By W. Aschnu. Lincoln College. 2018.

Depending on their stage of development generic 25mg clomid with amex, this may mean breastfeeding for the recommended time effective clomid 25mg, taking Relationships go through cycles. Should your medical marriage the maximum possible parental leave, delaying a career move, run into challenges, remember you are not alone. Even if you cannot Myers, through his book Doctors’ Marriages, shares his wisdom always be there, it is important to work with your partner and that face-to-face couples’ therapy works best. Seek professional to communicate with your child so that you are emotionally help through your community resources or your physician involved and up-to-date with what is going on in your child’s health program. In addition, more men than ever before are taking This chapter will advantage of parental leave policies. Thus, traditional gender • describe some of the challenges commonly faced by phy- roles in Canadian culture are clearly undergoing a healthy evo- sician parents, lution. However, these shifts have created new challenges for • summarize supports that programs can use to facilitate training programs as they strive to balance principles of sound sustainability of residents who are parents, and education and training, human rights and responsibilities, and • identify strategies for resident physicians to promote their health care human resource issues. Medical students are watching this transition and may choose not to Case engage in specialty medicine if it is perceived to be adverse to A second-year resident has recently adopted an infant their family-related values and expectations. However, several residents in the year are In the meantime, academic medicine has not been particularly off on parental leave, and the frequency of call is higher kind to physician parents who have typically enjoyed less insti- than usual. Several colleagues mention that they hope the tutional support (research funding, mentorship, administrative resident is not planning on taking parental leave, as that support) than non-parents, tend to have fewer publications, would increase call frequency to 1:4. In fact, the resident is perceive a slower progression of career goals, and have lower planning on taking leave, but is now dreading approaching levels of career satisfaction. Children add a dimen- sion to life that is unique and delightful, and the parental role Unique challenges of parenting provides opportunities to know ourselves better. That being Physician parents are in an unique position as they promote said, parenting can add to the complexity of managing busy and monitor their children’s health and development. Where some may argue that knowledge about health is valuable and helpful, but—as is the physician parents lack full professional commitment, others case with any parent—their objectivity is limited. Issues that they ensure their children have a primary care provider confronting physician parents are many, and their complexities who is skilled and comfortable working with the dynamics concern both professional and personal roles. It is also essential that physicians avoid boundary crossings or violations with their children; only in Parental leave emergencies should they assume a direct clinical role; other- Every provincial housestaff organization has negotiated paren- wise, they should join in a collaborative relationship with their tal leave policies for their members, and many directly address child’s physician and their child. These policies mesh nicely with the principles and goals of the federal paren- Physician parents report that long work hours reduce the qual- tal leave program and allow many trainees up to a year of leave. Where possible, Residents should be supported and, indeed, encouraged to parents should protect structured time to engage with their take advantage of parental leave during their training. Healthy children, be consistently involved with their children’s com- attachment and bonding with a child requires time. Adequate munity, and ensure that a culture of open and welcome com- leave also allows for the entire family to grow together as they munication is fostered. Children will not accept medicine as an move through the phases of expectation, arrival, integration excuse for parental distance or under-involvement, nor should and, fnally, resumption of professional roles. Besides, spending time with children is a healthy way to in physician families is a smart one and directly contributes to remove oneself from the stresses of medical training, return the long-term sustainability of the physician workforce. Career choices Specialty medicine in Canada is experiencing signifcant demo- graphic shifts, including with respect to the gender and age of practitioners. This creates a remarkably busy family environment that re- Case resolution quires careful planning, open communication, fexibility and The resident books a meeting with the program director creativity to manage well. Busy physician parents need to pay and formally requested the maximum parental leave open particularly good attention to their partner’s emotional and to them. The program director expressed his happiness physical needs in order to bring richness and closeness to for the resident and family while indicating that he will the relationship. However, there was one month in counselling should signifcant relationship diffculties arise: particular that posed a challenge in terms of call and early intervention is associated with high rates of success. This was readily managed with the resident’s Inadvertently, this can lead to physician parents having unreal- partner, and everyone was satisfed. Physician parents are well resident considers this year of leave one of their best life served by engaging in community activities with a diversity of experiences.

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He or she is demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice that includes the delivery of safe clomid 50 mg generic, effective discount 25mg clomid overnight delivery, patient-centered, timely, efficient, and equitable care. He or she is demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice that includes the delivery of safe, effective, patient-centered, timely, efficient, and equitable care. An improvement plan is in place to facilitate achievement of competence appropriate to the level of training. The Milestones are a product of the Internal Medicine Subspecialty Project, a Joint Initiative of the Accreditation Council for Graduate Medical Education and the American Board of Internal Medicine. Subject to statutory exception and to the provisions of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press. First published 2010 Printed in the United Kingdom at the University Press, Cambridge A catalog record for this publication is available from the British Library Library of Congress Cataloging in Publication data Mayer, Dan. To the extent permitted by applicable law, Cambridge University Press is not liable for direct damages or loss of any kind resulting from the use of this product or from errors or faults contained in it, and in every case Cambridge University Press’s liability shall be limited to the amount actually paid by the customer for the product. Every effort has been made in preparing this publication to provide accurate and up-to-date information which is in accord with accepted standards and practice at the time of publication. Although case histories are drawn from actual cases, every effort has been made to disguise the identities of the individuals involved. Nevertheless, the authors, editors, and publishers can make no warranties that the information contained herein is totally free from error, not least because clinical standards are constantly changing through research and regulation. The authors, editors, and publishers therefore disclaim all liability for direct or consequential damages resulting from the use of material contained in this publication. Readers are strongly advised to pay careful attention to information provided by the manufacturer of any drugs or equipment that they plan to use. However, the publisher has no responsibility for the websites and can make no guarantee that a site will remain live or that the content is or will remain appropriate. Kaplan v vi Contents 17 Applicability and strength of evidence 187 18 Communicating evidence to patients 199 Laura J. Henry Pohl, then Associate Dean for Aca- demic Affairs, asked me to develop a course to teach students how to become lifelong learners and how the health-care system works. The first syllabus was based on a course in critical appraisal of the medical literature intended for inter- nal medicine residents at Michigan State University. The basis for the orga- nization of the book lies in the concept of the educational prescription proposed by W. The goal of the text is to allow the reader, whether medical student, resident, allied health-care provider, or practicing physician, to become a critical con- sumer of the medical literature. This textbook will teach you to read between the lines in a research study and apply that information to your patients. For reasons I do not clearly understand, many physicians are “allergic” to mathematics. It seems that even the simplest mathematical calculations drive them to distraction. Although the math content in this book is on a pretty basic level, most daily interaction with patients involves some understanding of mathematical processes. We may want to determine how much better the patient sitting in our office will do with a particular drug, or how to interpret a patient’s concern about a new finding on their yearly physical. Far more commonly, we may need to interpret the information from the Internet that our patient brought in. The math is limited to simple arithmetic, and a handheld calculator is the only computing ix x Preface instrument that is needed. The layout of the book is an attempt to follow the process outlined in the edu- cational prescription. You will be given information about the answer after pressing “submit” if you get the question wrong. When you press “submit,” you will be shown the correct or suggested answer for that question and can proceed to the next question.

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Using abusable substances at this age can disrupt brain function in areas critical to motivation purchase clomid 50mg on line, memory purchase 25mg clomid fast delivery, learning, judgment, and behavior 7 control. So, it is not surprising that teens who use alcohol and other drugs often have family and social problems, poor academic perform- ance, health-related problems (including mental health), and involvement with the juvenile justice system. Can research-based programs The Drug Danger Zone: Most Illicit Drug Use Starts in the Teenage Years prevent drug addiction in 12 11. The term “research-based” means that these programs have been rationally designed 16-17 based on current scientific evidence, rigor- 8. Scientists have developed a broad range of programs that positively alter the 6 14-15 balance between risk and protective factors 4. These prevention programs work to boost protective factors and eliminate or reduce risk factors for drug use. The programs are designed for various ages and can be designed for individual or group settings, such as the school and home. There are three types of programs: z Universal programs address risk and protective factors common to all children in a given setting, such as a school or community. When research-based substance use prevention programs are properly implemented by schools and communities, use of alco- hol, tobacco, and illegal drugs is reduced. Such programs help teachers, parents, and health care professionals shape youths’ perceptions about the risks of substance use. While many social and cultural factors affect drug use trends, when young people 14 perceive drug use as harmful, they reduce their level of use. But marijuana use has 30 40 increased over the past several years as 20 perception of its 30 risks has declined. This three-pound mass of gray and white matter sits at the center of all human activity—you need it to drive a car, to enjoy a meal, to breathe, to create an artistic masterpiece, and to enjoy everyday activi- T ties. In brief, the brain regulates your body’s basic functions; enables you to interpret and respond to everything you experience; and shapes your thoughts, emotions, and behavior. Different parts of the brain are responsible for coordinating and per- forming specific functions. Drugs can alter important brain areas that are necessary for life-sustaining functions and can drive the compul- sive drug abuse that marks addiction. Brain areas affected by drug abuse include: z The brain stem, which controls basic functions critical to life, such as heart rate, breathing, and sleeping. Different areas process information from our senses, enabling us to see, feel, hear, and taste. The front part of the cortex, the frontal cortex or forebrain, is the thinking center of the brain; it powers our ability to think, plan, solve problems, and make decisions. It links together a number of brain structures that control and regulate our ability to feel pleasure. Feeling pleasure motivates us to repeat behaviors that are critical to our existence. The limbic system is activated by healthy, life-sustaining activities such as eating and socializing— but it is also activated by drugs of abuse. In addition, the limbic system is responsible for our perception of other emotions, both positive and negative, which explains the mood-altering properties of many drugs. Networks of neurons pass messages back z Receptors—The Brain’s Chemical Receivers and forth among different structures within the brain, the spinal cord, The neurotransmitter attaches to a specialized site on the receiving and nerves in the rest of the body (the peripheral nervous system). A neurotransmitter and its receptor oper- These nerve networks coordinate and regulate everything we feel, ate like a “key and lock,” an exquisitely specific mechanism that think, and do. Once a cell receives and porters recycle these neurotransmitters (that is, bring them back processes a message, it sends it on to other neurons. The neurotransmitter crosses the synapse and attaches to proteins (recep- tors) on the receiving brain cell. This causes changes in the receiving cell—the Transmitter Receptor Neurotransmitter Receptor message is delivered.

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The practitioner shapes this infor- draws on a 50-year evidence and theory base from the mation into a diagnosis that discount clomid 100mg otc, in turn generic 50mg clomid with visa, influences his/her view 2,3 and collection of subsequent information. Drawing on insights from research on how Patient care is a feedback process in which the clinician people manage problem solving that involves dynamic feed- makes judgments and takes actions with the intended ratio- back, we then describe how this process is likely to break nale of bringing the patient closer to the desired, presumably down. This process of observing/diagnosing/treat- problem solving and avoiding error are provided. Although physicians may be able to adjust a diagnosis stand-alone, discrete episode of judgment, the solutions and treatment based on conversation and examination dur- 1 suggested to resolve error focus on reducing cognitive bi- ing a specific patient encounter, Berner and Graber argue ases and increasing expertise and vigilance at the individual that lack of timely or consistent feedback on the accuracy clinician level. It is not that such recommendations have no and quality of diagnoses over the long term makes it diffi- merit, but simply that they are only a small piece of a much cult for them to improve their diagnostic problem-solving larger repertoire of possible solutions that come into sight skills over time. Once out of medical school and residency, when we regard diagnostic problem solving as a recursive, most physicians operate in a “no news is good news” mode, feedback-driven process. Put differently, rather than view- believing that unless they hear about problems, the diag- ing diagnosis as an event or episode, we suggest emphasiz- noses they have made are correct. Berner and Graber invoke a well-established fact of learning theory, namely, that im- provement is nearly impossible without accurate and timely feedback. Improving one’s diagnostic problem-solving Statement of Author Disclosure: Please see the Author Disclosures skill, they argue, requires an ability to calibrate the match section at the end of this article. Center for Medical Simulation, 65 Lansdowne Street, Cambridge, Massa- chusetts 02139. In the absence of significant information provided by autopsy, data from downstream clinicians, or tailored quality measures, clinicians are unable to update their diagnostic schema. Several decades of research on how people manage information in the face of dynamic feedback reveal other challenges as well. We highlight 3 significant barriers to updating diagnostic schema in a sound way: delays, ambiguous feedback, and superstitious 2,9,10 learning. The “B” labeled “long-term calibration” signifies a balancing loop Delays that updates clinicians’ diagnostic schema based on information For both an immediate patient encounter and the long-term that allows them to compare how they expect the patient to process of improving and updating one’s diagnostic schema, progress with the patient’s observed outcomes. Obviously, as the diagnostic skill, the quality of his/her “diagnostic schemas,” length of time between therapy and its impact increases, the is depicted in Figure 1. A diagnosis is the result of applying likelihood that the physician will observe the outcome de- a diagnostic schema to information about the patient as the creases. Schema is a term from cognitive ence the full consequences of the therapy or physicians who do science referring to a person’s mental model, or internal not see the patient again, thereby rendering outcome feedback 7 unavailable. Time delays, thus, partially explain why the link image of a given professional domain or area. Schemas form the basis of processes such as “recognition-primed from therapy to observed patient outcomes may be so weak, as 1 decision making” that allow clinicians to match a library of Berner and Graber suggest. The long-term feedback process in diagnosing and treat- inferences about causality far more difficult because they ing an individual patient depicted in Figure 1, like the give rise to a characteristic of feedback systems known as 2,9 short-term feedback process, is a balancing or adaptive dynamic complexity. It is a longer-term process of learning from expe- namic complexity can take the form of unexpected oscilla- rience, in which the clinician adjusts the diagnostic schema tions between desired and undesired therapeutic outcomes, for the patient by comparing expected outcomes with ob- amplification of certainty on the part of the clinician (e. To illustrate how this loop operates, fixation), and excessive or diminished commitment to par- 11 we start with Diagnosis. For example, if effects from therapy cian employs the current Diagnostic Schema, developed occur after the physician’s felt need to move forward with through training and experience, to interpret patient infor- patient care, he/she may pursue contraindicated interven- mation and recommend a specific course of Therapy. Based tions or drop indicated ones—continuing to intervene al- on the the therapy recommended, the clinician expects the though curative measures have been taken or failing to patient’s condition will evolve in a certain way to yield intervene although treatment has been inadequate. Ideally, after some time has repeatedly has demonstrated the failure to learn in situations 9 elapsed for the therapy to take effect, the clinician sees the with even modest amounts of dynamic complexity. Comparing the Ob- time delays quite simply slow down the completion of the served Patient Outcomes with Expected Patient Outcomes feedback loop; longer delays mean fewer learning cycles in (this comparison is often tacit or unconscious), the clinician any time period. In Ambigious Feedback optimal settings, this schema accounts well for the patient’s Although a clinican may receive feedback about how his/ history, constellation of signs and symptoms, and treatment her diagnosis and therapy has influenced the patient, effec- results. To the extent that the diagnostic schema improves, tiveness can be compromised because such feedback often the quality of the clinican’s diagnoses at later patient en- is ambiguous. The “R” labeled “self-confirming bias” signifies a reinforcing loop that amplifies clinicians’ confidence in their current diagnostic problem-solving skill. When that gap does not close, Confusingly, data about their patients can equally support a clinicians should seek additional or alternative data. But Berner wide variety of clinical conclusions, making it difficult for and Graber show that often does not happen.

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