M. Murat Civaner

Giris ve Amac: Gunumuzde giderek populerlik kazanan ‘Geleneksel’ ve ‘Tamamlayici’ tip (GTT) uygulamalarinin bilimselligi tartismalidir. Bu calisma, ulkemizde yasallastirilan GTT yontemlerinin etkililik ve guvenliligi uzerine yeterli duzeyde kanit olup olmadigini arastirmayi amaclamaktadir. Gerec ve Yontem: Cochrane Sistematik Derleme Veritabani’nda 27 Aralik 2018-12 Şubat 2019 tarihleri arasinda, tum uygulamalari temsil eden  anahtar kelimeler ile bir arama stratejisi olusturularak sistematik literatur taramasi yapilmistir. Fitoterapi calisma kapsamina alinmamistir. Toplamda 490 calismaya ulasilmis, ozetleri degerlendirildikten sonra 275 arastirma calisma disi birakilmistir. Hayvan ve/veya insan calismalarindan olusan, mudahale gruplarinda literaturdeki GTT uygulamalarindan bir veya birden fazlasini icermekte olan, kontrol olarak plasebo, ilac veya baska bir GTT uygulamasini degerlendiren, butun sistematik derlemeler meta-analiz kosulu aranmadan dahil edilmistir. Calismaya dahil arastirmalarin ulastigi kanitlarin niteligi Cochrane GRADE yaklasimi kullanilarak kayit altina alinmistir. Bu yaklasim ile kanit duzeyleri, dahil edilen arastirmalarin tipi, arastirma tasarimindaki kisitliliklar ve bias olasiliklari gibi etmenler degerlendirilerek belirlenmektedir. Her uygulama icin kanitlar ‘yuksek/orta/dusuk kalite’ biciminde siniflandirilmistir. Bulgular: Akupunktur ile ilgili calismalardan; cesitli endikasyonlarda etkililige yonelik 13 dusuk, dort orta duzeyde kaliteye sahip kanit elde edilirken, 13 calismada etkililiginin bulunmadigi gosterilmistir. Ayrica guvenlilige dair alti adet dusuk kalite ve bir adet orta kalite kanit mevcuttur. Apiterapinin bazi endikasyonlardaki etkililigine dair uc dusuk, iki orta ve bir adet yuksek duzeyde kaliteli kanitlara ulasilmis, bes calismada etkililiginin bulunmadigi gosterilmistir. Guvenliligine yonelik kesin kanitlar bulunamamakta; ari venom tedavisi alan hastalarin %14.2’sinde sistemik yan etkiler goruldugu bildirilmektedir. Apiterapi ile ilgili yuksek kalite duzeyine sahip cikti, balin yanik yaralarinin iyilesmesini hizlandirdigina dairdir. Hipnoterapinin bazi endikasyonlarda etkili olabilecegini gosteren dort dusuk kaliteli kanita ulasilmis, iki calismada etkili olmadigi gosterilmistir. Homeopatinin etkililigine dair var olan tek kanit dusuk niteliklidir ve Molluskum Kontagiozum’da plaseboya karsi ustunlugunu gostermektedir. Guvenliligine iliskin yine bir adet dusuk duzeyde kanit bulunmaktadir. Buna karsilik Homeopatinin etkili olmadigini gosteren dort calismaya ulasilmistir. Kayropraksinin etkililigine yonelik iki dusuk kaliteli kanita ulasilirken; Osteopati icin bir dusuk, bir orta duzeyde kanita ulasilmistir. Suluk, larva, Ozon tedavisi, Refleksoloji ve Proloterapi’nin etkili olabilecegini bildiren birer calisma mevcut iken kanit kalite duzeyleri belirsizdir. Bu uygulamalarin guvenliligine dair kanitlara ulasilamamistir. Refleksolojinin etkili olmadigini gosteren bir calisma mevcuttur. Kupa tedavisi icin sadece iki calismaya ulasilmistir ve ikisi de etkili olmadigini bildirmektedir. Ek olarak, bir calismada islak kupa tedavisinin bazi istenmeyen etkilerinin olabilecegine dair uyarida bulunulmustur. Muzik terapisinin etkililigine yonelik 13 dusuk ve uc orta duzeyde kaliteli kanitlara ulasilmis, bir calismada ise etkili olmadigi bildirilmistir. Mezoterapi hakkinda herhangi bir calismaya ulasilamamistir. Sonuc ve Oneriler: Calismaya dahil edilen geleneksel ve tamamlayici tip uygulamalarinin etkililigine iliskin tek yuksek nitelikli kanit, balin yanik yaralarinin iyilesmesini hizlandirdigina iliskindir; ancak apiterapinin guvenliligine dair yeterli kanit yoktur. Diger yontemlerin etkililik ve guvenliligini gosteren yeterli duzeyde yuksek kaliteli kanit bulunmamaktadir. Bu yontemlerin uygulanabilmesi icin daha fazla sayida yuksek kaliteli kanita ihtiyac vardir. Anahtar Sozcukler: Geleneksel Tip, Tamamlayici Tip, Sistematik Derleme

... Martial Massin Bernhard Meier Selma Metintaş Emine Dibek Mısırlıoğlu Wail Nammas Hüseyin Okutan Ahmet Özkara Namık Özmen Ümit Özyurda Bahar ... bir araflt›rman›no konunun otörü veya iyi de€erlendirme yapan hakem taraf›ndan k›saca de€erlendiril mesi amac› güder. ...

Background: As the information age wanes, enabling the prevalence of the artificial intelligence age; expectations, responsibilities, and job definitions need to be redefined for those who provide services in healthcare. This study examined the perceptions of future physicians on the possible influences of artificial intelligence on medicine, and to determine the needs that might be helpful for curriculum restructuring. Methods: A cross-sectional multi-centre study was conducted among medical students country-wide, where 3018 medical students participated. The instrument of the study was an online survey that was designed and distributed via a web-based service. Results: Most of the medical students perceived artificial intelligence as an assistive technology that could facilitate physicians' access to information (85.8%) and patients to healthcare (76.7%), and reduce errors (70.5%). However, half of the participants were worried about the possible reduction in the services of physicians, which could lead to unemployment (44.9%). Furthermore, it was agreed that using artificial intelligence in medicine could devalue the medical profession (58.6%), damage trust (45.5%), and negatively affect patient-physician relationships (42.7%). Moreover, nearly half of the participants affirmed that they could protect their professional confidentiality when using artificial intelligence applications (44.7%); whereas, 16.1% argued that artificial intelligence in medicine might cause violations of professional confidentiality. Of all the participants, only 6.0% stated that they were competent enough to inform patients about the features and risks of artificial intelligence. They further expressed that their educational gaps regarding their need for "knowledge and skills related to artificial intelligence applications" (96.2%), "applications for reducing medical errors" (95.8%), and "training to prevent and solve ethical problems that might arise as a result of using artificial intelligence applications" (93.8%). Conclusions: The participants expressed a need for an update on the medical curriculum, according to necessities in transforming healthcare driven by artificial intelligence. The update should revolve around equipping future physicians with the knowledge and skills to effectively use artificial intelligence applications and ensure that professional values and rights are protected.

Background The promotion strategies of pharmaceutical companies create many problems including irrational prescribing, diminished trust in the patient-physician relationship and unnecessary increases in pharmaceutical costs. Educating prescribers is known to be one of the few potentially effective measures to counteract those impacts. However such educational programs are limited in the literature, and their effectiveness against the effects of hidden curriculum in the long term is unknown. This study aims to evaluate the effectiveness of an education program both in the short term and the long term after the students have been exposed to informal and hidden curriculum and various pharmaceutical promotion methods.

Objective: This study aims to investigate the level of evidence on the effectiveness and safety of 14 complementary and alternative medicine (CAM) methods legalized in Turkey. Methods: A systematic literature search was conducted in the Cochrane Systematic Review Database for acupuncture, apitherapy, hypnotherapy, leech therapy, homeopathy, cupping therapy, chiropractic, prolotherapy, osteopathy, maggot therapy, mesotherapy, music therapy, reflexology, ozone therapy. After screening, 287 studies were included in the qualitative synthesis. Evidence quality was classified as ‘high/moderate/low’. AMSTAR-2 was used to evaluate the quality of systematic reviews. This study was registered to PROSPERO (CRD42019127509). Results: There are 16 low (LQE) and four moderate-quality evidence (MQE) of effectivity for various conditions were found for acupuncture, while it has no effectivity on 13 conditions. There are six LQE and one MQE on its safety. One study found high-quality evidence of the effectivity of apitherapy concluded that honey accelerates the healing of burn wounds. Three LQE and two MQE quality evidence found for some conditions, and five studies have shown no effectivity. Thirteen LQE and three MQE showed the effectiveness of music therapy, while one study reported it as ineffective. Four studies found LQE showing hypnotherapy might be effective in some conditions, and one study found it was ineffective. Regarding osteopathy, one study found MQE, and one study found LQE. One study reported LQE for the effectiveness of chiropractic. The only evidence for the effectivity of homeopathy is of low quality and four studies have shown that it is not effective. There is a LQE on its safety. Conclusions: Since there is insufficient evidence, 14 CAM methods legalised in Turkey shoud not be used in daily practice. Future researches aiming to produce high-quality evidence are needed to be able to make benefit-risk assessments scientifically.

... Murat Civaner, Özlem Sarıkaya1, Harun Balcıoğlu2 ... İzmir'de Çiçek, Terzi ve arkadaşları 2006 yılında asistanlar arasında TUS dershanesine gitme oranını %36.2 bulmuşken, Ankara'da yapılan benzeri bir araştırmada bu oran %51 olarak saptanmıştır (8, 9). Aynı çalışmada “TUS ...

Tıbbi uygulamalarda gözetilmesi gereken temel etik ilkelerden biri, kişi özerkliğine saygı göstermektir. Bununla birlikte, sadece bireyi değil toplumu ilgilendiren sağlık sorunları söz konusu olduğunda, özellikle de bulaşıcı hastalık salgınlarında, toplum yararını üstün tutarak kişi özerkliğinin çiğnenebileceği yaygın kabul gören bir görüştür. Bu görüş, salgınların ancak tüm duyarlı bireylerin bağışıklanması ile kontrol altına alınabileceği bilimsel gerçeğine dayanmaktadır. Yine de tüm duyarlı bireylerin bağışıklanmaya zorunlu tutulup tutulamayacağı dünya çapında bir tartışma konusu olagelmektedir. Özellikle son üç yıldır dünya çapında yaşanan Koronavirüs hastalığı-2019 [Coronavirus disease-2019 (COVID-19)] pandemisinde, toplumun önemli bir kesimi aşı olmakta kararsızlığa düşmüş, bir kesimi ise aşıların tümüyle reddedilmesi gerektiğini savunmuştur. Yukarıda özetlenen durum karşısında "bağışıklama zorunlu olmalı mı?" sorusunu olabildiğince geniş uzlaşı sağlayacak biçimde yanıtlayabilmek her zamankinden fazla önem kazanmıştır. Bu derleme yazıda; bağışıklamayı zorunlu tutmanın etik açısından hangi koşullarda haklı çıkarılabileceği ele alınmakta, böylece aşı kararsızlığı ve reddi olgusunun toplum sağlığı açısından yarattığı yaşamsal sorunun çözümüne katkıda bulunmak amaçlanmıştır. Bu amaçla öncelikle bazı kavramları netleştirme gereğinden söz edilmiştir. Sonrasında "zorunlu olmalı", "isteğe bağlı olmalı", "hiç kimseye yapılmamalı" argümanları gerekçeleriyle değerlendirilmiş ve bağışıklamanın zorunlu olması gerektiği argümanının etik açısından haklı çıkarılabildiği belirlenmiştir. Yazıda "birey özgürlüğü X toplum yararı" ve "kişi özerkliği X toplum yararı" çatışmalarının günümüz koşullarında söz konusu olmadığı ileri sürülmüş, ancak gerçeklik bilgisine sahip aydın bireyin bu bilginin pratiğe geçmiyor oluşu karşısında bir gerilim yaşadığı belirtilmiştir. Bu gerilimin aşılması için kuramsal arka planın sağlamlaştırılması ve ayrıca aşı kararsızlığı ve reddinin pratikteki makro belirleyenlerini dikkate almak gerektiği vurgulanmıştır. Tıp kurumuna karşı güvenin yeniden sağlamlaştırılması için yapılması gerekenler sıralanmış, zorunlu bağışıklamanın nasıl uygulanacağı sorusunun ancak toplumsal bir diyalog ile yaşama geçirilecek bir dönüşüm süreciyle sağlıklı yanıtlanabileceği savunulmuştur.

There are serious concerns about the commercialization of healthcare and adoption of the business approach in medicine. As market dynamics endanger established professional values, healthcare workers face more complicated ethical dilemmas in their daily practice. The aim of this study was to investigate the willingness of medical students to accept the assertions of commercialized healthcare and the factors affecting their level of agreement, factors which could influence their moral stance when market demands conflict with professional values. A cross-sectional study was conducted in three medical schools in Turkey. The study population consisted of first-, third-, and sixth-year students, and 1,781 students participated in total. Students were asked to state if they agreed with the assertions of commercialized healthcare. Of all students, 87.2 per cent agreed with at least one of the assertions, and one-fifth (20.8 per cent) of them agreed with more than half of the assertions. First-year students significantly agreed more with some assertions than third- and sixth-year students. Being female, having mid-level family income, choosing medicine due to idealistic reasons, and being in the third or sixth years of medical study increased the probability of disagreement. Also, studying in a medical school that included integrated lectures on health policies, rights related to health, and health inequities, along with early field visits, increased the probability of disagreement. This study suggests that agreement with the assertions of commercialized healthcare might be prevalent among students at a considerable level. We argue that this level of agreement is not compatible with best practice in professional ethics and indicates the need for an educational intervention in order to have physicians who give priority to patients' best interests in the face of market demands.

Victims of disaster suffer, not only at the very moment of the disaster, but also years after the disaster has taken place, they are still in an emotional journey. While many moral perspectives focus on the moment of the disaster itself, a lot of work is to be done years after the disaster. How do people go through their suffering and how can we take care of them? Research on human suffering after a major catastrophe, using an ethics of care perspective, is scarce. People suffering from disasters are often called to be in distress and their emotional difficulties 'medicalised'. This brings them often into a situation of long term use of medication, and one can wonder if medication is of help to them in the long run. In our paper, we will explore another moral perspective, focusing on the importance of the victims' narrative and their lived experiences. We will use Paul Ricoeur's phenomenological reflections from 'Suffering is not the same as pain' for conceptualizing human suffering and how to apply it to victims of disaster. Ricoeur suggests that suffering is not a quantity that can be measured, but a characteristic that should be studied qualitatively in interpersonal and narrative contexts. Above all, the perspective of care and listening could offer an opportunity to reconcile people from their loss and suffering.