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Input from hedychium fans needed
I've posted this on a few other forums and am trying to get as much input as I can. Feel free to mention any other traits you feel are important or would like to see etc. Any input is greatly appreciated
Hi all,
I am trying to gather some feedback for a Hedychium researcher and friend in India. Answers to the questions below will help them decide on how to proceed with possible new introductions. They have access to many species and forms that are not yet in general cultivation. I'll compile the info from here and elsewhere and forward it to them. Feel free to mention any other qualities that you feel important, and/or describe the perfect butterfly Ginger.
Q1: favorite flower Color
Q2: flower shape /size
Q3: inflorescence type. A cone like H coronarium or spike like H coccinuem
Q4: foliage type: wide leaves, narrow, etc
Q5: preferred height
Q6: how important is fragrance
Q7: what features of current species/hybrids to you find unattractive or problematic etc
Any other input would be appreciated.
Tim Chapman
Hey, Tim - not much going on this forum these days! I'm an Indiana gardener, so my needs may be different from many growers south of me who can put their gingers in the ground. I grow mine in pots and put them in a cool greenhouse, or indoors in the winter. Anyway, here goes:
Q1: favorite flower Color - totally a personal preference, I like saturated 'hot' colors...red/yellow/orange. There are lots of pastel hedychiums and there's room for more intense colors.
Q2: flower shape /size - I prefer broad petals and numerous flowers open at the same time, either a broad section of the bloom spike or the entire thing (e.g. gardnerianum or coccineum.) Having said that, large blooms like coronarium are OK in smaller bunches.
Q3: inflorescence type. A cone like H coronarium or spike like H coccineum - both are great. Variety is good.
Q4: foliage type: wide leaves, narrow, etc. - both are fine. I prefer blue-green leaves to lighter ones.
Q5: preferred height - Any indoor gardener will tell you that shorter and stouter is better. My favorite hedychiums are upright and self-supporting. If the nodes between the leaves could be shorter, you could have a plant three feet tall with lots of foliage and bloom it easily in a nursery tub. This would really enhance the popularity of the genus.
Q6: how important is fragrance - I love coccineum and its quick repeat, but am always a little disappointed when it has little fragrance. Gingers and fragrance go together. Fragrant plants are always my preference. The stronger, the better.
Q7: what features of current species/hybrids to you find unattractive or problematic etc.- I already mentioned my preference for self-supporting plants. Stalks that droop don't work well in pots. Quick bloom and rebloom are always good. Heat tolerance is good (I have trouble growing densiflorum, but it does well in Britain).
Hope that helps...anybody else?
Hi Tim, always good to see post from you. I guess Hedychiums are my most favorite tropical plant, and one that grows well for me. I have over 20 different plants. Some have performed beautifully under adverse conditions, while others have not done so well. This year was especially troublesome water wise I live inside city limits and have city water only. We have had a very hot dry year and two months straits my water bill was outrageous. Something had to give. So the plant were told to grow or die.
Most survived but flowering was really late on 4 or 5 types. Ok to the questions.
1,color,I agree with the above poster there are plenty of pastels which I do love, but would love to see more deeper oranges and really red reds.
2,shape size, honestly I have seen very few that I didn't like I have a coccineum that is a nice orange and it has small flowers but it is a thing of beauty. I have some of those really large flowers and they just amaze me. so any size as long as it is strong, healthy and vigorous.
3, type flower, again I have some of both and I like them all. I guess I really would prefer larger and fuller heads with multiply individual flowers than a small head with just a few flowers.
4,type of foliage, I like any type wide, narrow, I guess I would prefer more upright than too much weeping type. I don't mind staking a few heavy stalks but if I had to stake all of them they would become compost.
5, height, and again I have some that top out at about 3and 1/2 feet and some that are near 8ft. and all heights in between and I like every one of them. The main thing is discovering how tall they get under your own growing conditions and working with that. I am certainly gonna have to move some clumps to more suitably viewing areas, but any height it good with me.
6, fragrance, important but will not throw out a vigorous,healthy plant with gorgeous flowers just because it doesn't smell like a gardenia, and I find the older I get the less I can smell anyway. But others can still enjoy.
7, my thoughts, gosh I have already said so much. I guess it would be nice if hedychiums were a bit more sun and heat tolerant, but I really can't fault them for that. I guess really would love to see more red color or red/orange, maybe if I saw a really good yellow I would care more for them. The one I have is a really late bloomer, and usually by the time it starts we have an early freeze and it is done. So maybe over all some earlier blooming types. of course if I lived farther south they would be earlier, so again I shouldn't complain about that. I am really happy they grow so far north and come back reliably, multiply quickly, And they do bloom when little else is in this heat. Hope this helps. I hope you will also let the folks who posted know how this turns out, or let us know what the hybridizers think.
James Maloy
Thanks for the input, any bit helps.
My personal preference would be plants that are early to flower but free flowering all season. Shorter plants with wide and textured leaves that have long spikes instead of closed cones. I like a range of colors but would like to see more unique bicolors. Colored foliage and colored bracts would be a plus. Fragrance is nice but not necessary the fact that some hedychium are fragrant is somewhat of a problem cause people expect all gingers to be fragrant, 95% of them aren't.
From a hybrid standpoint I'd like to cross the early bloomers like densiflorum with various "more common" species. The English aren't doing this because many types won't bloom there and timing is a factor is well. Americans haven't done it as those early bloomers are much less common here. I've imported several this year and hopefully can cross some next season. It would great to get these types crossed and established here and in the UK and get lots of dwarf early blooming very cold hardy hybrids going.
I'm also trying to get as many red bract types as possible, as that will add another ornamental element. I think the hybrid potential of the genus is just barely tapped, so much more can be done!!
Tim Chapman
Hi Tim, this probably is not the best place to post this. But I was wondering if the ginger group on yahoo groups is still up and could you give me the address again. I had to empty my computer recently and lost tons of information I had bookmarked. I would really appreciate this. Hope this forum picks up. I know what the economy does to peoples hobby time. Makes it go away. Also if you would send the address for your website. Thanks a lot James Maloy.


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Page 1
RESEARCH ARTICLE Open Access
Promoting networks between evidence-based
medicine and values-based medicine in
continuing medical education
Myriam M Altamirano-Bustamante1,2*, Nelly F Altamirano-Bustamante1,3, Alberto Lifshitz1,4, Ignacio Mora-Magaña3,
Adalberto de Hoyos1,5, María Teresa Ávila-Osorio1, Silvia Quintana-Vargas6, Jorge A Aguirre6, Jorge Méndez1,
Chiharu Murata3, Rodrigo Nava-Diosdado1, Oscar Martínez-González7, Elisa Calleja1, Raúl Vargas1,
Juan Manuel Mejía-Arangure8, Araceli Cortez-Domínguez6, Fernand Vedrenne-Gutiérrez1, Perla Sueiras1,
Juan Garduño9, Sergio Islas-Andrade2, Fabio Salamanca4, Jesús Kumate-Rodríguez10and
Alejandro Reyes-Fuentes10
Background: In recent years, medical practice has followed two different paradigms: evidence-based medicine
(EBM) and values-based medicine (VBM). There is an urgent need to promote medical education that strengthens
the relationship between these two paradigms. This work is designed to establish the foundations for a continuing
medical education (CME) program aimed at encouraging the dialogue between EBM and VBM by determining the
values relevant to everyday medical activities.
Methods: A quasi-experimental, observational, comparative, prospective and qualitative study was conducted by
analyzing through a concurrent triangulation strategy the correlation between healthcare personnel-patient relationship,
healthcare personnel's life history, and ethical judgments regarding dilemmas that arise in daily clinical practice.
In 2009, healthcare personnel working in Mexico were invited to participate in a free, online clinical ethics course.
Each participant responded to a set of online survey instruments before and after the CME program. Face-to-face
semi-structured interviews were conducted with healthcare personnel, focusing on their views and representations
of clinical practice.
Results: The healthcare personnel's core values were honesty and respect. There were significant differences in the
clinical practice axiology before and after the course (P < 0.001); notably, autonomy climbed from the 10th(order
mean (OM) = 8.00) to the 3rdposition (OM = 5.86). In ethical discernment, the CME program had an impact on
autonomy (P ≤ 0.0001). Utilitarian autonomy was reinforced in the participants (P ≤ 0.0001). Regarding work values,
significant differences due to the CME intervention were found in openness to change (OC) (P < 0.000), self-
transcendence (ST) (P < 0.001), and self-enhancement (SE) (P < 0.019). Predominant values in life history, ethical
discernment and healthcare personnel-patient relation were beneficence, respect and compassion, respectively.
Conclusions: The healthcare personnel participating in a CME intervention in clinical ethics improved high-order
values: Openness to change (OC) and Self Transcendence (ST), which are essential to fulfilling the healing ends of
medicine. The CME intervention strengthened the role of educators and advisors with respect to healthcare
personnel. The ethical values developed by healthcare professionals arise from their life history and their
professional formation.
Keywords: clinical ethics, values, continuing medical education, concurrent triangulation strategy, axiology
* Correspondence: email@example.com
1Grupo Transfuncional en Etica Clínica, Centro Médico Nacional Siglo XXI,
IMSS, Av. Cuauhtémoc 330, Doctores, Mexico 06720 D.F., Mexico
Full list of author information is available at the end of the article
Altamirano-Bustamante et al. BMC Medicine 2013, 11:39
© 2013 Altamirano-Bustamante et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the
Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Page 2
In the 21stcentury, medicine tends to be dominated by
two paradigms, evidence-based medicine and values-based
medicine (EBM-VBM), which directly impact clinical
decision-making processes in daily healthcare practicea
Modern biomedical science faces the challenge of
reinforcing the pairing of EBM-VBM and constructing
links and networks between them [7,8]. Continuing
medical education (CME) promotes career-long compe-
tence with respect to medical advances (EBM); more-
over, it can support fine-tuning of professional values
and principles (VBM) [1,2,4,5,7,9-12].
Values are normative guidelines that allow us to con-
sider actions, objects or situations as good, desirable,
pleasant, convenient or useful towards certain aims [13].
These aims and the values that guide us towards them
lend a mindful sensibility to our life and our profes-
sional practice [14]. Clinical practice is axiologicallyb
complex because it is not limited to describing, explain-
ing or predicting what takes place within the human
body (epistemological values: EBM), but it also acts on
the bio-psycho-social spheres of a person and relates to
his/her dignity [15,16] (social, political and ethical
values: VBM). Furthermore, biomedical technical quali-
ties are as important to healthcare as ethical qualities,
yet ethical qualities are not always empirically evaluated.
Emerging actions, devices and technical/scientific bio-
medical scenarios present increasing uncertainty and
pose exponential risks that underscore the necessity of
promoting an analytical-empirical axiology that places
practice along a horizon of wisdom [7,17-22].
The healthcare sector is currently facing a crisis of
knowledge, compassion, care, cost and values in general;
however, few programs have addressed values among
healthcare personnel, and little data exist concerning the
effectiveness of such programs [23-27]. Values have a
strong impact on the decision-making process and the
final course of actions [27]. In other words, patients
complain more about the lack of courtesy, warmth,
understanding, care and communication than about the
lack of updated attention protocols.
Values are favorable dispositions towards aims that are
sought. A physician is willing to act in accordance with
the ends of medicine (healing, curing and caring)
because they guide and give sense to his/her practice.
These ends in medicine have traditionally been traced
by clinical ethics in the form of principles and virtues.
Principles state the deontological obligations of health-
care personnel and aim to offer an answer to ethical
dilemmas. Principles will always be grounded on values.
Principles explicitly state the values that we consider
important [28], they express a normative procedure
according to which actions can be guided to reach these
values. [29]. Virtue ethics have resolved some of the
shortcomings of principlism by arguing for the impor-
tance of the character traits and decision-making in
moral discussions. If we think of a Venn-Euler diagram,
values are the universe, while virtues and principles are
subsets. That is, every virtue is a value, but not every
value is a virtue; and the same goes for the principles;
they are the expression of a normative procedure that is
grounded on values, but at the same time they are valu-
able themselves (Figure 1). However, values have a
broader focus, and they encompass virtues and princi-
ples alongside other objective goods that must be con-
sidered in ethical discernment (Figure 1).
Life preservation is a value that, in order to be upheld,
is supported by several epistemic and ethical virtues and
principles. Virtues such as wisdom, temperance and
compassion aim at life preservation. In addition, princi-
ples such as beneficence are important in preserving life
because they specify the obligations and provide explicit
guidance to the agents' actions. However, in this paper,
we maintain a broad perspective regarding values that
allows us to move between virtues and principles and to
consider the personal and social dimensions of patients
and healthcare personnel in addition to the states of
affairs that are valuable in strengthening the conver-
gence of EBM-VBM (Figure 1). We acknowledge the
great influence of virtue ethics and the principles of bio-
medical ethics, but it is our contention that a general
and wider analysis can be carried out. Beauchamp and
Childress' principles, in fact, express a normative proce-
dure to uphold several values. For example, respect for
autonomy demands action on behalf of the physicians
towards an agent with the right to hold views and make
choices based on personal values and beliefs. This prin-
ciple specifies the actions to be carried out by someone
Figure 1 A Venn-Euler diagram of values. Values are the
universe, while virtues and principles are subsets. The subset of
virtue considers those values that refer directly to the healthcare
personnel, their traits of character and decision-making. The subset
of Principles expresses a normative procedure according to which
actions can be guided to reach certain values [29].
Altamirano-Bustamante et al. BMC Medicine 2013, 11:39
Page 2 of 17
Page 3
seeking to uphold the value of autonomy. Therefore, our
analysis will consider values as including principles and
virtues (Figure 1).
As stated earlier, one of the ways to create a novel ethi-
cal environment is through education in clinical ethics.
The first step is to carry out a situational diagnosis of what
the ends of healthcare are considered to be, along with the
values linked to these ends [7,14]. It is thought that when
healthcare professionals are aware of these values, they
will be guided by more careful reflection to adequately
approach the dilemmas that arise [1,2,4,5,7,9-12]. Such
reasoning has led us to pursue concurrent triangulation
approaches that use quantitative methods to assess
expressed values in medical practice and the decisions
made when facing three clinical vignettes that pose ethical
dilemmas. While capturing what health workers claim
to be their values, we use qualitative anthropological
methods and ethnography to define the values they display
in their daily activities. Thus, we are able to analyze the
concordance of such factors as life history, the doctor-
patient relationship and ethical judgements regarding
dilemmas that arise in the clinical practice.
The study's central hypothesis is that a cross-func-
tional clinical ethics course is able to amalgamate EBM
and VBM. Therefore, we seek to address the following
questions: (1) What are the values of a group of health-
care professionals participating in CME in clinical
ethics? (2) Why and how do participants respond to
values in their clinical practice? (3) How does CME in
clinical ethics impact the pairing of EBM-VBM? Here,
we describe the successful use of CME to engineer net-
works between EBM and VBM.
Study design
A concurrent triangulation design of mixed methods'
strategies to analyze both quantitative and qualitative
data was used to empirically explore the axiology in the
clinical practice of Mexican healthcare professionals
[30], as illustrated in Figure 2. Mixed methods were
combined for complementarity, where each method
addressed a different aspect of the research questions
and highlighted new connections [31]. Quantitative
methods were used to determine the self-declared values
of clinical practice before and after the CME program.
The qualitative semi-structured interviews (SSIs) and
three clinical vignettes (CVs) were employed to explore
participants' experiences and representation of their
clinical practice, with an emphasis on experiences with
the patient-healthcare personnel relationship and ethical
discernment. We conducted a quasi-experimental,
observational, longitudinal, comparative and prospective
study that allowed us to describe the state of the art and
to strengthen practices favorable to the pairing of EBM
and VBM (Figure 2).
Study population
Mexican healthcare personnel with current active prac-
tices in several clinical medical areas were invited to
participate in an online course in clinical ethics, at no
cost, from September 2009 to February 2010. Registra-
tion was conducted during a two-month period prior to
the CME program (N = 2,891). During registration, each
participant provided his/her demographic data and
responded to an online survey (Table 1).
Healthcare professionals who enrolled in the online
course represented every Mexican state and organiza-
tional level of healthcare. The primary healthcare level is
preventive and family medicine. The secondary level
comprises different medical specialties and general sur-
gery. The tertiary level includes highly specialized medi-
cal attention.
The research ethics committee of the Mexican Insti-
tute of Social Security (IMSS) approved the study. All
participants received written and oral study information
and signed a letter of informed consent granting the
authors permission to use and publish the data and
results of this study.
CME in clinical ethics Intervention
The course was designed by a cross-functional group
(including medical doctors, teachers, anthropologists,
sociologists, philosophers and bioethicists), and it
included five modules: the person and human dignity,
medical ethics, healthcare professional/patient relation-
ship, clinical ethics committees, and methodologies for
ethical discernment.
The Anahuac University and the IMSS awarded those
who completed the course with a 60-hour CME certifi-
cation. This on-line course provided information to
healthcare personnel about ethical terms, concepts and
theories. Additionally, the course reviewed guidelines for
ethical decision-making, which included exploration of
personal values in addition to problem-solving exercises
(patient simulation, motivational videos and online dis-
cussion forum) regarding how to apply ethical concepts
and theories to ethical dilemmas (Figure 2).
Quantitative study
Instrument design (survey)
Although numerous survey instruments measuring
values are used worldwide [15,16,32,33], they do not
explore the values or virtues specific to medical practice
(Figure 3). A set of survey instruments designed by a
cross-functional team (an expert panel in clinical axiol-
ogy) were drafted and initially tested on a small sample
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Analytic Methodological Framework
Central Hypothesis
What are the core values
of clinical practice?
Research questions
CME in clinical ethics (axiology of Clinical practice)
What are the core values
of clinical practice?
The central hypothesis
is that a cross-functional
Clinical ethics course is able
to amalgam EBM and VBM
Main characteristics of
participants before CME
in clinical ethics?
Values in their clinical
practice after CME in
clinical ethics?
Main characteristics of
participants after CME
in clinical ethics?
Values in their clinical practice
before CME in clinical ethics?
Statistical analysisStatistical analysis results
Statistical analysis results
Qualitative content
analysis results
S Step p1
Qualitative content
How do participants
deal with:
How do participants
deal with:
Qualitative content
analysis Results
S Step p p2
Statistical analysis
Ste ep3
content analysis
St tep4
Analytic methodology
a concurrent triangulation
design of mixed methods
Each analysis was con currently performed.
Each analysis was con currently performed.
engineer networks
between EBM‐VBM
successful use of
CME to engineer
networks between
Integration of results1
Integration of results 2
Integration of result3
Figure 2 Framework of the analytic methodology. In step 1, we used statistical analyses to examine the axiology of clinical practice (values in
healthcare, work values, virtues in medical practice and three clinical vignettes posing ethical dilemmas) and the characteristics of participants
prior to conducting the CME in clinical ethics. In step 2, we used qualitative content analysis of semi-structured interviews (SSIs) to examine
reasons for values usage in clinical practice and axiology in the ethical discernment process prior to conducting the CME in clinical ethics. After
quantitative and qualitative research questions were examined, these results were integrated based on the mutual validation model, which
regards the search for convergent findings as validity indicators as the most important purpose of triangulation. We explored potentially strong
connections between EBM and VBM using qualitative results, while we inferred the extent of the benefits of novel networks using quantitative
results. After conducting the CME in clinical ethics intervention, we repeated the analyses (steps 3 and 4), and the full results were integrated.
Table 1 Sociodemographic characteristics at two stages
Registration (n = 2,891)Final (n = 973)
Mean ± (SD)
39.38 (±9.9)
38.2 (±9.7)
Level of
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of 10 participants; they were subsequently used in this
paper. These instruments were used to assess the
respondents' values and priorities in healthcare practice
before and after the CME program. The survey collected
participants' declaration of personal values in addition to
measuring their values with respect to healthcare, work
and medical practice. The survey also included three
clinical vignettes posing ethical dilemmas [34].
Work values
To assess work values before and after the CME inter-
vention, we used an instrument proposed by Schwartz
that operationalizes four high-order values [33] in the
work environment. These high-order values encompass
a total of 16 items that constitute the EVAT (Escala de
Valores hacia el Trabajo) scale [35]. The EVAT scale
has been used among large samples of Mexican, Span-
ish, Portuguese and Italian workers [36].
Ethical discernment instrument
The survey included three clinical vignettes that were
used to assess discernment in some of the common
ethical dilemmas encountered in medical practice:
patient confidentiality, informed consent (autonomy)
and withdrawal of care (beneficence). The clinical vign-
ettes revealed differences in discernment before and
after the CME [34].
Statistical analysis
Distribution of participants according to gender, age, pro-
fession/discipline and healthcare level is described for each
of the two phases (Table 1). We explored the before-and-
after changes of self-declared values in medical practice.
The changes in the before-and-after ranking of these
items were determined using the Bonferroni-corrected
Figure 3 Hierarchy of values in clinical practice in Mexico. Each of the charts shows the state of values before the intervention (n = 2,891).
Deontological values are in blue, aretological values are in red, and utilitarian values are in green. The lower the values, the higher their level of
Altamirano-Bustamante et al. BMC Medicine 2013, 11:39
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Wilcoxon signed rank test. Differences among hierarchical
items were determined using the Kruskal-Wallis test, fol-
lowed by the Steel-Dwass test for pairwise comparison.
Parametric tests (Student's t-test, and paired t-test) were
used for the statistical analyses and were confirmed by
non-parametric tests (Mann-Whitney U-test). For the
cluster analyses, the mean and standardized values of
the aretological, deontological and utilitarian groups were
obtained. For the work values analyses, we obtained the
means for the group of high order values: openness to
change (OC), self-enhancement (SE), self-transcendence
(ST) and conservation (CO). These values were illustrated
on a three-dimensional scatter plot.
Qualitative study (interview)
The aim of the qualitative component of the study was
to explore the self-representations of the healthcare pro-
fessionals. Purposive sampling was undertaken [37] to
include a range of types of healthcare professionals and
a range of types of health institutions. A semi-structured
interview guide was designed by an expert panel on clin-
ical axiology and pilot-tested by Nava Diosdado et al.
[38]. Briefly, we designed an instrument that would
allow us to identify values and to assess career goals in
the following categories: life history, career goals, rea-
sons the interviewee joined the profession, working
values, how the interviewee resolves his or her day-to-
day problems, type of doctor-patient relationships estab-
lished, projections of the interviewee on his or her
patients, attitude towards clinical ethics, and how inter-
viewees see themselves in the next 10 years.
Face-to-face semi-structured interviews were con-
ducted with healthcare personnel by anthropologists.
The interviews focused on the personnel's views and
representations of clinical practice. The interviews took
place between September 2009 and February 2010,
before the CME intervention (78 interviews) and after
the CME intervention (42 interviews). Interviews lasted
approximately 80 minutes and were recorded and later
The transcriptions of interviews were analyzed using
the content and thematic analysis method described by
De Hoyos et al.c. Briefly, all data were analyzed following
five steps: familiarization with the data through listening
and immersion in the raw data several times, identifica-
tion of a framework, coding, charting and interpretation.
An axiological framework was developed in line with
Schwartz's work values and Pellegrino and Oakley and
Cocking's findings regarding the virtues and vices of
healthcare professionals. The main emerging themes
were representations of medical practice. Beliefs, desires,
meanings and their axiological interactions structure of
clinical practice were studied. One hundred codes were
grouped according to the following subjects: life history,
workday, ethical discernment, patient-doctor relation-
ship, medical procedures, decision making, ethics com-
mittee and future expectations of healthcare personnel.
For both sets of interviews, Atlas.ti 6.0 softwaredwas
used to identify emergent themes in addition to the views
of the participants. Each interview ended with the presen-
tation of short vignettes concerning clinical cases. The use
of vignettes with open-ended questions in qualitative
research attempts to determine perceptions, attitudes and
moral values, all of which are particularly pertinent for
this study [31]. Codification and analysis were performed
by the cross-functional team. The chart was thoroughly
discussed and interpreted in meetings among all members
of the cross-functional team (Figure 2).
Data analysis for ethics
We used an inductive, ethics-based process of analysis, fol-
lowing Josep Lozano's classification of ethical theories
founded on three major approaches [39,40]: the first one
is virtue (or aretological) ethics, where goodness is deter-
mined in relation to the type of moral agent involved and
the context of his/her actions. The second is deontological
(that is, duty or rule) ethics, where the emphasis is placed
on the generality of the rules and their rationality. Finally,
there is utilitarian ethics, which identify the good with its
consequences. The utilitarian principle demands the maxi-
mization of the good produced by one's actions.
These approaches allow the specification of which values
are in conflict for a given ethical dilemma: the confronta-
tion between virtue and duty, virtue and efficiency, or duty
and efficiency. The cross-functional research team identi-
fied codes for units of meaning in the survey.
Quantitative analyses
Study population
Axiological situational diagnostic data were obtained for
2,891 healthcare professionals who were initially enrolled
in the course (registration). The final sample included
973 healthcare professionals who successfully completed
the course and who had also completed the before-and-
after survey instruments as well as the clinical vignettes.
Table 1 shows the socio-demographic features of the
healthcare personnel during the two stages of the study.
We confirmed that the 973 participants of this study
represented the initial participants in the course, using
demographic and professional survey information. No
differences were found with respect to factors such as
professional distribution, gender, age, organizational
level of healthcare or geographic distribution.
Most of the participants were female (62%). The predo-
minant profession was physician (57%), followed by nurse
(20%). Participants' ages ranged from 17 to 82 years, with
43.5% of the participants being between 36 and 50 years of
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age (median age of 44 years). The healthcare personnel
represented different regions of Mexico. The sample
included the four organizational levels of Mexican health-
care: first level, 41%; second level, 32%; third level, 22%;
and central level, 5%.
Of the participants, 40% had prior training in bioethics
through courses taken during their higher education.
Participants' primary motivation to enroll in the course
was to improve their professional performance (54.6%),
followed by the desire to increase their knowledge of
clinical ethics (36.3%).
Axiology in clinical practice
The values of clinical practice refer to favorable atti-
tudes, actions and situations that will help to achieve
patients' wellbeing. The priorities and value rankings of
2,891 participants are shown in Figure 3. The values of
clinical practice differed significantly before and after
the educational intervention (Figure 4).
Healthcare professionals in Mexico assigned great
importance to the values of 'honesty' and 'respect' by
placing them first and second, respectively, in their hier-
archy of values, whereas a low level of importance was
given to values such as 'fidelity', 'purity' and 'beauty'.
Notably, the two highest and the three lowest values in
the ranking remained unchanged after the clinical ethics
course (Figure 4).
The value of 'autonomy' was ranked high (third) by the
participants after completing the course, whereas prior to
the course, it was ranked 10th(mean position shift from
8.00 to 5.86, a statistically significant difference) (Figure 4).
Other values deserving attention were 'justice', 'liberty',
'love' and 'charity'; these values assumed higher hierarchi-
cal positions after the CME intervention (statistically
significant, (Figure 4)).
Figure 5 shows the ethical clusters found in Mexican
healthcare personnel based on Josep Lozano's classifica-
tion of ethical theories (aretological, deontological and
utilitarian) [39]. The first group is deontological/utilitar-
ian; the second, aretological/deontological; the third,
mainly aretological; and the fourth, aretological/
Ethical dilemmas and values
A dilemma is a situation in which a person may choose
only one of two courses of action, each of which seems to
be well supported by certain values. The survey encom-
passed three clinical vignettes [34]. We assessed the clini-
cal vignettes following Gisondi's definitions of each value
[34] in a representative sample of 448 participants.
Mean Value Before
2.98 Honesty (aretological)
3.80 Respect (deontological)
5.14 Veracity (deontological)
5.45 Will to serve (aretological) Will to serve (aretological)
6.55 Equality (deontological
6.58 Justice (dentological)
6.86 Tolerance (utilitarian)
7.60 Liberty (utilitarian)
7.76 Love (aretological)
8.00 Autonomy (utilitarian)
8.08 Interest (utilitarian)
9.29 Charity (aretological)
9.65 Fidelity (utilitarian)
11.44 Purity ((aretological)
12.80 Beauty (aretological)
Blue-Value position remains unchanged; White-Value position falls;
Yellow-positions improves; Red-value position remarkably improves
Value After
Honesty (aretological)
Respect (deontological)
Autonomy (utilitarian)
3.90 0.000
4.30 0.000
5.86 0.000
6.17 0.000
6.09 0.001
6.31 0.000
6.98 0.000
7.18 0.001
6.98 0.000
8.32 0.000
9.97 0.000
10.21 0.000
10.42 0.000
12.27 0.000
13.48 0.000
Justice (dentological)
Veracity (deontological)
Equality (deontological
Love (aretological)
Liberty (utilitarian)
Tolerance (utilitarian)
Charity (aretological)
Interest (utilitarian)
Fidelity (utilitarian)
Purity ((aretological)
Beauty (aretological)
Figure 4 Hierarchy of values in clinical practice before and after CME intervention. All the values presented statistically significant change
before and after the intervention (Wilcoxon Signed Rank Test with Bonferroni's correction).
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We assigned the maximal score to 'patient confidentiality'
when "the healthcare professional does not discuss clini-
cal or confidential information about a patient with
others" [34] or only disclosed information in the case of
risk to public health. Confidentiality was one of the
strongest values for participants and was not modified by
the educational intervention (P = 0.06). For 'beneficence',
we assigned the highest score to situations where "health-
care personnel identify the surrogate decision maker,
obtain paperwork for advance directives, withdraw care
when appropriate, and when needed, requested some
form of palliative care for a patient" [34]. This value was
present among healthcare professionals working in Mex-
ico and was not modified by the educational intervention
The value of 'autonomy' was labelled as 'utilitarian
autonomy' when healthcare personnel attempted to
obtain informed consent or voluntary discharge, and
'deontological relationship-based autonomy' was a situa-
tion in which "the health personnel attempted to obtain
informed consent from the patient or surrogate by
explaining common risks, benefits, and alternatives
(including no intervention), while querying for and
answering patient questions in an unbiased fashion" [34].
Educational intervention had an impact on both types of
autonomy (P ≤ 0.0001). Utilitarian autonomy was largely
reinforced in the participants (P ≤ 0.0001).
Work values
According to Schwartz [32], individual behavior is highly
influenced by a specific set of values that the agent finds
Figure 5 Ethical clusters found among Mexican healthcare personnel. Aretological values are A; deontological values are D; utilitarian values
are U. Before (1) and after (2) the educational intervention.
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important. As observed in Table 2, the differences
encountered between the means on openness to change
(OC) and self-transcendence (ST) before and after CME
intervention were highly significant (P <0.001) according
to the values of the t tests. These results allow us to
confirm our central hypothesis that we can engineer
strong connections and networks between EBM and
VBM through CME (Figure 6A-D). Individuals who
assign a high priority to the high-order value of ST tend
to be more satisfied in their jobs because they introspec-
tively evaluate their professional values and find them to
be aligned with the ends of medicine [41] (Figure 6A-D).
Qualitative content analysis
To strengthen the knowledge claims of the study, the
declared values considered in the quantitative analysis
were paired with a qualitative analysis that aimed to
gain insights into the representations of the actors and
their beliefs. A well-validated study on a subject such as
clinical ethics and values would be incomplete without
both quantitative and qualitative perspectives.
The rise of vocation and its consolidation
When qualitatively tracing the most salient values in the
life history of the individuals interviewed, we found that
healthcare personnel referred to a core of values, where
beneficence is dominant together with tradition, incenti-
vizing, achievement and conformity, and that those traits
led them to choose a career in the medical field (Figure
7A). Self-transcendence (ST) is analytically divided into
'beneficence' as a concern for those with whom one is in
contact. 'Universalism' is an abstract sense of goodwill
with respect to the health of the general population.
Although both values were included in the healthcare
personnel's representations, beneficence was predomi-
nant (Figure 7A).
The configuration of beneficence as a guiding value
for the vocation of these professionals is associated
with two different and sometimes conflicting sources.
In one, social relations are protected through confor-
mity with established values and traditions; in the
other, innovations in these values are made when
incentives encourage new achievements in the medical
field (Figure 7A).
The educational intervention permitted the rediscovery
of certain values that would consolidate the vocation of
the healthcare personnel; even if the participant's perspec-
tive shifted, the centrality of beneficence remained. Self-
direction and incentivizing came to play an important role
once the professionals acquired greater experience, and
this experience supported improved knowledge and per-
formance. While self-direction and incentivizing demon-
strate an openness to change, they are still well balanced
with the protection of social relationships through adher-
ence to prevailing values (Figure 7A and Table 3).
Ethical discernment
Daily medical practice encounters ethical dilemmas when
treatment efficiency and other related values must be
taken into account to help the physician make a wise deci-
sion. The basal values that are most often cited in health-
care professionals' representations are justice, respect,
medical attention, an ability to appraise situations and
their consequences, compassion and beneficence, followed
by compliance with norms and autonomy (Figure 7B).
Autonomy, beneficence, justice and non-maleficence are
the values suggested by Beauchamp and Childress' princip-
lism for ethical discernment. As stated in the background
section, principles express normatively a procedure to
uphold a value (Figure 1). In this case, we analyze directly
the values that are reached through these principles. How-
ever, our data show that autonomy was not a founding
value in the ethical-discernment for healthcare profes-
sionals prior to CME; rather, among these four values,
justice is relevant and precedes the rest, and beneficence is
second. Both values relate to ethical judgement (Table 3
and Figure 7B).
In the analysis, with the exception of justice, values
such as respect and compassion were considered more
relevant to ethical judgment than the remainder of the
values related to principlism (Figure 7B). Respect and
compassion demonstrate that the patient-doctor rela-
tionship is understood in different ways that aim to
approach the patient with dignity. In general terms, the
Table 2 Work values
MedianMean ± S.D.Student's tP-value
C.I. 95%WilcoxonP-value
Openness to change-B
Openness to change-A
5.69 ± 0.89
5.77 ± 0.87
5.99 ± 0.94
6.05 ± 0.89
2.71 ± 1.10
2.75 ± 1.11
3.50 ± 0.89
3.48 ± 0.90
0.01; 0.05 0.171d
B = before, A = after,cWith significant differences,dWithout significant differences.
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interviewees described a discernment that is justice-cen-
tered. (Table 3 and Figure 7B).
Additionally, we investigated the interviewees' repre-
sentations of how medical attention should have an
impact. Generally, the medical practitioner described
not making decisions based on the notion of an ultimate
end of the practice but rather on the ability to appraise
specific situations. The ability to appraise situations is,
of course, useful in maintaining life and avoiding risks,
but it also helps to clarify courses of action in ethically
complex cases (Table 3 and Figure 7B).
The educational intervention modified participants'
configuration and hierarchy of values. After the CME
intervention, values such as respect, compassion and
justice were predominant over the others. Autonomy
moved from the eighth position to the fourth position
according to importance (Figure 7B).
Healthcare personnel-patient relationship
Different kinds of relationships between patients and
healthcare personnel We were able to discern a bundle
of values in the specific relationships that we studied.
The initial values that prevailed in this relationship were
self-direction, justice, medical attention, compassion and
beneficence. Again, we noticed that the values related to
virtue ethics are stronger than those related to princip-
lism (Figure 7C).
Medical attention, the main role played by health-
care professionals In describing their functions, all
interviewees quickly noted that their job was to provide
medical attention; they were all immediate and precise
in their description. The medical practitioners elo-
quently spoke about the different types of patient they
meet; they recognized in advance the types of persons
and diseases they would encounter (Table 3).
Figure 6 Four high order values (Schwartz's theory) before and after CME intervention. Each row includes N = Nurses, M = Medical Doctors,
HP = Others Healthcare Professionals. A = Administrative personnel. Spheres in red are females. 1 = Before and 2 = After educational intervention.
A: Scatter plot in 3D. Openness to Change. Spheres representing post-CME intervention appear compacted. B: Scatter plot in 3D. Self-
transcendence. Spheres representing post-CME intervention appear compacted. C: Scatter plot in 3D. Self-Enhancement. D: Scatter plot in 3D.
Altamirano-Bustamante et al. BMC Medicine 2013, 11:39
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Page 11
In relation to the particular situations in medical atten-
tion in which the link with the patient is the common
denominator, we found that values such as compassion,
justice and beneficence, self-effacement and trust are sali-
ent (Table 3 and Figure 7C).
The health professionals showed great patience when
working with patients after the CME intervention. Issues
that would normally act as a barrier between the health
professional and the patient became an opportunity for
the health professional to provide the patient with com-
prehensive medical care. The healthcare personnel sta-
ted that when patients abandon their treatment against
medical advice, reactions such anger, disappointment or
discomfort are not uncommon. Following the CME
intervention, they resolve these issues by informing
patients about the treatments and their benefits. Educat-
ing patients implies transmitting scientific information
that provides them with some certitude regarding their
treatment in general. This information must be provided
in an understandable and non-condescending way
(Table 3).
Virtues in clinical practice One way of creating a novel
ethical environment and improving the quality of medi-
cal care is fostering new values to face the challenges of
clinical practice. Among the different values that are
important for medicine, we find several virtues. Virtues
are values that refer directly to the healthcare personnel,
their traits of character and decision-making (Figure 1).
Hence, special attention must be paid to the virtues that
are fostered in clinical practice because well-established
character traits will help practitioners make sense of
their own practice and, at the same time, pursue the
valuable ends of medicine. A community has some well-
established virtues, but critical reflection of these values
may stimulate changes. The main virtues endorsed by
healthcare personnel in Mexico are 'trustworthiness',
Figure 7 Semantic networks. Keywords were identified with Atlas.ti 6.0 software. Words were sorted according to the frequency of their
appearance in the interviews. The cut-off point, which divides the set of words into a high-frequency and low-frequency groups, was identified.
Radial graphs explaining the frequency of appearance were created with MS Excel 2007. Red indicates before CME, and blue indicates after CME.
A: Semantic Networks for Life History. B: Semantic Networks for Ethical Discernment. C: Semantic Networks for Healthcare Personnel-Patient
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Table 3 Values and healthcare personnel roles
Values and Healthcare Personnel
"Yes, I have treated homosexuals, and I relate to them normally."
"You treat everyone the same, you give them [prisoners] the same attention as the rest. I mean, if you have to
treat them, and you have to do it that way. I think that maybe it's a risk of the profession, but either way, it's
the patient and you have to... treat everyone the same... equally."
"This has indeed happened. I have a patient with HIV, and ever since he first came to me, he told me, 'You
know what? Neither my mother, nor my siblings know I am HIV positive, and I don't want them to find out'.
Therefore, I believe you have to respect the patient's decision; if the patient is conscious, if he's oriented, you
have to respect his ideology."
"I'd say that in case I don't really need to transfuse him, I wouldn't do it, and not for my personal security or the
patient's security, but because one tries to respect the parent's decision, but the first thing to do is to convince
them to go ahead with it."
"We had lots of friction with them. All the personnel had frictions with that family. Then, I talked to the wife,
who felt awful because she could not get any money because she had already sold everything. I told her to
draw close to any religious faith. It is as if you were changing somebody's life; a psychologist must intervene;
something must be done to make them sensitive, to help them improve. It was not until I told the woman to
start working that she told me she did not know how to do anything. However, I told her she needed to help
her husband, and the man was not making any progress. It took her, like three months; the woman started
working, and it was very hard for her."
"I put myself in the patient's shoes. I have always said to my daughters and husband, if I come to this [need of
resuscitation], I am against doing everything until the end; tubing him, giving him electric shocks in the heart.
Tubing him all over is just tormenting the patient and his family, too. It is very hard to come and see your
loved one with tubes all over; it's shocking. I have always said that I don't want that for me. I wouldn't do it
either to someone else."
"I chose nursing. To tell the truth, ever since I was a kid, I liked the whole helping situation, being always aware
that my brother was sick, and me being there, helping him. It's as if I always thought of having to be there,
giving something to others."
"One just doesn't [treat him]. And yes, we have been asked, and one just doesn't do anything. One waits for the
end. You just stay there with him, but let me say we never leave them alone. They go into cardiac arrest and
all, but they do tell you, "If something happens to me, I don't want to be tubed or anything like that", but you
just stay there, with him. I mean, I don't know, you talk to them, maybe even pray or I don't know, but you just
stay there."
"Youngsters are forgetting that here in Mexico we practice a clinical medicine, using clinical skills. You must
figure out many things. Just by simply exploring the patient, I can get a feeling that the problem might be this
or that, and I support my opinions with lab tests in order to confirm or rule out anything. Now, it's going the
other way. If a patient tells them they have a headache, they send them for a CAT scan and forget about the
rest. That is why, nowadays, we are having so many problems. Because it's true; you can always send them for
a CAT scan, but you neglect other skills."
"Now, I have to accept that perhaps they want to take other opinions, visit other surgeons, or maybe they don't
want to be operated on. Maybe there's another alternative, and one has to accept that."
"When a patient does not follow the treatment, I comply with the rules by telling them what they need to do. I
tell them what their problem is because I cannot go to their place and take care of them. They are old enough,
and they are responsible. I try to make the patients feel committed so that they don't blame the doctor."
"I go to my colleagues at the ER, and I help them to set up an IV for a patient in pain. I just stay with my
pregnant patients, or I go with my vaccination colleague and help her capture the data about the shots the
patients are getting."
"That has also happened to me with certain religion that prohibits this. In this case, the family and the patient
were told about the risks if he was not transfused, and in spite of everything, of the complications and all, they
refused. One has to protect oneself, and you can ask them to sign their refusal of treatment, despite being
informed, and that way one is a bit more protected. One tells them about the consequences; if they do not
accept the procedure, it is their responsibility, one simply informs them."
"In this case, we would need to talk about it [a do-not-resuscitate order] with the family and the patient, in
writing and in accordance, if the patient is conscious and aware of what he says, in control of himself. We
need him to be capable. Many people express their will during their lifetime, they make it evident for their
families, it is the same for those who want to donate organs: 'You know what folks, if something happens to
me, I want to donate my organs'. This is very frequent, and in this type of patient, if he expresses his will and is
completely conscious, a document is written, and he signs it."
"That has also happened to me with certain religion that prohibits this. In this case, the family and the patient
were told about the risks if he was not transfused, and in spite of everything, of the complications and all, they
refused. One has to protect oneself, and you can ask them to sign their refusal of treatment, despite being
informed, and that way one is a bit more protected. One tells them about the consequences; if they do not
accept the procedure, it is their responsibility, one simply informs them."
Professional Humility
Compliance with standards
Capacity to appraise situations and
Altamirano-Bustamante et al. BMC Medicine 2013, 11:39
Page 12 of 17
Page 13
'intellectual honesty' and 'beneficence', followed by 'for-
titude', 'compassion' and 'courage'. The CME interven-
tion had a significant strengthening effect on these
virtues among the participants (Figures 4 and 8).
We have thus shown experimentally that the two para-
digms, EBM and VBM, can be converted into an EBM-
VBM binomial through CME intervention. (Figures 3, 4,
5, 6, 7, 8 and Tables 2 and 3).
Our results demonstrate that the healthcare personnel
participating in a CME intervention in clinical ethics
improved high-order values Openness to Change and Self-
Transcendence, as observed through a concurrent triangu-
lation approach (Figures 6A, Band 7A-C and Table 2).
Quantitative analysis showed that even if core values, such
as honesty and respect, remained unchanged after educa-
tional intervention, other important values for the health-
care professional-patient relationship were changed (for
example, justice, autonomy, love and charity). Moreover,
the representations of values found in the qualitative ana-
lysis are compatible with the preceding results (compas-
sion, justice, beneficence). In both cases, deontological and
aretological values are susceptible to change in such a way
as to fulfil the healing aims of medicine [2].
Ethical discernment is a daunting task from the per-
spective of integral ethics, which seeks the good of the
patient by integrating the three characteristics of action:
as a moral agent, as a process to be evaluated from the
perspective of rights and duties, and with respect to the
consequences of the action. This approach ensures that
healthcare professionals exercise their hierarchy of
values (Figure 4 and 8).
Following Lozano, dilemmas can arise from different
areas; different values and different kinds of ethics take
precedence. Values consider the good that is to be
achieved through a practice. However, when several of
these values are in conflict and a decision cannot be
Table 3 Values and healthcare personnel roles (Continued)
"One thing that I perceive and admire from the haematologist, for instance, is that, with the patients with
leukaemia, she tells them: 'This is the situation: your treatment is not working'. Then, they just remain there,
thinking. But she gives them a choice. 'You have to decide; if the treatment is not working, they are going to
ask you, if you are going to stay and continue with the treatment. In the meantime, you might pass away, you
need to decide if you want to go home and enjoy your family'."
"Family intervention is very important because it is the family who brings the patient; even if most of the times
the patient comes by himself, the family is the most worried. The role of the family is very important because
relatives are the ones who will follow the treatment at home. We only stabilise the patient."
"For me, the family is essential in the treatment. [Family] is the centrepiece of society; very often the failure or
success of the treatment depends on the family."
"That's why I always try to play music in my practice, all kinds of music, but mainly instrumental music. It's just
like they say, music calms the beasts because the beast can be unleashed at any moment. I try to calm down
and think about what I am going to say. Tell him why things are going wrong: 'Things might get complicated
with this and that'. For me, it has been useful to tell them they are not orders but suggestions or
recommendations that I hope they follow. And if they don't want to follow them, I cannot take care of them.
They are the ones who will end up worse. It won't be me or their families, but themselves. That works for me;
that, I learned with time and with teachers."
"I already enjoyed talking and listening, but now I have better reasons to do so! I do like talking to patients if
they tell me about their family and personal stuff, as well as other things. One has very frequent patients; they
come here all the time, and you already know them. You know their whole life and work; even their family
knows you and identifies you. And well, yes, my attitude has changed. I am more communicative, more
participative with my patients too.... For me, the most important thing this course has given me is that: more
humility, more... one very important difference."
"I try to explain their disease to them and how we will proceed in the treatment because I wouldn't like it if
someone left me with doubts. Sometimes, I see the doubt in their faces and I try to explain it to them; the same
goes with the treatment. I believe we have different educational levels, and sometimes one talks to them with
lots of technicalities. Before studying, we also didn't understand a thing, as if we spoke in another language."
"I would make him see that it's necessary, that it's part of the treatment, that there are maybe risks associated
to this surgical procedure because he can lose so much blood or have some other problems, and that therefore,
it is necessary."
"I treat everyone. Because I am a family doctor, I treat the child, the father, the mother, the insured, everything.
On average, I treat approximately 24 patients a day. I spend approximately 15 minutes with each of them, but
sometimes I can spend 5 minutes with one person and an hour with another. Sometimes there is not enough
time. You sometimes need more time, but that is compensated for if another patient comes with something
"They come and tell me: 'You know what? I went with that doctor, and he did not explain anything. I want to
know what my problem is. I want to know what I have'. Then, I do research, I go through the medical records
and files, I try to reach a conclusion, and well, I try to let the patient know about it."
Medical Attention
For each value and role, the boxes on top correspond to the interviews before CME intervention. The boxes at the bottom correspond to the interviews after
Altamirano-Bustamante et al. BMC Medicine 2013, 11:39
Page 13 of 17
Page 14
reached, virtue becomes central in solving an ethical
problem; the character, practical wisdom and experience
of the practitioner are important resources for ethical
deliberation (Figure 8) [7,9,12,14,42,43].
CME must focus on four areas to strengthen the
EBM-VBM binomial: The first area is extensive knowl-
edge of the pathophysiology of disease and availability of
real therapeutic alternatives (EBM). The second area is
knowledge and awareness of values (VBM). The third
one is development of an ability to analyze and discern
ethical dilemmas (VBM), and the fourth area is commu-
nication skills (VBM) [44,45].
In this study, we validated our instrument (a value
hierarchy in clinical practice) and identified the oppor-
tunity for CME intervention. Figure 3 demonstrates that
participants recognized that, to act fully as providers of
medical assistance, advisors and educators, the most
important values are honesty, respect and autonomy.
These values are similar to those enumerated in the lit-
erature [46]. These specific roles lend a multi-dimen-
sional character to the patient-healthcare professional
relationship. Our results (Table 3) show that the most
established role in this group of professionals is that of
a provider of medical assistance; however, the CME
intervention successfully developed bridges and net-
works to improve the practitioners' performance in the
role of educator and adviser.
A notable outcome of our CME clinical ethics course
is that it created awareness among physicians and
healthcare professionals of how their decisions are made
and the values that are at stake (Figures 3, 4, 5, 6, 7, 8).
Moreover, the intellectual exercise involving several
ethical perspectives ensured that healthcare professionals
deliberated in a comprehensive and thoughtful manner
(Figures 3, 4, 5, 6, 7, 8).
We propose that an integral approach to ethics similar
to the one described by Polo [40] is the solution to the
increasing number of ethical dilemmas in medicine.
Such an approach considers three features of ethical dis-
cernment: 1) The best decision is an integrated one that
does not spring from isolated principles but one that
allows the moral agent to consider due processes in a
given context, as well as his/her own virtues in deter-
mining a course of action [14]. Therefore, deontological,
aretological and utilitarian criteria may overlap in deci-
sion making.
2) These criteria emphasize different issues involved in
an ethical dilemma. A deontological criterion focuses on
the fulfilment of general and comprehensive rules. A
focus on virtue is more capable of addressing the
immediate context. Moreover, a value such as efficiency
should not be neglected in the healthcare professions.
However, the specific configuration of the dilemma and
the moral character of those involved will reveal which
criteria should be prioritized in a process of wide reflex-
ive equilibrium [47,48].
3) The most important criterion for decision making
is the respect for the universal trait of human dignity,
Average of positionAverage of position
Fidelity to Trust (utilitarian) 2.01
Intellectual honesty (utilitarian) 2.33*
Intellectual honesty (utilitarian) 2.02
Fidelity to Trust (utilitarian) 2.36*
Benevolence (deontological ) 3.63
Benevolence (deontological) 2.56*
F Fortitude (aretological) 3.65i d (l i l) 3 65F Fortitude (aretological) 4.10*i d (l i l) 4 10*
Compassion (aretological) 4.65 Compassion (aretological) 4.39*
Courage (aretological) 5.05Courage (aretological) 5.27*
Figure 8 Virtues of medical practice. *Denotes a statistically significant difference before and after the intervention (Wilcoxon Signed Rank
Test with Bonferroni correction). Vertical lines tie the pair of values between which no statistically significant difference was found (Steel-Dwass
All Pairs Comparison).
Altamirano-Bustamante et al. BMC Medicine 2013, 11:39
Page 14 of 17
Page 15
even if those who address this dilemma conceive of it in
different manners. Dignity supports the individual in
acting conscientiously and making his/her own life
choices [49,50].
It is of the utmost importance to keep in mind the
primacy of those affected by the decisions, ethical values
and discernment of healthcare personnel. However, the
decisions made by healthcare personnel not only affect
patients but also the decision-makers themselves. These
decisions determine what kind of person and profes-
sional one becomes, how sensitive one is towards others,
and how attentive one is towards one's own needs. The
best decisions justifiably solve a dilemma by integrating
different ethical theories related to human actions. An
integrated ethics approach is essential in medicine
because medicine is concerned with the person and his/
her interests, needs, vocation, virtues and transcendence.
In a nutshell, we can say that the CME intervention
favors the creation of networks between EBM and VBM
from a philosophical, epistemic, axiological and practical
point of view. From the philosophical point of view, we
were able to recover the ends of medical practice,
namely: healing, curing and caring, the recognition of
the person as central to healthcare. This is evident in
Table 3 where after the CME intervention; the represen-
tations and beliefs of the healthcare personnel were
modified, and exhibited a more thorough understanding
of the philosophy of medicine. From the epistemic point
of view, the epistemic values that are related with medi-
cal attention were strengthened. Simultaneously, we per-
ceived increased knowledge related to integral ethics.
This can be seen in Table 3 and Figures 3, 4, 5, 6, 7, 8,
where the physicians' roles were more balanced. The
promotion of personal growth through the exercise of
values, such as autonomy, love, justice and freedom,
could be seen. These values were rediscovered and used
to improve the patient-healthcare personnel relationship.
Both the quantitative (Figures 3, 4, 5, 6), and the quali-
tative (Figures 7 and 8, and Table 3) analyses show the
construction of links between EBM and VBM. From a
practical perspective, tools for ethical discernment were
provided, discursive spaces to reflect and critically ana-
lyze ethical dilemmas in clinical practice were created.
In ethical discernment, the use of clinical vignettes to
picture situations with moral dilemmas proved useful. In
these exercises autonomy stands out, it was a value pre-
viously overlooked and it became relevant for the health-
care personnel after the CME intervention. Additionally,
ethical committees as guarantors of the humanization of
healthcare were consolidated, while the promotion of a
professional environment directed by academic, ethical
and social excellence was encouraged. Strengthening
values-based medicine automatically strengthens the
EBM-VBM binomial given that they become more
balanced. This is clearly shown in the present study. We
are looking forward to continuing with the next phase of
this project, which involves carrying out participant
observation of the active healthcare personnel in medical
units, in order to follow up on these results in the long
term. This study is one of the first to explore the axiology
of clinical practice. Different values and representations
may be found depending on the studied population; how-
ever, we consider that the empirical method used to
explore the representations of these professionals opens a
window of opportunity for CME insofar as it strengthens
the already-existing values among healthcare personnel;
and at the same time, it promotes values that are missing
but essential to an effective patient-healthcare personnel
relationship. One dimension of medical responsibility
involves being attentive to the values that need to be
exercised. López Quintás [51] explains that this attentive-
ness requires certain value-sensitivity: an ability to dis-
cover and recognize the fertility that values have in our
lives, when they offer authentic possibilities for personal
This is the first endeavor to empirically investigate the
axiological foundations of healthcare professionals work-
ing in Mexico. It has long been known that values educa-
tion is one of the most effective methods to meet the
challenge of providing high-quality care to populations
and improving the patient-healthcare professional rela-
tionship [1,11,44]. Even if different configurations of these
values operate in each medical environment, by identifying
the values already held in high esteem and those that need
to be encouraged, we are certain that these benefits can be
extended globally to every level of care.
For CME design purposes, we successfully engineered
networks between EBM and VBM. Using the combined
approach of cross-functional design, online technology,
motivational videos, pictures and real-time decision-
making, these networks identified the advantages of
both paradigms. Perhaps the CME methods used in this
study will encourage the humanization of medicine
through routes not open to traditional CME methods,
thus potentially allowing access to more efficient CME
solutions, as in the example presented here.
It has long been speculated that CME in clinical ethics
in real time may be a useful platform for engineering
novel networks between EBM and VBM. Our strategy of
cross-functional CME in clinical ethics may be of broad
application in achieving high-quality care.
End notes
aOf these two paradigms, EBM appears to predominate:
Medline displays 49,491 EBM articles versus 1,701 arti-
cles addressing Humanistic Medicine, Patient-Centered
Altamirano-Bustamante et al. BMC Medicine 2013, 11:39
Page 15 of 17


text:
Check out this short interview with Nuggets shooting guard, Arron Afflalo, and make sure to view the photos while you're at it!
The following two tabs change content below.
Kalen Deremo
Kalen was born in Durango, CO, in 1988 and graduated from Metropolitan State University of Denver in 2013 with a degree in journalism. He's now an itinerant hoping to travel as much as possible before eventually succumbing to the "real world." Aside from writing Kalen likes movies, music, spicy food and the great outdoors. Edward Abbey is his current idol.
Latest posts by Kalen Deremo (see all)
- Timofey Mozgov wants things, tries his hardest to get them politely - December 12, 2014
- Link: Brian Shaw wonders if Nuggets need to add another point guard - December 9, 2014
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Econo Lodge
265 Memorial Ave.
Orillia, ON L3V 5X8
Phone: (705) 326-3554
Fax: (705) 326-5641
Church Street
Perhaps the most notable feature of this street is the number of gays and lesbians who feel comfortable making it their home away from home. From "the Steps" of Second Cup, where you can find people sitting during the summer. Whether you are part of that culture or not, you will be sure to enjoy the varied shops and restaurants along this street, as well as the National Ballet and Buddies In Bad Times Theatre.
Church Street
Toronto, ON M4Y 2C8
+1 416 338 0338 (Tourist Information)
Earn valuable points toward free nights.


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Saturday, 7 February 2015
Maidstone in Kent is situated on the Medway which links it with nearby Rochester and the Thames Estuary.
Maidstone was once a centre for industry with brewing and paper making being the most prominent industries. Maidstone today has a number of Hi Tech Industries and a lively town centre with two large shopping centres at Fremline Walk and The Mall.
The town has an abundance of good restaurants, bars and coffee shops with a mix of independent and well known high street retailers.
Posted by Editor at 15:40 No comments:
Labels: kent
Location: Maidstone, Maidstone, Kent, UK
Sunday, 18 January 2015
Newmarket in the county of Suffolk is approximately 65 miles from North London. It is recognised as the birthplace of horse racing and is known across the globe for its breeding centres and training stables.
Newmarket is also known for its famous racecourse which draws enthusiasts from around the world. With over 3000 racehorses in Newmarket this is vital to the local economy with one in three jobs in the town being attributed to horseracing.
Home of the National Horseracing Museum, the town has a busy high street and some branded and independent shops. There are some good cafes, bars and restaurants.
For more photos of Newmarket click here
Posted by Editor at 03:08 No comments:
Labels: suffolk
Location: Newmarket, Newmarket, Suffolk CB8, UK
Saturday, 22 November 2014
Morpeth in Northumberland is the administrative centre of the county. Situated on the River Wansbeck it is close to the border of Scotland.
Now a busy market town with the market still being held on Wednesdays and a Farmers Market on the first Saturday of every month. Morpeth offers a good selection of independent shops and some nice restaurants and cafes. The Sanderson Arcade has some particularly good quality retail outlets.
There is plenty of history here too, a beautiful park and even a bagpipe museum. Definitely worth stopping off to look at and taking a leisurely stroll around the local area.
For photos of Morpeth click here
Posted by Editor at 14:59 No comments:
Labels: Northumberland
Thursday, 23 October 2014
St Albans
St Albans is situated just 19 miles from London. It is a famous old established market town. St Albans Abbey Church looks more like a cathedral with its impressive architecture. The town benefits from a good selection of independent traders, restaurants and cafes.
There has been a settlement here since Roman times when it was the most populated town outside of London. Today it is a popular filming location with a number of films and soaps having used the backdrop of buildings and streets in St Albans.
Posted by Editor at 05:57 No comments:
Labels: hertfordshire
Location: St Albans, St Albans, Hertfordshire, UK
Sunday, 17 August 2014
Portsmouth. One of England's most famous cities and with a rich maritime history known around the world. You can find out more about its history here:
Just 65 miles from London and only 19 miles from Portsmouth this city is a must on your visit list if you are coming from overseas.
Portsmouth has the world's oldest dry dock which is still in use today. The city is home to one of the most famous ships in naval history - HMS Victory. Portsmouth is still a significant and important strategic base and dockyard for the Royal Navy.
With a population of over 200,000 the nearby Southampton, Havant, Eastleigh, Fareham and Gosport all contribute to making this the 6th largest urban area in England. Portsmouth today is still a busy port and ferry terminal. The centre of the town has an abundance of cafes, restaurants and bars and there is a long sea front promenade from where you can observe the old sea forts and the incoming vessels as they travel to and from port.
For more photos of Portsmouth and HMS Victory click here
Posted by Editor at 06:13 No comments:
Labels: hampshire
Location: Portsmouth, Portsmouth, UK
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Been trying and trying all friggen day to transfer my apps mainly my big game files to my SD card have watched video after video and the button thats suppose to be there to xfer to SD card just ain't there and i know i have one in my phone....any help?
settings - Apps and suppose to be able to go to an app and xfer to SD card
no i keep forgetting to change it, i'm currently running CM 10.1
XDA Developers was founded by developers, for developers. It is now a valuable resource for people who want to make the most of their mobile devices, from customizing the look and feel to adding new functionality.
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Copyright © xda-developers. Hosted by Leaseweb


text:
In his film, Dirty Wars, Jeremy Scahill unveils America's extrajudicial, covert, transcontinental battlefield.
The difference between rich and poor is stunting economic growth, the mayoral candidate says.
The annual Ridenhour Prizes recognize acts of truth-telling that protect the public interest, promote social justice or illuminate a more just vision of society.
With the killing of Awlaki, the president of the United States became judge, jury and executioner for American citizens.
It wasn't easy, but artists, musicians and activists met Thatcher's brutal tactics with compassionate responses.
So long as austerity-mongers have their way, "democracy" is just a buzzword.
What happens when the media depends on corporations to survive?
A special discussion on how to tackle the most profound threat humanity has ever faced.
A town hall meeting on the aggressive policing of black bodies in America.
Is a more sustainable future possible for farming?


text:
Marking the ascendance of another Indian in the global financial system, well known investment banker Anshu Jain will take over the reins of German banking giant Deutsche Bank as co-CEO on Friday.
The 49-year-old banker, well-respected for maintaining high profits at Deutsche Bank's investment banking operations during the 2008 financial meltdown, would take over at a time when the banking sector globally is grappling with regulatory and economic challenges. An economics graduate from the Delhi University, India-born Mr. Jain also holds an MBA in finance from the University of Massachusetts Amherst.
At present based in London, Mr. Jain heads the Corporate and Investment Bank business of Deutsche Bank, whose other co-CEO would be Juergen Fitschen.
Keywords: Anshu Jain, Deutsche Bank


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Launcher Update
Get the Desktop App for Battle.net Now
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Complete all mission objectives in "The Devil's Playground" mission.
Complete the "Outbreak" mission on Normal difficulty before the 5th night.
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Complete the Mar Sara missions in the Wings of Liberty campaign.
Watch any Battle.net replay.


text:
Music to Karmaloop founder's ears? Kanye West may be a buyer
The online apparel retailer's filing for Chapter 11 bankruptcy protection has drawn several potential suitors, including rapper West and music executive Damon Dash, Karmaloop ...
Music to Karmaloop founder's ears? Kanye West may be a buyer
The online apparel retailer's filing for Chapter 11 bankruptcy protection has drawn several potential suitors, including rapper West and music executive Damon Dash, Karmaloop ...
Stamps.com acquires Endicia for $215 million in cash
The online retailer has spent nearly $300 million acquiring three shipping software vendors over the past nine months.
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Sponsored by 2013 Social Media 300
As more consumers surf with their smartphones, retailers should think twice about Flash.
Before we begin, a brief newsflash:
In March, Gilt Groupe reported that 4% of its sales stemmed from the iPad.
In February, one retailer, wishing to remain anonymous, volunteered its web log to Forrester Research Inc., who in turn shared it with Internet Retailer. 46.5% of all mobile page views came from the iPad, the retailer said. 33.1% stemmed from the iPhone and 3.2% came from the iPod Touch. That means 82.8% of all mobile page views are coming from an Apple device.
Online travel site Expedia.com recently reported that about 4% of its visitors hailed from mobile devices.
At retailer Music Factory Direct, 5% of total online visitors now come from a mobile device and mobile sales account for 5% of total sales.
What's this mean? Retailers should slim down their use of Adobe Flash.
As mobile traffic to retail sites grows, retailers must consider all the new devices accessing their web sites, mobile sites and apps. Many of those mobile devices are made by Apple. Apple doesn't play nicely with Flash. In fact, it doesn't display it at all on its popular mobile devices.
For the three months ending in March, the number of smartphone subscribers rose 8% according to comScore Inc. Devices using Apple's iOS mobile platform, according to comScore, accounted for 24.7% of those smartphones. Then you have the iPad. Apple sold 15 million of them between April and December 2010 and an estimated 500,000 units of its iPad 2 the first weekend after its launch. Those tablets don't like Flash either.
Apple's corner on the mobile market makes a solid case for taking Flash off your web site—or at the very least off important pages such as the home page or product pages. The good news is that there's an emerging Flash replacement. HTML5 is the latest version of the HTML language used to create web sites. It renders on Apple devices and works well in the mobile realm as a replacement for Flash-based images like graphical hero shots that e-retailers use on e-commerce sites.
Hotel booking site Kiwi Collection had to provide mobile functionality to enable mobile users to check their booking status and complete bookings on the go from their phones. It used vendor Mobify to implement HTML5 for its mobile site and create a search box at the top of the screen, buttons that link to more information about Kiwi Collection, contact information and hero shots.
If you do have a mobile site that doesn't use Flash, great! But, then you've still got some 15.5 million and growing iPad users. Those consumers will likely access your traditional web site from their tablets, because web sites render just fine on the device which has roughly the screen size of a netbook.
If you don't have a mobile site, get one. But also, take Flash off important pages on your traditional site. 29% of online consumers have made a purchase via their mobile devices and 48% have used their devices to browse and research products, according to an Oracle/ATG study. Until you can give those consumers a fully optimized mobile site, at least make sure they can see what they need to buy.
Responsive design is the best way for retailers to serve mobile shoppers, argues the CEO ...
Posted 03/10/15
The chief technology officer at a web-only retailer discusses his company's approach to gaining a ...
Posted 02/19/15
Shari's Berries shows an absolutely, positively perfect way merchants can exploit a mobile app to ...
Posted 02/12/15
A mobile industry executive with more than 350 mobile commerce apps under his belt offers ...
Posted 02/05/15
If there's something you've bought offline that you weren't able to buy online, we're probably thinking about that."


text:
This attractive awning opens smoothly and quietly at the touch of a button that is located inside the house. There when you need them, rolled up when you don't, these motorized retractable awnings have a mind of their own, thanks to modern technology. Each awning has lateral arms that work almost like human arms, bending at an elbow. The arms fold up discreetly against the wall when the awning is closed.
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