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Encourage use of “not yet diagnosed” Base rate neglect Make readily available current incidence and prevalence data for common diseases for particular clinical groups in specific geographical area Context binding Promote awareness of the impact of context on the decision-making process discount viagra with dapoxetine 100/60mg without prescription; advance metacognitive training to detach from the immediate pull of the situation and decontextualize the clinical problem Limitations on transferability Illustrate how biases work in a variety of clinical contexts viagra with dapoxetine 100/60mg lowest price. Adopt universal debiasing approaches with applicability across multiple clinical domains Lack of critical thinking Introduce courses early in the undergraduate curriculum that cover the basic principles of critical thinking discount 100/60mg viagra with dapoxetine with mastercard, with iteration at higher levels of training 38 generic viagra with dapoxetine 100/60 mg fast delivery,39 pears lacking for System 1, the prevailing research emphasis noted earlier, several studies suggest that when the 51 52 in both medical and other domains has been on System 2. Overconfidence often occurs when determining a course of Prompt and reliable feedback about decision outcomes action and, accordingly, should be examined in the context appears to be a prerequisite for calibrating clinician perfor- of judgment and decision making. From the enced by a number of factors related to the individual as standpoint of clinical reasoning, it is disconcerting that well as the task, some of which interact with one another. It seems to be espe- cially dependent on the manner in which the individual enced clinicians, they are “less able to articulate what they gathers evidence to support a belief. In medical decision do than others who observe them,” or, if articulation were making, overconfidence frequently is manifest in the con- possible, it may amount to no more than a credible story 6 about what they believe they might have been thinking, and text of delayed and missed diagnoses, where it may exert its most harmful effects. But this is hardly surprising as it is sicians exhibit overconfidence in their judgment. It is rec- a natural consequence of the dominance of System 1 think- ognized as a common cognitive bias; additionally, it may be ing that emerges as one becomes an expert. As noted earlier, propagated as a component of a prevailing memeplex within conscious practice of System 2 strategies can get compiled the culture of medicine. A problem Numerous approaches may be taken to correct failures in once solved is not a problem; experts are expert in part 2 6 precisely because they have solved most problems before reasoning and decision making. Berner and Graber outline the major strategies; Table 3 expands on some of these and and need only recognize and recall a previous solution. Presently, no 1 strategy this means that much of expert thinking is, and will remain, has demonstrated superiority over another, although, as an invisible process. Often, the best we can do is make S28 The American Journal of Medicine, Vol 121 (5A), May 2008 inferences about what thinking might have occurred in the lectively lead to an overall improvement in decision making light of events that subsequently transpired. Halifax, Nova Scotia, Canada Seemingly, clinicians would benefit from an understand- ing of the 2 types of reasoning, providing a greater aware- Geoff Norman, PhD ness of the overall process and perhaps allowing them to Department of Clinical Epidemiology and Biostatistics explicate their decision making. Whereas System 1 thinking McMaster University is unavailable to introspection, it is available to observation Hamilton, Ontario, Canada and metacognition. The authors report the following conflicts of interest with Educational theorists in the critical thinking literature the sponsor of this supplement article or products discussed have expressed long-standing concerns about the need for in this article: introducing critical thinking skills into education. The implicit assumption is made that by the time students have References arrived at this tertiary level of education, they will have achieved appropriate levels of competence in critical think- 1. Evidence-based practice: logic and critical 1 ing skills, but this is not necessarily so. In: Mac- bly not, and there is a need for the general level of reasoning Kinnon N, Nguyen T, eds. Ottawa, Ontario: about detachment, overcoming belief bias effects, perspec- Canadian Pharmacists Association, 2007. Incidence of adverse events tive switching, decontextualizing, and a variety of other 55 and negligence in hospitalized patients: results of the Harvard Medical cognitive debiasing strategies. The epistemology of clinical reasoning: perspectives from philosophy, psychology, and neuroscience. Concise Encyclopedia of Information Processing in more than a brief session on cognitive debiasing. Individual differences in reasoning: implica- pertise with training, to date there is little evidence tions for the rationality debate? Psychopathological symptoms, social skills, and per- do clinical teachers need to guard against teaching pattern recognition sonality traits: a study with adolescents Spanish. Berner and Graber is analytic models of reasoning describe optimal diagnostic that the gaps in our knowledge far exceed the soundly process, i. If physicians are not established areas, particularly if we focus on empirical find- employing these analytic processes, the assertion is that ings based on real-world work by real physicians. How is it that our knowledge about diagno- situation, experts seldom engage in highly analytic modes sis—historically the most central aspect of clinical practice of decision making. Rather, under these conditions, experts and one that directs the trajectory of tests, procedures, are most likely to use fast and generally sufficient strategies. However, the lack of progress in ap- Most of the research performed regarding diagnosis in plying research findings to the messy world of clinical medical contexts has concerned static decision problems: practice suggests that we might benefit from examination only 1 decision needs to be made, the situation does not of an expanded set of questions. However, much of the work of medicine concerns dy- namic decision problems: (1) a series of interdependent Diagnostic Models decisions and/or actions is required to reach the goal; (2) A great deal of the work to date has assumed that diag- the situation changes over time, sometimes very rapidly; nostic thinking is best described by highly rationalized (3) goals shift or are redefined. In contrast to static problems, in dynamic little or no consideration of alternative approaches. There problems there is no theory or process element even close are some exceptions, including criticisms of this view 4,5 6 to being considered normative, either for approaching the (see Berg and colleagues and Toulmin ), Norman’s 7,8 problem or for establishing a particular sequence of de- research on clinical reasoning, and Patel and col- 9 cisions and/or actions as correct. Neverthe- Statement of Author Disclosures: Please see the Author Disclosures Problem Detection and Recognition section at the end of this article. One of the greatest holes in our current knowledge base Requests for reprints should be addressed to Beth Crandall, Klein is the failure to address issues of problem detection and Associates Division, Applied Research Associates, 1750 Commerce Center Boulevard North, Fairborn, Ohio 45324-6362. Diagnostic problems do not present them- E-mail address: bcrandall@decisionmaking. In may be the complexity of the systems and work processes order to discern the problem contained within a particular that surround diagnosis. We know that differences in set of circumstances, practitioners must make sense of an diagnostic performances exist, but we do not understand uncertain and disorganized set of conditions that initially diagnostic failure in any deep or detailed way. In the 15,16 emergency department, for example, the physician’s di- make little sense. Here, much of the work of diag- 10,17–19 agnostic process is carried out within the context of large nosis consists of preconscious acts of perception and sense making by clinicians who use a variety of numbers of patients, many of whom have multiple prob- 13 lems; there is little time, resources are constrained, and strategies to discern the real-world context. Given a stream of passing phenomena, distinguishing between conditions are chaotic. Some possibilities worth consid- items that are relevant or irrelevant, and those that must ering include: be accounted for compared with those that can be dis- ● Context: In what situations, and under what conditions, counted, creates a preconscious framing that bounds the are diagnostic failures most and least prevalent? We need problem of diagnosis before it is ever consciously con- to understand the real-world contexts in which medical sidered. If we are going to understand how prob- ● Team influences: The individual physician is surrounded lems are missed or misunderstood, we need to understand by other healthcare providers, including other clinicians, the processes involved in their detection and recognition. How does the distributed nature of patient care foster or prevent diagnostic failure? Having a concern to the captain and take assertive action if those solid diagnosis often makes much of clinical work easier. Is aviation’s example a useful ana- However, the lack of a firm diagnosis does not relieve the logue? Thus, one might argue that the central such as medication errors and nosocomial infections. This another way, the central question of clinical work might leads to the question, What system-level practices fos- not be, “What is the diagnosis? We know Individual Versus Distributed Cognition that with experience, diagnostic performance improves Most research on diagnostic decision making has concen- but that such progress is not invariant. Some physicians trated almost entirely on what goes on inside physicians’ become extraordinarily skilled at evaluation and are rec- minds, focusing on internal mental processes, including ognized by their peers as the “go to” person for the various cognitive biases and simplifying heuristics. Understanding the ele- though understanding the individual physician’s cognitive ments leading to such expertise would surely be informa- work is clearly necessary, it is not sufficient. Clinicians do tive, as would gleaning why experience appears to en- their work while embedded in a complex milieu of people, hance the diagnostic performance of some physicians artifacts, procedures, and organizations. Considering physicians step towards creating feedback systems that provide lever- 20 and their environment as joint cognitive systems, where age on the problem. Finding ways to provide feedback on cognition and expertise are distributed across multiple peo- diagnostic performance seems an important venue for im- 21 ple, objects, and procedures within a clinical setting, of- provement, however many difficulties exist. Thus, simply fers a way to widen the tight focus from “inside the physi- providing feedback is not a “magic bullet” automatically cian’s head” so that we can begin to examine this larger, and leading to improvement. These 3 issues, and a 4th—the differ- vide a rich fabric of information that allows members of ential values assigned to different types of failure—repre- the medical community to see what works and what does sent significant challenges to designing effective feedback not, to hone diagnostic skill, and to hold one another systems for physicians. To do this, we need to enlarge our notions of the nature of clinical work Specificity and of human performance in complex, conflicted, and Providing overall data about diagnostic error rates in uncertain contexts. Otherwise, they are left with unhelpful admo- The authors report the following conflicts of interest with nitions such as “work harder, don’t make mistakes, main- the sponsor of this supplement article or products discussed tain a high index of suspicion. The simpler the sys- affiliation with a corporate organization or a manufacturer tem, the more helpful statistical quality control data are of a product discussed in this article.

It is of the utmost importance to be proactive and continually strive to answer questions such as: ‘What else can go wrong? While the recommendations specifically apply to new external beam therapies buy viagra with dapoxetine 100/60 mg cheap, the general principles for prevention are applicable to the broad range of radiotherapy practices in which mistakes could result in serious consequences for the patient and practitioner purchase viagra with dapoxetine 100/60 mg online. The recommendations provide elements for mobilizing for future effective work as outlined below best 100/60mg viagra with dapoxetine. Independent verification should be performed of beam calibration in beam radiation therapy 100/60mg viagra with dapoxetine fast delivery. Independent calculation should be performed of the treatment times and monitor units for external beam radiotherapy. Prospective safety assessments should be undertaken for preventing accidental exposures from new external beam radiation therapy technologies, including failure modes and effects analysis, probabilistic safety assessment, and risk matrix, in order to develop risk informed and cost effective quality assurance programmes. Moderated electronic networks and panels of experts supported by professional bodies should be established in order to expedite the sharing of knowledge in the early phase of introducing new external beam radiation therapy technologies. A collaborating team of specifically trained personnel following quality assurance procedures is necessary to prevent accidents. Maintenance is an indispensable component of quality assurance; external audits of procedures reinforce good and safe practice, and identify potential causes of accidents. Accidents and incidents should be reported and the lessons learned should be shared with other users to prevent similar mistakes. The available data on doses received by people approaching patients after implantation show that, in the vast majority of cases, the dose to comforters and carers remains well below 1 mSv/a. Moreover, due to the low activity of an isolated seed and its low photon energy, no incident/accident linked to seed loss has ever been recorded. A review of available data shows that cremation can be allowed if 12 months have elapsed since 125 103 implantation with I (3 months for Pd). If the patient dies before this time has elapsed, specific measures must be undertaken. However, although the therapy related modifications of the semen reduce fertility, patients must be aware of the possibility of fathering children after such a permanent implantation, with a limited risk of genetic effects for the child. Patients with permanent implants must be aware of the possibility of triggering certain types of security radiation monitor. Considering the available experience after brachytherapy and external irradiation of prostate cancer, the risk of radio-induced secondary tumours appears to be extremely low, but further investigation might be helpful. Only the (rare) case where the patient’s partner is pregnant at the time of implantation may need specific precautions. Specific recommendations should be given to patients to allow them to deal adequately with this event. As far as cremation of bodies is concerned, consideration should be given to the activity that remains in the patient’s ashes and the airborne dose, potentially inhaled by crematorium staff or members of the public. Specific recommendations have to be given to the patient to warn the surgeon in case of subsequent pelvic or abdominal surgery. The wallet card including the main information about the implant (see above) may prove to be helpful in such a case of triggering certain types of security radiation monitor. The risk of radio-induced secondary tumours following brachytherapy should be further investigated. Avoidance of radiation injuries from medical interventional procedures Interventional radiology (fluoroscopically guided) techniques are being used by an increasing number of clinicians not adequately trained in radiation safety or radiobiology. Many of these interventionists are not aware of the potential for injury from these procedures or the simple methods for decreasing their incidence. Many patients are not being counselled on the radiation risks, nor followed up when radiation doses from difficult procedures may lead to injury. Some patients are suffering radiation induced skin injuries and younger patients may face an increased risk of future cancer. Interventionists are having their practice limited or suffering injury, and are exposing their staff to high doses. In some interventional procedures, skin doses to patients approach those experienced in some cancer radiotherapy fractions. Injuries to physicians and staff performing interventional procedures have also been observed. Acute radiation doses (to patients) may cause erythema, cataract, permanent epilation and delayed skin necrosis. Protracted (occupational) exposures to the eye may cause opacities in the crystalline lens. The absorbed dose to the patient in the area of skin that receives the maximum dose is of priority concern. Each local clinical protocol should include, for each type of interventional procedure, a statement on the cumulative skin doses and skin sites associated with the various parts of the procedure. Interventionists should be trained to use information on skin dose and on practical techniques to control dose. Maximum cumulative absorbed doses should be recorded in the patient record, and there should be a patient follow-up procedure for such cases. Patients should be counselled if there is a significant risk of radiation induced injury, and the patient’s personal physician should be informed of the possibility of radiation effects. Training in radiological protection for patients and staff should be an integral part of the education of those using interventional techniques. All interventionists should audit and review the outcomes of their procedures for radiation injury. Risks and benefits, including radiation risks, should be taken into account when new interventional techniques are introduced. Complex percutaneous coronary interventions and cardiac electrophysiology procedures are associated with high radiation doses. These procedures can result in patient skin doses high enough to cause radiation injury and an increased risk of cancer. Additionally, staff in cardiac catheterization laboratories may receive high radiation doses if radiological protection tools are not used properly. There is emphasis on those imaging procedures and interventions specific to cardiology. It includes discussions of the biological effects of radiation, principles of radiological protection, protection of staff during fluoroscopically guided interventions, radiological protection training and establishment of a quality assurance programme for cardiac imaging and intervention. They also provide advice on how to deal with the challenges presented by patient and staff radiological protection in cardiology. As tissue injury, principally skin injury, is a risk for fluoroscopically guided interventions, particular attention is devoted to clinical examples of radiation related skin injuries from cardiac interventions, methods to reduce patient radiation dose, training recommendations, and quality assurance programmes for interventional fluoroscopy. Individuals who request, perform or interpret cardiology imaging procedures should be aware of the radiation risks of the procedure. Appropriate use criteria and guidelines for justification should be used in clinical practice. The informed consent process should include information on radiation risk if the risk of radiation injury is thought to be significant. Radiation dose data should be recorded in the patient’s medical record after the procedure; patient dose reports should be archived for quality assurance purposes. When the patient’s radiation dose from an interventional procedure exceeds the institution’s trigger level, clinical follow-up should be performed for early detection and management of skin injuries. Individuals who perform cardiology procedures where there is a risk of tissue reactions should be able to recognize these skin injuries, and those who perform interventional cardiology or electrophysiology procedures should be familiar with methods to reduce radiation dose to patients and staff. When there is a risk of occupational radiation exposure, staff should use appropriate personal protective shielding. In addition to the training recommended for all physicians who use ionizing radiation, interventional cardiologists and electrophysiologists should receive a second, higher level of radiological protection training. A cardiologist should have management responsibility for the quality assurance programme aspects of radiological protection for cardiology procedures, and should be assisted by a medical physicist. Radiological protection in fluoroscopically guided procedures performed outside the imaging department A serious problem of our times is that an increasing number of medical specialists are using fluoroscopy outside imaging departments. It should be noted that there has been general neglect of radiological protection coverage of this practice. Lack of radiological protection training of those working with fluoroscopy outside imaging departments can increase the radiation risk to workers and patients. Procedures such as endovascular aneurysm repair, renal angioplasty, iliac angioplasty, ureteric stent placement, therapeutic endoscopic retrograde cholangiopancreatography, and bile duct stenting and drainage have the potential to impart high skin doses, thus making fluoroscopy use outside imaging departments a potential source for serious tissue reactions and injuries. As patient dose monitoring is essential whenever fluoroscopy is used, particularly outside the imaging department, manufacturers should develop systems to indicate patient dose indices with the possibility of producing patient dose reports that can be transferred to the hospital network, and shielding screens that can be effectively used for the protection of workers using fluoroscopy machines in operating theatres without hindering the clinical task. Specific aspects are covered separately, including those for vascular surgery, urology, orthopaedic surgery, obstetrics and gynaecology, gastroenterology and the hepato-biliary system, anaesthetics and pain management.

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Pacific Islanders pay heavy price for abandoning traditional diet Bulletin of the World Health Organization (Vol viagra with dapoxetine 100/60 mg line. Noncommunicable Disease and Poverty: The Need for Pro-poor Strategies in the Western Pacific Region - A Review viagra with dapoxetine 100/60 mg low cost. Noncommunicable Disease and Poverty: The Need for Pro-poor Strategies in the Western Pacific Region - A Review purchase viagra with dapoxetine 100/60 mg. Leaving No One Behind Public health—the practice of preventing disease and promoting health—effectively targets environmental factors and health behaviors that contribute to chronic conditions viagra with dapoxetine 100/60mg low price. The health risk factors of physical inactivity, tobacco use and exposure and poor nutrition are the leading causes of chronic disease. With even a small reduction in the prevalence of chronic disease, the combined health and productivity cost savings of prevention lead to a positive return on investment within a short time. Nearly 70% of frst heart attacks and 77% of frst strokes occur in people with hypertension. Cardiovascular disease is the estimation tool, which uses the leading cause of morbidity and mortality in the United States, Pooled Cohort Equations from accounting for 1 of every 3 deaths among adults. There is high certainty that the net benefit is moderate, or Offer or provide this service. There is at least moderate certainty patients depending on individual that the net benefit is small. There is moderate or high certainty that the service Discourage the use of this service. If the service is offered, I statement patients should understand the uncertainty about the balance of benefits and harms. This conclusion is therefore unlikely to be strongly affected by the results of future studies. The available evidence is sufficient to determine the effects of the preventive service on health outcomes, but confidence in the estimate is constrained by such factors as the number, size, or quality of individual studies. As more information becomes available, the magnitude or direction of the observed effect could change, and this change may be large enough to alter the conclusion. The calculator Risk Assessment derived from these equations takes into account age, sex, race, cholesterol levels, systolic blood pressure level, antihypertension treatment, presence of diabetes, and smoking status as risk factors. Statins are a class of lipid-lowering medications that function by inhibiting the enzyme 3-hydroxy-3-methyl-glutaryl coenzyme A Preventive reductase. For a summary of the evidence systematically reviewed in making this recommendation, the full recommendation statement, and supporting documents, please go to https://www. Aseparaterecommendationstatementalso bloodpressurelevel,antihypertensiontreatment,presenceofdia- found insufficient evidence to assess the balance of benefits and betes,andsmokingstatusasriskfactorsinthepredictionmodeland harms of screening for dyslipidemia in children and adolescents. Specific recommendations from other organiza- ofbenefitthataninterventionwithdemonstratedefficacycanhave tions for such individuals are discussed in the “Recommendations in a specific population directly depends on the incidence of dis- of Others” section. This is one of optimal intervals for cardiovascular risk assessment are uncertain. StatinRegimensUsedinAvailableTrials Dose, mga Statin Low Moderate High Atorvastatin 10-20 40-80 Fluvastatin 20–40 40 twice daily Fluvastatin extended release 80 Lovastatin 20 40 aDosecategoriesarefromthe AmericanCollegeof Pitavastatin 1 2-4 Cardiology/AmericanHeart Pravastatin 10-20 40-80 Association2013guidelinesonthe Rosuvastatin 5-10 20-40 treatmentofbloodcholesterolto reduceatherosclerotic Simvastatin 10 20-40 24 cardiovascularriskinadults. Thedegreeofcholesterolreductionmaybeattributable, shared decision making that weighs the potential benefits and in part, to interindividual variability in response to statins, not just harms, the uncertainty about risk prediction, and individual statin dosage. There Suggestions for Practice Regarding the I Statement may be individual clinical circumstances that warrant consider- for Initiating Statin Therapy for Primary Prevention ation of use of high-dose statins; decisions about dose should be based on shared decision making between patients and clinicians. Anotherstudyusing Burden of Disease datafromtheMedicalExpenditurePanelSurvey,whichdidallowfor In 2011, an estimated 375 000 adults died of coronary heart dis- thedifferentiationofindividualswithandwithoutvasculardisease easeand130 000diedofcerebrovasculardisease. Themediandurationoffollow-upwas3years, Other Considerations and 3 trials were stopped early because of observed benefits in the Research Needs and Gaps interventiongroup. Research is needed to Scandinavian Cardiac Outcomes Trial—Lipid Lowering Arm) evaluate the optimal frequency of cardiovascular risk assessment, trials10,40 because of their large sample sizes, the estimate was including serum lipid screening. After6months harms of initiating statin use for the primary prevention of cardio- to 6 years of follow-up, statin use was associated with a decreased vascular events in adults 76 years and older. However, in the available estimates when trials were stratified according to dose. Nostudieswere tent across different clinical and demographic subgroups (even identifiedthatdirectlycomparedtreatmentwithstatinstitratedto among adults without marked dyslipidemia). Becausetheab- Harms of Statin Use soluteunderlyingriskislower,feweradultswhosmokeorhavedys- In randomized trials of statin use for the primary prevention of lipidemia,diabetes,orhypertensionanda7. As such, any decision to ini- withdrawal because of adverse events compared with placebo, tiateuseofalow-tomoderate-dosestatininthispopulationshould and there were no statistically significant differences in the risk of involve shared decision making that weighs the potential benefits experiencing any serious adverse event. It should also take into consideration the personal prefer- levels with statin use. Some comments requested clarification regarding the op- foundnoassociationwithstatinuse,41butananalysisfromtheWo- timal dose of statins. Thesepersonsshouldbescreenedandtreatedinaccordancetoclini- Recommendations of Others cal judgment for the treatment of dyslipidemia. Thetreatmentstrat- ment is no longer relevant and has been replaced by a preventive egy is treatment-to-target rather than by therapy dose (eg, 50% medication framework. Total cardiovascularrisk:areportoftheAmerican AspirinUsetoPreventCardiovascularDiseaseand cholesterol and risk of mortality in the oldest old. The tables and figures in this Pocket Guide follow the numbering of the 2017 Global Strategy Report for reference consistency. These include genetic abnormalities, abnormal lung development and accelerated aging. These comorbidities should be actively sought and treated appropriately when present as they can influence mortality and hospitalizations independently. Spirometry is the most reproducible and objective measurement of airflow limitation. Despite its good sensitivity, peak expiratory flow measurement alone cannot be reliably used as the only diagnostic test because of its weak specificity. Spirometry should be performed after the administration of an adequate dose of at least one short-acting inhaled bronchodilator in order to minimize variability. Spirometry in conjunction with patient symptoms and exacerbation history remains vital for the diagnosis, prognostication and consideration of other important therapeutic approaches. In the refined assessment scheme, patients should undergo spirometry to determine the severity of airflow limitation (i. Finally, their history of exacerbations (including prior hospitalizations) should be recorded. This classification scheme may facilitate consideration of individual therapies (exacerbation prevention versus symptom relief as outlined in the above example) and also help guide escalation and de-escalation therapeutic strategies for a specific patient. Pharmacotherapy and nicotine replacement reliably increase long-term smoking abstinence rates. However, individual patient factors must be considered when evaluating the patient’s need for supplemental oxygen. If effective resources and time are dedicated to smoking cessation, long-term quit success rates of up to 25% can be achieved. Counseling delivered by physicians and other health professionals significantly increases quit rates over self-initiated strategies. Stimulation of beta2-adrenergic receptors can produce resting sinus tachycardia and has the potential to precipitate cardiac rhythm disturbances in susceptible patients. Exaggerated somatic tremor is troublesome in some older patients treated with higher doses of beta2-agonists, regardless of route of administration. Antimuscarinic drugs  Antimuscarinic drugs block the bronchoconstrictor effects of acetylcholine on M3 muscarinic receptors expressed in airway smooth muscle. Inhaled anticholinergic drugs are poorly absorbed which limits the troublesome systemic effects observed with atropine. Toxicity is dose-related, which is a particular problem with xanthine derivatives because their therapeutic ratio is small and most of the benefit occurs only when near-toxic doses are given. Results from withdrawal studies provide equivocal results regarding consequences of withdrawal on lung function, symptoms and exacerbations. Reduction of total personal exposure to occupational dusts, fumes, and gases, and to indoor and outdoor air pollutants, should also be addressed.

More than ever viagra with dapoxetine 100/60 mg, we area and fnd a succinct summary of information along with need every available health professional to possess the healthy the tools for further exploration viagra with dapoxetine 100/60mg line. Numerous pioneering leaders As the nature of contemporary health care evolves and de- have developed physician health generic viagra with dapoxetine 100/60mg with mastercard, not only as an area of practice buy generic viagra with dapoxetine 100/60 mg, velops, so does the role of physician. In health” has become one of the cornerstone ideas to improving this book, Puddester, Flynn, and Cohen et al, answer this call. Medicine can be a very rewarding career but it ready resource for those thinking or teaching about physician is also a very demanding profession. The chapters are created to be accessible cine by creating resources and Train-the-trainer Workshops within the busy schedule many physicians maintain. This to support each of the seven identifed domains of physician handbook not only creates awareness to the wide-ranging fac- competence. As a presents many of the practical resources currently available to toolkit, this publication is an easy-to-access resource which all assist physicians and their own health needs. Using divided into chapters which present the specifc elements that real-world situations and scenarios, this guide will help physi- make up the larger themes. The chapters are presented in a cians discover practical and useful strategies for introducing two-page layout complete with specifc learning objectives, a and promoting physical, emotional, and spiritual well-being. As Professionals, physicians are committed to the health Although the guide provides information for physicians and well-being of individuals and society through ethi- throughout their careers the information is presented to show cal practice, profession-led regulation, and high personal students and residents many of the everyday issues that can standards of behaviour. Along with presenting learn- ing moments, this publication provides practical advice for Key Competencies those in training to help manage their own health in the form Physicians are able to… of available resources, practical advice, and key references for 1. Demonstrate a commitment to physician health “bigger picture” for all the phases of a physician’s lifecycle and sustainable practice. The information and cases are based on sce- only describes what makes up physician health, but to have narios that practicing physicians will recognize. Similarly the an easy to access handbook for dealing with physician health resources identifed throughout the handbook make this guide issues directly. There is a quick reference index at the end of a powerful tool for maintaining one’s own health. Medical educators Medical educators will fnd a resource on the principles of phy- sician health. The cases are derived from evidence of patients’ needs, from practicing physicians’ perspectives, from content experts and from empirical research. This guide helps teachers ask effective educational questions that explore the variety of aspects that make up physician health and lead to sustainable practice. Societal expectations 8 Jordan Cohen Section 2 - The individual physician Introduction 11 Derek Puddester A. Leadership and leadership skills 18 Derek Puddester Section 3 - Balancing personal and professional life Introduction 21 Jordan Cohen A. Intimidation and harassment in training 54 Jordan Cohen Section 6 - Collegiality Introduction 57 Jordan Cohen A. Interdisciplinary relationships 66 Janet Wright Section 7 - Physician health and the doctor–patient relationship Introduction 68 Leslie Flynn A. Coping with an adverse event, complaint or litigation 70 Canadian Medical Protective Association B. Boundary issues 76 Michael Paré Section 8 - The physician life-cycle Introduction 79 Jordan Cohen A. Coping with and respecting the obligations of mandatory reporting 98 Canadian Medical Protective Association F. Physicians with an illness or a disability 104 Ashok Muzumdar Section 10 - Financial health Introduction 107 Jordan Cohen A. Puddester completed his undergraduate training in English/Russian Studies and Medicine at Memorial University of Newfoundland. He completed a Psychiatry Residency at McMaster University and a Fellowship in Child Psychiatry at uOttawa. He is the Medical Leader of the Behavioural Neurosciences and Consultation-Liaison Team at the Children’s Hospital of Eastern Ontario. Puddester is an Associate Professor at uOttawa’s Faculty of Medicine where he also serves as the Director of the Faculty Wellness Program. Puddester’s educational and research work focuses on physician health, healthy work environments, e-learning, and curriculum theory and development. The Canadian Association of Interns and Residents has recognized his leadership in physician health by creating the Dr. Derek Puddester Resident Well-Being Award which is given annually to a person or program that has made a signifcant contribution to the improvement of resident health and wellness. She became certifed as a Family Physician in 1988 and subsequently as a psychiatrist in 1995. She then began her professional ca- reer at Queen’s University when she was cross-appointed to the Departments of Family Medicine and Psychiatry in the role of Family Medicine Liaison Psychiatrist. She has held roles as Director of the Continuing Medical Education program, Postgraduate Program Director and the Director of Psychotherapy in the Department of Psychiatry. Flynn is currently an Associate Professor in the Departments of Psychiatry and Family Medicine and the Associate Dean of Postgraduate Medical Education at Queen’s University. Flynn has received departmental awards for Excellent Leadership in Education and Dedication to the Ideals of the Department as well as the Annual Staff Excellence in Teaching Award. She has conducted research in physician health, the Role of Health Advocate, interprofessional education and the scholarship of teaching and learning. Cohen is currently an Assistant Clinical Professor in the Department of Psychiatry of the Faculty of Medicine at the University of Calgary, where he completed both his residency and undergraduate medical training. He is also the Director of Student Affairs of Undergraduate Medical Education and Chair of The Physicianship Course for the Faculty of Medicine at the University of Calgary. His educational and research work focuses on balancing medicine, physician health and professionalism. He is also a board member of the Physician Health Monitoring Program for the Alberta College of Physicians and Surgeons. Derek Puddester Resident Well Being Award 2006 for his contributions to resident health; the Department of Psychiatry’s Postgraduate Clinical Education Award 2008 in recognition of outstanding contribution in the area of postgraduate clinical education; and the Department of Psychiatry’s Postgraduate Research Award for Part-time Faculty 2008 in recognition of outstanding research contributions in Psychiatry. Goals and objectives of this guide The vast majority of today’s physicians entered their profession This handbook is designed to help educators and learners after considerable refection, years of academic preparation, better understand the broad meaning of “physician health,” and in the face of signifcant competition and challenge. The to discover practical strategies to promote professional health intellectual, emotional, physical and social demands of medi- and to apply such knowledge to real-world situations. It is not cal training are rigorous, as are the professional and personal meant to be an academic exercise, but rather to form part of demands of practice. The good news is that most physicians a practical toolkit of resources that Canadian physicians can thrive in their work environments, are strong and healthy, access and apply as they see ft. Readers can use this handbook practise excellent strategies to safeguard their own well-being, to explore their own questions and needs, educators can draw and enjoy long and healthy lives. When physicians’ personal upon it as a resource for teaching and learning programs, and well-being and professional commitment are in balance, posi- investigators may fnd it helpful in identifying avenues for tive synergies result that sustain them in their healing role, to research in physician health. Topic areas were identifed by a panel of experts who work in And yet the phrase physician health seems not to convey that the trenches with physicians presenting with health concerns. For many decades it was a euphemistic refer- Content experts were invited to cover these topics—including ence to struggles with addiction. Slowly, provincial medical as- sample cases, strategies and solutions, references, and refective sociations and colleges began to develop innovative programs exercises—in a succinct format that would allow readers to that provided treatment and support services primarily for access information quickly while encouraging further explora- issues related to substance abuse. The growth of and enthusiastic volunteer contributors, the project team, and these programs has been consistent across Canada, and physi- the many colleagues and learners who provided feedback and cian organizations continue to support a deeper understanding guidance along the way. Ottawa: The Royal College, committed to the health and well-being of individuals and 23–4. Well over a million Canadians have no physi- • articulate the basic concepts of physician health and cian, and thousands of physicians are working more hours sustainability, per week than is permitted for long-distance truck drivers, air • introduce a potential conceptual framework for physician traffc controllers or airline pilots. The demand for health care health, and simply outstrips resources, and most physicians respond by • describe critical aspects of such a framework in detail for working harder, longer and in more complex environments. Case Conceptual Framework for Physician Health A resident entered medicine after volunteering at an Easter i Seals camp for many summers and discovering a love of working with children with disabilities. With divorced parents, and not having a strong relationship with either of them; this early experience taught the resident to be independent, contributed to some social isolation and trig- gered a certain ineptness in interpersonal relationships. By choosing a specialty the resident found the work stimulat- ing, the hours reasonable, and the job opportunities broad. Until recently, life has been highly focused on training, but now the resident has begun to realize that they are lonely. This resident has few friends, has not dated anyone in sev- eral years, and has no real interests outside of training.

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