By Z. Nafalem. American University of Judasim. 2018.
The collusion between cult practices and medical practices are usually hidden voluntarily; and the same holds true for the "consulting" doctors to whom potential followers are addressed for a "second opin- ion" and often the prescription of a "method" dispensed by the cult quality 100 mg neurontin. Some doctors who "sympathize" with these movements have been ac- cused (rightly) of actively discount neurontin 600 mg with mastercard, if discreetly order neurontin 100 mg with visa, supporting harmful cult prac- tices when they have been publicly exposed and attacked buy neurontin 300 mg low cost. Several practitioners have been convicted for having proselytized on behalf of one cult or another. They strongly de- nounce the relationships between certain "soft" or alternative medi- cines and cults, relationships that are very clear in some cases. Alterna- tive medicines and pseudo-medicines are often preached and used in- side cults, and there is considerable danger in the fact that alternative and pseudo-scientific therapies are promoted by associations or groups known to serve as "screens" for cults. Similarities between Cults and Alternative Medicine In many cases, there are clear parallels between alternative medi- cines and cult practices, and their guiding principles are often very similar (both may reject scientific medicine, both may lean toward "orientalist" and/or "ecological" notions, etc. In the general context of alternative medicines, the border is diffi- cult to establish between tolerable and harmful prescriptions (whether active or passive — by rejecting recognized forms of treatment), and between appropriate and charlatanesque practices. In certain cases, a possible relationship should also be suspected between esoteric, 220 The Authorities vs. It may be time for a general reminder of the guiding principles that come from the "Primum non nocere" and the Hippocratic oath: The doctor’s role is to contribute to maintaining the health (the physical, moral and social well-being) of his patients and to respect their autonomy, to oppose point by point the goals of coercive cults, which are harmful to their followers. In the pursuit of his occupa- tion, the doctor is called upon (and is given the privilege) to pene- trate the intimacy of the life of his patients. Various incidents have been reported, personally implicating doc- tors, directly or indirectly, in reprehensible practices of cult groups. If a doctor takes part in any activity that destroys someone’s health, dis- avowing the commitments he has made, he should not be able to claim clemency on the basis of his profession. On the contrary, his status as an "expert" should mean all the more vigorous sanctions against him. Cult influence on education and child care, with the parents’ full assent, is alarming; and evidence frequently comes to light of active or passive complicity by doctors who live within these cults, performing professionally condemnable acts (faking certificates of vaccination, for example, or failing to censure physical abuse and maltreatment of chil- dren). Other doctors have taken part in attacking the physical integrity of the followers of certain cults and have supported and participated in methods of conditioning that lead to a progressive weakening of the victims’ physical capacities, and in the savage use of psychological or psychiatric methods designed to brainwash the cult members and place them in a condition of dependency. The confirmed or potential danger of certain cults, with the pres- ence and even the active cooperation of doctors in their midst, poses an 221 Healing or Stealing? The medical practices that show up inside the cult phenomena are very complex, especially given: - the extreme polymorphism of cults; - the very diverse degrees of participation of doctors in certain activi- ties of cults; - the intricate blend of the various forms of collusion with cult move- ments of which a practitioner: might be guilty: a doctor may "recruit" his clients, and may also lend a hand to the "medical" activities of the cult, he may be an accessory to the illegal practice of medicine or pro- vide a cover, claiming to be unaware of harmful, even dangerous prac- tices. Every time a doctor is reported for any type of cult-related abnor- mality, an objective analysis of the circumstances and the evidence is essential; and once the facts have been gathered and assessed, there must be consequences imposed by the public health authorities. The European principles of medical ethics, adopted in 1987, also stipulate: "The doctor shall avoid imposing upon the patient his per- sonal philosophical, moral or political opinions in the practice of his profession"; thus, any proselytism in favor of cult movements in the scope of the medical practice is banned. Sanctions Against Fake Medical Practices In a recent hearing in France, the cult IVI and the doctors who collaborated in its practices were tried and convicted, and one doctor was barred for life from any further practice of medicine. X was convicted of having disregarded the basic medical principles and allow- ing one of his patients’ cancer to progress, causing his death. In its de- cision, the National Council of Physicians gives an opinion that soft- 222 The Authorities vs. Let us pray that in the future, the authorities will not shrink from confronting the storm that will be raised by lawsuits brought against these practitioners who are more charlatans than doctors. To Conclude: The Pill for Fools In another of its efforts to protect the public from moronic scams, the magazine Science et Vie published an article entitled "The Enigmatic Pill from the Kremlin", debunking one of the new fantasy products of- fered to gullible clients of the alternative medicine movement, in May 1997. The Politburo pill, as it was called, was one of the by-products of the former USSR’s military research and production. Invented at the Tomsk military-industrial complex, it seems that the Kremlin pill was intended for members of the Politburo and was supposed to have been used to treat the former First Party Secretary Leonid Brezhnev for gas- tric disorders. It was composed of a stainless steel case containing a silver oxide battery and a miniaturized electronic circuit that would emit discharges of approximately 20 millivolts under ten milliamperes. In 1985 and again in 1995 the pill received approval from the Soviet Ministry of Health. W ith the fall of the Soviet empire and the ensuing economic debacle, it was decided to offer this miracle pill — which had been kept under wraps and hidden as securely as a nuclear warhead — for sale on the international market. Once it has been swallowed and enters the acid environ- ment of the stomach, the capsule behaves like an electro-stimulation system, producing mild electric shocks to the stomach wall for about 24 hours. This gastric system electric shock is recommended for vari- ous disorders: slow bowel, constipation, ulcers, stress, diabetes and 223 Healing or Stealing?
Streptococcus pneumoniae – Range from isolated paresis to global in- jury cheap 100 mg neurontin free shipping, leading to tetra- plegia purchase 800 mg neurontin otc. Only 20% of motor handicaps present at discharge persist at one-year follow-up Deafness buy neurontin 100 mg with mastercard, hearing loss! Diagnostic Clinical Criteria Major criteria – Regional pain complaint – Pain complaint or altered sensation in the expected distribution of referred pain from a myofascial trigger point – Taut band palpable in an accessible muscle – Exquisite spot tenderness at one point along the length of the taut band – Some degree of restricted range of motion cheap 300 mg neurontin, when measurable Minor criteria – Reproduction of clinical pain complaint, or altered sensation, when pressure is applied at the tender spot – Elicitation of a local twitch response by transverse snapping – Palpation at the tender spot or by needle insertion into the tender spot in the taut band – Pain alleviated by stretching the muscle or by injecting the tender spot From: Simons DG. Associated Neurological Disorders Neuropathies – Radiculopathy – Entrapment neuropathies – Peripheral neuropathy – Plexopathy Multiple sclerosis Rheumatological disorders – Osteoarthritis – Rheumatoid arthritis – Systemic lupus erythematosus Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. The incidence of postherpetic neuralgia (PHN) after herpes zoster varies between 9% and 15%, with 35–55% of patients continuing to have pain three months later, and 30% having intractable pain for one year. Thoracic dermatome 55% Trigeminal distribution 20% Cervical dermatomes 10% Lumbar dermatomes 10% Sacral dermatomes 5% Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Atypical Facial Pain 309 Atypical Facial Pain The pain usually starts in the upper jaw. Postherpetic neuralgia This occurs mainly with first-division herpes; although the whole zone hurts, pain in the eyebrow and around the eye is especially severe. Pain is continual and burn- ing, with severe pain added by touching the eyebrow or brushing the hair. The condition shows a tendency to spontaneous remission Temporal arteritis Swelling, redness and tenderness of the temporal artery and a headache in the distribution of the artery are the classic hallmarks of the disease. Nocturnal attacks of pain in and around the eye, which may become bloodshot with the nose "stuffed up," with lacrimation and nasal wa- tering. Bouts last 6–12 weeks and may recur at the same time each year Temporomandibular Pain is mainly in the TMJ, spreading forward onto the joint (TMJ) dysfunction, face and up into the temporalis muscle. The joint is or Costen’s syndrome tender to the touch, and pain is provoked by chewing or just opening the mouth. The pain ceases almost entirely if the mouth is held shut and still Odontalgia A dull, aching, throbbing, or burning pain that is more or less continuous and is triggered by mechanical stimulation of one of the teeth. It is relieved by sympathetic blockade Myofascial pain Aching pain lasting from days to months, elicited by syndrome palpation of trigger points in the affected muscle Atypical facial neuralgia Chronic aching pain involving the whole side of the face, or even the head beyond the distribution of the trigeminal nerve. This condition is much more com- mon in women than in men, and is often associated with significant depression Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Usually self-limiting, lasting from 30 minutes to several hours – Cluster headache Nocturnal attacks of pain in and around the eye, (migrainous neural- which may become bloodshot and with the nose gia) "stuffed up," with lacrimation and nasal watering. Bouts last 6–12 weeks and may recur at the same time each year – Chronic paroxysmal Unilateral, shooting, drilling headache, associated with hemicrania lacrimation, facial flushing and lid swelling and lasting 5–30 minutes day or night, without remissions Temporomandibular Pain is mainly in the TMJ, spreading forward onto the joint (TMJ) dysfunction, face and up into the temporalis muscle. The joint is or Costen’s syndrome tender to the touch, and pain is provoked by chewing or just opening the mouth. The pain ceases almost en- tirely if the mouth is held shut and still Odontalgia A dull, aching, throbbing, or burning pain that is more or less continuous and is triggered by mechanical stimulation of one of the teeth. It is relieved by sym- pathetic blockade Tension headache Pain is believed to be due to spasm in the scalp and suboccipital muscles, which are tender and knotted. Descriptions such as experiencing tightness like a "band" or the scalp being "too tight" are a frequent clue Temporal arteritis Swelling, redness, and tenderness of the temporal artery and a headache in the distribution of the artery are the classic hallmarks of the disease. Diffuse head- ache can occur Psychotic headaches A specific spot on the head is isolated, and bizarre complaints such as "bone going bad," "worms crawl- ing under the skin," quickly followed by an invitation to feel the increasingly large lump. This condition should always be suspected if the patient offers to locate the headache with one finger. A re- lentless sense of pressure over the vertex is typical of simple depression headache Pressure headache Occurs on waking, is aggravated by bending or cough- ing, produces a "bursting" sensation in the head, and does not respond well to analgesics Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Cephalic Pain 311 Posttraumatic head- Pain occurs as a persistent and occasionally progres- aches sive and localized symptom following head trauma, with an onset often many months after the accident. It may relate to an entrapped cutaneous nerve neu- roma, extensive base of skull fractures associated with injuries to the middle third of the face, or stripping of the dura from the floor of the middle fossa, after dia- static linear fractures, etc. Occipital neuralgia This is commonly a secondary manifestation of a benign process affecting the second cervical dorsal roots of the occipital nerves Carcinoma of the head Often a deep, drilling, heavy ache, debilitating in its and neck progressive persistence, regional or diffuse, and in- duced by carcinoma of the face, sinuses, nasopharynx, cervical lymph nodes, scalp, or cranium Headaches related to A "cough" or "exertional" headache may be the sole brain tumors or mass sign of an intracranial mass lesion. Patients often wake lesions up early in the morning with the headaches, which may be more frequent daily, in contrast to the epi- sodic occurrence in migraine. Neural examination may reveal focal abnormalities, as well as papilledema on funduscopic examination Headaches related to The pain is usually sudden in onset, severe or disabling ruptured aneurysms in intensity, and with a bioccipital, frontal and orbito- and arteriovenous frontal location anomalies Carotid artery May present as an acute unilateral headache as- dissection sociated with face or neck pain, Horner’s syndrome, bruit, pulsatile tinnitus, and focal fluctuation neuro- logical deficits due to transient ischemic attacks. Dis- sections occur in trauma, migraine, cystic medial necrosis, Marfan’s syndrome, fibromuscular dysplasia, arteritis, atherosclerosis, or congenital anomalies of the arterial wall Spinal tap headaches These occur in approximately 20–25% of patients who undergo lumbar puncture, irrespective of whether or not there was a traumatic tap and regard- less of the amount of CSF removed.
Oxford and Cambridge remain perfectly 59 LEARNING MEDICINE reasonable exceptions cheap 100 mg neurontin with amex, having retained a strongly and intrinsically medical science centred curriculum in the first three years discount 600 mg neurontin fast delivery. The GMC encourages diversity within the curriculum and students should carefully consider which sort of curriculum would best inspire their mind 600 mg neurontin sale, heart neurontin 300 mg with amex, and enthusiasm. You can usually get a flavour of how the course is delivered at each school by reading the curriculum and students’ views section on the medical schools’ websites or in their prospectuses. Nevertheless, at most universities the traditionally separate scientific and clinical aspects of the course have become very substantially integrated to prevent excited and enthusiastic students becoming disillusioned in the first two years with what understandably seemed to be divorced from real patients and real lives, from clinical relevance and clinical understanding. The subjects, systems, and topics Most first year students begin with a foundation course covering the fundamental principles of the basic medical sciences. These include anatomy—the structure of the human body, including cell and tissue biology and embryology, the process of development; physiology—the normal functions of the body; biochemistry—the chemistry of body processes, with increasing amounts of molecular biology and genetics; pharmacology—the properties and metabolism of drugs within the body; psychology and sociology—the basis of human behaviour and the placing of health and illness in a wider context; and basic pathology—the general principles underlying the process of disease. As the general understanding of the basics increases, the focus of the teaching often then moves from parallel courses in each individual subject to integrated interdepartmental teaching based on body systems—such as the respiratory system, the cardiovascular system, or the locomotor system—and into topics such as development and aging, infection and immunity, and public health and epidemiology. In the systems approach the anatomy, physiology, and biochemistry of a system can be looked at simultaneously, building up knowledge of the body in a steady logical way. As time and knowledge progress the pathology and pharmacology of the system can be studied, and the psychological and sociological aspects of related illnesses are considered. Often the normal structure and function can best be understood by illustrating how it can go wrong in disease, and so clinicians are increasingly involved at an early stage; this has an added advantage of placing the science into a patient focused context, making the subject more relevant and stimulating for would be doctors. It also allows for early contact with patients to take place in the form of clinical demonstrations or, for example, in a project looking at chronic disease in a general practice population or on a hospital ward. In some medical schools, such as Manchester and Liverpool, practically all the learning in the early years is built around clinical problems that focus 60 MEDICAL SCHOOL: THE EARLY YEARS all the different dimensions of knowledge needed to understand the illness, the patient, and the management. The teaching and the teachers The teaching of these subjects usually takes the form of lectures, laboratory practicals, demonstrations, films, tutorials and projects, and, increasingly, computer assisted interactive learning programmes; even virtual reality is beginning to find its uses in teaching medical students. Dissection of dead bodies (cadavers) has been replaced in most schools by increased use of closed circuit television and demonstrations of prosected specimens and an ever improving range of synthetic models. Preserved cadavers make for difficult dissection, especially in inexperienced if enthusiastic hands, and, although many regarded the dissecting room as an important initiation for the young medical student, fortunately much of the detail needed for surgical practice is revised and extended later by observing and assisting at operations and during postgraduate training. Much more useful to general clinical practice is the increased teaching of living and radiological anatomy. In living anatomy, which is vital before trying to learn how to examine a patient, the surface markings of internal structures are learnt by using each other as models. This makes for a fun change from a stuffy lecture theatre as willing volunteers (and there are always one or two in every year) strip off to their smalls while some blushing colleague draws out the position of their liver and spleen with a felt tip marker pen. Practical sessions in other subjects, especially physiology and pharmacology, often involve students performing simple tests on each other under supervision. Memorable afternoons are recalled in the lab being tipped upside down on a special revolving table while someone checked my blood pressure or peddling on an exercise bike at 20 km/h for half an hour with a long air pipe in my mouth and a clip on my nose while my vital signs were recorded by highly entertained friends or recording the effect on the colour of my urine of eating three whole beetroots, feeling relieved not to be the one who had to test the effects of 20 fish oil capsules. As well as the performing of the experiments, the collation and analysis of the data and the researching and writing up of conclusions is seen as central to the exercise, and so students may find themselves being introduced to teaching in information technology, effective use of a library, statistics, critical reading of academic papers, and data handling and presentation skills. The teaching of much of the early parts of the course is carried out by basic medical scientists, most of whom are not medically qualified but who are specialist researchers in their subject. Few have formal training in teaching but despite this the quality of the teaching is generally good and the widespread introduction of student evaluation of their teachers is pushing up standards even further. Small group tutorials play an important part in supplementing the more formal lectures, particularly when learning is centred around a problem solving approach, with students working through clinical based problems to aid the understanding of the system or topic being studied at that time. The tutorial system is also an important anchor point for students who find the self discipline of much of the learning harder than the spoon feeding they may have become used to at school. Students may also have an academic tutor or director of studies or a personal tutor, or both, a member of staff who can act as a friend and adviser. The success or failure of such a system depends on the individuals concerned, and many students prefer to obtain personal advice from sympathetic staff members they encounter in their day to day course rather than seeking out a contrived adviser with whom they have little or no natural contact. In some schools, most notably in Oxbridge, the college based tutor system is much more established and generally plays a more important personal and academic part.
Fifteen years ago buy neurontin 300mg low cost, when I took up m y first research post buy generic neurontin 600mg, a work weary colleague advised m e: "Find som ething to m easure purchase neurontin 300mg overnight delivery, and keep on m easuring it until you’ve got a boxful of data generic neurontin 400 mg on-line. Epidem iologist N ick Black has argued that a finding or a result is m ore likely to be accepted as a fact if it is quantified (expressed in num bers) than if it is not. Yet, observes Black, m ost of us are happy to accept uncritically such sim plified, reductionist, and blatantly incorrect statem ents so long as they contain at least one num ber. They aim to "study things in their natural setting, attem pting to m ake sense of, or interpret, phenom ena in term s of the m eanings people bring to them ",2 and they use "a holistic perspective which preserves the com plexities of hum an behaviour". It is now increasingly recognised as being not just com plem entary to but, in m any cases, a prerequisite for the 166 PAPERS TH AT G O BEYON D N U M BERS quantitative research with which m ost of us who trained in the biom edical sciences are m ore fam iliar. Certainly, the view that the two approaches are m utually exclusive has itself becom e "unscientific" and it is currently rather trendy, particularly in the fields of prim ary care and health services research, to say that you are doing som e qualitative research – and since the first edition of this book was published, qualitative research has even becom e m ainstream within the evidence based m edicine m ovem ent. A sm all child runs in from the garden and says, excitedly, "M um m y, the leaves are falling off the trees". A second child, when asked "tell m e m ore", m ight reply, "W ell, the leaves are big and flat, and m ostly yellow or red, and they seem to be falling off som e trees but not others. Questions such as "H ow m any parents would consult their general practitioner when their child has a m ild tem perature? But questions like "W hy do parents worry so m uch about their children’s tem perature? Rather, we need to hang out, listen to what people have to say, and explore the ideas and concerns which the subjects them selves com e up with. After a while, we m ay notice a pattern em erging, which m ay prom pt us to m ake our observations in a different way. In reality, there is a great deal of overlap between them , the im portance of which is increasingly being recognised. D oes not use preset questions but is shaped by a defined set of topics Focus groups M ethod of group interview that explicitly includes and uses the group interaction to generate data Box 11. It begins with an 168 PAPERS TH AT G O BEYON D N U M BERS intention to explore a particular area, collects "data" (i. The strength of qualitative research lies in validity (closeness to the truth), i. The validity of qualitative m ethods is greatly im proved by the use of m ore than one m ethod (see Box 11. Those who are ignorant about qualitative research often believe that it constitutes little m ore than hanging out and watching leaves fall. It is beyond the scope of this book to take you through the substantial literature on how to (and how not to) proceed when observing, interviewing, leading a focus group, and so on. But sophisticated m ethods for all these techniques certainly exist and if you are interested I suggest you try the introductory7, 10, 11 or m ore detailed2, 12 texts listed at the end of this chapter. Qualitative m ethods really com e into their own when researching uncharted territory, i. But it is in precisely these circum stances that the qualitative researcher m ust ensure that (s)he has, at the outset, carefully delineated a particular focus of research and identified som e specific questions to try to answer (see Question 1 in section 11. The m ethods of qualitative research allow for and even encourage2 m odification of the research question in the light of findings generated along the way. Failure to recognise the legitim acy of this approach has, in the past, led critics to accuse qualitative researchers of continually m oving their own goalposts. W hilst these 169 H OW TO READ A PAPER criticism s are often m isguided, there is, as N icky Britten and colleagues have observed, a real danger "that the flexibility [of the iterative approach] will slide into sloppiness as the researcher ceases to be clear about what it is (s)he is investigating". It is debatable, therefore, whether an all-encom passing critical appraisal checklist along the lines of the "U sers’ guides to the m edical literature" (see references 8–32 in Chapter 3) could ever be developed. M y own view, and that of a num ber of individuals who have attem pted or are currently working on this very task,7, 12, 13, 14 is that such a checklist m ay not be as exhaustive or as universally applicable as the various guides for appraising quantitative research, but that it is certainly possible to set som e ground rules. The list which follows has been distilled from the published work cited earlier2, 7, 13 and also from discussions with D r Rod Taylor of Exeter U niversity, who has worked with the CASP Project on a m ore detailed and extensive critical appraisal guide for qualitative papers. Question 1 Did the paper describe an important clinical problem addressed via a clearly formulated question? Qualitative papers are no exception to this rule: there is absolutely no scientific value in interviewing or observing people just for the sake of it. Papers which cannot define their topic of research m ore closely than "W e decided to interview 20 patients with epilepsy" inspire little confidence that the researchers really knew what they were studying or why.
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