By V. Tuwas. Armstrong Atlantic State University.

Simple ignorance Physicians have to know what they are doing in order to be able to do it well buy 135mg colospa. For example generic 135mg colospa with mastercard, if a physician doesn’t know the significance of the straight leg raise test in the back examination buy colospa 135 mg free shipping, he or she won’t do it or will do it incorrectly purchase colospa 135 mg on-line. This can lead to a missed diagnosis of a herniated lumbar disc and continued pain for the patient buy generic colospa 135 mg line. If the physician doesn’t personally like taking risks, then he or she may try to minimize risk for the patient. On the other hand, if the physician doesn’t mind taking risks, he or she may not try to minimize risk for the patient. Physicians can be classified by their risk-taking behavior into risk minimizers or test minimizers. Risk-taking physicians are less likely to admit patients with chest pain to the hospital than physicians who are risk averse or risk minimizers. They may order more tests than would be necessary in order to reduce the risk of missing the diagnosis. They are more likely to order tests or recommend treatments even when the risk of missing a diagnosis or the potential benefit from the therapy is small. Test minimizers may order fewer tests than might be necessary and thereby increase the risk of missing a diagnosis in the patient. They are less likely to recommend certain tests or treatments, thinking that their patient would not want to take the risk associated with the test or therapy, but will be willing to take the risk associated with an error of omission in the process of diagnosis or treatment. The test minimizer projects that the patient is willing to take the risk of missing an unlikely diagnosis and would not want any additional tests performed. Additionally, use the communica- tions techniques discussed in Chapter 18 to maximize understanding, informed consent, and shared decision making with the patient. If things aren’t working right because of personal issues, such as a fight with your spouse, kids, or partners, problems paying your bills, or other issues, don’t take it out on patients. Physicians must learn to overcome their own feelings and not let them get in the way of good and empathic com- munications with patients. The examinee Biologic variation in the system being examined The main source of random error in medicine is biologic variation. People are complex biological organisms and all physiological responses vary from per- son to person, or from time to time in the same person. For example, some patients with chronic bronchitis will have audible wheezes and rhonchi while others won’t have wheezes and will only have a cough on forced expiration. Some people with heart attacks have typical crushing substantial chest pain while oth- ers have a fainting spell, weakness, or shortness of breath as their only symptom. Understanding this will lead to better appreciation of subtle variations in the his- tory and physical examination. Effects of illness and medication Ignoring the effect of medication or illness on the physiologic response of the patient may result in an inaccurate examination. For instance, patients who take beta-blocker drugs for hypertension will have a slowing of the pulse, so they may not have the expected physical exam findings like tachycardia even if they are in a condition such as shock. Memory and rumination Patients may remember their medical history differently at different times, which results in a form of recall bias. This explains the commonly observed 238 Essential Evidence-Based Medicine phenomenon that the attending seems to obtain the most accurate history. The intern or medical student will usually obtain the first history from a patient. When the attending gets the history later, the patient will have had time to recon- sider their answers to the questions and may give a different and more accurate history. They may have recalled things they did not remember or thought were not important during the first questioning. A way to reduce this is by summariz- ing the history obtained several times during the initial encounter. Filling in Sometimes patients will invent parts of the history because they cannot recall what actually happened. In some instances, otherwise oriented patients will be unable to recall an event because they were briefly impaired and actually don’t know what happened.

The Expert Panel endorsed the approach of the project and content of the outcomes framework cheap colospa 135mg otc. The fnal report and outcomes framework were presented to the European Commission in January 008 discount colospa 135mg with mastercard. This process of discussion and agreement was at the heart of the Tuning (medicine) project order colospa 135 mg with visa. For example buy colospa 135 mg free shipping, “Ability to provide evidence to a court of law“ was rated very low by respondents as a core outcome and so was removed as a Level outcome buy 135mg colospa mastercard. The original draft included the following Level outcomes: • Ability to design research experiments • Ability to carry out practical laboratory research procedures • Ability to analyse and disseminate experimental results These were rated very low by respondents in terms of importance for all graduates as core outcomes of the primary medical degree. The conclusion was that under the Level 1 outcome ‘Ability to apply scientifc principles, method and knowledge to medical practice and research’, no specifc Level outcomes should be included. Similarly, “Research skills”, with no further specifcation, is included as an outcome under Medical professionalism. This leaves it open to individual countries, schools or students to decide how to prioritise practical research experience, in keeping with their profle, educational philosophy or career intentions. Individual schools can also select additional learning outcomes in order to develop or preserve a distinct educational profle – for example, a specifc emphasis on research-related experience and skills - without compromising the essential competence of their graduates and their ftness to care for patients. The structure of the outcomes framework has been chosen to be useful to those involved in planning and designing new undergraduate medical degree programmes. The Level 1 outcomes describe domains of teaching, learning and assessment that lend themselves to becoming “curriculum themes”, with defned academic leadership and dedicated resources. The Level outcomes can help to defne the content of such themes in terms of teaching, learning and assessment. The Professionalism outcomes are relevant when addressing the personal and professional development and ftness to practise of medical students. In future work we aim to document best practice in learning, teaching and assessing these outcomes. Meantime useful information on outcome-based assessment can be accessed through the Scottish Doctor website (http://www. Mobility It seems likely that schools which share a common set of graduating learning outcomes will fnd it much more straightforward to exchange students and staf, particularly in the later parts of the curriculum. Similarly, assurance that graduates have achieved the necessary learning outcomes is likely to facilitate mobility of doctors in Europe and provide reassurance to employers and patients. Quality enhancement and quality assurance Consideration of a medical school’s graduating outcomes in relation to an agreed framework should be an integral part of quality assurance and accreditation, sitting alongside evaluation of education process and infrastructure. Recently developed methodologies permit systematic mapping of one outcomes framework against another, so that a school’s learning outcomes could simply be cross-referenced against the European framework (Ellaway, R et al, 007). Although it is likely that national systems of quality assurance and accreditation will continue to predominate in Europe, the Tuning outcomes can support a developing European dimension in medical education as part of a harmonisation process. European Ministers of Education (1999) Joint declaration of the European Ministers of Education convened in Bologna on the 19th of June 1999 [The Bologna Declaration]. Joint Quality Initiative informal group ( 004) Shared ‘Dublin’ descriptors for Short Cycle, First Cycle, Second Cycle & Third Cycle Awards. Ensuring global standards for medical graduates: a pilot study of international standard-setting. Association of American Medical Colleges (1998) Learning objectives for medical student education: Guidelines for medical schools. Medical Teacher, 007; 9:636-641 3 Appendix A: Knowledge Outcomes Although not formally part of Tuning methodology, the web-base questionnaire survey also sought opinion about important areas of knowledge for medical graduates. In general, the highest scores and rankings related to knowledge of traditional scientifc disciplines which underpin medical practice, such as physiology, anatomy, biochemistry, and immunology, together with clinical sciences such as pathology, microbiology and clinical pharmacology. The lowest ranking related to knowledge of “diferent types of complementary / alternative medicine and their use in patient care”. Graduates from medical degree programmes in Europe should be able to demonstrate knowledge of: Basic Sciences Normal function (physiology) Normal structure (anatomy) Normal body metabolism and hormonal function (biochemistry) Normal immune function (immunology) Normal cell biology Normal molecular biology Normal human development (embryology) Behavioural and social sciences Psychology Human development (child/adolescent/adult) Sociology Clinical Sciences Abnormal structure and mechanisms of disease (pathology) Infection (microbiology) Immunity and immunological disease Genetics and inherited disease 4 Drugs and prescribing Use of antibiotics and antibiotic resistance Principles of prescribing Drug side efects Drug interactions Use of blood transfusion and blood products Drug action and pharmacokinetics Individual drugs Diferent types of complementary / alternative medicine and their use in patient care Public Health Disease prevention Lifestyle, diet and nutrition Health promotion Screening for disease and disease surveillance Disability Gender issues relevant to health care Epidemiology Cultural and ethnic infuences on health care Resource allocation and health economics Global health and inequality Ethical and legal principles in medical practice Rights of patients Rights of disabled people Responsibilities in relation to colleagues Role of the doctor in health care systems Laws relevant to medicine Systems of professional regulation Principles of clinical audit Systems for health care delivery 5 Appendix B: Clinical Attachments and Experiential Learning Although not formally part of Tuning methodology, the web-base questionnaire survey also sought opinion about which areas of clinical medical practice were most important to be included as part of the core undergraduate medical school programme. In general, the highest rankings related to acute medical and surgical care settings, with community and primary care also ranking highly.

In the magazine “Electrical Review” for 1896 some X-ray observations by Tesla were pub- lished order colospa 135 mg visa. He described some clinical benefts of x-rays – for example generic colospa 135mg visa; determination of for- eign body position and detection of lung diseases colospa 135 mg low price. Furthermore generic colospa 135mg mastercard, during the next 50 years x-ray pictures and fuoroscopy played an important role in the treatment of tuberculosis cheap 135 mg colospa overnight delivery. In the period before streptomycin (1947) the only treatment was pneumothorax – an attempt to let the lung rest by accumulation of air in the pleural cavity – and the lung more or less collapsed. We can note that no dosimetry was carried out at the time – and the doses now quoted are very much speculations (see page 210). The idea was to introduce elements that could absorb ef- fciently the x-rays and thus enhance the contrast. The main absorption mechanism is the photoelectric effect – which varies consider- ably with the atomic number (approximately as Z4). In a complex mixture of elements like that found in the organs of a patient, the degree of attenuation varies with the average of the atomic number of all the atoms involved. If two organs have similar densities and similar average atomic numbers, it is not possible to distinguish them on a radiograph, because no natural contrast exists. For example, it is not possible to identify blood vessels within an organ, or to demonstrate the internal structure of the kidney, without artifcially altering the electron density and absorption. In the period from 1931 until it was stopped2 2 – 10 million patients worldwide have been treated with Thorotrast. In 1910 barium sulfate was introduced as contrast agent for gastrointestinal diagnosis. In 1924 the frst imaging of the gallbladder, bile duct and blood vessels took place. This tube was superior to other tubes at the time because of; 1) its high vacuum and 2) a heated flament as the source for electrons. He was able to show that a narrow catheter could be advanced from a vein in the arm into the right atrium of the heart, a distance of almost two-thirds of a meter. Obviously, this constituted a remarkable advance – and could be visual- ized by contrast compounds. This opened the way for angiography which al- lowed the routine imaging of blood vessels and the heart. In connection to this “break-through” in medical im- aging we have to mention the forerunner of the tech- nique called “planigraphy”. In 1948 Marius Kolsrud at the University of Oslo pre- sented a master thesis with the title; Godfrey Hounsfeld Allan Cormack Røntgen-skikt-avbildning. Kolsrud made equipment that made it possible to take x-ray pictures of a single plane in the object. Consequently, structures in the focal plane appear sharper, while structures in other planes appear blurred. It is thus possible to select different focal planes which contain the structures of interest. This method was used for chest x-ray pictures in connection with tuberculo- sis for a number of years. This technique uses x-ray fuo- roscopy to guide the compression of plaques and minimize the dangerous constriction of the heart vessels. The signal from the x-ray system is con- verted to a digital picture which can then be enhanced for clearer diagnosis Andreas Gruentzig and stored digitally for future review. The physical basis for an x-ray picture The x-ray picture is a shadow picture of the part of the body that is between the x-ray tube and the flm. Only the x-ray photons that penetrate the object and reach the flm can give a signal or blacken- ing of the flm. To see into the body we must have “something” that can penetrate the body – come out again – and give information. The fgure below is an attempt to illustrate the main points for making an x-ray photo. The two drawings – one vertical and one hor- Incoming x-ray photons izontal – are attempts to illustrate the basic principles for an x-ray photo. Absorber Part of the body Transmitted Electron photons The x-rays is absorbed according to the electron density Incoming photons Detector Scattered flm, fuoeresent screen, etc.

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