Co-Director, Michigan State University College of Osteopathic Medicine
This approach to problem solving is a natural ability and does not have to be taught in its own right gastritis diet áĺňńčňč order pantoprazole 40mg without prescription. These findings provide one of the arguments for why increasing numbers of medical schools are using problem-based learning as the keystone of the curriculum gastritis diet in pregnancy order pantoprazole master card. Patient problems are used to trigger the search for factual information rather than teaching factual information before exposing students to patient problems (see Chapter 7) gastritis x estres buy discount pantoprazole line. How to teach clinical problem solving: from what we have said the aim must be to provide your students with as much experience as possible in manipulating their factual knowledge in relation to patient problems. You should avoid conducting tutorials in which you or your students simply present topics. If, for example, you wish to have a tutorial dealing with hypertension then a patient with hypertension should be the focus. The student will then be required to consider the implications of hypertension in relation to that particularpatient. Though this may sound rather structured and formal, in practice this will not be so. You will soon learn to judge the pace, learn how much new information is to be given before stopping and so on. However, you may initially find sessions of this type hard going if the students are not used to the challenge of this method of teaching. Those previously relying on the regurgitation of lists and pages from the books may be particularly discomforted. They may attempt to avoid answering or justifying their suggestions but persistence will pay off. With sessions of this type it is important to create a non- threatening atmosphere. Let the presenting students bring along a case or patient whom you do not know. Still encourage the students to answer first but you can then add your own thoughts. You may even find this more threatening than the students but it is important they learn that infallibility is not an attribute of clinical teachers and that it is quite normal for even the most experienced clinician to have to admit indecision and a need to obtain advice or further information. ALTERNATIVES TO TRADITIONAL CLINICAL TEACHING We have already provided evidence that traditional clinical teaching is often inadequate in meeting the aims of both the medical school and the students. This has led many schools to introduce structured courses to teach basic clinical skills in a less haphazard manner. The skills taught are often not restricted to interviewing and physical examination but include technical skills and clinical problem solving. Should you have the opportunity to introduce or participate in such an approach then the first step must be to define the objectives of the exercise. These must take into account the seniority of the students, the time allocated in the curriculum, the facilities, and the availability of teachers and other resources. There are obviously many ways in which this could be done but we will restrict ourselves to outlining such a programme 78 which has been run successfully for many years jointly by a Department of Medicine and a Department of Surgery. Opposite each are the teaching activities which are planned to help the student achieve the objectives. In the right-hand column are the assessment procedures which are also matched to the objectives. The key to the programme is the attachment of only three students to a preceptor for instruction on history taking and physical examination.
He received his degree of orthopedic literature in English gastritis diet 6 small cheap 20 mg pantoprazole with mastercard, French gastritis h pylori buy pantoprazole 20mg without prescription, and Doctor of Medicine from Harvard Medical German; he expected all of his associates to be School in 1882 gastritis symptoms images buy pantoprazole mastercard, and for a while he practiced in equally well informed and up to date, so that dis- 358 Whoâs Who in Orthopedics cussions, which were very frequent, would be lent anatomist and, through hints dropped here most fruitful and thought-provoking. Whitman was a profound student of ortho- anatomy; second, on the day before an operation pedic surgery, a pioneer, and a pathďŹnder. He was he continuously reviewed what he contemplated always trying out new procedures, either those he doing, and hence he came to the operating table initiated or those suggested by others. He avoided an insatiable curiosity about the pathogenesis of complicated operations, believing that the goal orthopedic diseases and deformities, and an imag- could be attained through simple measures. He was his own sternest operation was rarely an emergency procedure, critic and never reported favorably upon any and that the end result would be better if he used technique or procedure until he himself was several simple separate operations. When he He taught orthopedic surgery for 40 years, both became convinced of the value of any treatment, at the College of Physicians and Surgeons of he would, through addresses or medical essays, Columbia University and at the Hospital for the hammer away at the profession until his opinion Ruptured and Crippled. His method of teaching was not always a manual correction of deformities, of which he placid procedure. Although short of stature and thin, not always agreeable, method of sarcastic criti- he many times surprised his young and more vig- cism. His students, orous assistants by the rapidity and ease with however, soon recognized the light in his eyes and which he would correct a resistant deformity over the smile on his lips, and knew that there was no which they had labored ineffectually. He meant only to em- when the use of great manual force was condoned phasize indelibly some point in observation, in the correction of a club foot or the reduction of diagnosis, or surgical technique. To the less a congenital dislocation of the hip, he exhibited understanding students and visitors, this peda- remarkable dexterity and strength in overcoming gogic method was disconcerting. Whitman was particularly insistent upon a As an investigator and teacher, Dr. Whitman thorough knowledge of mechanical principles, the was undoubtedly one of the great contributors to pathology of deformities, and the observance of the advancement of orthopedic surgery in the these in therapeutics. His textbook on orthopedic surgery for the support of the trunk or limbs, and not for is a classic. These were pub- varus of the foot, a ďŹexion at the hip or the knee, lished in English, but often were translated or or a rigid ďŹat foot had to be corrected; then, and abstracted in foreign languages, so that his teach- only then, might the surgeon apply a brace. Woe ings went to every corner of the world and to all to the assistant who did not obey this rule! He methods of treatment, which have been univer- was second to none in speed, dexterity, thor- sally acknowledged and adopted as classical pro- oughness and careful handling of tissues. He initiated the giously avoided undue or excessive trauma, and abduction treatment for fractures of the hip. His was ever mindful of the fact that the recovery of insistence on a method that created the opportu- tissues operated upon depended directly upon the nity for repair of the fractured hip gave the gentleness with which they were treated. Two factors part of Twentieth Century in the management of contributed outstandingly to Dr. He was an excel- astragalectomy and backward displacement of the 359 Whoâs Who in Orthopedics foot for paralytic calcaneus, an operation that sion and to his patients. He often worked day and formerly was generally accepted for stabilization night together with his collaborators to care for of the paralytic calcaneus foot. If an unex- ment, including the use of the Whitman foot pected bad result of a treatment happened, all brace.
The danger of this approach is not only that it leads to the continuation of costly and ineffective programmes gastritis quiz order pantoprazole. It also means that the harms of screening are passed over in silence: to mention them could discourage people from taking up the offer of testing gastritis symptoms belching generic pantoprazole 40mg fast delivery. Indeed this was the first concern of the cancer charities in response to reports of the Danish study of mammography quoted above; public reassurances about the quality of the national cervical screening programme accompany every exposure of poor standards chronic atrophic gastritis definition buy 40mg pantoprazole with visa. Yet the harms resulting from screening are substantial: for every woman who benefits, tens of thousands undergo testing and hundreds receive unnecessary treatment. In presenting screening as an unequivocal benefit to women, doctors become advocates of state policy rather than of their patientsâ interests. State intervention in personal life In the screening programme the author was assigned an âadviserâ who would âhelp her with her healthâ on an ongoing basis and monitor her progress towards âbetter healthâ. The extensive questionnaire Taking the first step to better healthâ included the tendentious and extraordinarily patronising statement that the screening âhas been devised to help you change the way you look after your health. The author took umbrage at (a) the assump-tion that she was not healthy already, and (b) the assumption she didnât know how to look after herself⌠64 SCREENING The questionnaire also included a âWomenâs sectionâ of questions from the banal to the intrusively, impertinently and offensively intimate to âhelp her with her healthâ. The author objected and was told that she was unusual in questioning the questions (most women, apparently donât because they trust doctors and have been brainwashed into believing that they need this nonsense). Over the past twenty years there has been, in the name of health promotion, a dramatic increase in state intervention in the personal life of the individualâironically in a period when the state has been inclined to withdraw from economic and social commitments. The immediate consequence has been a stricter regulation of individual behaviour, though because this has been justified in the cause of improving the health of both the individual and the nation, it has not generally been experienced as coercive. The changed relationship between the state and the individual that is reflected in the greatly enhanced role of health has also changed the role of the medical profession and has given rise to a range of new institutions and professionals working in the sphere of health promotion. The origins of each of the lifestyle interventions we have examined lie within the world of medicine and its attempts to tackle the âmodern epidemicsâ of heart disease and cancer. However, as is clear from our brief survey of the development of these interventions, at a certain point each was taken up by the state and transformed into a major national initiative. In the case of smoking, this occurred with the shift of focus to passive smoking in the late 1980s; in relation to CHD, government promotion of âhealthy eatingâ began earlier but also became a major campaign in the late 1980s and in the Health of the Nation initiatives of the early 1990s; both the cervical and breast screening programmes were nationalised in 1987â88. The stateâs assumption of a leading role in health promotion inevitably changed the character of these initiatives. Once they had acquired a wider political and ideological role, their contribution to health became of secondary importance. At a time when politicians were preoccupied with the declining prestige of government, projecting an image of concern with health helped to shore up public 65 SCREENING approval. Successive governments recognised the potential of health as a means of establishing points of contact between the state and an increasingly atomised society, a trend which reached its apotheosis in NHS Direct, the 24-hour telephone advice line set up in 1999, claimed by Tony Blair as one of the greatest achievements of his first 1,000 days in office. Employers too recognised the potential of health promotion in managing relations with workers. In a perceptive study, Margaret May and Edward Brunsdon noted the shift in the 1980s away from traditional âoccupational healthâ concerns towards ânew âwellnessâ interventionsâ, including medical âcheck-upsâ, âhealth risk appraisalâ, screening tests and preventive lifestyle advice (May, Brunsdon 1994). They characterised this as âa new form of employee controlâ, far beyond the familiar organisation of work, as the jurisdiction of the employers extended into workersâ private lives. They commented on the convergence of management theory and government health policy around the themes of personal responsibility. The proliferation of workplace smoking bans in the 1990s was another indication of the extension of managerial authority justified by concern for employeeâs welfare. As health promotion assumed an ever greater profile, there was some divergence between the ways in which prevention strategies were presented to the public and how they were perceived within the private world of medicine. The politicians and the media wanted simple messages, soundbites, and doctors who took the lead in health promotion campaigns were happy to provide themâon the evils of passive smoking, the dangers of dairy products or the need for screening tests. Meanwhile, as we have seen, a highâand often increasingâlevel of scepticism came to prevail among medical experts about the value of all these interventions.
X Negotiate a length of time for the interview and stick to it gastritis sintomas buy pantoprazole visa, unless the interviewee is happy to continue distal gastritis definition discount 20mg pantoprazole mastercard. X Check recording equipment is working without draw- ing attention to it gastritis in the antrum cheap 40mg pantoprazole mastercard. X Achieve closure, thank them and leave a contact num- berincasetheywishtogetintouchwithyouabout anything that has arisen. HOW TO CONDUCT INTERVIEWS / 75 X Respect their conďŹdentiality â do not pass on what has been said to third parties unless you have requested permission to do so. They are popular within the ďŹelds of market research, political research and educational research. The focus group is facilitated by a moderator who asks questions, probes for more detail, makes sure the discussion does not digress and tries to ensure that everyone has an input and that no one person dominates the discussion. If you are interested in running focus groups for your re- search you will need to acquire a basic understanding of how people interact in a group setting and learn how to deal with awkward situations (see Table 8). However, the best way to become a successful moderator is through experience and practice. If possible, try to sit in on a focus group run by an experienced moderator. Once you have done this, hold your own pilot focus group, either with friends or ac- tual research participants. You might ďŹnd it useful to video tape this focus group so that you can assess your body lan- guage, see how you deal with awkward situations, analyse how you ask questions, and so on. Donât be disappointed if your ďŹrst few groups do not go according to plan. In all focus groups you need to explain the purpose of the group, what is expected of participants andwhatwillhappentotheresults. Negotiatealength for the discussion and ask that everyone respects this as it can be very disruptive having people come in late, or leave early. Usually one and a half hours is an ideal length, although some focus groups may last a lot longer. Assure the participants about anonymity and conďŹdenti- ality, asking also that they respect this and do not pass on what has been said in the group to third parties. You may ďŹnd it useful to produce and distribute a Code of Ethics (see Chapter 13). Asking questions General, easy to answer questions should be asked ďŹrst. As moderator, listen carefully to everything people say, acknowledging that you are listening by mak- ing good eye contact and taking notes regarding issues to which you may return later. Make sure that no one person dominates the discussion as this will inďŹuence your data. Some moderators prefer to use a list of questions as their interview schedule, whereas others prefer to use a list of topics (see Chapter 7 for more information on developing an interview schedule). The overall aim is a free-ďŹowing discussion within the subject area, and once this happens the input from the moderator may be considerably less than it would be in a one-to-one interview. You will ďŹnd that in most focus groups, most people will talk some of the time, although to varying de- grees. In some groups, some people may need gentle per- suasion to make a contribution.
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