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By R. Benito. North Georgia College and State University, the Military College of Georgia. 2018.

As a naturalist tadalis sx 20 mg with mastercard, he seeks to work on and with human inclinations discount 20mg tadalis sx otc, developing and engaging them for beneficial purposes tadalis sx 20mg discount. His view contrasts sharply with Kant discount tadalis sx 20mg without a prescription, who thought that will could and in fact should control action based on rational considerations alone and that action based on inclination alone could not be morally meritorious. We need to be cultivating inclination according to Dewey, not counting on emotionally unsupported "will. To state explicitly what is implicit in Dewey’s moral work, virtuous characters and virtuous actions are mutually reinforcing, and can either be seen as means or ends. Some tasks involve the character of the performer and are colored by it, whereas others can be accomplished by any character who learns a technique. Attending 102 CHAPTER 4 a terminal patient, for example, is one of the former whereas deciding whether a biopsy slide indicates malignant melanoma is one of the latter. I have been contending throughout this work that clinical judgment often properly involves experience and breadth of spirit, which is why robots will never be more than adjuncts to physicians. Dewey, in Democracy and Education refers to four "traits of individual method" which are essential for teachers. The flexibility, adaptation, responsiveness to context and ability to innovate required for teachers in many unsettled situations is also needed in commonly unsettled medical settings. When we doctors exercise poor judgment, or run from responsibility by pretending that judgment is not our job, we cannot simply be taught techniques which will obviate our incapacity. Real transformation of character – the inculcation of virtues, is needed to perform this trick on us. Here again, the personality of an inquiring caregiver cannot be separated from the results of her or his endeavor. Only in those less common than assumed situations when technique alone counts, does personality fail to leave an imprint on results. I should note that this list has been greatly expanded by later writers on the topic of "epistemic virtues," and I will not argue for any particular list as being either exhaustive or entirely correct. Directness This is a character trait enabling caregivers (Dewey’s example, again, is teachers) to immerse themselves in the work. To the greatest extent possible, and obviously this increases after one becomes relatively at ease with one’s general scientific and technical competence, the caregiver needs to focus on the "doing" and not the "How am I doing? In other words, self-consciousness and performance anxiety get in between the caregiver and the goal rather than facilitating pursuit of it. In particular, a physician who is responding to the potential chart reviewer or plaintiff’s attorney is not responding directly in that measure to the needs of the patient in this particular unsatisfactory circumstance. Open mindedness One must not be too proud or sure that one knows what is going on, but must look for clues and accept them from everywhere. It is very possible that a medical student, a nurse, a nurse’s aide, or the patient’s twelve year old child will present information or come up with an idea which is crucial to the case. The attending, and especially the senior attending physician should be the most, and not the least receptive to helpful information and suggestions, whatever their source. I, myself recall taking a somewhat extended history about a critically ill infant who turned DEWEY’S VIEW OF SITUATIONS, PROBLEMS, MEANS AND ENDS103 out to have Reye Syndrome, when an office aide brought me back to reality saying, "Doctor, I think the baby is really sick. Open mindedness as Dewey describes it means we can continue to expect the expected, but not stop looking for the unexpected. Certainly, we often form hypotheses about what is occurring on the sketchiest of preliminary data and impressions, but such hypotheses should not be prematurely converted into conclusions which are proof against expanded or contrary information. Whereas we cannot purge ourselves of outside concerns, such as earning a living, getting home to our families, gaining a good reputation and taking care of our biological needs, we will not be good teachers (or nurses or doctors) if we do not feel called to do our special professional work. So some of the most important questions for a potential medical student or for a graduate nurse who is choosing a field are: "Do you feel a knack for doing this? When the answers are yes, then we can attend to our professional duties more single-mindedly. Responsibility This refers to rigorous projection of consequences and acceptance of one’s own role in producing them.

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Trisha G reenhalgh was the kind of m edical student who never let her teachers get away with a loose thought and this inquiring attitude seem s to have flowered over the years; this is a splendid and tim ely book and I wish it all the success it deserves purchase 20 mg tadalis sx amex. After all discount tadalis sx 20 mg without a prescription, the concept of evidence based m edicine is nothing m ore than the state of m ind that every clinical teacher hopes to develop in their students; D r G reenhalgh’s sceptical but constructive approach to m edical literature suggests that such a happy outcom e is possible at least once in the lifetim e of a professor of m edicine 20mg tadalis sx with mastercard. Professor Sir D avid W eatherall xi In N ovem ber 1995 buy discount tadalis sx 20 mg, m y friend Ruth H olland, book reviews editor of the British Medical Journal, suggested that I write a book to dem ystify the im portant but often inaccessible subject of evidence based m edicine. She provided invaluable com m ents on earlier drafts of the m anuscript but was tragically killed in a train crash on 8th August 1996. A handful of academ ics (including m e) were enthusiastic and had already begun running "training the trainers" courses to dissem inate what we saw as a highly logical and system atic approach to clinical practice. Others – certainly the m ajority of clinicians – were convinced that this was a passing fad that was of lim ited im portance and would never catch on. First, students on m y own courses were asking for a sim ple introduction to the principles presented in what was then known as "D ave Sackett’s big red book" (Sackett D L, H aynes RB, G uyatt G H , Tugwell P. London: Little, Brown, 1991) – an outstanding and inspirational volum e that was already in its fourth reprint, but which som e novices apparently found a hard read. Second, it was clear to m e that m any of the critics of evidence based m edicine didn’t really understand what they were dism issing and that until they did, serious debate on the political, ideological, and pedagogical place of evidence based m edicine as a discipline could not begin. I am of course delighted that How to read a paper has becom e a standard reader in m any m edical and nursing schools and has so far been translated into French, G erm an, Italian, Polish, Japanese, and Russian. I am also delighted that what was so recently a fringe subject in academ ia has been well and truly m ainstream ed in clinical service in the U K. For exam ple, it is now a contractual requirem ent for all doctors, nurses, and pharm acists to practise (and for m anagers to m anage) according to best research evidence. In the three and a half years since the first edition of this book was published, evidence based m edicine has becom e a growth industry. D ave Sackett’s big red book and Trisha G reenhalgh’s little blue book have been joined by som e 200 other textbooks and 1500 journal articles offering different angles on the 12 topics covered xiii H OW TO READ A PAPER briefly in the chapters which follow. M y biggest task in preparing this second edition has been to update and extend the reference lists to reflect the wide range of excellent m aterial now available to those who wish to go beyond the basics. N evertheless, there is clearly still room on the bookshelves for a no-frills introductory text so I have generally resisted the tem ptation to go into greater depth in these pages. Trisha G reenhalgh xiv Preface to the first edition: Do you need to read this book? This book is intended for anyone, whether m edically qualified or not, who wishes to find their way into the m edical literature, assess the scientific validity and practical relevance of the articles they find, and, where appropriate, put the results into practice. M any of the descriptions given by cynics of what evidence based m edicine is (the glorification of things that can be m easured without regard for the usefulness or accuracy of what is m easured; the uncritical acceptance of published num erical data; the preparation of all-encom passing guidelines by self-appointed "experts" who are out of touch with real m edicine; the debasem ent of clinical freedom through the im position of rigid and dogm atic clinical protocols; and the overreliance on sim plistic, inappropriate, and often incorrect econom ic analyses) are actually criticism s of what the evidence based m edicine m ovem ent is fighting against, rather than of what it represents. D o not, however, think of m e as an evangelist for the gospel according to evidence based m edicine. I believe that the science of finding, evaluating and im plem enting the results of m edical research can, and often does, m ake patient care m ore objective, m ore logical, and m ore cost effective. If I didn’t believe that, I wouldn’t spend so m uch of m y tim e teaching it and trying, as a general practitioner, to practise it. N evertheless, I believe that when applied in a vacuum (that is, in the absence of com m on sense and without regard to the individual circum stances and priorities of the xv H OW TO READ A PAPER person being offered treatm ent), the evidence based approach to patient care is a reductionist process with a real potential for harm. Finally, you should note that I am neither an epidem iologist nor a statistician but a person who reads papers and who has developed a pragm atic (and at tim es unconventional) system for testing their m erits. If you wish to pursue the epidem iological or statistical them es covered in this book, I would encourage you to m ove on to a m ore definitive text, references for which you will find at the end of each chapter. Trisha G reenhalgh xvi Acknowledgments I am not by any standards an expert on all the subjects covered in this book (in particular, I am very bad at sum s) and I am grateful to the people listed below for help along the way. I am , however, the final author of every chapter and responsibility for any inaccuracies is m ine alone.

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There are purchase 20mg tadalis sx amex, however purchase tadalis sx 20 mg fast delivery, m any situations where health professionals discount 20 mg tadalis sx, particularly those who purchase health care from real cash lim ited budgets generic tadalis sx 20mg line, m ust choose between interventions for a host of different conditions whose outcom es (such as cases of m easles prevented, increased m obility after a hip replacem ent, reduced risk of death from heart attack or likelihood of giving birth to a live baby) cannot be directly com pared with one another. Controversy surrounds not just how these com parisons should be m ade (see section 10. These essential, fascinating, and frustrating questions are beyond the scope of this book but if you are interested I would recom m end you look up the references listed at the end of this chapter. From the hospital’s point of view, the cost of m y care included m y board and lodging for five days, a proportion of doctors’ and nurses’ tim e, drugs and dressings, and investigations (blood tests and a scan). I was off work for three weeks and m y dom estic duties were tem porarily divided between various friends, neighbours, and a nice young girl from a nanny agency. And, from m y point of view, there were several intangible costs, such as discom fort, loss of 153 H OW TO READ A PAPER independence, the allergic rash I developed on the m edication, and the cosm etically unsightly scar which I now carry on m y abdom en. On the benefit side, the operation greatly increased m y chances of staying alive. In addition, I had a nice rest from work and, to be honest, I rather enjoyed all the attention and sym pathy. I would be less likely to brag about m y experience if m y hospital adm ission had been precipitated by, say, an epileptic fit or a nervous breakdown, which have negative social stigm ata. Avoidance of hospital adm ission Investigations Return to paid work Staff salaries Indirect Clinical W ork days lost Postponem ent of death or disability Value of "unpaid" Relief of pain, nausea, breathlessness, etc. Intangible Quality of life Pain and suffering Increased m obility and independence Social stigm a Im proved wellbeing Release from sick role In the appendicitis exam ple, few patients (and even fewer purchasers) would perceive m uch freedom of choice in deciding to opt for the operation. But m ost health interventions do not concern definitive procedures for acutely life threatening diseases. M ost of us can count on developing at least one chronic, disabling, and progressive condition such as ischaem ic heart disease, high blood pressure, arthritis, chronic bronchitis, cancer, rheum atism , prostatic hypertrophy or diabetes. At som e stage, alm ost all of us will be forced to decide whether having a routine operation, taking a particular drug or m aking a com prom ise in our lifestyle (reducing our alcohol intake or sticking to a low-fat diet) is "worth it". But when the choices are about other people’s care, subjective judgem ents are the last thing that should enter the equation. M ost of us would want the planners and policym akers to use objective, explicit, and defensible criteria when m aking decisions such as "N o, M rs Brown m ay not have a kidney transplant". A num ber of questionnaires have been developed which attem pt to m easure overall health status, such as the N ottingham H ealth Profile, the SF-36 general health questionnaire (widely used in the U K) and the M cM aster H ealth U tilities Index Questionnaire (popular in N orth Am erica). For exam ple, answering "yes" to the question "D o you get very concerned about the food you are eating? Of course, when quality of life is being analysed from the point of view of the patient, this is a sensible and hum ane approach. H owever, the health econom ist tends to m ake decisions about groups of patients or populations, in which case patient specific, and even disease specific, m easures of quality of life have lim ited relevance. If you would like to get up to speed in the ongoing debate on how to m easure health related quality of life, take tim e to look up som e of the references listed at the end of this chapter. For this reason, you should be highly suspicious of a paper which 155 H OW TO READ A PAPER eschews these standard instrum ents in favour of the authors’ own rough and ready scale ("Functional ability was classified as good, m oderate or poor according to the clinician’s overall im pression" or "W e asked patients to score both their pain and their overall energy level from one to ten, and added the results together"). N ote also that even instrum ents which have apparently been well validated often do not stand up to rigorous evaluation of their psychom etric validity. The odds are then varied to see at what point the respondent decides the gam ble is not worth taking. The quality adjusted life year or QALY can be calculated by m ultiplying the preference value for that state with the tim e the patient is likely to spend in that state. The results of cost benefit analyses are usually expressed in term s of "cost per QALY", som e exam ples of which are shown in Box 10. Any m easure of health state preference values is, at best, a reflection of the preferences and prejudices of the individuals who contributed 156 PAPERS TH AT TELL YOU W H AT TH IN G S COST Box 10. Indeed, it is possible to com e up with different values for QALYs depending on how the questions from which health state preference values are derived were posed. Furtherm ore, QALYs distort our ethical instincts by focusing our m inds on life years rather than people’s lives. A disabled prem ature infant in need of an intensive care cot will, argues H arris, be allocated m ore resources than it deserves in com parison with a 50 year old wom an with cancer, since the infant, were it to survive, would have so m any m ore life years to quality adjust. Som e of the ones that were in vogue when this book went to press include the following.

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Guidelines for recombinant human growth hormone on donor-site the prevention of surgical site infection order 20mg tadalis sx, 1999 discount tadalis sx 20mg line. Growth preoperative bowel preparation among North American hormone treatment for burned children 20 mg tadalis sx visa. New York: tomy and nephrouretectomy in the octogenarian and Springer-Verlag; 2000;331–342:1021–1035 cheap tadalis sx 20 mg otc. Long Term Care Survey showed the overall prevalence Disability is a common problem among older of disability (21. Kunkel and Applebaum estimated that by However, the rate of disability in individuals increases the year 2020, between 9. In 1995, among noninstitutionalized will have moderate to severe disability, an increase of persons over the age of 70, 32% had difficulty perform- 85% to 167% over current levels. By enhancing the person’s functional abilities, limitations increase with age and are more prevalent in the impact of a disability can be lessened. Most elderly patients with disability tion shifts from a goal of returning the patient to gainful require assistance from family members or special com- employment to helping the older person live more inde- munity services. This type of care can be provided in any health ties of daily living (ADLs) impaired], either personal care setting, including the home, office, acute or rehabil- assistance only or equipment use only appeared insuffi- itation hospital, and long-term care facility. Rehabilitation is a philosophic approach to the patient Definitions of Disability that recognizes that improvement in functional abilities is an important goal of medicine, that having a disability The World Health Organization’s classification system is does not diminish one’s social worth, and that the psy- useful when discussing geriatric rehabilitation11 (Table chosocial aspects of care are at least as important as its 23. Rehabilitation is an essential component that may or may not be evident clinically. Impairment of quality geriatric care that should be available to all refers to alterations of function at the organ level. A study of attitudes and knowl- • Disability—a restriction or lack of ability to perform an activity in a normal manner, a disturbance in the performance of daily tasks edge of a large sample of policy makers in the federal and • Handicap—a disadvantage resulting from impairment or disability state governments indicated that comprehensive rehabil- that limits or prevents fulfillment of a role that is normal itation programs were widely unavailable because few of these officials considered it a priority need. Rehabilitation Principles These declinations, however, may not affect the person’s ability to perform daily activities. An impairment severe Components of Rehabilitation enough to affect the person’s daily functioning is a Rehabilitation comprises a number of components of disability. Each of these compo- appropriate rehabilitation training and have adapted to nents requires special attention in geriatric patients. With the change in functional status, they often can be fully older persons, it is not always possible to completely independent. Furthermore, there often rehabilitation interventions or services because of age, is more than one "primary problem. Therefore, by this with a recent amputation may have underlying cardiac definition, there are no handicapped persons; there are disease, diabetes, and mild renal failure, necessitating only handicapping societies. Unfortunately, there is evi- close supervision by the geriatric provider during an dence that such factors as race and hospital size can affect inpatient rehabilitation stay. He also may be more prone whether older people receive rehabilitation interven- 12 to secondary complications than a younger person. Although this chapter is devoted to the problems venting such complications is crucial in geriatric popula- of aged persons with a disability, the sociopolitical impli- tions because of the remarkable ease with which such cations of rehabilitation must not be forgotten. Secondary complications are frequently seen in older patients, in- cluding such conditions as falls, pressure sores, deep Demographics of Disability venous thrombosis, contractures, deconditioning, malnu- trition, incontinence, family discord, and depression. A large percentage of persons with a disability are These complications also disproportionately affect elderly. Decreased subcutaneous fat, poor capil- are beneficial disproportionately affect the elderly popu- lary function, and low blood volumes increase the risk of lation. Besides adding great costs to older persons and the most common cause of disability. The average 80-year-old white woman has a 15 exercise may then increase the risk of other secondary 1% to 2% risk of hip fracture per year. Most amputa- 16 complications, such as deconditioning or psychologic tions are performed in the geriatric age group.

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