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Constitutions of Clarendon

In Custodia Legis - Tue, 12/16/2014 - 2:47pm

The Constitutions of Clarendon were issued by Henry II in 1164.  This document became the bone of contention between Henry II and the Archbishop of Canterbury, who was also his former chancellor and friend, Thomas Beckett.  The quarrel between these two men eventually led to Thomas’s murder and then elevation to sainthood, as well as a papal interdict against England.

The development of national kingdoms during the Middle Ages often led to clashes between kings and the church particularly over the appointment and discipline of clergymen.  The church argued that it had exclusive jurisdiction to try clergy who committed crimes and also should have full authority to elect bishops and abbots without royal interference.  The reality was that the papacy often agreed to royal appointments.  Ironically, Henry II had nominated Thomas Beckett to be the archbishop of Canterbury in 1162.  Thomas had been Henry’s chancellor and was close to Henry – presumably Henry had backed Thomas as archbishop in anticipation that his leading churchman would advance his agenda for tighter control over the English church.  That Thomas should have defied the king undoubtedly added a note of personal bitterness to the fight.

The Constitutions of Clarendon have been variously seen either as an innovation by Henry to control the church in England or an attempt to reassert controls that had been established as a result of the Norman Conquest.  Norman Cantor in his book, The Civilization of the Middle Ages, argues that William I had established firm control over the church in England: “through lay investiture and and the vassalage of bishops and abbots he completely controlled the affairs of the English church.”  This meant that the bishops and abbots were given their land and positions by the king and so owed him greater loyalty.  It is useful to remember that bishops of this time period were great landowners and feudal lords in their own right.  For Cantor, Henry II is primarily reasserting the control over the church following a tradition which had been established under his great grandfather, William.  The introduction to the Constitutions bears out this construction: “this memorandum or inquest was made of some part of the customs and liberties, and dignities of his predecessors, viz of King Henry his grandfather and other, which ought to be observed and kept in the kingdom.”  This inquest is being carried out because of “discords” which had arisen between the clergy, the king’s justices and the barons.

Thirteen of the sixteen clauses in the document, cover various aspects of church relations in England.  Clause 3, which was to be one of the bones of contention between Henry and Thomas Beckett, concerned procedures for “clerks [clergyman] charged and accused on anything” (clerical immunity).  Clause 3 overturned this principle and ordered that clergy accused of secular crimes should be delivered to the king’s court for sentencing and punishment.

Clause 4 tends to support Cantor’s argument that Henry was really reasserting previous established controls over the English church – although this clause too was another sticking point for Thomas.  This clause directed that clergy could not leave the kingdom without the king’s permission which harks back to a decree by William forbidding his clergy to travel to Rome, or to appeal cases to the pope with royal permission.

Although Henry claimed the document was merely laying out customs sanctified by history, clause 7 is likely to have arisen out a quarrel between Henry and Thomas Beckett the previous year.  In July 1163, Thomas had enraged the king by excommunicating a royal vassal without first obtaining the king’s permission.  Clause 7 avers that this action is firmly against the ‘customs’ of the kingdom: “No one who holds of the king in chief, and no one of his demesne servitors, shall be excommunicated, nor shall lands of any one of them be placed under an interdict, unless first the lord king, … be asked to do justice concerning him;”  It is possible this was a custom from time immemorial, but it is also certain that in this document it was a re-assertion of royal prerogative.

The Constitutions also contained innovations in procedures.  Thomas J. McSweeney in his article Magna Carta and the Right to Trial in Magna Carta: Muse & Mentor points out that clause 9 represented a new procedure for handling disputes between clergy and laity about land ownership when the church contended the land had been donated to them (free alms).  Henry decided that in cases where there was a dispute as to whether land had been donated to the church should be heard in the royal court:  “If a dispute shall arise between a clerk and a layman or between a layman and a clerk, in respect to any holding which the clerk desires to treat as free alms but the layman as lay fee, it shall be determined by the recognition of twelve lawful men through the deliberation, the presence of the king’s chief justice, whether the holding pertains to free alms or to lay fee.”  Mr. McSweeney argues that Henry would have had a number of possible inspirations for the use of a jury to help determine the facts in a case – both from Anglo-Saxon and Norman precedents.

The introduction to the Constitutions also states that the customs listed in the document have been recognized by various archbishops, bishops, counts and barons and other elders of the kingdom.  Thomas Archbishop of Canterbury is listed as one  who recognized the customs listed in the Constitutions.  This was not the case.  After an acrimonious meeting with the king in October 1164, Thomas fled to the continent, appealing to the pope and French king for help in his quarrel with Henry.  Thomas did not return again to England until December 1, 1170 and 29 days later he was murdered in his cathedral at Canterbury.  However, the Constitutions largely survived.  The controversy between king and pope was settled by the Compromise of Avranches which absolved Henry from responsibility for Thomas’s murder; provided for the free appeal of cases to Rome (clause 4); and the promise by Henry that he would ‘abolish all evil customs prejudicial to church which he had instituted.’  It did not however, specify which were the evil customs and the use of a grand jury to investigate land disputes remained in place.

Categories: Research & Litigation

A Prescription For Better Teaching, Stronger Doctors

CommonHealth (WBUR) - Tue, 12/16/2014 - 1:52pm

The author’s stethoscope from medical school. (Courtesy)

By James Morris
Guest Contributor

Medicine, in many ways, is changing. Patient-centered care is all the rage and the old, iconic image of the all-knowing, God-like doctor is fading away.

In one concrete example of this shift, a new Medical College Admission Test (MCAT) is just around the corner. Starting in spring 2015 for the class that will enter medical school in the fall of 2016, the new MCAT promises a “better test for tomorrow’s doctors.”

Among other changes, it will have a new section focusing on the social determinants of health — essentially asking students to consider how income and social status, education, home and work environments and other factors shape health outcomes.

Premedical education takes place at the undergraduate level. I went to medical school, but now spend most of my time working with undergraduates in the classroom.  I often think about what I learned in medical school and how it translates — or doesn’t translate — to teaching, and why it matters.

Of course, there are the obvious connections. One of the classes I teach is comparative vertebrate anatomy, and I use what I learned about anatomy in medical school directly in this class.

But there are other lessons that don’t apply. Doctors often use three-letter abbreviations in their notes. HPI is the history of the present illness, the patient’s narrative of what brought them to the doctor’s office or hospital, as heard and interpreted by the physician.

CAD is coronary artery disease. TIA is a transient ischemic attack, a “mini-stroke.”

There is a saying I remember from medical school: Physicians are especially fond of TLA’s … three letter abbreviations.

I don’t use many acronyms in my teaching. But sometimes, it’s helpful: For problem sets, I sometimes use “PS.” However, when I do this, I am inundated with emails and questions asking what they mean.

In medical school, mnemonics are also widely used to help aspiring physicians learn and remember all kinds of information. The 12 cranial nerves can be recalled using the mnemonic “On Old Olympus’ Towering Top, A Finn And German Viewed Some Hops,” where the first letter of each word of the saying is the first letter of each of the cranial nerves: olfactory, optic, oculomotor, trochlear, trigeminal, abducens, facial, auditory, glossopharyngeal, vagus, spinal accessory, and hypoglossal.

Or, for Harry Potter aficionados, there is “Only Owls Observe Them Traveling And Finding Voldemort Guarding Very Ambiguous Horcruxes.”

These are handy, but I learned so many mnemonics in medical school that I often had trouble remembering which mnemonic was used for what kind of information. Is that the mnemonic for the cranial nerves, or the bones in the wrist, or the femoral triangle, or the major branches of the aorta?

For this reason, I also shy away from using these in my teaching, except perhaps when I am teaching the cranial nerves.

But then there are sayings. It’s these that have stuck with me and are surprisingly relevant to teaching.

When I went to medical school, the first two years were classroom-based, where we learned everything from anatomy to physiology to biochemistry to embryology to genetics to neuroscience. The last two years were spent in the hospital or doctor’s office.

This is where we began to learn clinical medicine: how to interact with patients, how to take a history, how to apply what we learned in the classroom to real people with real illnesses.

There is a saying I remember from my surgery rotation, one that is well known to physicians: “See one, do one, teach one.”

What this means is that to learn anything new – say, how to do a physical exam, or stitch a laceration, or do an EKG – first watch someone else do it. Like an apprentice, the first step is to watch an expert carrying out the task at hand. Then, do one. You may feel shaky or unsure, but there is no substitute for doing something yourself. You probably start with someone watching and guiding your every move, but, as you gain confidence and expertise, you do it by yourself.

Finally, teach what you learned to someone else. This time-honored idea has sometimes been called into question, raising issues of whether it leads to competency. Nevertheless, it provides lessons for teachers, and I remember it when I think about teaching something new. While lectures are sometimes frowned upon these days as being passive, I find them useful as one part of a larger plan.

That is, a well-crafted lecture can give a perspective or overview that helps a student wrap their heads around a new or complex topic. This is the “see one.”

The problem is not lectures, but relying solely on lectures. The important thing is not to stop there. “Do one,” as the saying goes. Students need to construct their own knowledge, and it’s unlikely they will internalize what is being taught if all they do is sit passively listening to someone else go through the mental gymnastics, as Scott Freeman and colleagues convincingly demonstrated in a recent study. By doing something themselves – a problem, a hands-on activity, a group project – they run into their own questions and obstacles and have a chance to develop deep, meaningful learning.

But the gold standard is teaching. When you can explain something to someone else, then you really understand it. I find that it actually takes teaching something for several years, several times, until I really have a good handle on a particular topic.

There is one more saying that is well known to physicians – “First do no harm.” The Hippocratic Oath doesn’t contain these exact words, but the idea is expressed there.

When I went to medical school and worked at a hospital, this always seemed like a fairly low bar to me. That is, I went to medical school to care for people, to make them better, to cure disease. But the Hippocratic Oath does not mention any of these high ideals. Instead, it implores physicians to not make things worse.

It turns out, I learned, there are many ways to make things worse: Leaving a patient waiting too long in the waiting room when urgent attention is needed, making the wrong diagnosis, not treating patients with care and empathy, prescribing the wrong medicine, not being aware of side effects or how different medicines interact. The list is long and worrisome.

In teaching, I also keep the Hippocratic Oath front and center. What sort of harm could come from teaching? Harm comes if I am not able to connect with a student, if I cement a misconception rather than unseating it, if I don’t inspire students, if I don’t convey the wonder of the natural world.

It also comes if I make science seem too difficult, or not applicable to students’ lives, or simply a list of terms and facts to memorize.

These are all forms of harm, perhaps not life-threatening, but nevertheless ones that are hard to recover from. How many times have I heard a student say that he or she is not a “science person”? We are all science people in that we ask questions, come up with explanations, test them, and use science to understand the world around us.

But, somewhere along the road, harm was done.

Teachers, after all, can have a profound effect on students, on their attitudes about learning, on what careers they choose, about how they look at the world around them.

Consider what you do today or what you find interesting, and ask yourself – was there a teacher that inspired you? Sometimes, I think the best medicine in teaching is just a little TLC.

James Morris is Associate Professor of Biology at Brandeis University. More of his essays can be found on his Science Whys blog.

Categories: Health Care

Gov. Patrick Announces $1M Grant To Help Develop Faster Ebola Test

CommonHealth (WBUR) - Tue, 12/16/2014 - 11:16am

Dr. Rick Sacra, a Massachusetts doctor who contracted the Ebola virus in Liberia, and Gov. Deval Patrick converse Tuesday at the State House. (Stephan Savoia/AP)

The Massachusetts Life Sciences Center, a quasi-public agency, will issue a $1 million grant to help develop a faster, more accurate test for diagnosing Ebola, Gov. Deval Patrick announced Tuesday.

Also Tuesday, a Massachusetts doctor who had Ebola announced he’s returning to Liberia, where he contracted the virus, to resume his work.

The grant will support a partnership of local life sciences companies, nonprofits and academic institutions that will try to speed up the launch of an Ebola detection tool already in development by Diagnostics For All, a nonprofit organization.

Officials on hand for the State House announcement promised the new tool — which will accept a “single finger-stick of blood” and provide a clear “yes” or “no” response in 45 minutes — will be cheaper, easier to use and lead to earlier diagnosis than current tests.

They said current tests are time- and labor-intensive and not always sensitive enough to detect Ebola at its earliest onset, which they said is critical to containing and effectively treating the disease.

Patrick said the investment would assure that Massachusetts will play a central role in saving many lives from the deadly virus.

Richard Sacra, a Massachusetts doctor cured of Ebola in the U.S. after working in Liberia, said the testing tool would make an enormous difference for West Africa, where there have been nearly 18,000 confirmed or suspected cases and approximately 6,400 deaths.

Sacra, a faculty member at the University of Massachusetts Medical School, also announced he’s returning to Liberia to resume working at a medical mission.

Sacra, who was one of at least 10 people so far treated for Ebola in the U.S., says he “feels great” and that doctors have said he’s now effectively immune to Ebola, which has no vaccine.

“I’m not hearing a lot of pushback from home,” Sacra said. “I’ve been working there for years, and my risk at this point is no different than it was before because I’m immune to Ebola.”

The $1 million “challenge” grant requires the partnership to raise an additional $4.5 million and deliver a field-ready product within six months.

The partnership will be headed by Diagnostics For All and includes Harvard University, UMass Medical School, GE Healthcare and Cambridge Consultants, among others.

This post was updated at 2:38 p.m.

Categories: Health Care

Rx For Reform: NC Pharmacists Try To Boost Health And Cut Costs

Kaiser Health News - Tue, 12/16/2014 - 10:38am

When Robin Blakeney of Concord stopped taking some of her medications to save money, she ended up hospitalized for two weeks.

Blakeney, who has congestive heart failure, diabetes and high blood pressure, is the kind of fragile patient who accounts for an outsized share of America’s soaring health care tab. The federal government has invested $15 million in a North Carolina experiment that gives community pharmacists a new role in patient care.

The pharmacy project is part of a 10-year, $10 billion federal exploration to overhaul the nation’s health care system. The Affordable Care Act created the Center for Medicare and Medicaid Innovation to launch experiments in every state. Successes can serve as models for national reform.

The office’s goal is lofty: making medicine less of an ordeal, improving patients’ health, and controlling the spiraling costs that burden taxpayers, employers and consumers.

The project created by the nonprofitCommunity Care of North Carolina gives pharmacists access to medical information about high-need patients and reimburses them for the extra work.

When Blakeney got out of the hospital this fall, Moose Pharmacy sent someone to her house to review her prescriptions and her follow-up care. Her drugs now come in a packet that she opens twice a day: eight pills each morning, four in the afternoon. The pharmacy delivers refills to her house, and pharmacist Carlie Traylor calls to check on Blakeney.

This copyrighted story comes from The Charlotte Observer, produced in partnership with KHN. All rights reserved.

If the effort works, it will keep the 45-year-old woman healthier and out of the hospital.

“People generally know their pharmacists, especially the small-town ones. They’re a good community contact,” said Paul Mahoney, vice president for communications with Community Care, a public-private partnership dedicated to improving care and controlling costs.

Keeping Patients On Track

People with complex medical conditions generally have a long list of medications, often prescribed by different doctors.

A national study of Medicare patients with multiple chronic illnesses found that they see an average of 13 doctors and have 50 prescriptions filled per year, said Troy Trygstad, vice president for pharmacy programs at Community Care. They see a doctor two or three times a year – and a pharmacist two or three times a month, he said.

Even before the federal grant, Moose Pharmacy, which has five Cabarrus County locations, was part of a local medical network putting those contacts to use. Doctors make sure the pharmacist knows the patient’s treatment plan, and pharmacists make home visits to see whether that plan is being carried out.

Owner Joe Moose says his staff has made about 1,000 visits: “We have yet to have a patient who’s actually taking what the physician thought they were on.”

Some are confused about their regimen, while others are just forgetful. Some suffer side effects and drop drugs without consulting their doctors. Some, such as Blakeney, skimp when they run out of money.

As a result, controllable conditions can turn into crises, sending patients to the emergency room and leading to hospital admissions. Not only do costs skyrocket, but patients’ lives and well-being are put at risk.

“These are expensive failures,” Moose says.

Moose and his staff use tactics such as packing multiple medications together, making check-in calls and reminding patients of the need for tests, such as blood pressure checks and blood glucose monitoring for diabetics. If they see something going wrong, they can alert the doctor.

Blakeney says she loves the new approach. She said Moose Pharmacy lets her charge her medications and makes sure there are no gaps between refills.

Expanding The Model

The Community Care program is working with about 120 pharmacies around the state, many in rural areas where distance adds to the challenge of seeing a doctor.

Community Care already works with 1,800 medical practices and asked those offices to identify pharmacies that would be good partners. Trygstad says he was pleasantly surprised by how readily the doctors embraced the idea of letting pharmacists help manage care for the most challenging patients – people with such conditions as heart disease, diabetes, behavioral health issues, asthma and chronic pain.

The traditional model involves very little contact between the doctors who write prescriptions and the pharmacies that fill them. The pharmacies are paid for the drugs they sell, regardless of whether they provide great personal service or none at all.

Under the new model, pharmacies get $70 to $95 for the initial work-up, which can take 30 to 90 minutes, and a monthly fee of $2 to $5 for each of the chronically ill patients taking part. There’s also a “pay-for-performance” reward based on such measures as patient health, quality of life, and reduction in hospital admissions and emergency room visits.

The grant program provides technology to ensure that pharmacies can track information about their patients, such as hospital admissions and discharges and care plans from all their doctors.

The Eshelman School of Pharmacy at UNC Chapel Hill is working with Community Care to monitor the program and tweak it to work better during the three-year grant. The federal government will also hire an outside evaluator.

The center is doing the same for grant recipients across the nation to determine whether successful results could be expanded. But those contractors are prohibited from disclosing data to anyone other than the center. The health law requires the federal government to disclose evaluation reports on its tests “in a timely fashion,” but so far the innovation center itself is largely silent.

One reason is that it’s early, officials say; there’s no reason to publish results in the first or second years of a three-year study. Another reason is the political risk of revealing the investments that don’t produce results. Some failures are inevitable, federal officials say, but even those will produce useful information on what doesn’t work.

Categories: Health Care

Why To Exercise (Outdoors) Today: Tranquility For Aging Ladies

CommonHealth (WBUR) - Tue, 12/16/2014 - 10:20am

(frodrig/Flickr)

It’s cold, it’s dark, it’s uninviting out there. So, all the more reason to drag yourself outside and do something.

In yet another study on how exercise can combat the bad physical and mental effects of aging, new research suggests that women who can get out the door, fight the elements and exercise might find some nifty benefits. Those benefits include alleviating depression and increasing adherence to an exercise program.

The small study, published in the journal Menopause, asserts it’s the outside air that really helps (as opposed to the stuffy gym or the treadmill in your basement, though I’ve found that when you’re desperate, those work too):

“Between baseline and week 12, depression symptoms decreased and physical activity level increased only for the outdoor group…” write the authors, led by Isabelle Dionne of the University Institute of Geriatrics of Sherbrooke in Quebec.

From the Reuters report:

Outdoor workouts left women in a better mood and kept them exercising longer than counterparts who exercised indoors, according to a small study from Canada.

Results of the three-month trial involving women in their 50s and 60s suggest that outdoor exercise programs should be promoted to help older women keep active, the researchers conclude…Only about 13 percent of Canadian women older than 59 years and less than 9 percent of older American adults get at least 150 minutes of physical activity each week…

For the study, Dionne and her colleagues enrolled 23 post-menopausal women to participate in a 12-week long exercise program…

The women were randomly assigned to one of two groups. One group exercised together outdoors three times per week while the other group followed the same program indoors. The exercise programs included both aerobic exercises and strength training.

The women were asked how they were feeling before and halfway through their midweek sessions. In addition, before and after their workouts, the women answered questionnaires designed to measure feelings of positive engagement, revitalization, physical exhaustion and tranquility.

The study team found that on average, the women who exercised outdoors had a greater sense of tranquility after working out and attended more sessions – 97 percent of the 36 sessions in the trial for the outdoor exercisers compared to 91 percent of sessions attended by the indoor group.

Categories: Health Care

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