By N. Ugrasal. Augustana College, Rock Island Illinois. 2018.
They know that medicine offers a wide range of career opportunities 400 mg etodolac with amex, that most doctors will end up looking after patients but not all do generic etodolac 200mg line, that more will work outside hospitals than in discount etodolac 300mg on line, and that both the training and the job itself are demanding physically and emotionally etodolac 400 mg low price. They also know that whatever their final occupation doctors need to make decisions, deal with uncertainty, and communicate effectively and compassionately with patients and colleagues alike as well as maintaining moderately exacting academic standards. The aim is not to pick men and women for specific tasks but to train wise, bright, humane, rounded individuals who will find their niche somewhere in medicine. The format may be formal, with the interview conducted in traditional fashion across a large table, or more informal, sitting in comfortable chairs around a coffee table by the fireside. The tenor of the interview, however, depends much more on the style of questioning; no matter how soft the armchairs are, they can still feel decidedly uncomfortable if you are made to feel like you are being grilled and about to be eaten for breakfast. Dress and demeanour Although the interview is a chance to be yourself and sell yourself, there are certain codes of conduct that even the most individual or eccentric candidate should be encouraged to heed. Dress smartly and comfortably and make an effort to look as presentable as you would expect from a mature professional. If your usual style of clothing is rather off beat, then perhaps for once it may be wise to let your tongue make any statements about your individuality rather than your all in one leather number and preference for nose piercing. Nothing is more of a turn off to interviewers than someone who is full of himself (or herself! On the other hand an obviously talented and caring student whose modesty and nerves get the better of him and who fails to give the panel any reasons at all to give him an offer is almost as frustrating. When asked to blow your own trumpet make it sound like a melodious fugue not a ship’s fog horn. Many schools will be able to organise mock interviews, which can be useful, but often the more specific points relating to entering medical school can be best thought through by enlisting the help of your local family doctor or a family friend who is a doctor or by talking to anyone experienced in interviewing or being interviewed in any context or by asking the advice of people who have themselves recently been through it when you visit the medical schools on open days or tours. You should be able to show you have a realistic insight into the life of a doctor, and this is often best achieved by relating personal experience of spending some time with a doctor in hospital or general practice or, for example, by voluntary work in an old people’s home or with children with special needs. Some panels put great store by your showing them how much you can achieve when you put your mind to it and will want to discuss your expedition to Nepal, your work on the school magazine, your musical or sporting successes. Remember to keep a copy of your UCAS form personal statement to read before you go into your interview. It is very often used as a source for questions and it can be embarrassing if you appear not to remember what you wrote. Even more importantly, do not invent interests or experience, as you may get caught out. One candidate at interview recently struggled through his interview after he was asked about the voluntary work at a local nursing home which he put on his form and replied: "I haven’t actually got round to doing it yet, but I’d like to. It is often sensible to have kept in touch with current affairs and developments in research. This is particularly relevant if the medical school has a strong interest in a research topic which has a high media profile. By reading a good quality daily newspaper you will greatly assist your ability to provide informed comment on issues of the moment. One candidate at interview cited the strong research background as a reason for applying to that school, and when asked to discuss which research at the school impressed him he replied: "Fleming’s discovery of penicillin". He knew he had not done himself any favours when the dean replied: "Could you not perhaps think of anything a little more recent than 1928? Specific questions on subjects such as abortion, religion, or party politics are discouraged, but if they are likely to cause personal professional dilemmas it is reasonable and sensible to have thought about them and to be able to discuss how you would approach resolving such issues. Candidates with special circumstances, especially mature students, should be fully prepared for the interview panel to concentrate on particularly relevant factors such as whether they can afford to support themselves during the course, rigorous testing of their motivation, and questioning of the reasons behind their decision to enter the medical profession. It is usual for the panel to offer an opportunity for the candidate to ask questions. A current student at the school sitting in on the interview can often be useful in answering the candidate’s questions. Make sure if you do ask a question that you do not spoil an otherwise successful interview by asking a question which simply indicates that you have failed to read the 55 LEARNING MEDICINE prospectus thoroughly or which has no direct bearing on your entry to or time at medical school. Offers An offer made to a candidate who has already achieved the minimum academic requirement is unconditional. All candidates who have already attained the minimum grades at first attempt cannot automatically receive a place because far more applicants will achieve this than the school can take.
Externalizing conversations help to assuage blaming practices discount 300mg etodolac, challenge limiting ways of being generic etodolac 200mg without a prescription, and create distance from problematic ways of relating so that couples can create alternatives etodolac 300mg on-line. The language used in naming problems comes directly from the partners consulting with the therapist purchase etodolac 200mg on line. The fol- lowing questions illustrate how the therapist and couple can engage in an externalizing conversation: "You mentioned feeling guilty. Would Guilt be a good name for the prob- lem that has you avoiding each other at home? Here, we invite inquiry into the knowledge that each partner carries about how the problem first gained access to their relationship and how it has managed to gain control over time. We are looking for specific examples of the problem’s real effects and the methods it uses to exert its influence. Mapping events through time is necessary to help couples perceive differences that may lead to new possi- bilities for action (Bateson, 1972), as evidenced by the following questions: "What is the earliest recollection you have of Defensiveness infiltrating your relationship? Will they continue to submit to the requirements of problematic practices or do they want to take a different stance? The following questions aim to help couples evaluate the real effects of problems that are influencing their relationship: "Is it acceptable that Suspicion has co-opted your relationship in this way? This provides an opening for therapists to explore new perspectives and hopes for helping the couple to move forward with their relationship, as seen by the following questions: "Can you tell me a story that illustrates why this problem of Withdrawal is important to you? By exploring the history and effects of these unique experiences, we reconnect the couple to resources that often have become dormant due to the escalating strength of the problem. The following questions seek to make visible unique experiences that contradict problematic ways of relating: "I understand that Sorrow is currently in the driver’s seat for your rela- tionship. What would you call this quality that enabled you to sidestep Manipulation’s influence? How do these new descriptions alter the stories the couple holds about their partnership? We also look for evidence of experiences, intentions, and people that support the couple’s new path. Identifying this evidence from the past and imagining how it might evolve into the future adds density to the emerging story, as evidenced by the following questions: "You mentioned Collaboration as a recent re-discovery. Is Collaboration more indicative of your preferred way of relating with your partner? This may take the form of letter writing or having outside members of the couple’s community par- ticipate in a therapy session. We also create communities of support by invit- ing others to share their past successes (in taking their lives back from certain problems) with couples currently struggling with similar problems. The following questions invite the couple to consider ways of expanding their community of support: "Would you be interested in hearing about strategies that other couples have used in coping with Suicide? If you could carry your grandmother with you as you risk having this conversation with Bill, what difference might that make? Partners often come into our offices engaged in monologue or in ways of relating that restrain genuine listening. Clinical theories tend to focus on improving speaking skills, while paying less at- tention to forces that restrain the listening process. Like the construction of music, dialogue exists in a space that allows for the participation of many voices. This requires openness to expressions from the other, which transports the conversation to a place it hasn’t been before. When restraints to listening dominate, new perspectives are not in- tegrated into the conversations. Or one might be fitting the partner’s ex- pressions into a framework that’s congruent with one’s own beliefs, ideas, and assumptions. Conversations can open space and generate possibilities or close down space and limit options for moving the dialogue forward (Chasin et al. Following are examples of how some of the ideas used by the Public Con- versation Project in their work fostering dialogue between polarized groups around divisive issues (Chasin et al. Concepts from the Winslade and Monk (2001) text on narrative me- diation are also reflected in the following practices.
The emphasis is on those instru- two scores obtained by two simultaneous observers discount etodolac 400mg with visa. A list of some suggested scores obtained serially by the same observer over a time instruments appears in Table 17 buy 400 mg etodolac. Domain Instrument Sensitivity Speciﬁcity Time (min) Cutpoint Comments Cognition Dementia MMSE7 79%–100%a 46%–100% 9 <24b Widely studied and accepted Timed time and 94%–100% 37%–46% <2 <3 s for time and Sensitive and quick change test20 <10 s for change Delirium CAM23 94%–100% 90%–95% <5 Sensitive and easy to apply Affective GDS 5 question 97% 85% 1 2 Rapid screen disorders form33 Visual Snellen chart4 Gold standard Gold standard 2 Inability to read Universally used impairment at 20/40 line Hearing Whispered voice4 purchase etodolac 400 mg online,40 80%–90% 70%–89% 0 quality etodolac 200mg. Responsiveness refers to an instrument’s ability to detect This criterion does not mean, however, that they must clinically signiﬁcant changes over time, even if these 2 be administered by the primary clinicians. Tests demonstrating a high sensitivity utilities of administering various instruments in clinical to small changes may have an increased rate of false settings by nonphysician ofﬁce staff are reasonably positives. Furthermore, patients can are likely to be responsive, the two terms are not complete self-administered surveys at home. Self-administered Strengths and Weaknesses questionnaires, although efﬁcient and inexpensive, may of Instruments introduce elements of underreporting or overreporting because of lack of motivation or denial of dysfunction. Assessment instruments are simply tools to begin an Furthermore, elderly patients may require or request evaluation process. It is easy to overestimate their value assistance from family members when completing the and make their application an end unto itself. The crucial questionnaire, thus introducing the biases of a second step in the use of assessment instruments is the inter- reporter; this may be especially true for those with cog- pretation of their ﬁndings. However, even trained interviewers based on positive or negative results is one of the most can introduce their own biases during the information- 5 important duties of the clinician. The choice of which assessment instrument to use is Another element to consider is the contrast between based on a careful consideration of its relative strengths measures of capacity and those of performance. For instance, comprehensive but lengthy interview-based Capacity refers to what patients report they are able to questionnaires may be appropriate for research settings do. As the task or skill at issue is not actually performed but not in clinical practice. Patients are usually unwilling in an observed setting, the rating process can be com- to submit to prolonged interviews, and practitioners are pleted quickly. The chief disadvantage of capacity assess- fulﬁll all these requirements, these principles should be ment is the reliance on patients’ subjective estimates considered when deciding whether it is worth assessing a of their abilities. Because some patients function substantially below their capacity, this approach may underestimate their functional ability. Dimensions of Geriatric Assessment Performance-based measures are direct observations of particular actions. Advantages include an increase in Cognitive Function objectivity as patients’ biases and those of their proxies are minimized. Disadvantages include the need to train Assessment of the cognition of elderly patients generally the observer and the costs for specialized equipment to focuses on detection of dementia and delirium. Although create the task being observed: an audiometer to create these two conditions can be distinguished by time course, a tone, stairs to climb, etc. In fact, the presence of dementia is a risk factor for Patient factors may also affect the performance of the the development of delirium in elderly hospitalized instrument in clinical settings; these include educational patients. Finally, each test has a limited range in which it is sen- The prevalence of dementia, an acquired, progressive sitive, commonly referred to as ceiling and ﬂoor effects. Therefore, the yield of screening for cognitive impair- ment because virtually everyone scores at the top. Because the initial Conversely, a ﬂoor effect is when everyone scores at the phases of impairment can be quite subtle, it can be dif- bottom of the scales. For example, in a population of ﬁcult for a clinician to make the incidental discovery healthy community-dwelling older persons, the ceiling of cognitive impairment. Structured examination tech- effect would apply if one measured basic activities of niques may be helpful in detecting early dementia. Such daily living (BADL, discussed below); almost all the detection has become increasingly important because a patients are able to complete all the relevant tasks. Sim- number of pharmacologic and behavioral interventions ilarly, in a nursing home population, almost all patients have been shown to slow the progression of symptoms will be dependent in all items of the instrumental activi- and delay nursing home placement for patients with ties of daily living scale (IADL; discussed below); thus, moderate Alzheimer’s disease.
In this context the overall aim is to move from controlling one or more relapses cheap 400mg etodolac with mastercard, to minimizing and ideally halting further disease progression order etodolac 400 mg. Steroid drugs have been used for many years to try and control the inﬂamma- tion attending relapses and lessen symptoms order etodolac 400 mg overnight delivery, but they have little effect on the underlying disease purchase etodolac 300 mg line. More recently, drugs based on beta-interferon and others based on glatiramer acetate are showing more promise in not only assisting in the control of relapses, but also appearing to modify the disease course in some people, as their effects seem to continue for sev- eral years. There are also as many as 50 promising individual therapies undergoing clinical trials at any one time, although few will end up 14 MANAGING YOUR MULTIPLE SCLEROSIS being used in clinical practice, and the drugs are often targeted to only very speciﬁc types of the disease. In this respect there is no single drug treatment – an ‘MS drug’ – for all the symptoms of MS because of the immense variation and different rates of progression in each individual. Fortu- nately, MS is a condition where many symptoms can, in most cases, be relatively well managed for long periods of time. Interferons are naturally occurring substances in the body, produced in response to ‘invasion’ by a foreign substance, such as a virus. Two different kinds of beta-interferons have shown a signiﬁcant effect in MS by reducing the number and severity of its ‘attacks’: beta-interferon 1b (trade name Betaferon) and, more recently, beta-interferon 1a (trade names Avonex and Rebif). They seem to stabilize the immune system but there is conﬂicting evidence as to whether it also slows disease progression. The drugs have been extensively tested on people with speciﬁc kinds of relapsing-remitting MS, mainly those in the earlier stages of MS and who can walk (in the jargon, those who were ‘ambulant’). This was because it was easier to demonstrate the effectiveness of the drugs on people who were more mildly affected and who were having relatively regular ‘relapses’. Findings of several trials showed that these people had a (statistically) signiﬁcantly lower rate of relapses compared to a group of others who did not take the drugs and, furthermore, when they did have a relapse, it was likely to be less severe. In the case of secondary progression, as it is preceded by a relapsing- remitting phase, such people may beneﬁt through some of the therapies, which could have some effect on modifying the earlier phase of the disease. In primary progressive MS, there is less compelling evidence at present that beta-interferons substantially affect the longer term course of the disease. MEDICAL MANAGEMENT OF MS 15 These current ﬁndings mean ‘statistically’ that there are still some people who took the drugs and who did not beneﬁt a great deal from them. Beta-interferons may have less effect on people whose disease pro- gression is substantial. Nevertheless, at present, drug therapy for primary progressive MS is still mainly to manage any symptoms as they appear. However, given the evidence that beta-interferons can produce some beneﬁts for both relapsing-remitting and secondary progressive MS, research is now increasingly interested in their potential effects in primary progressive MS. Effects of beta-interferons Expectations of the drugs have been so high that many people have been disappointed that they do not feel much better when they take them, but the drugs do not cure MS nor do they appear to repair existing damage: they just seem to slow down further damage and symptoms in some people, so both the original symptoms and any internal damage to your CNS will still be there. The drugs are working ‘silently’, thus, we anticipate, preventing some future symptoms and damage. You might wonder why you are taking drugs that you may think have no effect on your present symptoms! The effect of beta-interferons, as far as we know, is to encourage the immune system to become more ‘placid’. This seems to reduce the number and extent of the periodic ‘inﬂammations’ that lead to more MS symptoms; however, they do not necessarily eliminate those ‘inﬂamma- tions’. So relapses may still occur, even if they are fewer in number and less in degree than they would otherwise have been. The problem is that neither the doctor treating you, nor you yourself, know what would ‘otherwise have been’. All you may know is that you now have (perhaps a minor) relapse, and are feeling worse. Your relapses might well have been worse without beta-interferon but, of course, you might feel that it was not effective at all.