discussed above). Only one recipe is new in the revised ensemble: ¶, which oﬀers an additional remedy for deafness. Sometime around the middle of the thirteenth century, the ‘‘standard- ized ensemble’’ ﬁrst appeared. The last major version of the ensemble (and that edited here), the standardized ensemble oﬀers no substantive additions or deletions; the content of the text is entirely identical to the revised ensemble. Its editor chose to replace the assertion that Nature wished ‘‘to recuperate’’ women’s de- fective heat by the more poetic phrase ‘‘to temper the poverty of their heat’’ (¶). This editor had a particular taste for synonymy, that is, introducing a sec- ond term to more fully convey breadth of meaning: the veins of the womb are both ‘‘wide and open,’’ not simply ‘‘open’’ (¶); pain occurs in the ‘‘more prominent’’ or the more anterior part of the womb (¶). This editor was also not averse to what apparently passed for ethnic humor in the thirteenth Introduction century: s/he was responsible for the suggestion that the language of Lom- bards is particularly noxious to the newborn (¶). Finally and more positively, to this editor can be attributed regularized chapter divisions and rubrics. True, there should have been quite a few more chapter headings than were actually added. For example, in the Treatments for Women section, the chapter on cancer of the nose is followed immediately by one on provoking the menses (¶¶ and ), with no chapter division to signal the separation of two such obviously distinct topics. Still, the addition of the regularized rubrics undoubtedly increased the utility of the text for ref- erence purposes. Perhaps the most important of these rubrics was the open- ing one: ‘‘On the Diseases of Women According to Trotula’’ (De passionibus mulierum secundum Trotulam), yet another reinforcement of the attribution of this wide-ranging collection of texts on women’s medicine to the single author ‘‘Trotula. Many of the changes that the texts underwent between their com- position and the mid-thirteenth century were subtle and insigniﬁcant for the works’ actual theoretical or therapeutic content. Some changes might be con- sidered real improvements: the transposition of several of Treatments for Women’s cosmetic chapters into the Women’s Cosmetics section rendered them more accessible, while additions like the precise instructions for the prepara- tion of starch (¶) must have been genuinely helpful. But some changes were not calculated emendments but accidental errors that crept into the texts. The loss of the negative in the opening sentence of ¶ in Treatments for Women, for example, had the result of encouraging treatment of old women suﬀer- ing from a sanious ﬂux, whereas the original text had said it was pointless to treat them because they were already incapable of bearing children. Many errors or corruptions, of course, would not have been obvious to readers without multiple copies of the texts at hand. Yet the failure of later scribes or readers to correct some of the more glaring errors must give us pause when imagining how actively the standardized ensemble in particular might Introduction have been used in any kind of clinical setting. Not a single reader of the extant standardized ensemble manuscripts seems to have noticed, for example, the obvious logical inconsistency within a recipe in Women’s Cosmetics for redden- ing the skin and lips, where an accidental misreading changed a prescription to use a violet dye into one for a green dye (¶).
The Web or homicide and one case involving the patent on Adverts that encourage “mood olanzapine (Zyprexa) purchase lisinopril 17.5 mg blood pressure knowledge scale. None of these interests played site contains a “mood disorder watching” risk transforming variations any part in the submission or preparation of this questionnaire” (http:⁄⁄www purchase lisinopril 17.5mg amex blood pressure ed. This is an the viewer to follow her example: “Take open-access article distributed under the terms running trials aimed at establishing of the Creative Commons Attribution License cheap lisinopril 17.5 mg online hypertension epidemiology, the test you can take to your doctor, it olanzapine as a “mood stabilizer,” one of which permits unrestricted use, distribution, and can change your life…. A range of medication is working; almost everyone in the title of scientiﬁc articles (see academic institutions has also grown who stops taking the medication will Figure 1). Information available from clear that the academic psychiatric disorders, as they are effective in Janssen (the makers of Risperdal) states community still has not come to a acute manic states [13,14]. However, “medicines are crucially important in consensus on what the term “mood no companies making antipsychotics the treatment of bipolar disorders. But this lack had previously sought a license Studies over the past twenty years of consensus did not get in the way of for prophylaxis against bipolar have shown beyond the shadow of the message that patients with bipolar disorders. Against a background of doubt that people who receive the disorders needed to be detected epidemiological studies indicating that appropriate drugs are better off in the and once detected needed mood the prevalence of bipolar disorders long term than those who receive no stabilizers, and perhaps should only be might be greater than previously medicine” . Anticonvulsants are however, no consensus on a theoretical depressive net by the lure of bipolar beneﬁcial in epilepsy and were until rationale that would lead the average disorder. This may stem in part mood disorders on the risk of further criterion, while acute treatment from difﬁculties in conducting trials episodes . It was this idea that trials of antipsychotics for mania, on psychotropic drugs that last more provided a pharmacological rationale and prophylactic trials of lithium for than a few weeks in conditions as for treatment of bipolar disorders that manic-depressive illness, have for the complex as manic-depressive illness. This necessarily raises the controlled trial (in which patients were the growth of awareness of mood prospect that increased efforts to detect only followed for up to 48 weeks) that stabilization and of bipolar disorders and to treat people risks crossing the some see as a basis for claiming that was sensational. At the time, prevalence estimates came new produces a withdrawal-induced the criteria for bipolar I disorder journals, Bipolar Disorders (http:⁄⁄www. If the treating physician A recent book, The Bipolar Child had only realized the patient was , brings out the extent of the bipolar, they would not have mistakenly current mania. Author’s Graph of p-Value psychiatrists would ﬁnd it difﬁcult difference to Heather Norris, whose Function Based on Data in  to leave any person with a case of mother, after reading it, challenged (Illustration: Sapna Khandwala) bipolar disorder unmedicated. As a result, Heather, at the (1) a consistent body of evidence Storosum and colleagues analyzed age of two, became the youngest child indicates that regular treatment with all placebo-controlled, double-blind, in Tarrant County, Texas, to have a antipsychotics in the longer run randomized trials of mood stabilizers diagnosis of bipolar disorder. The Star increases mortality [22–26]; and (2) for the prevention of manic/depressive Telegram article noted that “along with there is evidence that in placebo- episode that were part of a registration the insurance woes, lack of treatment controlled trials of antipsychotics dossier submitted to the regulatory options and weak support systems that submitted in application for authority of the Netherlands, the plague most families with mentally ill schizophrenia licenses there is a Medicines Evaluation Board, between children, parents of the very young statistically signiﬁcant excess of 1997 and 2003 . A range of problems associated suicide risk in patients on placebo a nightmare because of scant research with antipsychotics, from increased compared with patients on active into childhood mental illness and the mortality to tardive dyskinesia, never medication. If use of these agents based Based on these absolute numbers from hospitalization or being off work for a on demonstrated effects leads on these four trials, I have calculated (see month). The potential is compounded to efﬁcacy, admissions for bipolar Figure S1 showing calculation, and in the pediatric domain by the fact disorder might be expected to fall, see Figure 2) that active agents are that the diagnosis is based on caregiver but the evidence for this is difﬁcult most likely to be associated with a 2. Experts that appear willing on average four admissions every ten The Bipolar Future to go so far as to accept the possibility years. In contrast, against a background Until recently the general clinical that the ﬁrst signs of bipolar disorder of a constant incidence of bipolar I wisdom was that it was very rare for may be patterns of overactivity in disorder, and dramatic improvements manic-depressive illness to have an utero  can only further compound in service provision, bipolar I patients onset in the preteen years. If the resulting show a 4-fold increase in the prevalence is now a surge of diagnoses of bipolar diagnoses were provisional, aimed of admissions despite being treated disorder in American children [29,30], at researching the natural history of with the very latest psychotropic even though these children do not childhood irritability, rather than medications . This is not ordinarily meet the traditional criteria for bipolar reaching diagnoses that lead on to what happens when treatments “work,” I disorder (from the Diagnostic and pharmacotherapy, there might be but quite often is what happens when Statistical Manual of Mental Disorders) little problem. The mania for pediatric bipolar Zyprexa and Risperdal are now being The selling of bipolar disorder disorder hit the front cover of the used for preschoolers in America with stresses that the disorder takes American edition of Time in August little questioning of this development a fearsome toll of suicides. Episheet Showing Author’s D (2003) Mood stabilizers: The archaeology of Hospital, have run trials of Risperdal the concept. Relative Risk Calculation, Based on Data in and Zyprexa on children with a  20. Psychiatric Association meeting; Atlanta Massachusetts General Hospital in fact pmed. Symposium 37A; May 2005; Atlanta, Georgie, recruited trial participants by running United States. The epidemiology of characterized by overactivity not to show Neuropsychopharmacology 19: 194–199. A handbook for on bipolar disorder: the 1890s and 1990s who had experienced a single seizure compared. J Affect Unrecognized epidemic of manic-depressive immediate antiepileptic drug illness in children. Harris J (2005) The increased diagnosis of seizures in the next 1–2 years, in combination for acute mania. The absence of a States: Results from the National Comorbidity (2004) Open trial of atypical antipsychotics in Study. Marson A, Jacoby A, Johnson A, Kim L, “mood stabilizers” raises questions as Prevention Booklet. Because we believe that we owe corporations our wealth and well-being, we tend not to question corporations’ fundamental practices, and they become invisible to us. What follows is an attempt to demystify some of the assumptions at work in the “culture of marketing,” toward the goal of explaining contemporary disease t is often said that leading drug mongering. While such There are three beliefs commonly Pills are often marketed as a solution to contemporary pharmaceutical associated with the “free market. The second is that to us our discontent with the status of 19th-century patent medicine the free market is a place where these quo. The last of watching television advertisements, and are noted in the history of advertising these beliefs is that the surest avenue the effect is that they are conditioned as having been the leading spenders to innovation in all industries is to want more and more. The anthropologist personal anxieties and dissatisfactions sellers pioneered print advertising, Marshall Sahlins theorizes that the are best addressed by consumption. In a consumer design and commissioning of medical This results, says Sahlins, in a peculiar society, when individuals make choices almanacs that functioned as vehicles for idea of the person “as an imperfect toward the satisfaction of their needs promotion of disease awareness. Henry creature of need and desire, whose and wants, they experience this as James’s psychologist brother, William whole earthly existence can be reduced constructing their own individuality James, was so exasperated by “the to the pursuit of bodily pleasure and medical advertisement abomination” the avoidance of pain” . A historical that in 1894 he declared that “the and philosophical examination of Funding: The author received no speciﬁc funding for authors of these advertisements should professional marketing shows that an this article. In this sense, marketing can company discoveries have profoundly be regarded as the institutionalization Citation: Applbaum K (2006) Pharmaceutical of this view of human nature. The marketing and the invention of the medical improved upon our capacity to treat consumer. But pharmaceutical marketing marketer’s challenge is to translate is more closely aligned with consumer those limitless needs into proﬁts. This is an than with medicine, for which the the world’s richest societies, the open-access article distributed under the terms subjective experience of lack increases of the Creative Commons Attribution License, consequences are not trivial. Once we which permits unrestricted use, distribution, and view pharmaceutical industry activities in proportion to the objective output reproduction in any medium, provided the original in this light, we can disentangle of wealth” . Kalman Applbaum teaches medical anthropology at One explanation of this paradox lies the University of Wisconsin Milwaukee, Milwaukee, in the way marketing activities are Wisconsin, United States of America.
In a routine basis buy lisinopril 17.5mg without prescription arrhythmia in 7 year old, but rethink their strategies when that does a typical experiment a cohort with varying degrees of ex- not work buy lisinopril 17.5 mg otc blood pressure questions and answers. Physicians also rethink their diagnoses when it is pertise are asked to undertake a skilled task cost of lisinopril heart attack 1d. In fact, it is in these situations of the task, the test subjects are asked to grade their own that diagnostic decision-support tools are most likely to be performance. In fact, it could be Data from a study conducted by Friedman and col- 108 argued that their awareness needs to be increased for a leagues showed similar results: residents in training per- select type of case: that in which the healthcare provider formed worse than faculty physicians, but were more con- thinks he/she is correct and does not receive any timely ﬁdent in the correctness of their diagnoses. A systematic feedback to the contrary, but where he/she is, in fact, mis- review of studies assessing the accuracy of physicians’ taken. Typically, most of the clinician’s cases are diagnosed self-assessment of knowledge compared with an external correctly; these do not pose a problem. For the few cases measure of competence showed very little correlation be- 148 where the clinician is consciously puzzled about the diag- tween self-assessment and objective data. The authors nosis, it is likely that an extended workup, consultation, and also found that those physicians who were least expert research into possible diagnoses occurs. In ad- categories of solutions: strategies that focus on the individ- dition to their enhanced ability to make this distinction, ual and system approaches directed at the healthcare envi- experts are likely to make the correct diagnosis more ronment in which diagnosis takes place. Another approach is to the healthcare environment so that the data on the patients, advocate the development of expertise in a narrow domain. At the level of the individual clini- mutually exclusive and the major aim of both is to improve cian, the mandate to become a true expert would drive more the physician’s calibration between his/her perception of the trainees into subspecialty training and emphasize develop- case and the actual case. Both Bordage and Norman champion this the rate of diagnostic errors is not yet available, although 156 approach, arguing that “practice is the best predictor of preliminary results are encouraging. Extensive practice with simulated cases may rates the principles of metacognition and 4 additional at- supplement, although not supplant, experience with real tributes: (1) the tendency to search for alternative hypothe- ones. The key requirements in regard to clinical practice are ses when considering a complex, unfamiliar problem; extensive, i. Experi- tion to strategies that aim to increase the overall level of mental studies show that reﬂective practice enhances diag- clinicians’ knowledge, other educational approaches focus 161 nostic accuracy in complex situations. However, even on increasing physicians’ self-awareness so that they can advocates of this approach recognize that it is an untested recognize when additional information is needed or the assumption in terms of whether lessons learned in educa- wrong diagnostic path is taken. Singh and colleagues advocate this strategy; their deﬁnition of types of situational awareness is similar to what One could argue that effectively incorporating the education 115,155 and training described above would require system-level others have called metacognitive skills. For instance, at the level of healthcare systems, in Hall champion the idea that metacognitive training can reduce diagnostic errors, especially those involving subcon- addition to the development of required training and edu- scious processing. The logic behind this approach is appeal- cation, a concerted effort to increase the level of expertise of ing: Because much of intuitive medical decision making the individual would require changes in stafﬁng policies and involves the use of cognitive dispositions to respond, the access to specialists. These would orient clinicians to the general allow the less expert clinician to function like a more expert concepts of metacognition (a universal forcing strategy), clinician. Computer- or web-based information sources also familiarize them with the various heuristics they use intu- may serve this function. These resources may not be very itively and their associated biases (generic forcing strate- different from traditional knowledge resources (e. Once the initial diagnosis is made, the clinician ﬁguratively gazes into a These approaches focus on providing better and more ac- crystal ball to see the future, sees that the initial diagnosis is curate information to the clinician primarily to improve not correct, and is thus forced to consider what else it could calibration. A related technique, which is taught in every medical for reducing medical errors have formed the background of school, is to construct a comprehensive differential diagno- the patient safety movement, although they have not been 163 164 sis on each case before planning an appropriate workup. Nolan advo- Although students and residents excel at this exercise, they cates 3 main strategies based on a systems approach: pre- rarely use it outside the classroom or teaching rounds. As vention, making error visible, and mitigating the effects of we discussed earlier, with more experience, clinicians begin error. Most of the cognitive strategies described above fall to use a pattern-recognition approach rather than an exhaus- into the category of prevention. Other examples of cognitive The systems approaches described below fall chieﬂy into forcing strategies include advice to always “consider the the latter two of Nolan’s strategies. One approach is to opposite,” or ask “what diagnosis can I not afford to provide expert consultation to the physician. Usually a diagnostic decision-sup- only in artiﬁcial situations and many of them have been per- port system is used once the error is visible (e. The history of these systems is reﬂective of the overall Using the system may prevent an initial misdiagnosis and problem we have demonstrated in other domains: despite may also mitigate possible sequelae. A variety they do use them, many physicians are simply reluctant to of diagnostic decision-support systems were developed out 181 use decision-support tools in practice. Miller’s overall conclusions were that while data on how often they are used compared with how often the niche systems for well-deﬁned speciﬁc areas were they could/should have been used. The title, “A Report Card on data into the programs, it is likely that their usage would be Computer-Assisted Diagnosis—The Grade Is C,” of Kas- even lower or that the data entry may be incomplete. In a subsequent study, Berner tering, because what is usually displayed is a (sometimes 167 and colleagues found that less experienced physicians lengthy) list of diagnostic considerations. Also, as Teich and colleagues noted with of the Iliad system in educational settings. More disturbing was potentially useful, but the limited interest in them has made that use of the system actually increased costs, perhaps by several commercial ventures unsustainable. Because such puzzles occur rarely, which was initially begun as a pediatric system and now is there is not enough use of the systems in real practice 174–178 also available for use in adults. A second general category of a 179 180 Miller and Berner have reviewed the challenges in systems approach is to design systems to provide feedback evaluating medical diagnostic programs. Overconﬁdence represents a mismatch be- ﬁcult to determine the gold standard against which the systems tween perceived and actual performance. It is a state of should be evaluated, but both investigators advocate that the miscalibration that, according to existing paradigms of cog- criterion should be how well the clinician using the computer nitive psychology, should be correctable by providing feed- 179,180 compares with use of only his/her own cognition. In this program, radiologists keep back can improve the basis on which the clinicians are track of their agreement with any prior imaging studies they judging the frequency of events, which may improve re-review while they are evaluating a current study, and the calibration. In this framework, a possible approach to reducing diagnostic error, overconﬁdence, and Pathology. Experiments conﬁrm that feedback can improve perfor- 184 This act mandated more rigorous quality measures in regard mance, especially if the feedback includes cognitive in- to cytopathology, including proﬁciency testing and manda- formation (for example, why a certain diagnosis is favored) 189 tory reviews of negative smears. Even with these mea- as opposed to simple feedback on whether the diagnosis was 185,186 sures in place, however, rescreening of randomly selected correct or not. A recent investigation by Sieck and 131 smears discloses a discordance rate in the range of 10% to Arkes, however, emphasizes that overconﬁdence is 30%, although only a fraction of these discordances have highly ingrained and often resistant to amelioration by sim- 190 major clinical impact. There are no comparable proﬁciency requirements for The timing of feedback is important. Immediate feed- 187 anatomic pathology, other than the voluntary “Q-Probes” back is effective, delayed feedback less so. Q-Probes are highly focused re- feedback often is not available at all, much less immediately views that examine individual aspects of diagnostic testing, or soon after the diagnosis is made. In fact, the gold stan- including preanalytical, analytical, and postanalytical er- dard for feedback regarding clinical judgment is the au- rors. Q-Tracks are monitors that “reach beyond the testing some cases adopted, as a method of improving performance phase to evaluate the processes both within and beyond the 191 and calibration. The accuracy of radiologic diagnosis is most isons with all other participating labs.