Evidence-based medicine (EBM) is maturing from its early focus on epidemiology to embrace a wider range of disciplines and methodologies. At the heart of EBM is the patient, whose informed choices have long been recognised as paramount. However, good evidence-based care is more than choices.We discuss six potential ‘biases’ in EBM that may inadvertently devalue the patient and carer agenda: limited patient input to research design, low status given to experience in the hierarchy of evidence, a tendency to conflate patient-centred consulting with use of decision tools; insufficient attention to power imbalances that suppress the patient’s voice, over-emphasis on the clinical consultation, and focus on people who seek and obtain care (rather than the hidden denominator of those that do not seek or cannot access care).To reduce these ‘biases’, EBM should embrace patient involvement in research, make more systematic use of individual  evidence, take a more interdisciplinary and humanistic view of consultations, address unequal power dynamics in healthcare encounters, support patient communities, and address the inverse care law. All authors have research experience and academic qualifications, but we are patients and carers as well see ‘’ below. Incorporating the patient’s perspective in EBM is sometimes conflated with ascertaining his or her preferences and sharing decisions about possible tests and treatments. These are important elements of good practice , butAn ‘evidence-based’ healthcare decision is inevitably informed by the stages of evidence creation. First, some people – traditionally researchers and/or doctors, but increasingly with patient and carer input – decide which outcomes count. Next, research is undertaken to find out how to best achieve the designated outcomes. Results are published and, later on, a clinician interprets and shares them in the clinical encounter.The patient in the above scenario begins from a different place. Even when patients are ‘informed’, ‘empowered’, and ‘health-literate’ , they rarely inhabit a world of controlled experiments, abstracted variables, objective measurement of pre-defined outcomes, average results, or generalizable truths. Rather, they live in the messy, idiosyncratic, and unpredictable world of a particular person in a particular family context  , 6. NotwThe options tabled by the clinician for a ‘shared decision’ may or may not resonate with what has occurred in the patient’s world up to this point. Furthermore, following a (more or less) shared decision, the patient goes away and re-enters what has been termed the ‘lifeworld’  – a worlBelow, we discuss six features of EBM – which we refer to, figuratively, as ‘biases’ – that may inadvertently devalue this broader patient and carer agenda: 1) the lack of patient input to the research process; (2) the low status given to experience (‘anecdote’) in the hierarchy of evidence; (3) EBM’s tendency to conflate patient-centred care with use of shared decision-making tools; (4) the limited attention given in EBM to power imbalances that suppress the patient’s voice; (5) EBM’s over-emphasis on the clinician-patient dyad ; and (6) EBM’s primary focus on people who seek and obtain care (rather than on the hidden denominator of those that do not seek or cannot access care). These influences, and their potential effects on the process and outcome of evidence-based care, are summarised in Table  the lackNote that whilst all the ‘biases’ below are evident in the EBM literature, we are not suggesting that practitioners, researchers, or teachers of EBM are, as individuals, biased  against patients or carers. On the contrary, many protagonists of EBM are passionately committed to working in a patient-centred way. Our argument is that despite the best intentions of these individuals, EBM’s paradigmatic assumptions, theories, tools, and techniques, as well as its existing evidence base, contain potential distortions that may have negative consequences for the people it aims to serve. In short, it is the paradigm that contains the biases highlighted below, not  the people who seek to develop or apply it. We hope that practitioners, teachers, and researchers of EBM will ask themselves when reading each of the biases below: “Given that I personally seek to be unbiased in relation to patients and carers, how should I alter my use of evidence/teaching approach/research focus to help redress this bias?”Evidence generated by clinical research will depend on who asks the questions, who defines the outcome measures, who interprets the findings, and who disseminates the outputs. In the past few years, many research funders have encouraged patient input to each of these steps . Howeverin which [medical] assistance was required in the provision of treatment”  perspective by providers; the sharing of decisions and responsibilities between patients and providers; the strengthening of practitioners’ compassion, sensitivity to patients’ distress and commitment to respond to patients with empathy in an effort to alleviate suffering.” , EBM’s epidemiological focus, which is appropriate and rigorous when considering populations or samples, places limited emphasis on aspects of healthcare that are key to the successful application of quantitative research evidence to the individual patient. The conceptual frames of EBM effectively configure the patient as an autonomous rational chooser, a model that does not readily translate into the everyday lives of real patients – multifaceted individuals with physical, cognitive, emotional, and social dimensions, who lead messy, idiosyncratic, networked, and often complicated lives in contexts that are shaped by cultural, economic, and political forces. As Mark Tonelli observed in 1999,However, whilst this problem has been described for decades, workable solutions have not arisen from within the EBM literature. In our view, this is because generating such solutions would require a fundamental change in perspective, an abandoning of certain deeply held principles and assumptions, and the introduction of new ideas and methodologies from disciplines beyond EBM. Given the policy push for greater patient and carer involvement in research, the time is surely ripe for those who adhere to the EBM paradigm to question its rigid ‘gold standard’  and consIn particular, EBM researchers should learn from the literature on civic engagement with a view to building a level of patient and public involvement in research that goes beyond the limited goal of increasing recruitment to research trials . EBM praThose who seek to apply EBM in policy and practice should also consider the literature from social and political sciences and critical public health on power and inequality, especially research on power dynamics in healthcare encounters , 46, socIn conclusion, as we have argued previously, EBM may not be ‘a movement in crisis’, but it is certainly at a crossroads . The sucWe bring extensive collective experience as patients  and as parents and carers of people who are ill, dependent, or vulnerable. One of us (RS) used her experience of living with a long-term condition as the basis for a PhD in the sociology of healthcare ; another


This summer, Europe’s Journal of Psychology hosts a fruitful discussion about phenomenology, its method, the possibilities of application in today's context and its current troubled waters stemming from recent historical-ideological debates. Prof. Roberta De Monticelli offers lush and informative answers to provocative issues like overdriving the epoché, Heidegger's dark undertones, the relation between pedagogy and authorship in phenomenology and the idea of filtering politics through Husserlian phenomenology. Andrei Simionescu-Panait: Each year, the San Raffaele University hosts an international Spring School, which gathers around for debate numerous big authors in philosophy and connected areas of research, as well as plenty of students. This year, the event  hosted a direct dialogue between phenomenologists, experts in social ontology, applied ethics, normativity and researchers interested by intersubjectivity and empathy – in short, an important interdisciplinary event. How would you appreciate the presence of Husserlian concepts or Schelerian axiology in this fresh environment of ideas? Does phenomenology display a tendency of growth in recognised importance, considering research in recent years?Roberta De Monticelli: The latter question is important. Indeed, we are looking at a re-awakening of true phenomenological research all over the world. This rekindled interest in all sorts of issues  book by Margaret Gilbert, but it’s also a key concept pinning down a source of social normativity. As most concepts in contemporary analytic philosophy, it is both a guideline for conceptual analysis of complex facts, and a template needing intuitive fulfilment, that is, requiring or at least exciting phenomenological descriptions and insights. Is a conjugal pact, or even a friendship, a bond, and a source of deontology, of exactly the same nature of, say, a commercial partnership? What distinguishes the three latter joint commitments from the one underlying a quarrel, or even a refined philosophical discussion? As soon as one raises these questions, all the fine-grained phenomenological descriptions of different “forms” of collective intentionality, from basic pre-personal collective habits up to sharing values of a personal level, come to the mind, and one sees why Moritz Geiger, a phenomenologist of the Munich circle, called phenomenology “a passion for distinctions”. An ideal travel mate for some bold generalizing minds, issued from the analytic tradition, such as most keynote speakers of our past Schools: such as Peter van Inwagen on Free Will, Lynne Baker on Personhood, Barry Smith on Taste, John Searle on Status Functions or Margaret Gilbert herself on Joint Commitment. Thus, your reference to Husserlian concepts or Schelerian axiology is quite to the point. Gemeingeist is the title of one of the manuscripts out of which Ideas II should have been worked out in one of the phases of its vexed history. Also, shared values are one of the main issues of Scheler’s two masterpieces, Formalism in Ethics and On the Nature and Forms of Sympathy.Andrei Simionescu-Panait: There's an academic anathema floating on Heidegger's head, with all the Schwartze Hefte English translation and related discussions. The popular conception that places Heidegger as a philosopher who bettered Husserlian phenomenology is now fading. As Jeanne Hersch remarked, he had the chance of either being “the first priest of a new liturgy, or the last priest of a forgotten one”  is another astonishing fact, haunting almost the whole history of the scholarly research on Husserl and phenomenology . The very heart of Husserl's thought beats in his question on the sources of normativity, a question he meant in so radical a way as to invest logical, axiological and practical normativity alike. Husserl’s answer provides a basis for the pars construens of the Logical Investigations, starting from that masterpiece analysis in Prolegomena §14, which displays the equivalences between eidetic and axiologic statements and their normative or deontic versions. It is impossible to see the unitary project being developed throughout the six Investigations without considering this main claim about the eidetic sources of normativity, overarching all detailed inquiries into the given eidetic  bonds “keeping together”, within definite ranges of possible variations, all parts and moments of any concrete object. This pars construens of the phenomenological thought, i.e. the discovery and exact conceptualization of what I proposed to call “The gift of bonds”  and Historicism/Cultural Relativism, on the other hand.But let’s turn to a related issue which is more to the point of your question. The reason why many of the researchers and scholars who are currently placed within the f bonds” , 2013c, material apriori: such is Husserlian phenomenology in the eye of his founder himself  opposition between a continent and a method, which is the analytic/continental divide. It is no chance that this divide did not really exist before breaking out with Carnap’s bitter  pamphlet against Heidegger’s best seller, taphysik . It did Andrei Simionescu-Panait: In a letter to Ingarden from 1917, Edith Stein jokes about how cumbersome her work with Husserl in editing the Ideen manuscripts may “force” her to attain an “absolute epoché in terms of waiting”. However mildly funny this might be, it betrays her conception about this phenomenological instrument, as a desired and perhaps attainable philosophical state of consciousness with which to proceed in philosophical endeavours. In contrast to this, epoché is only a preliminary step in the process of reduction. Both bracketing and  applying the reduction unfold as practice, by the way of exercise, which means that we're talking about processes here and not states. How do you position yourself between these two presumably opposite takes on working in phenomenology?Roberta De Monticelli: I emphatically disagree from Luft’s claim that “the reduction marks a significant rupture within Husserl’s thought and stands for the establishment of Phenomenology as a transcendental philosophy in the tradition of Kant”  the priority of the given on the construed (“Back to the things themselves”); ii) the theory of eide, i.e. of those ontological (not just epistemic) bonds of (co)variation of possible contents which make up the very material ontology of concrete objects and states of affairs or events, grounding the “laws of essence” of different ontological regions ; iii) intentionality explained as an  internal or essential relation, i.e. as a relation whose terms cannot subsist independently of the relation itself .of Kant” , p. 243.eide, iii) might be read as an “idealistic” claim in a Kantian sense. Wrongly so. For its rationale is a rigorous definition of the first-person perspective, as an essential feature of consciousness. All the possible different modalities of consciousness  are different modes of presence of objects , quite obviously inseparable from the subject whom they are presented in a given perspective. Yet “inseparable from” does not mean “reducible to”: quite on the contrary, everything worth the name of real is (given as) transcendent the aspect or part of it which is present, or presently “given” to consciousness. In case of direct cognition or “original presence”, such as perception, emotion, empathy or, in short, experience  this transcendence lets the object appear as an infinite source of information, open to active exploration and capable of disconfirming illusions, resisting to cognitive mistakes and, above all, resisting to our wishes, wills, endeavours.Now whereas ii) explains the meaning of “idealism”, which in several passages Husserl takes as referring to his theory of Ideen I, § 31). What are these “posits”? Quite simply, the obvious, pre-reflective, automatic, sometimes wrong and often right endorsements of all contingent particularity of both object and subject bound in a given intentional relation, or state of consciousness. Let’s exemplify with perception. “Posit” is the tacit stance taken by the perceiver (Stellungnahme) as concerns the true existence of the thing perceived. Even if it can turn out wrong  it is no “judgement” or reflective statement: it definitely is “built in” the perception as such. A perceived thing is given or experienced as existing here and now, as opposed to a remembered or an imagined one. Here and now, that is, given to me, from exactly the point of view that I myself am presently and contingently taking over.In this background the meaning of the phenomenological epoché can be better clarified. Epoché is the “radical alteration of the natural attitude” consisting in “bracketing” or setting out of power (without rejecting) - the “posits” built in the natural attitude . The point is: phenomenology is a method of research, aiming at universally accessible evidence; but it cannot achieve universal accessibility by giving up first-person perspective, and switching to third-person, or “impersonal” one, as Scientific Naturalism does by adopting the positive stance of an empirical science, e.g. cognitive psychology. It is specific to phenomenology to safeguard any intentional state – say perception – as it is actually lived, i.e. in first-person perspective. Living in first person perspective is (en)acting life as a subject – that’s why phenomenologists prefer the term “act” to “state” when it comes to instances of the intentional relation.Why bracketing posits? That’s the way to “alter” the natural attitude, i.e. epoché is the idealizing device by which universal accessibility of descriptions is reached, starting from actual, first person experience. It is the voluntary switch from everyday natural attitude to phenomenological attitude and perspective.In short, how that object appears from an appropriate first-person perspective, e.g., a perceptual one, if it is a perceptual object, or an emotionally qualified one, if it is an object of emotional experience, and so on. To sum up: adopting the phenomenological attitude means putting oneself ideally in the place of the subject of some kind of intentional state. One adopts this stance “ideally” by “bracketing” whatever is contingent upon an actual object, e.g. its present situation in space and time, and upon an actual subject, e.g., this person I am.A brief clarification of what phenomenological perspective amounts to is in order here. It is the perspective one has when adopting the phenomenological stance via epoché. Adopting the phenomenological stance toward any object is clarifying constitutive of the phenomenological method as such, that even where it is not explicitly theorized  or it is qualified with caveats and distinctions  it is of course practiced as soon as the phenomenological description and analysis takes over.So explained, phenomenological epoché has nothing whatsoever to do with Kantian transcendentalism . It seems to such an extent responses to all sorts of circumstances, encounters and events, that we spontaneously enact in the life world. Some responses are further cognitive explorations, most of them are just habitual actions, life-routines like preparing breakfast or making one’s bed or submitting one’s corrected proofs to the publisher. We are constantly in action  as concerns the priority of a “practical” epoché, that is of a setting out of the power of all more or less automatic n action , this isAndrei Simionescu-Panait: Self from surface to depth: in your  and the “depth” or “centrality” in our lives of the corresponding experiences. Which is in other words the motivational power they have for us . On the “noetic” side it discovers a correspondence between the layer of sensibility concerned by each (type of) experience and the layer of (one)self that the same experience “reveals”. The increasing role that each (type of) feeling plays in personal life  explains the deeper and deeper self-revealing power which that feeling experience exhibits/produces.Formalism; my attempt consists in putting them together as the two terms of emotional intentionality. The result is the schematic representation of Self “from depth to surface”, i.e. the layered theory of self-constituting sensibility underlying it. By “self” I mean a person, as she experiences herself, or as she is “given to herself”, in that quite peculiar, irreducible way, in which anybody is not given to anybody else - that is, from a first person perspective. From this perspective, layers of sensibility simply are layers of (one)self, as they are lived/experienced from within.Both ideas stem from Scheler’s there is a specific layer of sensibility constituting individual personality, whereas other, more basic, layers of sensibility are in a way pre-personal, i.e., both virtually shared with other animals and activated all the time from the very beginning of human life, even before a layer of well-structured personal sensibility, ordered by a personal or cultural scale of values, has developed. Call this latter the layer of sentiments, or the value-preferences ordering layer. If my theory is plausible, this is the very central, or most intimate, layer of selfhood. Call it the core-self: it is what ordinary language still calls a person’s “soul”.A further step I endeavoured is that of exploiting this self-constitutive role of feeling experiences to provide a taxonomy of feeling experiences by exhibiting its ordering principle in the correspondence between the layer of sensibility concerned by each (type of) experience and the layer of (one)self that the same experience “reveals”. Not all feeling experiences, indeed, come to be felt from inside as “really” concerning oneself in one’s personal identity – one’s deepest self, so to speak. My theory suggests that how we are, or what we need.This is the rationale of the partition you referred to, between sensory feelings, bodily feelings and moods on one hand, all of them belonging to the more basic pre-personal layers, “sensory” and “vital” ones; and the personal layer(s) comprising sentiments, sentiment-based emotions, passions. Incidentally, moods do indeed provide us with information about our global state, whose experience can be inclusive of bodily feelings  or not: yet they don’t really tell us “who” we are . Feeling experiences of the vital layer simply tell us The preceding clarification may lay out some answers to your questions. (A) No Cartesian dualism in the distinction between vital and personal layers of sensibility, because they are in fact layers of (one)self, of the same person as given to herself – as different, more or less central or deep “parts” – yet inseparable parts – of the concrete whole that a person is – an embodied person, of course: do we know of other ones? The ontologically independent being is the whole, not its parts. Hence there is no dualism of substances. (B) “Abstract” values, if we mean by that values of the personal level, can indeed reveal themselves as essentially dependent on the values of the vital level, and normally do: there is no personal flourishing in endeavors striving after justice, truth or beauty, without a minimum satisfaction of basic needs – hunger, having a shelter, security… Even if you may as well “sacrifice” your health or life to your passion for truth or for justice. And this tells us, once again, the (correctly felt) hierarchic relations of these value-spheres.Andrei Simionescu-Panait: Husserlian phenomenology has intriguing concepts. Some of them are static and aim at mapping consciousness , while others try to seize the way in which consciousness processes unfold . Husserl is always under the tension between offering radical answers (in methodology at least) and inviting phenomenologists to ponder at the elusive character of consciousness, that simply can't stay still in order to be analysed (difficult to practice). Post-Husserlian phenomenologists borrow and reanimate the importance of some concepts from Husserl, in different combinations that constitute their own “voices” in phenomenology. It is said about Schoenberg that he was the first, the last and by far the best of serialists, because only he knew how to practice his own custom-tailored radical method. (A) In what way can phenomenology avoid this harsh but possible future evaluation? (B) Science rarely wonders about its foundations. Husserl fought to make a radical change when it comes to those heavy cornerstones of human enquiries. But this was one century ago. Now, can phenomenological practice also be conceived outside the realm of books, while fierce discussions about methodology can be tamed and put into the background (like in regular science)? Or is this a step back towards regular, “natural attitude” driven, pre-phenomenological science?Roberta De Monticelli: I have always believed that phenomenology is applied phenomenology, or it’s nothing at all. Endless methodological discussions, or worse, philological ones on the true exegesis of the sacred texts – betray the very spirit of phenomenology. It’s indeed ironic that the philosopher who revived a living way of thinking based on lived experience, the one who used to ban sheer speculation or just deductive thought not supported by the intuitive presence of the things themselves about which one is thinking, was also a compulsive writer, one who could not think without writing. Yet Husserl is not the only classical source of our methodology and technicalities. If there is a first limit to overcome in the scholarly training of young phenomenologists, that is a too exclusive study of Husserl . There are plenty of other sources even among the very classics, from Scheler to Stein, from Reinach to Spiegelberg, from Pfaender to von Hildebrand, not to mention Hedwig Conrad-Martius, Gertha Walter, Nikolai Hartmann, Rudolf Plessner... But the second, even more harmful limit to overcome is a purely scholarly training, confined to reading literature without practicing phenomenological analysis and description of particular issues. Our Centre in Milan tries to improve teaching in both directions: by enlarging the “canon” – and including not only the mentioned authors but also many contemporary ones, and many “applied phenomenologists” from different disciplines: psychiatrists, psychologists, social ontologists, legal philosophers, moral philosophers. And, more importantly, by focusing on particular topics, allowing for discussion and comparison between phenomenological and other analytical approaches, and suggesting personal exercise in the techniques of eidetic variation, design of mental or empirical experiments, rewording of many classical issues in phenomenological terms: free will, personhood, personal identity, consciousness, emotions, perceptions, value theory, normativity theory, collective intentionality, intersubjectivity. All this can count as answers to your questions (A) and (B). I shall add that the best practice of phenomenology requires a training in that kind of structural-eidetic exploration, discovering “laws of essence”, which is based on experience, but in a way different from empirical or statistical induction: eidetic generalizations are based on experienced tokens of typical or eidetic cases. Such generalizations are necessarily true if they are true, and their epistemic status is apriori. Yet they are far from being “purely conceptual” or just rooted in semantics: they really are substantive relations, rooted in the contents of the envisaged states of affairs, as given to experiences of the appropriate sort.Andrei Simionescu-Panait: In an article from 1999 in Zahavi, Depraz (Eds.), P. Ducat sees phenomenology as a discipline that is supposed to be separated from ideologies of any sort  up to the conditional and unconditional obligations pervading the realms of morals, law and politics. Obligations and requirements pervade also, as we saw, the realms of logics and cognitive research or technology. Norms and their critical examination, issuing in either renewed, universally accessible justification, or else in their reject , are everywhere subject to what Husserl called “the jurisdiction of reason”. More than that: there is no intentional state (or rather act) which would not be subject to this “jurisdiction”. For experience and consciousness crave for adequacy. A perception can be illusory, an emotion inappropriate, a desire inconvenient, a will unjust, a judgment false, a sentiment wrong, a piece of imagination incoherent or impossible.Reason can be defined as (not only) a disposition,  a willingness this “noetic” side of the intentional relation, namely the validity claim built into each act, depending on its characteristic “posit”, making up the naïve dogmatism of common sense, ordinary experience, traditional beliefs, shared or “social” emotions and sentiments. It is an implicit claim, spanning each act, without which we could not even discover our cognitive, emotional and practical mistakes, and “learn from experience”. Hence it is really constitutive of any intentional act, quite as much as its relation to an intentional object, despite being ignored by Brentano and the analytical tradition. Yet this validity claim can turn out to be justifiable, or not. The very possibility of questioning the rightness of any act whatsoever, or the critical possibility, certifies the overall “jurisdiction of reason” on personal consciousness and experience. This discovery is the act of birth of philosophy. Even according to Husserl’s rich lecture texts on history of philosophy and, what is more, human civilization . A civilization founded on reason should be understood as opposed to a civilisation founded on tradition, religion (God’s will), or whatever “voluntarism” of the modern age might justify modern Realpolitik. That is, the reject of the rule of law in favour of a man’s government and of his decision-making powers, along the lines of political thought of, say, Carl Schmitt, Heidegger himself, and post-Foucaultian schools   .immer wieder” rising demand of (public) justice, freely and rightly accepted and engaging one to corresponding action, or freely and wrongly rejected by delivering oneself, for example, to dark totalitarian and nationalistic adventures of the Nazi kind. This is why Husserl not only does not reject, but passionately advocates a phenomenological foundation of political theory, as part of a “rational science of society”, where, of course, rationality is meant in its double face, theoretical and practical . This term is “telos”, yet this word should be understood as a synonym of “task”, “duty”, overall project of our practical thought, subject to an “always renewed” verification and criticism. And by no means as a “destiny” of “western” civilisation, since it is quite the opposite of a destiny. It is just a past commitment, freely obliging autonomous moral subjects capable of verifying it and endorsing it again, maybe in new forms. It is an “ractical ii. More material ontologies  and material axiology, two main research fields of phenomenology. Between the spheres of values  we definitely find the sphere of political values, or values making up a well ordered polity (or a project thereof): justice, with all its “moments”, or partial contents: responsible freedom, equal dignity-and-rights, equal opportunities, minimum welfare, solidarity, citizenship, legality, transparency, pluralism, independence of the truth agencies such as information, education, judiciary... Here is a vast program of analysis and discovery for a material axiology of phenomenological obedience.On the other hand, it would be quite surprising if political obligation did not find a place, definitely not reducible to, and yet conditioned by, legal and moral obligation, within the general scheme of Andrei Simionescu-Panait: If we were to check correspondence from the First World War, we see that Edith Stein was very unhappy with the way Husserl gave next to no feedback on his students' text, as well with the very unstable way in which Husserl would share his thoughts on how his own Ideen manuscripts should be handled by his followers. Their communication (cooperation) was precarious because of Husserl's fast paced rhythm of writing on new manuscripts. As expected, Husserl was in turn dissatisfied of the reception of his phenomenology, dissatisfied with his students' phenomenological directions as he grew older and became dominated by his genetic attitude in thought. He was especially dissatisfied with Heidegger, in a letter to Pfaender from 1933: “I arrived at the distressing conclusion that philosophically I have nothing to do with this Heideggerian profundity, with this brilliant unscientific genius; that Heidegger’s criticism, both open and veiled, is based upon a gross misunderstanding; that he may be involved in the formation of a philosophical system of the kind which I have always considered it my life's work to make forever impossible. Everyone except me has realized this for a long time.”, Roberta De Monticelli: We are back to the misunderstandings concerning the real legacy of phenomenology, but in the context of a larger, interesting inquiry into philosophical pedagogy. Let me come back to Husserl-Heidegger first, this time with a personal experience. Husserl’s Krisis . Instead of accepting the gap between science, which does admit of such a foundation, and the governance of human affairs, left over to arbitrariness, Realpolitik, or the conflict of faiths. Not a single word about the tragic meaning of Husserl picture of philosophers as “Funktionäre der Menschheit”, officials of humanity – as written by a man who had just been deprived of his role of public official, that is of his venia legendi, the power to teach, by his own university, with the approval of his former student, Martin Heidegger. Not a single word about the two principles affirmed throughout those seven sections. That is, I) the principle of responsible personhood, grounding practical reason on freedom of the moral subject, conceived as a reasonable, sensible and autonomous agent, capable of value experience and research, and II) the principle of moral, legal and cosmopolitical universalism, grounded on universal accessibility of the fundamentals of public ethics, making up what post-war humanity called “the human rights”.s Krisis  was the s Krisis  was thenNot a single word on the fact that Heidegger had built his “system of thought”, in those years, on the very reject of those two principles, and on their replacement with two opposite principles. Here they are: I) a principle of historical destiny, removing autonomy and moral responsibility of individual persons; and II) a principle of ethnic, Blut-und-Boden community as prior to that of personhood and equal dignity, on the basis of which he enslaved philosophy to the exaltation of the Fuehrerprinzip, and of the “intimate greatness of national socialism” (Rectorship Speech).synphilosophein”, or the debating community of philosophers, preferring attention to “the thing itself” and to each other’s work, to monologue in later “Hirsch-of-Being’s style”. After all the dream of reviving an international community of researchers, truth being “an ideal situated in infinity” and not the revelation of some guru or visionary bard, is a recurring dream of phenomenologists of all ages. Our Centre too is still dreaming that dream, and you and I are collaborating to make it more real, in this very moment.In this respect, compared with some masters of my generation, even the celebrated (or ill-famed) kind of solipsism of Husserl’s teaching was a paradigm of rigour, intellectual honesty and passion for truth. As one gathers, after all, from the memories of Edith Stein, Ingarden, Spiegelberg and many others – all of them recognizing, as a defining mark of true phenomenology, that crucial love for “Andrei Simionescu-Panait: You have had a productive publishing rhythm in recent years. Ontologia del nuovo: la rivoluzione fenomenologica e la ricerca oggi (2008), La novità di ognuno. Persona e libertà (2009) or L'ordine del cuore. Etica e teoria del sentire (2012) are some of your works in recent years, in which you analysed the manners in which phenomenology today can reshape ethics, epistemology, or questions about selfhood and choice, to name a few. Towards which area of human experience will your next project be focused?Roberta De Monticelli: Let me just add the last group of works on moral and civil issues in contemporary Italy, La questione morale (2010), La questione civile (2011) and Sull’idea di rinnovamento (2013), if only to stress once again the link I feel mandatory for a Socratic philosopher, between pure research and participation in public debate. I tried to perform this duty by taking a stance in the “space of reasons”, or in the face to face of argument and criticism, against a tendency of governments to bypass legality and even constitutional norms in favour of informal powers and particular constituted interests. Using the empirical materials of some battles against corruption or lack of transparency in the public sphere I tried a phenomenological investigation of our so widespread indifference to public ethics, finding its origin in a special kind of self-destitution of the autonomous moral subject, in a cultural climate of moral and political scepticism. All this descriptive materials form the background and intuitive source of evidence for an outline of a phenomenological theory of values, opposing most meta-ethical positions, from metaphysical realism to expressivism, emotivism, constructivism of different sorts. The result is now in print – it will come out next Fall under the anti-Nietzschean title Al di qua del bene e del male (Einaudi).an ontology of concreteness. Some initial hints at this research program are to be found in Yet my research project for the future is different. I have written even too much in Italian or French, in an age where you should not escape confrontation and criticism on the part of the international philosophical community. I’m writing in English (or a faint imitation of it) several papers and the project of a book tackling with what I deem to be a real gap in the current phenomenological renaissance: the theory of ontological dependencies, i.e., eidetic invariants and “the gift of bonds”. My utopian dream is that of rethinking that sort of Ockham’s fork which set modern thought on the path of naturalistic metaphysics, empiricist epistemology and axiological scepticism. I am trying to think anew, by contemporary standards of rigour and exactness, the other path – the one whose rejection threw back Duns Scotus and the essentialistic tradition among the myths or the fairy tales of the past. Wrongly so – for it is the path of phenomenology, conceived as Andrei Simionescu-Panait: One last question, a curiosity. You're known to have a close relationship to literature, novels and poetry, and it seems that the best of authors manage to informally capture specific particularities about human attitudes, situations and changes that blend all of these together. They can seize the shapes of flowing experience, they can grasp contrasting emotions in events and successful recurrences of failure in characters, they can see “essences” in motion. I wonder, which author in literature would you consider to have great phenomenological intuitions, even if lacking formal phenomenological training?Roberta De Monticelli: There is a question that has always been intriguing to me: how comes that we learn much more about the essential features of emotional experiences by reading novels, poems or ancient and modern tragedy and comedy, rather than by studying dedicated chapters in psychology handbooks? I think I found an answer to this quandary. Emotional phenomena are dependent not only on personhood, but even on individual personality, because they are constitutive of both. They are both individuating and individuated! Quite as much as actions, where “si duo faciunt non est unum”, the same type of action is instantiated by essentially different tokens depending on the agent. Recall the dramatic differences in the ways people have to walk, to speak, to respond to similar circumstances. Conversely, one will find this person’s voice, dynamic style, smile, unmistakable or unique. The same happens with emotions and sentiments of a personal level. They don’t just manifest personhood, but individual personality. In the very richness of their contents and implications, they cannot be separated from the individual person experiencing and enacting – somehow “interpreting” them. Think of the deep differences between the ways different familiar persons have to be and to appear unhappy. This is not the case with instances of logical or mathematical reasoning, or even philosophical thoughts, that, as Frege used to say, “have no master”. And in fact, as far as psychology of cognition, logics or even perception is concerned, we do learn from academic psychology much more than from literary texts. Acts of the strictly cognitive spheres are not individuated and individuating.A phenomenologist  much more than by studying academic psychology.haecceity – of personality or essential individuality of persons, as it unfolds through all value and disvalue experiences of a given life, confronting good and evil of all sorts. A character, in this sense, is very much as you say, “essence in motion”. We have often more vivid memories of fictional characters, encountered in literary worlds, than of some real persons met in our environment. What young girl would not fall in love with Prince Andrei Bolkonsky on a ball night in Moscow, exactly like Natasha?As a way of conclusion, I would say that any great novelist or poet is a master in phenomenology of


Although expressions such as “shed some light” or “I saw the light” figure often in our everyday speech, we do not typically contemplate light. We may marvel at its seemingly mysterious expression through auroras, rainbows, lasers, or celestial objects or find comfort in its subtler forms such as sunbeams, candles, campfires, or fireflies. Artists and scientists, by contrast, do study and manipulate light, reflection, and illumination. Impressionistic painters strive to capture an impression of a fleeting moment, a particular scene. Many among their numbers are considered masters for their skill at capturing light as it shimmers across surfaces. Claude Monet once described Joaquín Sorolla y Bastida Sorolla as “the painter of light above all other.”Sorolla, was born in Valencia, Spain, in 1863. He and his infant sister Concha were orphaned when their parents died during a cholera epidemic 2 years later, and they were raised by their mother’s relatives. Early on, Sorolla seemed destined to become an artist: “When Joaquin was of an age to go to school, he manifested little inclination for his studies proper, though he revealed a stealthy and incorrigible craze for scrawling embryonic drawings in his copy books. . . .” In 1878, he began studies at the Fine Arts School of San Carlos, and he soon won awards at the Academy of Valencia. During 1879, the young artist traveled to Paris, where he toured exhibitions and met painters who worked in the open air, a practice that accentuated attention to light, color, and movement. That experience proved pivotal. Sorolla developed a passion for painting outdoors, preferring natural light and settings. After his military service, Sorolla subsequently attended the Fine Arts Academy in Rome on a 4-year scholarship beginning when he was 21. By the time Sorolla was 30, his paintings had been displayed across Europe and in the United States, and by the turn of the century, he was acknowledged to be among the Western world’s best living painters. He created many memorable paintings portraying the sun-drenched Spanish Mediterranean beaches and seascapes; he often painted portraits outside, reinvigorating the form with his fresh perspective. Sorolla’s mastery is largely accorded to his ability to depict tones and colors of sunlight, and he dedicated his life to chasing the sun as it played over the people and places of his beloved Spain. He himself acknowledged, “I hate darkness. Claude Monet once said that painting in general did not have light enough in it. I agree with him. We painters, however, can never reproduce sunlight as it really is. I can only approach the truth of it.”Sorolla cut a dashing figure, dressed in a suit, working from a table-sized palette dabbed with an array of colors squeezed from emptied tubes, and wielding yard-long brushes. The vigor with which he worked—he often finished a painting within a few days—did not diminish even as his reputation and wealth grew: he completed more than 500 paintings during an energetic 4-year spurt. The Wounded Foot, is among a series of paintings Sorolla made on the beach at Valencia. This painting focuses on 2 children, one of whom sits on the wet sand inspecting her foot, possibly injured from a jagged shell or broken shard of glass; her companion crouches, peering from under a wide-brimmed hat, perhaps offering comfort. That child’s arm falls beyond the edge of the canvas; blurred figures bob, swim, and frolic in the ocean. Reflected light scatters and glistens across the wet sand, swirling water, and foamy edges of waves. The casual composition belies the artist’s expertise in capturing transitory light and motion. The J. Paul Getty Museum notes that “The colored reflections of late afternoon light animate this beach scene and actively define the forms, from the injured child’s shoulder to the liquid sea and the figures playing in the water. The sun’s highlights on the hurt child’s hand, the sand around her foot, and her companion’s hat draw the viewer's attention to the injured limb.” This months’ cover image,The study of light, reflection, and illumination also seized the imagination of German scientist August Köhler, one of Sorolla’s contemporaries. In 1893, Köhler developed the microscope illumination technique that both bears his name and remains in use: Köhler illumination. This technique uniformly illuminates specimens without background glare. When this means of illumination is used on Gram-stained specimens, the defining features and structures of bacteria are readily and vividly revealed.The National Action Plan for Combating Antibiotic-Resistant Bacteria, acknowledging the global scope of the problem and supporting the One Health approach to disease surveillance for pathogens of humans and animals as being critical for combating resistance to antibiotics.Köhler illumination proved ground-breaking. Advances in detection and surveillance cannot come swiftly enough as researchers and public health professionals grapple with the increasing emergence of drug resistance in bacteria. Antimicrobial drug resistance diminishes the ability to treat bacterial infections, increases risks associated with many medical procedures, and threatens animal health and agriculture. In 2014, the United States government released The Wounded Foot and inspired a scientist to find a durable solution for a problem that had vexed researchers. The growing problem of antimicrobial resistance could make treating that child’s wound today more complicated than we imagined when the widespread use of antibiotics began in the 1940s, reminding us that we must keep shedding new light on an old problem.Light, reflection, and illumination led an artist to capture a fleeting incident on a sunny beach in


Concerns about burnout, and its consequences, among German physicians are rising. However, data on burnout among German physicians are scarce. Also, a suspected association between burnout and German physicians’ wishes to leave remains to be studied. Therefore, the extent of burnout, and the association between burnout and wishes to leave clinical practice or to go abroad for clinical work was studied in a sample of young physicians in Saxony.n = 5956) received a paper-pencil questionnaire inquiring about socio-demographics, job satisfaction, and wishes to leave clinical practice or to go abroad for clinical work. Response rate was 40 % (n = 2357). Burnout was measured with the German version of the Maslach Burnout Inventory - Human Services Survey (MBI) consisting of the subscales emotional exhaustion , depersonalization (feelings of cynicsm) and personal accomplishment . Variables associated with burnout, and the association between burnout and wishes to leave were assessed in multivariate logistic regression analyses.In a cross-sectional survey, all physicians ≤40 years and registered with the State Chamber of Physicians of Saxony, Germany . Eleven percent of participants showed a high degree of burnout on all subscales, while 35 % did not show a high degree of burnout on any subscale. Confirming that one would become a physician again, and higher satisfaction with the components “work environment” and “humaneness”, were associated with a lower chance for a high degree of burnout on all subscales. Higher emotional exhaustion and lower personal accomplishment were associated with an increased chance of wishing to leave clinical practice. Higher emotional exhaustion and higher depersonalization were associated with an increased chance of wishing to go abroad for clinical work.For Preventing physician burnout may not only benefit the affected individual. It may also benefit the health care system by potentially preventing physicians from leaving clinical practice or from going abroad for clinical work. The issue of burnout is of high concern in the current debate in Germany , 2. In Gemotional exhaustion, depersonalization and personal accomplishment [Emotional exhaustion reflects “feelings of being emotionally overextended” [Depersonalization relates to an “impersonal response towards recipients of one’s service” [Personal accomplishment stands for “feelings of competence and successful achievement in one’s work with people” [There have been several studies of burnout among German physicians within specific specialties. However, they are scarce and employ various measuring instruments. One of the most widely used instruments is the Maslach Burnout Inventory (MBI). It consists of the three subscales lishment . Emotionxtended” . Depersoservice” . Persona people” , which temotional exhaustion, high depersonalization and low personal accomplishment, respectively. With the same instrument, Pajonk et al. [Instruments other than the MBI are also in use and results are therefore difficult to compare: Klein et al.  used thek et al.  estimatek et al.  employink et al.  performeMental distress among physicians has been associated with, among others, substance abuse, depression and family conflicts . In seveImportantly, burnout among physicians has also been associated with increased rates of job turnover intentions , 18, andIn Germany, there is an ongoing debate about a potential shortage of physicians, among other reasons, due to physicians leaving clinical practice and/or going abroad for clinical work –23. To tTo what extent are symptoms of burnout present among the study population?Is there an association between burnout symptoms and physicians’ wishes to leave clinical practice or to go abroad for clinical work?To address these gaps in knowledge, we aimed to assess the following questions within a study on wishes to leave among young physicians in Saxony, Germany:n = 5956) were sent a paper-pencil questionnaire. Registration with the SLÄK is obligatory for all licensed physicians practicing medicine in Saxony or, if not practicing medicine, having their main residence in Saxony. Two thousand three hundred fifty-seven questionnaires were returned from September 2012 to February 2013, equaling a response rate of 40 %. Compared to the population of physicians in Saxony, the sample contained more women  and participants were slightly younger . The letter accompanying the paper-pencil questionnaire stated that sending back the filled out questionnaire was regarded as giving consent to participating in the study. All questionnaires were anonymous and at no point could a filled out questionnaire be related to the respective respondent. The study was approved of by the Ethics committee of the University of Leipzig (Ethik-Kommission an der Medizinischen Fakultät der Universität Leipzig).The study was designed as a cross-sectional study. In a comprehensive survey, all physicians up to 40 years of age and registered with the State Chamber of Physicians of Saxony (SLÄK) , depersonalization (ranging from 0 to 30 points) and personal accomplishment (ranging from 0 to 48 points). Higher scores on the subscales emotional exhaustion and depersonalization indicate a higher degree of burnout, while a higher score on the subscale personal accomplishment indicates a lower degree of burnout.Symptoms of burnout were measured with the German version of the Maslach Burnout Inventory - Human Services Survey (MBI) . The MBIemotional exhaustion this translates into ≤18, 19–26, and ≥27 points, respectively; for the subscale depersonalization into ≤5, 6–9, and ≥10 points, respectively; and for the subscale personal accomplishment into ≥40, 39–34, and ≤33 points, respectively. Before employing it in the study, the questionnaire was pretested by physicians for comprehensibility and usability. The questionnaire is available from the authors upon request.Means were calculated and subscales were categorized into “low”, “average”, and “high” degrees of burnout using the cut off values suggested by Maslach et al. : For then = 1784). Means on MBI subscales were compared with t-test, and proportions were compared with χ2 -test.Of the 2357 questionnaires returned, 9 questionnaires were excluded from the analysis: 3 persons were older than 40 years, 1 person worked abroad and 5 questionnaires were incomplete. For the purpose of studying burnout, only questionnaires of physicians working in patient care who fully completed the MBI were analysed , clinical work experience (in years), and satisfaction with the factors “work environment”, “work load”, “patient care”, “structural aspects”, and “humaneness” were introduced as continuous variables. Female sex , being in a relationship (rc: no relationship), having children (rc: no children), having German citizenship (rc: no German citizenship), being a specialist , would become a physician again (rc: would not become a physician again or indecisive), working full-time (rc: part-time), working in an urban setting , working in an inpatient setting (rc: outpatient setting), having a leading position/having their own practice (rc: non-leading position/employee in a practice) were dummy coded before introducing them into the regression models. Participants with missing values on variables were excluded from the analyses.emotional exhaustion, depersonalization and personal accomplishment, as well as age, were introduced as continuous independent variables. Female sex , being in a relationship (rc: no relationship), and having children (rc: no children) were dummy coded before introducing them into the regression models. Participants with missing values on variables were excluded from the analyses.Multivariate logistic regression analyses were also performed to study the association between burnout symptoms and wishing to leave. Dependent variables were wishing to leave clinical practice and wishing to go abroad for clinical work. Scores on the subscales As not all participants fully completed all questions, the percentages in the results section correspond to the number of actual answers given. Data analysis was performed with Stata 12.0 for Windows.n = 1457) of the physicians worked in an inpatient setting and of these 85 % (n = 1222) worked in a hospital with more than 100 beds. Fifty percent (n = 138) of the physicians working in an outpatient setting worked as primary care physicians.The characteristics of the study population are detailed in Table depersonalization . Subscales were also categorized into low, middle and high degrees of burnout . The means of each subscale are presented in Table sus 9 5.6, p <0.00To assess the overall extent of burnout symptoms, the percentage of participants showing a high degree of burnout over all of the scales was analysed.p < 0.01), of participants working full-time , and of participants working in an inpatient setting  showed a high degree of burnout on all subscales   were similar to those detected among European family doctors  and among hospital physicians in Hamburg, Germany  [This study investigated the extent of burnout symptoms among a large sample of young physicians in Saxony, Germany. The achieved mean scores on the MBI subscales (t: 34.1) , 12. Likt: 34.1) . In botht: 34.1) . As sevedepersonalization, an “impersonal response towards recipients of one’s service” [depersonalization. A possible explanation may be that the German society expects less of men than of women to be empathic and to show emotions, but rather to be strong and not to show weakness. Thus, the social context may promote men to experience, but also to express, feelings of depersonalization. Similarly, in a meta-analysis by Purvanova et al. [depersonalization, whereas women showed higher emotional exhaustion. Purvanova and colleagues argue that women rather report emotional exhaustion as the main symptom of burnout, whereas men tend to present with increased levels of depersonalization as the main symptom of burnout [In the present sample, a higher percentage of men exhibited high symptoms of burnout in bivariate analyses. Men also showed higher degrees of service” , widely a et al.  includin burnout .emotional exhaustion. This is consistent with a meta-analysis of worldwide studies: Outpatient-based physicians showed a higher degree of emotional exhaustion [emotional exhaustion and depersonalization. However, lower personal accomplishment was more common among hospitalists [In bivariate analysis, physicians who work in an inpatient setting exhibited more burnout. In multivariate analysis, however, inpatient work was associated with a lower chance for high haustion . In contitalists . In crosdepersonalization [Among a sample of French physicians, low quality of teamwork was associated with burnout and highly associated with intentions to leave the medical profession . Likewislization .can be addressed and improved by specific measures in an effort to improve the work environment and to prevent burnout – in contrast to the work setting, as in- and outpatient settings most likely will always be needed in a health care system.Long-term studies are needed to define predictors of burnout instead of mere associations. It is conceivable that burnout may prevent good teamwork and prevent from perceiving the work environment as intellectually stimulating. However, it would make even more sense if good teamwork and an intellectually stimulating work environment contributed to mental well-being, reduced work-related stress, and also to the prevention of burnout. Moreover, quality of teamwork and training emotional exhaustion and depersonalization. In the context of this study, qualitative aspects related to private life seem to be more important than quantitative facts. German hospital physicians exhibit a higher degree of “work interfering with family” conflicts when compared to the general public [While neither being in a relationship nor having children were associated with a high degree of burnout, higher satisfaction with the factor “work load”  was associated with a lower chance for high l public . Work-fal public , 33. Thel public , 34. A pl public . These dl public .emotional exhaustion and lower personal accomplishment were associated with the wish to leave clinical practice. Higher emotional exhaustion and higher depersonalization were associated with the wish to go abroad for clinical work.There is an ongoing discussion in Germany about whether physicians may leave clinical practice or go abroad for clinical work –23. TherEmotional exhaustion, the core symptom of burnout, was associated with both the wish to leave clinical practice and the wish to go abroad for clinical work. We can only speculate why, in the setting of this study, lower personal accomplishment was associated with the wish to leave clinical practice but higher depersonalization with the wish to go abroad. Perhaps participants scoring low on personal accomplishment rather focus on professional success and hope for better achievements by changing the occupational field. In contrast, participants scoring high on depersonalization may consider a change of health care systems to allow for more, or less, contact with patients, with the additional benefit of the adventure of going abroad. To elucidate this, further research would be warranted on burned out physicians’ expectations associated with leaving clinical practice or going abroad.It should be taken into account that also factors not measured in the context of this study may contribute to the development of wishing to leave, such as available career opportunities, financial investments, etc. In the setting of this study, female sex, being in a relationship and having children were associated with a lower chance of wishing to go abroad. Participants with a partner and/or children may be more rooted in their current living situation in Germany and not consider moving abroad attractive due to the difficulties of finding a job for the partner and day care or school for the children.The present results are consistent with a recent study among French physicians in which burnout increased the risk for intentions to leave the medical profession . Similaremotional exhaustion decreased significantly [These findings raise the question of how to prevent or to reduce burnout among physicians. Two recent randomized controlled trials from Spain and the USA indicate that mindfulness-based interventions in a group setting may decrease physician burnout at the individual level , 36. Theficantly .It remains to be evaluated whether similar approaches may be effective in reducing or preventing burnout among physician populations in Germany. A recent systematic review by Seidler et al. points out that multidimensional approaches are needed as burnout is most likely multifactorial, and which work related factors are perceived as strain depends on the individual .Preventing or reducing symptoms of burnout among physicians will not only improve individual health and decrease personal suffering. It may also be beneficial for the health care system as a whole in terms of lower costs, e.g. by avoiding costly treatment of burned-out physicians as well as avoiding early physician retirement and decreased physician productivity due to burnout , 16. PreAlthough we investigated a large sample of physicians, the results cannot be generalized to the population of physicians in Saxony: The sample is younger than the population and the proportion of women is larger in the sample. Due to the anonymised nature of the survey, non-responders could not be followed up and reasons for non-participation could not be elucidated. It is possible that only those participants who felt that the topics applied to them, and might exhibit higher symptoms of burnout, responded. Thus, prevalence of burnout would be overestimated. However, it is also conceivable that those physicians with higher burnout symptoms did not respond to the survey, which would lead to an underestimation of the prevalence of burnout. Importantly, participants could not be followed up and therefore it is not possible to trace whether wishes to leave were actually put into practice. Among family practitioners in England, intention to leave predicted actually leaving . Among UThe study was a cross sectional study and no conclusions regarding causality can be drawn.The sample of physicians in the present study was not more burdened by burnout than previous physician samples. Still, the extent of burnout among these young physicians in Saxony is of concern. Higher satisfaction with the components “work environment” and “humaneness” were associated with a lower chance for burnout on all subscales. This may be a starting point for developing measures to reduce or prevent burnout in this study population. Several recent studies suggest that interventions on the individual or organizational level may improve symptoms of burnout among physicians. Future projects should concentrate on adapting preventive measures to the reality of physicians in Germany.emotional exhaustion was associated with a higher probability for wishing to leave clinical practice or to go abroad for clinical work. While the link between burnout and intentions to quit the job or the profession has been established in previous studies, to the best of our knowledge, this is the first study to investigate the association between burnout and the wish to leave the country and practice medicine abroad. Future studies are warranted to evaluate burned out physicians’ expectations associated with leaving clinical practice or going abroad for clinical work.Furthermore, higher Preventing or reducing burnout among physicians will not only improve individual health and decrease personal suffering. Importantly, preventing or reducing burnout may potentially also prevent the German health care system from losing physicians.


The efficacy of high-intensity interval training for a broad spectrum of cardio-metabolic health outcomes is not in question. Rather, the effectiveness of this form of exercise is at stake. In this paper we debate the issues concerning the likely success or failure of high-intensity interval training interventions for population-level health promotion.Biddle maintains that high-intensity interval training cannot be a viable public health strategy as it will not be adopted or maintained by many people. This conclusion is based on an analysis of perceptions of competence, the psychologically aversive nature of high-intensity exercise, the affective component of attitudes, the less conscious elements of motivated behaviour that reflect our likes and dislikes, and analysis using the RE-AIM framework. Batterham argues that this appraisal is based on a constrained and outmoded definition of high-intensity interval training and that truly practical and scalable protocols have been - and continue to be - developed. He contends that the purported displeasure associated with this type of exercise has been overstated. Biddle suggests that the way forward is to help the least active become more active rather than the already active to do more. Batterham claims that traditional physical activity promotion has been a spectacular failure. He proposes that, within an evolutionary health promotion framework, high-intensity interval training could be a successful population strategy for producing rapid physiological adaptations benefiting public health, independent of changes in total physical activity energy expenditure.Biddle recommends that we focus our attention elsewhere if we want population-level gains in physical activity impacting public health. His conclusion is based on his belief that high-intensity interval training interventions will have limited reach, effectiveness, and adoption, and poor implementation and maintenance. In contrast, Batterham maintains that there is genuine potential for scalable, enjoyable high-intensity interval exercise interventions to contribute substantially to addressing areas of public health priority, including prevention and treatment of Type 2 diabetes and cardiovascular disease. In this paper, we debate the pros and cons on ‘high-intensity interval training’ (HIT) as a public health strategy. The paper is the product of a debate held at the ISBNPA Conference in Edinburgh in June 2015.PRO: Alan M Batterhamdoes work, under optimal controlled circumstances with full compliance, but it will not work in practice. Herein, I challenge this position.High-intensity interval training (HIT) has been defined as either repeated short <45 s) to long 2–4 min) bouts of rather high  intensity exercise, or short  or long  all-out sprints, interspersed with recovery periods [–4 min bo5 s to loOn Liberty, John Stuart Mill stated that “He who knows only his own side of the case knows little of that.” [In his magnum opus, f that.” . This ph1; clearly, engaging in HIT results in a broad spectrum of cardio-metabolic benefits [reach) and that in those who do participate there will be poor adherence and high attrition, such that effectiveness will be low. For example, Hardcastle et al. [et al. [et al. [Even for HIT detractors its efficacy is not in questionbenefits –10. Rathe et al.  argue th [et al.  are care [et al. . The fie [et al. , 12. Har [et al.  are cleaet al. article [may also be a barrier to”, “may lead to subsequent avoidance”, “may be inappropriate”, and “could” diminish intrinsic motivation and discourage adherence. This tactic is powerful, as many people will focus on the article title and the success of a straw man argument depends on the audience being uninformed or misinformed regarding the true position.I have focused on the Hardcastle  article , as it pet al. claim that the ‘feel-good’ effect is unlikely during high-intensity exercise [The research evidence typically advanced to justify attacks on HIT based on negative affect and lack of enjoyment is grounded in dual-mode theory , 14. Howexercise , a viewpexercise  countersThe practice of ignoring evidence that contradicts their position, and repeating the anti-HIT mantra in publications, on social media, and at conferences, is an example of “blame gossip” in established-outsider relations . Certainnot the dependent variable. Health outcomes are what matter to public health commissioners and policy makers – not physical activity levels per se [I argue that HIT deserves a prominent place among a smörgåsbord of physical activity and exercise options . A commos per se . The diss per se , we haves per se .any sustained physical activity or exercise behaviour requires a high level of motivation, as there is no innate drive for it.One explanation proposed for the failure of physical activity promotion is the focus to date on health benefits, rather than acute and chronic psychological well-being . HoweverIn the final section of my pro-HIT case, I advance the hypothesis that a public health campaign based on explaining the mismatch between our genes and our environment – and its consequences for chronic disease  – might There is great potential for HIT interventions to contribute to addressing areas of public health priority, including prevention and treatment of Type 2 diabetes and cardiovascular disease. As a potent weapon in waging war on non-communicable disease, HIT should be embraced.Physical activity has become an important element of health promotion in many countries over the past few decades. Using the behavioural epidemiological framework , before This is not being disputed here. But in order to determine if more physically demanding forms of physical activity are viable as a public health strategy, we need to consider the correlates and barriers to such behaviours, and whether the behaviours themselves will be adopted. It is largely pointless if some forms of physical activity are shown to produce significant health gains if few people adopt the behaviours.Regarding the health benefits of physical activity, it has been known for many years that a variety of dose-response curves exist . Essenti2peak ” (p.58). These may last from a few seconds to several minutes, with periods of rest or low-intensity exercise. In referring to HIT, therefore, I am talking about very high exercise intensity, not just increasing intensity to the normal ‘vigorous’ range within the ubiquitous ‘moderate-to-vigorous’ (MVPA) nomenclature.In recent years, physiologists have shown a great deal of interest in the effects of very high intensities of physical activity. Often termed ‘high intensity interval training’ or ‘high intensity exercise training’, the catchy abbreviation of HITT, or simply ‘HIT’, has been adopted. Gibala and McGee  have defpopulation as a whole. Its activities aim to provide conditions in which people can be healthy and focus on entire populations, not on individual patients or diseases” (http://www.who.int/trade/glossary/story076/en/) (emphasis added). Therefore, public health strategies, such as those aimed at tackling the pandemic of physical inactivity, need to attempt to reach the largest population possible. The greatest public health gains will be made by creating at least small changes but across large populations. This is in contrast to large gains in health but in only a small minority of people. The latter will leave the health of the population largely unaffected.The World Health Organisation (WHO) says that public health “refers to all organized measures … to prevent disease, promote health, and prolong life among the i.e., correlates and barriers). These can be numerous and will sometimes differ by population and type of physical activity.To understand how best to promote more physical activity at the population level we need to understand what factors are associated with greater or lesser levels of physical activity , maximal volitional intensity training (MVIT), or a walking group [The Dual-Mode Model of affective responses to exercise makes a number of propositions concerning the association between exercise intensity and affective (feeling) states , 37. Prong group . The walet al. [One important factor often claimed to be associated with participation in physical activity is enjoyment, although the evidence is a little more complex than one might imagine . On one et al. . Howeveret al. , were inIn looking at the PACES instrument in more detail, there are items signifying constructs where competent runners might be reporting their ‘liking’ for HIT through feelings of challenge and accomplishment. After all, it usually feels good after hitting one’s head against a brick wall! Although the paper doesn’t report individual item scores, I would not be surprised to see elevated scores, in this sample of competent runners, for items such as ‘it’s very gratifying’, ‘it’s very stimulating’, and ‘it gives me a strong sense of accomplishment’, particularly as all responses were made after the exercise bout. The dual-mode model would support such post-exercise feelings, but equally would predict feelings of considerable displeasure during exercise .One of the most frequently mentioned barriers to taking part in physical activity is perceived lack of time . For thiThe key issue, therefore, is not to find more time but to enable people to re-allocate their time to exercise because they value participation and its outcomes. To do this, psychological theory would suggest that behavioural intentions and behaviours will be enhanced by focussing on the positive affective element of attitudes more than instrument elements . In otheRecent thinking on health behaviour change has highlighted the use of both conscious and less conscious processing for health behaviours , 42. ForAutomatic processes of motivation will also be in operation for physical activity. This is where behaviours are triggered by much less conscious ‘gut feelings’, such as likes and dislikes. ‘Nudging’ people into health, by making environments more conducive and pleasant, seems most unlikely for HIT. HIT will require considerable psychological effort through planning and self-regulation and be accompanied by feelings of unpleasantness at a more sub-conscious level. In addition, it is logical to think that people’s capacity will be challenged with HIT, which is a similar argument made earlier about lacking perceived competence or confidence.http://www.re-aim.hnfe.vt.edu/about_re-aim/index.html). RE-AIM stands for the five elements of Reach (the target population), Effectiveness or efficacy of the intervention, Adoption by targeted staff, settings, or institutions, Implementation consistency, costs and adaptations made during delivery, and Maintenance of intervention effects in individuals and settings over time. Although data to analyse HIT using the RE-AIM framework is not currently available, I speculate that reach will be very low, effectiveness will also be low at a population level , adoption will be low, implementation will be poor, and maintenance will be low. In short, the “external validity (for) sustainable adoption and implementation” of HIT is likely to be very poor indeed.The goal of the RE-AIM framework is to “encourage program planners, evaluators, … policy-makers to pay more attention to essential program elements including external validity that can improve the sustainable adoption and implementation of effective, generalizable, evidence-based interventions” , have small sample sizes, have insufficient duration to determine the effects on longer term health outcomes, as well as adherence and changes on key psychological constructs known to be important for involvement in physical activity2. Moreover, even some of the main proponents of HIT have stated that “given the extreme nature of the exercise, it is doubtful that the general population could safely or practically adopt the model” [There is currently no evidence supporting HIT as a viable public health strategy. Studies conducted to date are only efficacy studies, are limited by design (e model”  (p. 62).The live debate at ISBNPA 2015 hinged on two interrelated issues – how HIT is defined and whether it is associated with negative exercise affect (displeasure) likely to result in low adoption and poor adherence. First, let us re-examine the definition of HIT. Biddle states that he is referring to “very high exercise intensity, not just increasing intensity to the normal ‘vigorous’ range within the ubiquitous ‘moderate-to-vigorous’ (MVPA) nomenclature.” I, too, am talking about low-volume practical modes eliciting very high exercise intensity, above the ventilatory threshold in the ‘heavy’ intensity domain. However, it was clear from the live debate that Biddle is actually clinging to a much more constrained definition of HIT, as Sprint Interval Training (SIT) performed in 4-6 repeat Wingate tests involving 30 s of all-out maximal cycling against a high braking force on a specialized ergometer . I reiteBiddle’s denial that SIT has evolved into more practical, scalable HIT interventions - which result in similar cardio-metabolic responses to those observed with more extreme Wingate-based protocols - is illogical. In the live debate, Biddle derided my assertion that brisk incline walking , 32 is aBiddle’s seemingly irrational constraint of the definition of HIT is critical to his case, as defining HIT in its most extreme form creates a straw man that is easy to knock down. Without this definition, his case against HIT collapses. If my opponent will not acknowledge the evolution of SIT to HIT, then we shall have reached an impasse and he will be stuck in Plato’s Cave  as the fet al. [The second main point of contention concerns the claim that HIT is associated with displeasure during the exercise leading to aversion and drop out. The ‘evidence’ used to sustain this assertion is derived from research on exercise affect within a dual-mode theory framework. The bottom line is that dual mode theory applies to continuous exercise above the ventilatory threshold, not to low-volume HIT with its built-in recovery periods. Anticipation of impending recovery, and the recovery period per se, results in more positive affect than continuous vigorous intensity exercise. For example, Jung et al.  reportedet al. . Similaret al. . In conjet al. ; dual mohttp://bit.ly/1Ml69Nq), resulting in a rating of “Poor, needs serious attention”. Presenting this ‘result’ as a detached, objective finding is, of course, entirely specious.Biddle argues that HIT can never be a viable population health strategy. In the live debate, he judged HIT interventions using the RE-AIM framework Self-Rating Quiz . I believe HIT will not achieve this.We are in agreement regarding the efficacy of HIT; clearly it produces rapid cardio-metabolic adaptations benefiting health. There is no other common ground between us, as we clearly disagree on the potential effectiveness of HIT and its likely impact on public health. Our polarized positions are informed by different conceptions regarding precisely what constitutes HIT, diverse interpretations of the literature on the relationship between exercise intensity and psychological affect, and contrasting philosophies for physical activity or exercise promotion. However, we are clearly both passionate about improving population health, and hope that our debate will stimulate further research to inform policy and practice. One key issue is to establish a commonly accepted definition of what constitutes ‘HIT’.1As with any intervention, a full evaluation of efficacy includes an assessment of potential harms, necessitating large long-term studies.2SJHB is grateful to an anonymous reviewer for some excellent observations and suggestions noted here.


As a molecular biologist, you start by learning the basics of the DNA code. Reading and translating the code come first, and then you can move on to doing your own careful editing using cut and paste and copy and paste. Once you’ve acquired these skills, you can manipulate genes, genomes, and proteins to examine how cells “work” and to adjust the way they work. The power, versatility, and affordability of these techniques have improved in leaps and bounds in recent years, in parallel with improvements in information technologies. For example, DNA sequencing, or the ability to “read” an entire genome, is now accessible to any reasonably well-resourced research team.var genes in 1995, the African trypanosome human serum resistance-associated gene in 1998, and the malaria parasite chloroquine resistance transporter in 2000 are just a few examples. It remains challenging, though, to identify genes involved in a particular process of interest. Discovery of a new and important gene is also only the first step in research aimed at fully understanding function and potential as a therapeutic target or a vaccination candidate, for example. The outstanding challenges, however, are exactly what continue to drive technological innovation in the life sciences.The techniques are important, but it’s really what you do with them that can capture the imagination. The discovery of key disease-associated genes, often many years after the consequences of their action, or inaction, are known, has been a source of inspiration to me personally. In particular, I recall reading about identification of the cystic fibrosis gene in 1989, when starting my PhD, and hearing about identification of the leptin gene, linked to obesity, as a post-doc in 1995. Then, I saw what impact gene discovery could have on my own molecular parasitology community: the malaria parasite So what’s the situation for the unicellular trypanosomatid parasites we work on in Dundee? These highly motile cells, about 1/50th of a millimetre long, are spread between mammals by blood-sucking insects. They have a devastating impact on the world’s poor, causing the “neglected tropical diseases” African trypanosomiasis, Chagas disease, and the leishmaniases. The consequences of this range of human and animal diseases are hundreds of thousands of deaths each year and around a million cases a year of the disfiguring lesions associated with cutaneous leishmaniasis. Trypanosomes also severely curtail the import of susceptible horses, cattle, sheep, and goats across Africa.We’ve focussed on African trypanosomes in particular and see that antiparasitic adaptations in the host and antiparasitic drugs are constantly threatened by obsolescence in the “arms race” between us and the parasites. In the hope of helping to gain the upper hand in this race, we adapted a genetic screening approach that allows us to survey every parasite gene for roles in drug action and drug resistance. This revealed >50 new genes linked to drugs in clinical use. The drugs nifurtimox and eflornithine, for example, are widely used as a combination therapy. We confirmed that nifurtimox is converted to a more potent drug by a parasite enzyme and, as also reported independently by other groups, found that eflornithine is taken up by a parasite amino acid transporter.A much older drug, suramin, was found to hitch-a-ride into the cell on a parasite surface protein. This was a particularly satisfying discovery because Paul Ehrlich, “the father of chemotherapy,” who developed both the “magic bullet” hypothesis and the precursors to suramin over 100 years ago, stated, “When once we are acquainted with the majority of the chemioreceptors of a particular kind of parasite…we shall have far-reaching possibilities of simultaneous attack by various agencies” . So, we found one of Ehrlich’s “chemioreceptors,” and this does indeed present new opportunities for therapeutic development.Another finding related to two more old drugs for which cross-resistance had been reported over 60 years ago. This melarsoprol and pentamidine cross-resistance was linked to a defect in an aquaglyceroporin, another parasite membrane transporter. Resistance to melarsoprol, a rather toxic but otherwise effective arsenic-containing drug, had been observed in up to 50% of patients in some areas. Teams that collected and stored resistant parasites from across Africa were able to rapidly identify defects in this transporter and to trace them back to the mid-1970s. Thus, the genetic changes that allowed trypanosomes to resist this particular therapy are now known, the impact of these changes can be investigated in detail, and the spread and distribution of resistant parasites can be effectively monitored.It’s quite remarkable how biological processes frequently become experimentally accessible in unanticipated ways, probably because we still have so much to learn about many of them. This has also been my personal experience. In the case of our own findings, it was our work on DNA repair that allowed us to develop the genetic screening approach described above. In addition, our initial motivation for developing this approach was a desire to tackle a completely different gene expression question; fortunately, we were able to initiate collaborations with colleagues who were already established experts in drug resistance.What is clear is that knowing how drugs work and how they stop working helps improve the prospects of devising more effective and durable therapies and also improves prospects for monitoring and tackling resistance when it arises. As primarily “basic researchers,” working with partners in the Dundee Drug Discovery Unit, we will continue our efforts to discover and dissect druggable biology in the trypanosomatids. Indeed, tools and technologies are now in place to probe these chemical–biology interactions at higher throughput than ever before.Since our work continuously relies upon the work and discoveries of many colleagues—too many to mention, I’m afraid—I end by reiterating what’s probably rather obvious: impact against these and other human and animal pathogens requires a community of researchers, critical mass, open interaction, collaboration, and access to powerful technology, at both basic and translational levels. What is also clear is that experiments with pathogens will continue to yield insights of far broader relevance to the life sciences and beyond.