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The repertoire of a 1 year old is limited to vomiting vardenafil 10mg without a prescription, diarrhoea order vardenafil 20 mg fast delivery, fever buy vardenafil 20 mg free shipping, cough vardenafil 20 mg low price, and breathlessness order 20mg vardenafil visa, and with measles all are present in abundance. Red eyes, throat, and eardrums complete the picture examined carefully on the mother’s knee (not my own after it was drenched on day one), and the vague but, with experience, characteristic graininess that will pass for a rash on black skin the next day is hardly needed. Many of them will die of bronchopneumonia (ampicillin is probably just to keep the doctors happy, but we watch carefully for signs of staphylococci) or of dehydration, which has become my personal crusade. My five minute lecture in broken Swahili attempts to persuade the mother to take on the responsibility of forcing in rehydration fluid tirelessly. So my round of the measles ward is basically to take the temperature and respiratory rate and get a general feeling for each child’s health. The sick ones get a closer look that always comes down to not 86 MEDICAL SCHOOL: THE LATER YEARS enough water, and so, to the general amusement of all, I’m back on my hobby horse for a bit more negotiating about why the child won’t drink or is not getting enough. Discussions in small groups, wandering round the rickety shacks both in town and out in the surrounding forest, stumble on in Swahili or are translated from Giriama by the wonderful local fieldworker who introduces me. Drunken men lolling in front of their huts accost us and gesticulate aggressively; a group of young women waiting to fill their buckets with water are shy but add their opinions once the most assured has spoken. Water and blood are symbolically related, and when water is drunk they believe it goes into the lungs (hence people with not enough blood, with anaemia, are breathless) and from there round the body in the veins (everyone knows doctors shortcut this by pouring water into the veins direct). Measles, in turn, is within the essence of all people, and must "come out" at some time, inevitably. Vaccines are accepted with equanimity and wry suspension of disbelief in their action. Most dangerous is when the measles goes "back in"—I would explain it as severe dehydration that stops a child’s tears, vomit, and diarrhoea—but we agree anyway that death may be imminent. The ward round continues, from the successes—the child with nephrotic syndrome receiving steroids, whose smile widens daily as his swelling subsides, and the bored happy ones with broken legs hanging from pulleys— to the failures—a paralysed speechless girl brought in after fitting with meningitis for hours, whose family can no longer manage, her living skeleton malnourished and fading away despite all our efforts. By the end of the ward round the first five or so of the day’s 10 or 20 admissions are gathered. The Kenyan medical students amaze me yet again with their skill at slipping needles into the most fragile of dried out baby scalp veins; I amaze myself with a perfect lumbar puncture on a screaming urchin, and take the happily crystal-clear drops off to the laboratory. There I check the results from the day’s malaria slides and write the prescriptions accordingly. After a lunch break, I wander into one of the town’s cafes, the loose ends on the ward are tied up, and it is time for projects. Rob’s is with the high tech transcranial Doppler ultrasound measuring blood flow in the middle cerebral artery—will this tell us important things about disease processes in very sick children? The whoosh-whoosh-whoosh pulses out at us as we walk past the little research ward. My project is to count every drop of fluid going into and out of a child with cerebral malaria over 24 hours. Endlessly there are extra sources of error, not noticed by me as I try to add up volumes and nappy weights in the middle of the night. This year, for better and worse, the rains haven’t come properly, so there is little severe malaria, and instead today I can amble back to the guesthouse, luxurious by local standards, for a swim in the balmy buoyant water. There I can dream of my next trip up the coast to the ancient Islamic island city of Lamu, an African Venice of narrow streets, donkeys, cool wind, relaxed gossip, and self indulgence by the waterside. TA 87 LEARNING MEDICINE Assessments and exams Schools adopt different systems of assessing students’ clinical progress. Most combine end of attachment assessments with a final MB exam at the end of the course, which were traditionally taken in one grand slam but are increasingly now divided up into different parts over a year or longer. The final MB consists of different sections in pathology, medicine, surgery, clinical pharmacology and therapeutics, and obstetrics and gynaecology. The amount of emphasis placed on each varies, and within each the emphasis is on the ability to reason and use knowledge rather than to function as a mixture between a sponge and a parrot. Some schools prefer almost total continuous assessment with each exam contributing to the final MB. Others continue to put major emphasis on finals with the regular assessments being used to monitor progress and certify satisfactory attendance and completion of an attachment. An increasing number of schools split finals into two, with the written papers taken a year earlier than clinicals, to encourage concentration on clinical skills and decision making before becoming a house officer. The final MB comprises multiple choice questions, extended answers to structured questions, or essays, and practicals. In medicine (which includes paediatrics and psychiatry), surgery, and obstetrics and gynaecology considerable emphasis is placed on the clinical bedside examination, which tests skills in talking to patients, eliciting the relevant clinical signs, and making a diagnosis.

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In such situations ends are assigned cheap vardenafil 10 mg without a prescription, relevance is prescribed and possible behaviors are specified by rules at the outset purchase 20 mg vardenafil visa. Purely tactical means/ends deliberations are somewhat less applicable but still of great import in activities like planning and applying drip irrigation and designing sails discount vardenafil 20 mg online, catheters or heart valves generic vardenafil 10 mg otc. But they are greatly deficient in fluid fields such as internal medicine generic vardenafil 20 mg amex, pediatrics and psychiatry, wherein certain large consequences of the "means" are either unknown or likely to be overlooked, where valued qualities do not lend themselves readily to quantified ranking, where particularity makes much of the difference and where process and product are dissolved in each other. This book argues that rationales appropriate for the solution of simple problems aptly modeled by games or nut and bolt reproduction are being inappropriately applied to complex and/or dynamic problems like those in health care; that they are damaging in practice when so applied; and that there are fuller models of rational deliberation available to us which are likely to be much more helpful. Broad deliberation is needed even for choosing when to avail ourselves of mechanical decision aids. Such broad deliberation will be examined in order to understand why we still need it, and how it can be improved. And if, indeed, such deliberation is indispensable, then major alterations are needed in the environments of medical training and clinical care in order to facilitate it. The argument for broad means/ends deliberation is in essence developed along four complementary lines. First, giving medical examples, a summary of evidence is presented showing that much reasoning is necessarily imaginative, not formal. Second, a tentative, but detailed outline is offered, demonstrating how the categories and cognitive models used to understand disease and health are imaginatively constructed rather than classically defined. Third, drawing on the work of John Dewey, the real subtleties involved in defining means/ends problems and in under- standing the complex and dynamic nature of means and ends in practice are illus- trated. Fourth, the axioms and assumptions of expected utility theory are reviewed, illustrating how ineptly it deals with clinical realities. Medical care examples BROAD CONSIDERATIONS IN THE RELATION 3 supplemented by ordinary life examples will be found throughout, since the points at issue are well illustrated by the demands of clinical judgment. Finally, suggestions are given for changes in training, caregiving and the evaluation of results which emphasize improving judgments, including value judgments, instead of dispensing with them. FIRST LINE OF ARGUMENT: COGNITIVE STRUCTURES AND CAUSAL LOGICS FOR MEANS AND ENDS REASONING This argument is mainly put forth in Chapter One. Studies in cognitive science and linguistics have shown that our common sense deliberations about causation and means and ends avail themselves of deeply embedded categorical, imagistic and metaphorical structures which enable our thinking. Taking account of these deeply embedded and often unconscious structures makes it possible to propose that means and ends deliberation could be modified, opened up and hence improved. These roots allow a certain amount of flexibility, but are not inessentials from which we can cut ourselves free. Now that we understand more about the embodied forms and origins of our concepts and the variety of metaphors which structure and facilitate our approach to means/ends problems, we should be able to determine whether we are making the best use of this rich imaginative endowment. How much freedom do we have in conceptualizing means/ends problems in complex and dynamic areas like health care? Given whatever degree of freedom exists, can we make helpful choices among scenarios, metaphors and category understandings with respect to using them on different types of problems? Or, in spite of historic selection for certain thinking patterns is there still room for creativity and improvement? Enmeshed as we are in the most dominant of existing causal logics, from what standpoint can we imagine that we could do better? These questions may appear theoretical, but in the clinic and the hospital they have enormous practical importance. For example, conceiving of causation in mechanical rather than organic terms has much to do with the present emphasis on tertiary and rescue care over primary prevention. SECOND LINE OF ARGUMENT: COGNITIVE MODELS OF HEALTH AND DISEASE AND THE RADIAL STRUCTURE OF THE LARGE DISEASE CATEGORY This subject occupies Chapter Two. Although it is plainly evident that health and disease are not clear-cut, well defined concepts, the reasons for this fact, as well as its implications, have often been ignored. Chapter Two outlines the principal cognitive models which appear to direct the identification of disease. The role of symptoms in providing a literal starting point for disease is brought out.

This approach also allows continuous and it provides important evidence in case of a malprac- assessment of outcomes over time so that the plan can be tice suit 20 mg vardenafil, although such lawsuits are rare vardenafil 10mg fast delivery. The collaborative nature of this practice requires com- munication among the varied disciplines that provide What Is in the Doctor’s Bag services in the home best 10 mg vardenafil. In addition buy vardenafil 10 mg visa, there may be overlap The old-time doctor’s "black bag" is probably not large of shared tasks generic 10 mg vardenafil free shipping. In the case of a patient undergoing enough to accommodate the items that most home care poststroke rehabilitation, for example, a speech-and- physicians might need on a routine or emergent home swallowing specialist might work closely with a nutri- visit. In the Boston University practice, we use a light- tionist and visiting nurse in providing a patient with a safe weight diaper bag with multiple pockets. A bag on wheels might also family, patient, home health aide, and visiting nurse on a be appropriate in the case of a long walk from the car to plan for safe transfers. If communication is adequate, the entire team should be apprised of current and future plans. In small Interdisciplinary Teams practices where the physician does not have the luxury The home is the ideal location to identify the elder’s of an interdisciplinary team, the physician must act as strengths, abilities, and supports, both formal and infor- the case manager in concert with a visiting nurse. These factors are important in developing a care Although most patients receiving home care services do plan that can be put into operation realistically and that not receive house calls from physicians, the physician 128 S. Possible members of a home care interdisciplinary The initial home visit to a medically and socially com- team. It may take Licensed nurse several home visits for the physician or team to gather all Physical therapist the information in a comprehensive geriatric assessment. Occupational therapist Basic elements of the house call should include the Speech therapist Home health aide history and physical exam, social interaction that Homemaker solidifies the doctor–patient relationship, assessment of Physician assistant caregivers and their burden, environmental safety assess- Social worker ment, psychosocial assessment, nutritional assessment, Pharmacist financial assessment, cognitive assessment, a medication Dentist Podiatrist review (including prescribed and over-the-counter Audiologist medications), functional assessment, an introduction to a Chore aide discussion of advance directives and personal prefer- Optometrist ences, an exploration of spiritual needs, and a discussion Nutritionist of the care management plan. Dietician Friendly visitor The physician may have to take into account various Volunteer environmental barriers when taking the history in the Psychologist home setting. Families may need to be asked to leave the Personal care assistant room for private conversations, and the television or Laboratory assistant radio may need to be turned off. The physical examina- Home repairman Rehabilitation personnel tion poses its own problems. If lighting is poor, the physician should have a light source available; to avoid Source: Adapted from the American Medical Association, with self-injury, the physician should use caution when exam- permission. The physician may need to bring disposal remains an important member of the team and must containers for needles, syringes, and other instruments. Situations in which a visit by the physician subsequent exams can be focused on the patient’s par- may be required include discrepancies in reports of the ticular needs. For instance, a look at the feet of a diabetic patient’s status, acute declines in health or function in patient with neuropathy may be more important than frail patients, unexplained failure to thrive, unexplained weighing the patient. The home environment patient/family meeting to make an important decision, alters the traditional doctor–patient relationship in that and routine medical care for the patient who cannot leave the patient is on his or her own "turf" and therefore has home. Some providers may feel uncom- fortable about having less control, but the situation sets the stage for more realistic establishment of goals and Conducting the Home Visit involvement of the family. As a guest in someone’s home, Before the home visit, the physician or team should a physician should ask permission to walk through the gather important data, including the patient’s medical house, turn off the television, wash hands, use the tele- diagnoses, current community-based services, formal and phone, or even simply sit at the bedside. Because care- informal supports, insurance information, and medica- givers provide the bulk of home care, assessment of tions. Patients should be clustered geographically identify and enlist the support of potential informal and the most efficient route planned. If the patient is non-English-speaking, it is study, home safety problems posed great risks to especially helpful to have English-speaking caregivers 32 patients. The safety of the neighborhood and the present to ensure that problems are identified and the patient’s access to shopping and other services can be plan of care can be carried out. The dence of self-neglect, memory impairment, or medication odors of garbage, urine, animal waste, and vermin can noncompliance. When alcohol or cognitive assessment in the clinic setting may produce drug abuse on the part of the patient or caregivers is sus- misleading results. In one study, the scores of one-quarter pected, bottles or other containers can provide evidence. A walk through In such situations, the physician can refer to guidelines the kitchen will reveal the nutritional status and food regarding the complex and nuanced issue of decision- preferences of the patient. It can reveal that patients are not as home health aides, transportation, and shopping taking medications they have listed in drug histories at services. Problems such as malnutrition, vitamin B12 defi- clinics, or, conversely, that they are taking medications ciency, and dietary indiscretion in patients on special diets they have not listed. For Additionally, such a review may reveal that certain instance, in Massachusetts, patients who are Medicaid medical problems are caused by adverse drug reactions, eligible will qualify for adult day care, which may mean drug–drug reactions, or drug–food reactions involving the difference between independent community living nonprescription drugs.

After the test purchase vardenafil 10mg with amex, the probability of anyone testing positive actually being infected is about cheap 20mg vardenafil otc. The predictive value of a negative test only improves the odds that one is not infected in this group from purchase vardenafil 10 mg otc. In contrast generic 20mg vardenafil fast delivery, for the prisoners buy discount vardenafil 20mg on-line, out of the 100 actually infected, 95 will test positive and out of the 900 not infected, 9 will test positive. A test is most useful when it most strongly changes the odds that a disease is present, and that depends on the setting in which it is used. Bayesian theory is a wonderful way to improve the precision of informal reasoning about some contextual questions. But, as Dewey has shown, informal reasoning deals with much more than just weighing the significance of prior probabilities. Informal reasoning even includes deciding when to use a more formal decision process. CONCLUSION Dewey’s claims about natural and interactional values, real qualities, situated reason and the importance of context provide the groundwork for understanding what he means by a "situation. After the discussion of "situations," a fairly comprehensive and direct presentation of his theory of means and ends can be made. I have saved discussion of the difficulties and problems with this theory, some of which I think are major, until the end of that chapter. Dewey appears to be overconfident that "situations" and "problems" are self-evident; that if there is no worry, there is no problem. However, modifications which might be required regarding certain of his claims do not render his insights useless. Already, in this chapter, we can see how his considerations make it totally inappropriate to put on blinders when making medical decisions, and how they show that common assumptions about "costs" and "benefits" misrepresent the nature of means, ends and values. Dewey’s work on means and ends reasoning dovetails with the discoveries of cognitive psychology and linguistics in showing us how our reasoning in many practical domains both is, and cannot escape being, informal. Chapter IV gives more detail of how Dewey thinks engaged judgment can grapple with amorphous and shifting circumstance. Dewey often failed to note that there have been many philosophers of process whose views should have been quite sympathetic to his own. For example, Heraclitus, whose words as reported by Plato this passage echoes: "Heraclitus somewhere says that all things are in process and nothing stays still, and likening existing things to the stream of a river he says that you would not step twice into the same river. Kant elaborates on the meaning of an end in itself in the following several pages. It signifies the order, perspective, proportion which is achieved, during deliberation, out of a diversity of earlier incompatible preferences. Choice is reasonable when it induces us to act reasonably; that is with regard to the claims of each of the competing habits and impulses. CHAPTER 4 JOHN DEWEY’S VIEW OF SITUATIONS, PROBLEMS, MEANS AND ENDS The general purpose of reflectively based action for Dewey is to transform an "unsatisfactory situation" into a "satisfactory" one. Medical encounters, both narrowly circumscribed brief ones and broad continued ones, exemplify Deweyan "situations. While acknowledging that even after a close look there are residual ambiguities in Dewey’s theory of means and ends, the theory illuminates much of what is actually at stake in offering medical care, and what constraints exist on our responses to health problems in the real world. For we never experience nor form judgments about objects and events in isolation, but only in connection with a contextual whole. The "situation" for Dewey encompasses the relation of an individual (not neces- sarily a person) to its surroundings. On many occasions (as Dewey indicates when discussing the quality which is shared by everyone at a ball game when the umpire yells, "You’re out! There would be no point in talking if we could not use the conventional commonality of words to enhance mutual participation in and evaluation of situations that underlie joint endeavor. An experience is always what it is because of a transaction taking place between an individual and what, at the time, constitutes his environment. It should be noted that such an environment is not solely "given" and "out there" apart from the individual, but is in several key ways dependent on the individual. The capacities of the individual to be affected already equip and limit any possible environment. The physical disposition of a person, including positioning and focus of attention, screens potential environmental inputs. And finally, there are all the unintentional marks and intentional artifacts of individuals which shape their surroundings.

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