Thursday, May 17, 2012

FBI Behavioral Analysis Unit (BAU)

by Shelly on May 11, 2012

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The FBI’s Podcasts and Radio page offers a fascinating account of what it’s like to be a Behavioral Analyst. “Making sense of the incomprehensible. That’s the specialty of the eight agents of the FBI’s Behavioral Analysis Unit-2, or BAU-2”, shares FBI’s Mollie Halpern. “They get inside the twisted minds of serial murderers like Ted Bundy, Jeffrey Dahmer, and John Allen Muhammed”.
Contrary to fictional depictions, members of the BAU are not necessarily called out to crime scenes or in charge of an investigation; many times they act as consultants, sharing their expertise in order to contribute to cases being closed. FBI Behavioral Analysts are assigned to work for the National Center for the Analysis of Violent Crime (NCAVC) based in Quantico and each FBI field office is staffed with a NCAVC supervisory agent.
The NCVAC has four Behavioral Analysis Units: BAU-1 deals with counterterrorism/threat assessment, the BAU-2 deals with crimes where adults are the victims, BAU-3 deals with cases where children are the victims and the BAU-4 focuses on ViCAP. ViCAP stands for the Violent Criminal Apprehension Program which has the largest database of violent crimes, including murder, abductions, and sexual assaults, in the United States.
So while members of the BAU may not lead SWAT teams into a suspect’s home, physically chase after a fugitive or directly interrogate potential criminals, they do play vital and intriguing roles in assisting law enforcement agencies, such as developing the profile of an Unsub, providing key recommendations for how to interview a suspect, assessing threats, providing information to legal counsel and many more.
“The type of cases we get involved in … are the type of cases that the average individual struggles to understand themselves,” states the FBI’s BAU-2 Mark A. Hilts. “Why would somebody kill 10 different people over a year’s time period? What kind of person would chop somebody up or would carve something into a victim or would do some other bondage or other type of activity?”
If you’re interested in working for NCAVC as a Behavioral Analyst with the FBI, a degree in behavioral or forensic science, criminal justice or criminology would be extremely helpful. Those who wish to work for the NCVAC are eligible after they’ve served a minimum of three years as a special agent. However, many of these supervisory special agents have at least eight years experience with the FBI before being considered for a promotion to the NCVAC. Naturally, exemplary service as a special agent will increase your chances of being promoted to the BAU. “The most important qualifications include overall experience as an investigator specializing in violent crimes, particularly homicides, rapes, child abductions, and threats”, states the FBI Career Page.

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Tuesday, May 15, 2012

Mental Illness (Stanford Encyclopedia of Philosophy)

Mental Illness

First published Fri Nov 30, 2001; substantive revision Mon Feb 22, 2010

Psychiatry involves theories of the mind, theories of the causes of mental disorders, classification schemes for those disorders, research about the disorders, proven treatments and research into new treatments, and a number of professions whose job it is to work with or on behalf of people with mental disorders. The philosophical study of psychiatry discusses conceptual, ethical, metaphysical, social, and epistemological issues that arise in all these aspects of psychiatry. Central to this study is the nature of mental illness.
The central philosophical debate over mental illness is not about its existence, but rather over how to define it, and whether it can be given a scientific or objective definition, or whether normative and subjective elements are essential to our concept of mental illness. One desideratum for a successful definition of mental illness is that it will settle debates over particular purported mental illnesses.
The connection between philosophical issues in the study and treatment of mental illness and these other areas of philosophy is in many cases obvious, as in the question of when and how people with mental disorders are responsible for their actions is connected with the insanity defense in law, and the more general debate over the justification of punishment. The philosophical investigation of the nature of mental illness is therefore relevant to many other areas of philosophy. While there is no sharp divide between the philosophical discussion of the nature of mental illness and the wider philosophical discussion of psychiatry, we can focus on four major issues that have preoccupied the philosophical literature.

What can philosophy do for psychiatry?

World Psychiatry. 2004 October; 3(3): 130–135.

PMCID: PMC1414692

What can philosophy do for psychiatry?

Kenneth WM Fulford,^1,^2,³ Giovanni Stanghellini,^3,⁴ and Matthew Broome^3,⁵

¹Department of Philosophy, University of Warwick, Coventry, UK

²Department of Psychiatry, University of Oxford, UK

³WPA Section on Philosophy and Humanities in Psychiatry

⁴Department of Mental Health, University of Florence, Italy

⁵Institute of Psychiatry, University of London, UK

This article has been cited by other articles in PMC.

Abstract

This article illustrates the practical impact of recent developments in the philosophy of psychiatry in five key areas: patient-centred practice, new models of service delivery, neuroscience research, psychiatric education, and the organisation of psychiatry as an international science-led discipline focused on patient care. We conclude with a note on the role of philosophy in countering the stigmatisation of mental disorder.

Keywords: Concepts of disorder, classification, neuroimaging, early diagnosis, values-based practice, patient-centred practice

According to the great 20th century psychologist and philosopher William James, philosophy is "an unusually stubborn effort to think clearly" (1). The need for clear thinking in psychiatry arises from the fact that our subject raises problems of meaning alongside empirical difficulties in a particularly acute way. A recent Forum in World Psychiatry, dealing with "the challenge of psychiatric comorbidity" (2), makes the point. That Forum covered empirical issues such as the likely impact on psychiatric classifications of future advances in behavioural genetics (2, 3), but much of the debate was about conceptual difficulties; about the meanings, for example, of such key terms as "disease" and "disorder" (4), and "syndrome" (5); about the tension between "reliability" and various aspects of "validity" (6); and about the competing claims of categorical and dimensional classifications to reflect "the state of nature, not merely how clinicians think about the state of nature" (7).

As Allen Frances pointed out in his role as Chairperson of the DSM-IV Task Force (8), it is one thing to recognise the importance of conceptual difficulties in psychiatry, it is quite another to do something about them. In this article, therefore, we will be focusing not on problems but on solutions. The last few years have witnessed a remarkable explosion of cross-disciplinary work between philosophy and psychiatry (9). Rather than attempting a full review of the field, however, we will be illustrating what philosophy can do for psychiatry, with examples of what it is already doing in five key areas: a) patient-centred practice, b) models of service delivery, c) research, d) education and e) international organisations.

PATIENTS: PHILOSOPHY PUTS PATIENTS FIRST

Philosophy, through a new model linking values with evidence, called values-based practice (VBP), gives us specific tools to help make science work for us in a more patient centred way (10). VBP is the theory and skills-base for effective healthcare decision-making where different (and hence potentially conflicting) values are involved. VBP, somewhat like a political democracy, starts from respect for different values and relies on good process for its practical effectiveness.

Good process in VBP, as shown in Table Table1, depends1, depends on 10 key "pointers". The starting point of good process in VBP is careful attention to individual patients' values (pointer 1). Where values conflict, however, VBP seeks to achieve a balanced approach to clinical decision-making by drawing on a range of different value perspectives, represented here by the multi-disciplinary team (pointer 2). Achieving a balance of value perspectives in turn depends on four key clinical skills: raising awareness, reasoning skills, knowledge and communication skills (pointers 3 to 6). Values-based and evidence-based approaches, as the next three pointers (pointers 7 to 9) indicate, are complementary. In particular, as David Sackett, one of the leaders of evidence-based practice, has emphasised, they are both essential to building genuine partnership between professionals, their patients and their patients' families (11). This aspect of good process in VBP is reflected in the partnership model of decision-making summarised in Table Table11 in pointer 10.

Table 1

Ten pointers to good process in values-based practice

The philosophical sources of VBP include abstract formal disciplines such as linguistic analysis, phenomenology and hermeneutics (10). But its practical applications already include a number of both treatment (12) and policy and service development initiatives within the Modernisation Agency of the UK's National Health Service (www.connects.org.uk/conferences). Central to all these initiatives, is a training workbook covering the skills of VBP (13). This workbook, which is the result of a unique collaboration between a Philosophy Department (at Warwick University) and an in-service training provider (the Sainsbury Centre for Mental Health), has been recently launched in London by the Minister of State responsible for mental health, Rosie Winterton, and will be the basis for training of front-line clinical staff from April of next year in each of the main national health service (NHS) regions of England and Wales.

Future developments in VBP will be supported by a lively international programme of ongoing research. A particular focus of this research is the role of values in classification and diagnosis. The American psychiatrist and co-editor (with Fulford) of the international journal Philosophy, Psychiatry, & Psychology, John Sadler, has been particularly active in this field (14, 15). A research methods meeting last year in London, funded by the UK government, brought together work on values in diagnosis from phenomenological (, 17) and empirical (18) as well as philosophical sources. This work will contribute to the development of more inclusive models of psychiatric classification through the work of the WPA Sections on Philosophy and Humanities in Psychiatry and on Classification, Diagnostic Assessment and Nomenclature ().

There is also ongoing educational research. Werdie van Staden, a psychiatrist and philosopher at Pretoria University, and founder, with Tuviah Zabow at Capetown University, of the Philosophy Special Interest Group in the South African Society of Psychiatrists, has established a joint educational research programme with Warwick University Medical School, dealing with the effectiveness of training in VBP for medical students.

SERVICES: PHILOSOPHY SUPPORTS NEW MODELS OF SERVICE DELIVERY

Mental health services in many parts of the world are nowadays delivered by multi-disciplinary teams. This ensures that a variety of different skills– medical, psychological, social, etc. – are available to meet the needs of individual patients. However, team working is too often associated with conflicts and failures of communication, with the result that patients are at risk of "falling through the net" through lack of collaborative decision-making (20). In addition, there are some cultures with very different models of disorder altogether, for example where families and social networks are valued more highly than individual autonomy (21).

In a study combining philosophical work on concepts of disorder with empirical social science methods, Anthony Colombo and colleagues at Warwick University have shown that such difficulties in multi-disciplinary team working are often driven by unrecognised differences in models of disorder (). Despite the contested status of the concept of mental disorder, most mental health professionals nowadays claim to work within a shared biopsychosocial model (23). But what Colombo et al's study showed is that in practice, and often without being aware of it, different professional disciplines actually work with very different implicit models – hence the conflicts and difficulties in multi-disciplinary teamworking. Studies paralleling Colombo et al's project are currently underway at Linköping University in Sweden and at the Maudsley Hospital in London.

Colombo et al's study illustrates one of the general roles of philosophy in psychiatry. As the Oxford philosopher J. L. Austin put it, the characteristic output of philosophical "clear thinking" is to give us a more complete picture of the full meanings of the complex concepts by which we make sense of the world around us (24).

Phenomenology, and its close relatives existentialism and hermeneutics, are particularly helpful in giving us a "more complete" picture. Phenomenology, as Karl Jaspers (25, 26) recognised, provides a range of practical tools for working with personal meanings, alongside scientific findings, in psychopathology. This is important in research (see below). But phenomenology and related disciplines are already generating new models of service delivery more directly geared to individual and cultural meanings. Such models include the Irish psychiatrist and philosopher Patrick Bracken's use of Heideggerian phenomenology to support new approaches to the management of post-traumatic stress disorder in traditional societies (27), the American psychologist and philosopher Steven Sabat's use of discursive analysis to improve communication with Alzheimer's disease sufferers (28), and the Dutch philosopher Guy Widdershoven's work on collaborative decision-making, also in Alzheimer's disease, employing the "hermeneutic circle" (29).

RESEARCH: PHILOSOPHY RE-CONNECTS MINDS WITH BRAINS IN RESEARCH

It is no coincidence that the emergence of a new and vigorous philosophy of psychiatry in the closing years of the 20th century coincided with dramatic advances in the neurosciences (9). As no less a neuroscientist than Nancy Andreasen has pointed out, the neurosciences themselves are among the factors pushing traditional philosophical problems, such as the nature of personal identity and of our knowledge of "other minds", to the top of our agenda in psychiatry (30).

The new philosophy of psychiatry is certainly not shy of problems of this magnitude (31-33). The British psychiatrist Sean Spence's brain imaging studies of hysteria, for example, raise a number of the traditional problems of psychiatry in exactly the challenging way that Andreasen anticipated (34), and a joint research programme between Warwick and Oxford Universities and the Institute of Psychiatry in London, funded by the McDonnell-Pew Centre for Cognitive Neuroscience in Oxford, has brought together philosophers, neuroscientists and patients, in a collaborative study of schizophrenia published as a special double issue of Philosophy, Psychiatry, & Psychology, edited by the Warwick philosopher Christoph Hoerl (35).

It is however particularly through the phenomenological tradition, with its focus on subjective experience, that the new philosophy of psychiatry is connecting most directly with neuroscience research (36-39). Imaging studies, in particular, demand more sophisticated ways of characterising and defining the contents of experience and how these are linked to brain functioning (40, 41). The work of the Cologne group on early detection and prediction of psychotic illnesses, for example, draws directly on phenomenological methods (). Research in this area is a two way process, however, in which phenomenology and philosophy of mind also draw on the rich varieties of psychopathology (43, 44).

Early in the field with the potential applications of phenomenology to psychopathology was of course Karl Jaspers (45), perhaps the first philosopher-psychiatrist. Building on a strong 20th century tradition of conceptually informed work on classification and diagnosis (46, 47), the new philosophy of psychiatry has picked up Jaspers' concern to link meanings with causes in psychopathology (48-51). But a strong tradition of phenomenological work was maintained through much of the 20th century in a number of European countries (notably France, Germany and Italy), in Japan and in South America (9).

It is impossible within the scope of this article even to list the many distinguished recent contributors to this tradition. The main areas of work include both specific symptoms (52-55) and wider issues of psychiatric nosology (56). Examples of work in this area, drawing on the phenomenologies of such seminal 20th century philosophers as Martin Heiddegger, Maurice Merleau-Ponty and Jean Paul Sartre, are included in a number of recent collections (9, 57); new work is reviewed regularly in the History and Philosophy section of Current Opinion in Psychiatry (e.g., 58); and a more comprehensive treatment will be given in one of the volumes in the new book series from Oxford University Press on International Perspectives in Philosophy and Psychiatry (59).

EDUCATION: PHILOSOPHY CONTRIBUTES TO GENERIC SKILLS TRAINING IN PSYCHIATRIC EDUCATION

Research in the philosophy of psychiatry requires the same high-level skills as in any other technical discipline. When it comes to education and training, however, philosophy has a wider contribution to make to psychiatry, through the development of the generic thinking skills, the "clear thinking" of William James' aphorism (above), that are essential in all areas of practice.

The training manual for VBP noted above is a well-developed example of the effectiveness of philosophy in this respect (13). The exercises used for the development of VBP-skills are based directly on ideas from philosophers such as J.L. Austin (24) and R.M. Hare (60), working in the most abstract areas of philosophical value theory. Yet, these training exercises have been particularly well received, in pilot studies, not by academic psychiatrists, but by patient advocates, mental health nurses, social workers and others, working in such challenging areas of front-line mental health practice as crisis intervention and assertive outreach (61).

A full curriculum for philosophy of psychiatry has been introduced in the latest revision of the Royal College of Psychiatrists' curriculum for higher psychiatric training, the "MRCPsych" (62). Besides other sources cited in this article, training in this area will build on rich resources from classical philosophy (63, 64) and history of ideas (65, 66).

ORGANISATIONS: PHILOSOPHY UNDERPINS AN 'INTERNATIONAL' OPEN SOCIETY IN MENTAL HEALTH

Psychiatry is peculiar among medical disciplines in being particularly vulnerable to abusive uses for purposes of political or social control. The notorious "delusions of reformism", the basis on which political dissidents were diagnosed with "schizophrenia" in the former Soviet Union, is but one example of our vulnerability in this respect (67).

The prevention of such abuses involves a wide range of resources –political, scientific, legal and educational. Philosophy contributes generally in each of these areas, drawing on cross-cultural () and historical (69, 70) scholarship and political philosophy (71). Among other results, such work shows that the underlying vulnerability of psychiatry in this respect arises from a failure to maintain a balance of different perspectives. In the Soviet Union, it was the unbalanced dominance of the Soviet ethic that distorted diagnostic judgements (). This led to a kind of conceptual blindness arising from what the 17th century political philosopher, and founder of British empiricism, John Locke, called "enthusiasms" (73). We have seen similar "enthusiasms" in psychiatry throughout the 20th century– for psychoanalysis at one stage in America, for example, and more recently, in some quarters, for a narrow model of "biological psychiatry" (74).

We can counter such "enthusiasms" only by maintaining what Jim Birley, a Past President of the Royal College of Psychiatrists, and founder chair of the reforming organisation Geneva Initiative for Psychiatry, has called an "open society" in international psychiatry (75). The new philosophy of psychiatry will contribute to maintaining such an open society, partly through the more complete picture of the conceptual structure of the subject which, as noted above, is its characteristic output, but also, and importantly, through its own organisation as an open and collegial discipline, inclusive of methodological pluralism, and embracing intellectual and cultural diversity (9).

Future international developments in the philosophy of psychiatry will be supported by an International Network for Philosophy and Psychiatry (INPP), launched from South Africa as part of the 2002 biennial meeting of the South African Society of Psychiatrists, hosted by Professors Tuviah Zabow and Werdie van Staden. The INPP has been set up to support local, national and subject based organisations. Collaborating closely with new Sections in both the WPA and the European Psychiatric Association, the INPP will aim to contribute to the development of international psychiatry as a strongly dynamic "open society" of the kind Jim Birley envisaged.

CONCLUSIONS: PHILOSOPHY PUTS PSYCHIATRY FIRST

Perhaps the deepest difficulty with which psychiatry ended the 20th century was the continuing stigmatisation to which both patients and practitioners were subject. Despite developments in the neurosciences, psychiatry was still perceived by many as being somehow "unscientific" (76), and mental disorders continued to carry unwarranted negative associations such as violence and untreatability (12).

Philosophy, in giving us a more complete picture of the conceptual structure of psychiatry, shows that our subject, far from being scientifically deficient, is simply a good deal more difficult than other areas of healthcare. Philosophy is important in psychiatry for much the same reason that it is important in theoretical physics. Both disciplines demand clear thinking about concepts as well as sophisticated scientific instruments for gathering data.

As we enter the 21st century, however, other areas of medicine, besides psychiatry, will increasingly face conceptual difficulties driven by scientific advances (77). In engaging with philosophy, therefore, across the five key areas outlined in this article, psychiatry, far from running second to the rest of medicine as it did in the 20th century, is leading the way for 21st century medical science.

Acknowledgement

The Table is based on a figure published in Woodbridge K, Fulford KWM. Whose values? A workbook for values-based practice in mental health care. London: Sainsbury Centre for Mental Health (in press), and we are grateful to the Sainsbury Centre for Mental Health in London for permission to reproduce it here.

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Philosophy and Mental Health - Tim Thornton

Philosophy and Mental Health - Tim Thornton

Philosophy and Mental Health

Because of its very nature, mental health care raises as many conceptual questions as empirical ones. The philosophy of mental health - also called the 'new philosophy of psychiatry' although it is not narrowly psychiatric - is a rapidly developing field developed by philosophers, clinicians (e.g. psychiatrists and mental health nurses) and mental health service users.

As well as its youth, the new philosophy of psychiatry has two further features that make it stand out. Firstly, it is not a 'natural kind'. There is not an established set of inter-related problems with familiar, if rival, solutions. It is an area where philosophical methods, accounts and theories can be applied to psychiatric phenomena and thus it also serves to test those accounts. To take one type of example, psychopathology is a test track for theories in the philosophy of mind. Symptoms such as thought insertion, where subjects experience their thoughts as somehow not their own, challenge accounts of the everyday 'ownership' of thoughts. But there is also traffic the other way. Three centuries of discussing the relationship of mind and body have furnished philosophers with a variety of subtle models (from forms of dualism, through gradations of physicalism, to eliminativism with modern alternatives such as enactivism) which can help in the interpretation of psychiatric data.

Secondly, unlike some areas of philosophy, philosophy of psychiatry can have a genuine impact on practice. It is a philosophy of, and for, mental health care. It provides tools for critical understanding of contemporary practices, and of the assumptions on which mental health care more broadly, and psychiatry more narrowly, are based. Thus it is not merely an abstract area of thought and research, of interest only to academics. In providing a deeper, clearer understanding of the concepts, principles and values inherent in everyday thinking about mental health, psychiatric diagnoses and the theoretical drivers of mental health policy, it can impact directly on the lives of people involved in all aspects of mental health care.
Values, meanings, facts
A brief examination of the history of the subject reveals why the discipline of psychiatry is particularly suited to contributions from philosophy. Whilst the father of psychopathology, the German philosopher and psychiatrist Karl Jaspers, combined psychiatric and philosophical expertise, within the English speaking tradition philosophy and psychiatry went their separate ways throughout most of the twentieth century. (By contrast, in mainland Europe the connection between psychiatry and phenomenological philosophy has continued since Jaspers' day.)
But towards the end of the twentieth century, the rise of the anti-psychiatry movement prompted a resurgence of philosophical interest in psychiatry. This was because a key element of the anti-psychiatric criticism of mental health care turned on a contentious claim about the nature of mental illness: mental illness does not exist; it is a myth. Such a sceptical claim is paradigmatically philosophical and one of the main proponents of anti-psychiatry, the psychiatrist Thomas Szasz, put forward a number of philosophical arguments in support of it. These turned on the fact that psychiatric diagnosis is essentially evaluative. From this he concluded that, unlike physical illness, it could not be medically treated because as illness it was not real. (The apparent reality of mental illness is best explained, according to Szasz, as the reality of non-medically treatable life problems.)
Szasz's sceptical arguments spurred responses by both psychiatrists and philosophers questioning whether diagnosis is, after all, essentially evaluative and, if it is, whether Szasz's conclusions followed. Thus the analysis of mental illness, and the role of values in that analysis, lies at the heart of recent philosophy of psychiatry.
In addition to the importance of values, two further key areas of mental health care prompt immediate philosophical questioning. Firstly, psychiatry since Jaspers has sought to balance two key elements: investigation of the bio-medical facts and empathic investigation of subjects' experiences. Both bio-medical facts and meanings (broadly construed to include experiences, beliefs and utterances) need somehow to be integrated into mental health care. This marks a sharp delineation from other areas of medicine where subjects' experiences are subordinate to the physically described symptoms and organic pathology with which they present. By contrast, psychiatric disorders seem to involve problems of the 'self' (however this is construed) in which experiences, behaviour and beliefs play a fundamentally important role in the onset, course and recovery of symptoms.
This raises questions of both the nature of the distinction between explanation according to the canons of the natural sciences (the 'realm of law') and understanding meaningful connections (in the 'space of reasons') and the relationship between natural scientific facts and meanings. If there is a clear distinction and meanings are conceptually irreducible to biomedical facts, efforts to understand the nature of this relationship become all the more philosophically interesting.
Secondly, there has been much work by psychiatrists since the Second World War to develop psychiatric classification or taxonomy. This has, historically, been in response to a concern about a lack of agreement or reliability about psychiatric diagnosis. More recently, there has been growing concern that reliability has been improved but only at the cost of validity, or underlying truth, of classificatory schemas. The worry is that psychiatric diagnostic systems may not 'carve nature at the joints'. This concern has also been reflected in philosophy of psychiatry as an instance of a broader question of the role of science in mental health care. Thus the nature of the facts in question is still very much up for grabs.

Philosophical Perspectives on Psychiatric Diagnostic Classification (The Johns Hopkins Series in Psychiatry and Neuroscience): Dr. John Z. Sadler MD, Dr. Osborne P. Wiggins Jr. PhD, Dr. Michael A. Schwartz MD: 9780801847707: Amazon.com: Books

Philosophical Perspectives on Psychiatric Diagnostic Classification (The Johns Hopkins Series in Psychiatry and Neuroscience): Dr. John Z. Sadler MD, Dr. Osborne P. Wiggins Jr. PhD, Dr. Michael A. Schwartz MD: 9780801847707: Amazon.com: Books

Philosophical Perspectives on Psychiatric Diagnostic Classification (The Johns Hopkins Series in Psychiatry and Neuroscience) [Paperback]

Dr. John Z. Sadler MD (Editor), Dr. Osborne P. Wiggins Jr. PhD (Editor), Dr. Michael A. Schwartz MD (Editor)

Book Description

Publication Date: April 1, 1994 | Series: The Johns Hopkins Series in Psychiatry and Neuroscience

As the biological and psychosocial technologies in psychiatry continue to expand, the need for careful critical reflection on the scientific, ethical and practical aspects of psychiatry becomes ever greater. In "Philosophical Perspectives on Psychiatric Diagnostic Classification", John Osborne Wiggins, Michael Scwartz and others present a philosophical exploration of conceptual difficulties in psychiatric taxonomies or nosologies, using the current official American Psychiatric Association diagnostic handbook, the "Diagnosis and Statistical Manual of Mental Disorders (DSM)" as an example.

Editorial Reviews

Review

"The book begins with a 'must read' introductory and historical chapter by Edwin R. Wallace IV that provides a good foundations for readers embarking on a philosophical journey through psychiatric taxonomy." -- Journal of the American Medical Association