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Background: The oligometastatic paradigm suggests that some patients with a limited number of metastases might be cured if all lesions are eradicated. Evidence from randomised controlled trials to support this paradigm is scarce. We aimed to assess the effect of stereotactic ablative radiotherapy (SABR) on survival, oncological outcomes, toxicity, and quality of life in patients with a controlled primary tumour and one to five oligometastatic lesions.Methods: This randomised, open-label phase 2 study was done at 10 hospitals in Canada, the Netherlands, Scotland, and Australia. Patients aged 18 or older with a controlled primary tumour and one to five metastatic lesions, Eastern Cooperative Oncology Group score of 0-1, and a life expectancy of at least 6 months were eligible. After stratifying by the number of metastases (1-3 vs 4-5), we randomly assigned patients (1:2) to receive either palliative standard of care treatments alone (control group), or standard of care plus SABR to all metastatic lesions (SABR group), using a computer-generated randomisation list with permuted blocks of nine. Neither patients nor physicians were masked to treatment allocation. The primary endpoint was overall survival. We used a randomised phase 2 screening design with a two-sided α of 0·20 (wherein p<0·20 designates a positive trial). All analyses were intention to treat. This study is registered with ClinicalTrials.gov, number NCT01446744.Findings: 99 patients were randomised between Feb 10, 2012, and Aug 30, 2016. Of 99 patients, 33 (33%) were assigned to the control group and 66 (67%) to the SABR group. Two (3%) patients in the SABR group did not receive allocated treatment and withdrew from the trial; two (6%) patients in the control group also withdrew from the trial. Median follow-up was 25 months (IQR 19-54) in the control group versus 26 months (23-37) in the SABR group. Median overall survival was 28 months (95% CI 19-33) in the control group versus 41 months (26-not reached) in the SABR group (hazard ratio 0·57, 95% CI 0·30-1·10; p=0·090). Adverse events of grade 2 or worse occurred in three (9%) of 33 controls and 19 (29%) of 66 patients in the SABR group (p=0·026), an absolute increase of 20% (95% CI 5-34). Treatment-related deaths occurred in three (4·5%) of 66 patients after SABR, compared with none in the control group.Interpretation: SABR was associated with an improvement in overall survival, meeting the primary endpoint of this trial, but three (4·5%) of 66 patients in the SABR group had treatment-related death. Phase 3 trials are needed to conclusively show an overall survival benefit, and to determine the maximum number of metastatic lesions wherein SABR provides a benefit.Funding: Ontario Institute for Cancer Research and London Regional Cancer Program Catalyst Grant. [ABSTRACT FROM AUTHOR]

The global ubiquity of overuse and underuse of health-care resources and the gravity of resulting harms necessitate an investigation of drivers to inform potential solutions. We describe the network of influences that contribute to poor care and suggest that it is driven by factors that fall into three domains: money and finance; knowledge, bias, and uncertainty; and power and human relationships. In each domain the drivers operate at the global, national, regional, and individual level, and are modulated by the specific contexts within which they act. We discuss in detail drivers of poor care in each domain. [ABSTRACT FROM AUTHOR]

The article discusses the issue of sexual harassment and abuse of women physicians by their patients, its negative impact on the former and the established rules that provide safety to them. It suggests that direct and proactive measures are required to deal with sexual harassment of physicians. It recommends that clear, written expectations and responsibilities are required as to how patients and providers should behave in clinical settings.

The article discusses cerebral amyloid angiopathy (CAA) and implications for atrial fibrillation management. It states that CAA and its implications for atrial fibrillation management is useful for shared decision making between the patient and the clinician. It also says that identification of CAA patients could affect the management of atrial fibrillation patients because they are also at risk of atrial fibrillation and stroke.

The author discusses aspects of the report titled "Eroding Trust: the UK's Prevent Counter-Extremism Strategy in Health and Education" which stresses the importance of confidentiality and trust in preventing extremism in health industry. Topics include the criticism on the practices in responding terrorism, the importance of preventing risks which undermines the trust of patients to doctors, and the danger associated with wrongful identification of the vulnerability of people to terrorism.

The author reflects on the biggest challenge facing future surgical and medical professionals in the paucity of hands-on learning opportunities in mainland China. He explains the consequences of surgical service delivery amid obvious workforce shortage. The author thinks that China desperately needs to train a new generation of surgeons with urgent bureaucratic reforms as part of the solution.

The article discusses the ideal shared decision making procedure used to determine the viability of kidneys donated from deceased patients. Due to the increase in demand, doctors are now forced to consider using organs of poorer quality. These kidneys have a higher chance of transplantation failure and of complications. Because of these risks, shared decision making is important. The process acknowledges both the doctor's medical knowledge and the patient's preferences. It can also help hold doctors accountable to their own preferences and prejudices. A grading system that can be used by doctor and patient is essential to facilitate shared decision making.

This article focuses on concerns about surgical professionalism amid technological and political changes. The author provides examples of how technology has greatly improved modern surgery. This includes routine and steadily less invasive heart and lung surgery, stapling devices that have improved the speed and reliability of gastrointestinal surgery, and the use of minimally invasive techniques used in procedures including adrenalectomy, to difficult hernia repairs. The future may include robotic surgery, telesurgery, and simultaneous optical and MRI examination of tissues. Despite advances, there is concern about the profession due to new social and political attitudes. Medicine is growing more complex, which leads to rises in technical specialization and the cost of health care. Social and political attitudes heighten expectations but force surgeons to work less hours with less training. Surgeons are pragmatists, the author claims, and are good at making the most of difficult situations. The article explores five areas, including training, specialization, knowledge management, theater teamwork, and quality improvement, that will experience major changes.

Presents the opinions of the author, a Catholic, regarding end-of-life issues. Suggestion that sickness, suffering, and death can have a positive meaning because Jesus Christ also suffered and died; Faith of Catholics in an afterlife; Values that shape Catholic bioethics, including human dignity and the interconnectedness of every individual; Commitment of Catholics to bring about dignity and social justice by providing end-of-life care to the poor; Discussion of how interconnectedness affects the physician-patient relationship; Discussion of how the values of human dignity and respect for human life affect the questions of pain and suffering and the withholding or withdrawing of treatment; Reference to the book "The Silent World of Doctor and Patient," by Jay Katz.

Background Although mental incapacity is becoming increasingly important in clinical practice, little information is available on its frequency in medical inpatients. We aimed to estimate the prevalence of mental incapacity in acutely admitted medical inpatients; to determine the frequency that medical teams recognised patients who did not have mental capacity; and to identify factors associated with mental incapacity. Methods Over an 18-month period, we recruited 302 consecutive acute medical inpatients. Participants were assessed with the MacArthur competence tool for treatment and by clinical interview. Cognitive impairment was measured by the mini-mental state examination. Findings 72 (24%) patients were severely cognitively impaired, unconscious, or unable to express a choice and were automatically assigned to the incapacity group. 71 (24%) refused to participate or could not speak English. Thus, 159 patients were interviewed. Of these, 31% (95% CI 24--38) were judged not to have mental capacity. For the total sample (n=302), we estimated that at least 40% did not have mental capacity. Clinical teams rarely identified patients who did not have mental capacity: of 50 patients interviewed, 12 (24%) were rated as lacking capacity. Factors associated with mental incapacity were increasing age and cognitive impairment. Interpretation Mental incapacity is common in acutely ill medical inpatients, and clinicians tend not to recognise it. Screening methods for cognitive impairment could be useful in detecting those with doubtful capacity to consent. [ABSTRACT FROM AUTHOR]

In every medical specialty bad, sad, and difficult information must be given to patients and their families. An insensitive approach increases the distress of recipients of bad news, may exert a lasting impact on their ability to adapt and adjust, and can lead to anger and an increased risk of litigation. Many doctors also find these interactions stressful, and in the absence of much effective training they may adopt inappropriate ways of delivering bad news and coping with the emotional fall-out. Recognition of these difficulties has led to many initiatives, ranging from increased communication skills training to the development of guidelines and protocols. We review some of the research on the impact that giving sad, bad, and difficult news has on doctors and patients, and assess whether interventions are helping. We focus mainly on difficulties encountered involving parents in an obstetric or paediatric setting, people in acute trauma situations such as accident and emergency departments, and patients with cancer. [ABSTRACT FROM AUTHOR]

Summary: Methods: We did a cross-sectional, multicentre study of women attending five departments of gynaecology in Denmark, Finland, Iceland, Norway, and Sweden. We recruited 4729 patients; 3641 (77%) responded and were included in the study. Participants completed a postal questionnaire (norvold abuse questionnaire) confidentially. Primary outcome measures were prevalences of emotional, physical, and sexual abuse, and whether abused patients had told their gynaecologist about these experiences. We assessed differences between countries with Pearson's Chi [sup 2] test. Findings: The ranges across the five countries of lifetime prevalence were 38-66% for physical abuse, 19-37% for emotional abuse, and 17-33% for sexual abuse. Not all abused women reported current ill-effects from the abusive experience. Most women (92-98%) had not talked to their gynaecologist about their experiences of abuse at their latest clinic visit. Interpretation: Despite prevalences of emotional, physical, and sexual abuse being high in patients visiting gynaecology clinics in the Nordic countries, most victims of abuse are not identified by their gynaecologists. This lack of discussion might increase the risk of abused patients not being treated according to their needs. Gynaecologists should always consider asking their patients about abuse. [ABSTRACT FROM AUTHOR]

Body piercing is increasing in popularity around the world. This article describes the history, origins, and peculiarities of various forms of body piercing, and procedures involved, variations in healing time, legal aspects and regulations, and complications and side-effects. This article also discusses the motivation for and psychological background behind body piercing. In presenting research results, the author aims to raise awareness of the many risks associated with body piercing. In presenting psychological data, the article intends to create an understanding of the multifaceted and often intense motivations associated with body piercing, and, thus, to diminish any prejudices held by health professionals against people with piercings. [ABSTRACT FROM AUTHOR]

Background: Doctors' communication with patients is commonly hampered by lack of training in this core skill. This study aimed to assess the efficacy of an intensive 3-day training course on communication skills in a randomised controlled trial with a two-by-two factorial design and several outcomes. Methods: 160 oncologists from 34 UK cancer centres were randomly allocated to four groups: written feedback followed by course; course alone; written feedback alone; and control. At each of two assessment periods, consultations with six to ten consecutive, consenting patients per doctor were videotaped. 2407 patients participated. Outcome measures included objective and subjective ratings made by researchers, doctors, and patients. The primary outcomes were objective improvements after the intervention in key communication skills. Course content included structured feedback, videotape review of consultations, role-play with simulated patients, interactive group demonstrations, and discussion led by a trained facilitator. Findings: In Poisson regression analysis of counts of communication behaviours, course attendance significantly improved key outcomes. The estimated effect sizes corresponded to higher rates of use of focused questions (difference between course attenders [n=80] and non-attenders [n=80] 34%, p=0.003), focused and open questions (27%, p=0.005), expressions of empathy (69%, p=0.003), and appropriate responses to patients' cues (38%, p=0.026), and a 24% lower rate of use of leading questions (p=0.11). There was little evidence for the effectiveness of written feedback. Interpretation: The communication problems of senior doctors working in cancer medicine are not resolved by time and clinical experience. This trial shows that training courses significantly improve key communication skills. More resources should be allocated to address doctors' training needs in this vital area. [ABSTRACT FROM AUTHOR]

Public mistrust in the medical profession is not new. We describe a series of street riots that took place in the city of Liverpool in north-west England in 1832 during a cholera epidemic. The disturbances were directed primarily against the local medical fraternity. The episode is of interest, since the same city recently experienced a similar crisis of confidence between doctors and public. On this occasion the cause was not cholera, but rather the reports from Alder Hey Children's Hospital that organ parts from deceased infants undergoing necropsy had been kept for several years without parental consent. [ABSTRACT FROM AUTHOR]

Interpretation: Negative experiences do not affect subsequent decision making. However, doctors do comply with wishes from patients or relatives when presented with direct threats. [ABSTRACT FROM AUTHOR]

Interpretation: There is much inconsistency regarding emotional and cognitive care, although one relatively consistent finding is that physicians who adopt a warm, friendly, and reassuring manner are more effective than those who keep consultations formal and do not offer reassurance. [ABSTRACT FROM AUTHOR]

Discusses the place of narrative in medical practice. How patients relate their symptoms in narrative form; Comparison of a doctor to a detective who has to interpret the stories and events in order to diagnose the patient; Opinion that the consultation with a patient can be a critical point in the generation of medical knowledge.

Focuses on the role of advance care planning in the quality of end-of-life care. Initiatives such as the hospice movement launched to improve such care, including the St. Christopher's Hospice/King's College London program of palliative care; Opinion that the goal of advance directives is to assist families in making treatment decisions; Assertion that the process is one of communication between a patient, physician, and loved ones.

Looks at the study of pain. Assessment of a patient's level of pain; How physical pain is expressed; How patients can report pain to physicians; Psychological effects of pain.

Summarizes some of the major areas of health sociology and shows how many areas have been incorporated into clinical practice. The relation between health and poverty; The role of inequality in health care; How society's response to the ill effects care; The importance of the relationship between health professionals and patients.

Background: The available literature on medical communication reports almost exclusively on observational, qualitative studies. We aimed to apply a novel approach to the analysis of doctor-patient consultation by means of computer concordancing. This methodology, established in linguistic research but rarely applied to professional language, allows both the quantitative and qualitative study of language.Methods: We analysed the language of 40 doctors and their patients during 373 complete primary-care consultations. We examined the use of jargon by doctors, the language of power and absence of power, and ways in which language was used to diminish the potential threat of the presenting disorder.Findings: There was no evidence that the doctors used medical jargon. Some doctors used language associated with social power, and some patients used language associated with absence of power. There was substantial evidence that the doctors used language to express emotions (eg, anxiety), to diminish threats (eg, words such as "little"), and to reassure patients.Interpretation: Concordancing is a valuable resource to study the consultation. The finding that doctors do not use jargon suggests that they are aware of the need to avoid it, but it does not follow that they are easily understood by patients. The use of some elements of the language of power may imply that consultations may be less democratic than is appropriate. The language of emotion and diminution is a major part of the primary-care doctor's repertoire and denotes a therapeutic use of language. [ABSTRACT FROM AUTHOR]

Details a survey concerning the variations in attitudes among European gastroenterologists to truth telling in cases of cancer. Responses of gastroenterologists in southern and eastern Europe; Use of vignettes describing typical ethical dilemmas form clinical practice and clinical research; Characteristics of respondents by country; More.

Examines reasons why patients and their relatives take legal actions against their doctors. Survey of 227 patients and relatives who were taking legal action through five firms of plaintiff medical negligence solicitors; Patients suing on their own behalf; Nature and effects of incidents. INSETS: Patients' descriptions of incidents.;Patients' and relatives' views of their care..

The article addresses women patients, and clinicians and health-care providers. Topics discussed include emotions of women patients when they hear that they have a deadly disease such as cancer; a case of a patient who had a breast excision biopsy and needed a mastectomy and further treatment; and the Pan-African Women's Association of Surgeons that aimed to support women in surgical specialties and trainees.

The article offers the author's view on emergency medicine. She mentions the tense occasion in emergency rooms wherein dispute is experienced among physicians and medical personnel as well as patients. An overview of the significance of communication in medicine amidst technological innovations is also presented.

The authors discuss the use and significance of patients' contracts, such as difficult patients, opioid and suicide prevention contracts, in clinical practice. They mention the uncertainty of the efficiency of contracts by referring to the varying results of a review of randomised trials of contracts. They cite various consequences of using contracts in medical care which includes breaches, violation of the ethical obligations of a physician and altering patient and physician relationships.

This article discusses research into the affect of war on the construction of illness narratives. Illness narratives are collected in research to establish the social context for a patient's treatment of their diseases and injured. The use of illness narratives is presented as an opportunity for developing some perspective on the state of public health in war-torn regions when the record keeping necessary for public health becomes infeasible. The development of these narratives to improve the efficacy of medical care in a context where poverty and violence can easily undermine treatment is described.

This article discusses research, printed elsewhere in this issue, relating to the provision of clinical services for patients in communities where economic inequality correlates with increased health risk. The author notes that the Great Britain national Health Service system does not apply pay for performance requirements in contexts where relative health deprivation undermines the potential for such a system. The author discusses the metrics used in this study to measure health outcomes and notes that they tend to focus on statistical measures of clinical performance rather than holistic approaches to patient health and well being assessment.

The author reflects on the use of antibiotics for sinusitis like symptoms in primary care. He suggests that sinusitis is challenging for physicians because patients associate antibiotics with recovery and evidence suggests that antibiotics only offer minimal benefit to sinusitis patients. He argues that the time has come for an agreement between researchers and physicians on the best mode of administration for treatment in common infections.

The article focuses on the diagnosis and treatment of essential body tremor. Drugs that may contribute to tremor are given. Contributory health factors such as smoking are noted. The need for laboratory work is seen as rare, with a thorough examination of the patient all that is needed for most diagnoses. Tests that can be given to eliminate certain diseases as the cause of tremors are presented.

The article presents the author's view that subjective interaction between doctor and patient, as opposed to an objectified stance on the part of the physician, will generate more favorable outcomes. The author believes that in minimizing the subjectivity of the doctor in working with patients the doctor becomes merely a competent technician and patients become interchangeable units of health need. In a system in which physician and patient units are respectively interchangeable, that system is considerably easier to organize and control in the interest of a market economy at the expense of the doctor-patient relationship. The treatment of depression and the effect of positive and negative psychological states on the nervous and immune systems are adduced to emphasize the author's viewpoint.

The article discusses direct-to-consumer advertisements of drugs in the U.S. The author suggests that if direct-to-consumer advertisements were used in Europe, physicians and patients could learn from the warnings of American critics of this pharmaceutical advertising practice. The critics claim that direct-to-consumer advertisements oppose the interests of medicine by encouraging patients to ask their doctors for certain drugs. The ways that direct-to-consumer advertisements affect both doctors and patients are discussed.

The article compares trends in medicalization of the 1970s to those of the 21st century. The author refers to the 1975 book "Medical Nemesis," by Ivan Illich. The book mainly blamed the medical profession in creating threats to health. The author believes that an increased role of the patient in making health decisions, as seen in 2006, has not necessarily solved problems in health care. The author calls for a reevaluation of patient-centered medicine and suggests that patients and physicians work together through intermediary groups to provide the best medical care. Evidence-based medicine is discussed.

This editorial discusses the deficiencies in quality of care by physicians in both the US and UK. Organizations in the US and UK are motivated to improve the quality of physicians. They have created new regulatory approaches, mandating quality measurement and public reporting, implementing pay-for-performance programmes and training. While both countries have taken steps towards self-regulation methods that set and maintain standards for the profession, critics view self-regulation as nonreliable and neither effective nor prudent due to an implicit social contract between physicians and the government.

This editorial comments on treating patients with medically unexplained symptoms who resist psychological explanations for their condition. Somatisation can put a burden on health-care services and put the patient at risk for iatrogenic harm. Adele Ring and colleagues at Liverpool University studied the somatising process and found that doctors suggested physical interventions more often than patients. The evidence in the Ring study is discussed, including the issue of 70% of the patients asking for biomedical intervention. The patient and doctor's roles in the somatisation process are mentioned. The authors suggest that a comprehensive biopsychological approach should be used to explore medically unexplained symptoms.

The article discusses problems with prompt communication of radiology diagnostics. All parties involved have their own dissatisfactions, including anxious patients, frustrated primary-care physicians, and radiologists, for whom lawsuits are an increasing concern. Conall Garvey and Sylvia Connolly, from Liverpool, Great Britain, observe legal and industry standards being set up to ensure the timely communication of crucial information to the patient and consumer. The American College of Radiology sets out guidelines for radiologist responsibility regarding the communication of abnormal findings to the patient.

Why don't doctors touch patients anymore? Having had the privilege of attending clinics in the UK's National Health Service almost every week since March this year, I can honestly say that at no stage has any physician, surgeon, or anaesthetist ever completed anything approaching a physical examination. The clinical examination, and the central place of touch in that examination, is about fostering a physical and mental connection between doctor and patient. [Extracted from the article]

An increasing number of physicians may be engaging in adverse selection and moral hazard behaviours, and this could be linked to the mixed inpatient reimbursement system. Driven by financial incentives, physicians may engage in moral hazard behaviours by supplying more services to a patient with slight illness, or fewer to a patient with severe illness, or may engage in adverse selection behaviours, thus changing the structure of patient cohorts. We assessed physicians' willingness to engage in, and attitudes towards, adverse selection and moral hazard behaviours under the current system, to explore whether changes to the mixed inpatient reimbursement system, from cost-based payment to value-based payment, are necessary to provide a fair and clinically optimal medical service to patients. Physicians (n=700) at seven tertiary hospitals in Guangzhou, China, were asked to complete an anonymous survey. Districts were ranked based on their level of economic development, then a representative sample of hospitals was selected. Through stratified sampling, physicians who had been qualified to provide health services to insured patients for 1 year or more and who were still in work in the selected hospitals were selected randomly from the physician lists of each hospital. The survey response rate was 85·9% (601 of 700) and there were 585 valid questionnaires. Respondents were presented with different scenarios based on the current situation in hospitals and were asked to choose whether they would engage in adverse selection or moral hazard behaviours depending on whether the patient had medical insurance. Questions were grouped into three categories: admission to hospitals, provision of health services, and department transfers, referrals, and hospital discharges. Binary logistic regression analysis of the dichotomised willingness and behaviour variables was performed. A majority of physicians reported that they would refuse to receive inpatients who were expected to bring about large costs (62·1%, 361 of 581), and that they would be more likely to do so if their income decreased (OR=1·489, p=0·031). Physicians also reported that they would try to avoid department transfers for patients who had medical insurance (52·8%, 308 of 583) (avoiding department transfers can result in repeated discharges and admissions, which can result in physicians being paid more by the mixed reimbursement system, but not if patients have no medical insurance). A decrease in income (OR 1·591, p=0·014) or dissatisfaction with the reimbursement system (OR 1·643, p=0·034) increased this risk. Respondents reported that they would refer inpatients who had brought about large costs to other hospitals, or discharge them from the hospital prematurely (42·1%, 246 of 584). Factors that increased this risk included PhD level education (OR 1·831, p=0·014) and dissatisfaction with the reimbursement system (OR 1·824, p=0·021), and physicians who felt that the physician–patient relationship is currently worsening were also more likely to report these behaviours (OR 1·784, p=0·013). Physicians in tertiary hospitals have low willingness to engage in moral hazard behaviours in the provision of health services. However, they express a high willingness to engage in adverse selection or moral hazard behaviours in relation to admission to hospitals and to department transfers, referrals, and hospital discharges. Governments should integrate payment standards into the hierarchical medical system effectively, and consider physicians' suggestions on policy reform. This study was supported by a grant from the Chinese Ministry of Education Project of Humanities and Social Sciences (18YJAZH086), a grant from the Philosophy and Social Sciences department of Guangdong College for the project 'Public Health Policy Research and Evaluation' (2015WSYS0010), and a grant from the Public Health Service System Construction Research Foundation of Guangzhou. The funders did not participate in study design, data collection, or analysis. [ABSTRACT FROM AUTHOR]

Growing evidence suggests that female physicians tend to deliver health services of higher quality than their male counterparts. We aimed to revisit the issue of gender disparities in health-care quality in a typical primary care setting. In our audit study, both male and female standardised patients (SPs) recruited from the local community and trained to present consistent cases of illness (unstable angina and asthma) were randomly assigned by computer generation to male and female primary health-care providers of community health centres (CHCs) in urban Xi'an, China. Written consent was obtained from clinicians and the hospital director 3 months before the SP visits. Data were anonymised when analysed. We estimated linear regression models to compare clinical practice and outcomes (including clinical process, assessment of treatment, service time, health expenditure, and physician–patient relationship) by physician gender and by physician–patient gender match after controlling for provider characteristics, and series of fixed effects. Ethics approval was obtained by the Ethics Committee of Xi'an Jiaotong University Health Science Center. In Aug 17–28, 2017, and July 30 to Aug 10, 2018, there were 492 interactions between 243 physicians and 12 SPs in 63 CHCs. We found little difference by physician gender. However, our results suggest a salient difference by patient gender, which was driven by a physician–patient gender match. Compared with female patients with female physicians, male patients with female physicians were prescribed 0·586 more items of invasive tests (p=0·003) and 0·623 more items of unnecessary tests (p=0·008). However, male patients were prescribed 0·299 less items of unnecessary drugs (p=0·026). Importantly, the interactions of male patients with female physicians came with a 23·0% higher correct diagnosis (p=0·008), and a 19·4% higher correct drug treatment (p=0·029) than for female patients with female physicians. Male patients had a 14·93 China Yuan higher clinical tests expense (p=0·008) and a 2·040 higher score in the measure of patient-centred communication (p=0·052). These findings might help to explain the gap in quality of care received by male and female patients, a form of health-care inequity and potential discrimination that has to be addressed. The National Natural Science Foundation of China (71874137), Shaanxi Social Science Foundation (2017S024), Shaanxi Soft Science (2015KRM117), Shaanxi Provincial Youth Star of Science and Technology in 2016, Xi'an Jiaotong University (SK2015007), Top-notch Young Professionals of China and China Medical Board (15-227), China Scholarship Council (201706280307; 201806280021), the US PEPPER Center Scholar Award (P30AG021342), and National Institutes of Health (R03AG048920; K01AG053408). [ABSTRACT FROM AUTHOR]

Comments on the reasons for medical personnel in foreign countries to emigrate to the U.S. for greater work opportunities. Profile of a surgeon in the Philippines who sought an education in nursing with the goal of emigrating to the U.S.; Report that frustration with health services administration in one's native country can inspire even the successful medical personnel to emigrate; Description of the provision of health services to the poor in the Philippines; Impact of medical malpractice litigation on physician and patient relationships; Frequency with which skilled professionals leave developing countries for work in developed countries, known as brain drain; Recommendation that developing countries improve medical education, preventive medical services, and professional ethics to retain skilled workers.

Examines ethical considerations of do-no-resuscitate (DNR) order for patients requiring anesthesia and surgery. Historical development of the conception and documentation of DNR orders; Impact of guidelines on the interpretation of DNR orders; Application of DNR orders during surgical procedures; View that DNR orders are applicable to surgical settings.

Discusses communication between physicians and patients concerning risk factors. Purposes of communication of risk, including giving patients choices; Difficulty of uncertainty; Role of the public in medical care; Importance of trust.

Argues that the presence of a nurse chaperone during gynecological examinations does not necessarily protect the doctor or the patient. Discussion of cases in the United Kingdom, involving Clifford Ayling, who was convicted of indecent assault on female patients, and Rodney Ledward, who was struck off the medical register for malpractice; Issues of privacy and communication between physician and patient; Conclusion that the presence of a chaperone disempowers the patient. INSET: Excerpts from the Royal College of Obstetricians.

Asserts that poor training in communication skills leaves most doctors unable to give bad news appropriately. Recent increases in the amount of time allocated to the teaching of communication skills in medical schools; Points to be considered when breaking bad news; Breaking bad news in a non-urgent setting; More.

A personal narrative is presented which explores the author's experience of losing a patient.

The author offers information on "Encountering Pain" conference at University College London, England, on which keynote lecturer Rita Charon discusses dilemma and challenges associated with pain. Topics discussed include communication problems related with pain, value of images and image making processes to the management of chronic pain, and effect of the pain cards on clinician-patient interactions.