By T. Tizgar. Chaminade University of Honolulu, Hawaii. 2019.

In the 2007 National Physician Survey cheap vardenafil 20 mg overnight delivery, 80 per cent of physi- What is the solution in the workplace? Wilkerson puts it this cians indicated that the complexity of their patient caseload as way: “The solution is the cornerstone of good old-fashioned the biggest factor affecting their time buy cheap vardenafil 20 mg online. Given an ever-increasing management, which is based on human decency, clear think- proportion of our aging population is affected by chronic dis- ing, open communications. The other cornerstone is clarity of ease and comorbidities, the average physician’s workload will purpose and function. CanadianMedicalAssociation Of the medical students who responded to the 2007 National Launches First Check-up of Doctors’ Health. Society grants physicians status, respect, autonomy in practice, ability to self-regulate and fnan- cial compensation. In return, society has high expectations of Case physicians, including competence, altruism, ethical behaviour A physician is ill and chooses to take a day off from his and the delivery of a high standard of care. A number of patient visits are professional role physicians must make their patients’ well- rescheduled, and students and residents are assigned to being their frst priority, this commitment must include a caveat other supervisors. Physicians should bear in mind the advice ents the following week but begins the clinical encounter given to airline passengers in case of a depressurization: put by expressing dissatisfaction, anger and frustration that on one’s own oxygen mask before assisting others. We must the postponement of the appointment resulted in losing maintain our own health in order to be ft to care for society. The physician feels regretful and guilty at having taken the day off, but at the same time is frustrated by the patient’s demanding tone. Refection for educators At the beginning of your residents’ rotation, have them keep a journal of the challenges they encounter with Introduction respect to meeting the expectations of their patients and Society is quite aware of basic lifestyle choices that promote maintaining their own health. You may wish to provide good health, such as maintaining a healthy diet, exercising your own example of challenges you have experienced. In regularly, avoiding smoking and street drugs, and limiting addition, you can keep your own journal of such physician alcohol use. Most Canadians also recognize the importance of health challenges and have a formal discussion half-way working with their primary care physician for health concerns, through the rotation on how you and your residents dealt follow-up and appropriate screening at different stages of life. At their regular evaluation However, how often do patients consider the health needs of meetings program directors can discuss with residents the their own doctors? The journal will provide clear examples of how the residents understand Healthy physician, healthy patient the key issue. Residents may also consider incorporating Some patients infuence the mental health of their physicians such discussions into their half-day educational sessions by virtue of challenging personality traits, the denial of their or at their regular retreats. Physicians may choose to prescribe unneces- sary antibiotics for a viral illness to pacify the expectations of a patient who wants a quick resolution of their ailment. However, while these physicians are well aware of the lack of effcacy of antibiotics in these situations and the potential to promote new strains of resistant bacteria, they may feel they lack the time or energy to go through the process of proper patient education. The evolution of medicine into the computer era has also contributed to the complexity of the physician–patient relationship where physician health is concerned. Although one rarely hears of a house calls nowadays, e-mail is today’s equivalent of yesterday’s housecall. Patients can now follow doctors home, on vacation, or literally anywhere technology may go. What about the concept that patients need to be seen in person for a physician to make clinically informed deci- sions about their care? Today’s society expects medicine to be a convenient service, similar to the fast-food industry—which likely contributed to the development of the walk-in clinic. The patient appreciates the bedside: social expectations and value triage in medical practice. Many of these elements can readily contribute acknowledge that individual physicians have an opportunity to personal health and sustainability. Thus, in the last chapter to identify and develop their skills in a several critical areas, of this section, readers are encouraged to consider practical namely personal awareness (described as values, beliefs and suggestions to guide the development of their own leadership knowledge), refective practice, emotional intelligence and skills. Emerging evidence suggests that the development readers can readily access to enhance their understanding and of skills in each of these areas is associated with improved practise of leadership. There is no doubt that many other facets of health and sus- Personal awareness tainability are of relevance to physicians. Starting with the perspective of search for information and practical ways to move forward Mahatma Gandhi, it considers what is meant by “values,” “be- with your own personal health and professional sustainability liefs” and “knowledge. Through exercises and refec- Key references tion, readers will have an opportunity to consider how best www. Interactive and practical, it includes sections on relationships, depression and anxiety, resiliency, substance Refective practice use, personal care and many other issues. Other professions and disciplines have long valued self- assessment, critical appraisal of the self, and introspection.

No one expects the clinician to always immediately come up with the correct diagnosis of a rare presentation or a rare disease purchase vardenafil 10 mg with visa. However order vardenafil 10 mg, the key to good diagnosis is recogniz- ing when a patient’s presentation or response to therapy is not following the pattern that was expected, and revisiting the differential diagnosis when this occurs. Premature closure of the differential diagnosis can be avoided by following two simple rules. The first is to always include a healthy list of possibilities in the dif- ferential diagnosis for any patient. When one finds oneself commonly diagnosing a patient within the first few minutes of initiating the history, step back and look for other clues that could dismiss one diagnosis and add other diagnoses to the list. Then ask one- self whether those other diseases can be excluded simply through the history 232 Essential Evidence-Based Medicine and physical examination. Since most common diseases do occur commonly, the disease that was first thought of will often turn out to be correct. However, it is more likely to miss important clues of the presence of another less common disease if a physician focuses only on that first diagnosis. The second step is to avoid modifying the final list until all the relevant infor- mation has been collected. After completing the history, make a detailed and objective list of all the diseases for consideration and determine their relative probabilities. The formal application of such a list will be invaluable for the novice student and resident, and will be done in a less and less formal way by the expert. Antoine de Saint-Exupery (1900–1944):´ The Little Prince Learning objectives In this chapter you will learn: r the measures of precision in clinical decision making r how to identify potential causes of clinical disagreement and inaccuracy in the clinical examination r strategies for preventing error in the clinical encounter The clinical encounter between doctor and patient is the beginning of the med- ical decision making process. During the clinical encounter, the physician has the opportunity to gather the most accurate information about the nature of the illness and the meaning of that illness to the patient. If there are errors made in processing this information, the resulting decisions may not be in the patient’s best interests. This can lead to overuse, underuse, or misuse of therapies and increased error in medical practice. Measuring clinical consistency Precision is the extent to which multiple examinations of the same patient agree with one another. In addition, each part of the examination should be accurately reproducible by a second examiner. Accuracy is the proximity of a given clin- ical observation to the true clinical state. The synthesis of all the clinical find- ings should represent the actual clinical or pathophysiological derangement pos- sessed by the patient. In this example, different observers can obtain different results when they mea- sure the temperature of a child using a thermometer because they use slightly different techniques such as varying the time that the thermometer is left in the patient or reading the mercury level differently. The kappa statistic is a statistical measurement of the precision of a clinical finding and measures inter-observer consistency between measurements and intra-observer consistency, the abil- ity of the same observer to reproduce a measurement. The kappa statistic is described in detail in Chapter 7 and should be calculated and reported in any study of the usefulness of a diagnostic test. Many studies have demonstrated that most non-automated tests have some some degree of sub- jectivity in their interpretation. It is also present in tests com- monly considered to be the gold standard such as the interpretation of tissue samples from biopsies or surgery. There are many potential sources of error and clinical disagreement in the pro- cess of the clinical examination. A broad classification of these sources of error includes the examiner, the examinee, and the environment. The examiner Tendencies to record inference rather than evidence The examiner should record actual findings including both the subjective ones reported by the patient and objective ones detected by the physician’s senses. The physician should not make assumptions about the meaning of exam find- ings prior to creating a complete differential diagnosis. For example, a physician examining a patient’s abdomen may feel a mass in the right upper quadrant and record that he or she felt the gall bladder. This may be incorrect, and in fact the mass could be a liver cancer, aneurysm, or hernia. Ensnarement by diagnostic classification schemes Jumping to conclusions about the nature of the diagnosis based on an incorrect coding scheme can lead to the wrong diagnosis through premature closure of the differential diagnosis. If a physician hears wheezes in the lungs and assumes that the patient has asthma when in fact they have congestive heart failure, there Sources of error in the clinical encounter 235 will be a serious error in diagnosis and lead to incorrect treatment. The diagnosis of heart failure can be made from other features of the history and clues in the physical exam. Entrapment by prior expectation Jumping to conclusions about the diagnosis based upon a first impression of the chief complaint can lead to the wrong diagnosis due to lack of consideration of other diagnoses. This, along with incorrect coding schemes, is called premature closure of the differential diagnosis, and discussed in Chapter 20. If a physician examines a patient who presents with a sore throat, fever, aches, nasal conges- tion, and cough and thinks it is a cold, he or she may miss hearing wheezes in the lungs by only doing a cursory examination of the chest. This occurs because the physician didn’t expect the wheezes to be present in a cold, but in fact, the patient may have acute bronchitis which will present with wheezing.

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When done promptly buy 10 mg vardenafil with visa, cancer may be detected at a potentially curable stage generic vardenafil 20 mg visa, improving survival and quality of life. There are three steps to early diagnosis: • Step 1: awareness of cancer symptoms and accessing care; • Step 2: clinical evaluation, diagnosis and staging; and • Step 3: access to treatment, including pain relief. Screening differs from early diagnosis in that an entire target popula- tion is evaluated for unrecognized cancer or precancer and the majority of individuals tested will not have the tested disease (Figure 2). Distinguishing screening from early diagnosis according to symptom onset symptom onset Healthy abnormal Pre-invasive invasive cancer death cells cells cancer cancer spread screening early diagnosis service provided for a target population service provided only for people with symptoms Screening should be viewed as a process not as administering a particular test, exam- ination or procedure. The screening process includes a system of informing and inviting the target population to participate; administering the screening test; follow- ing-up with test results and referral for further testing among those with abnormal test results; and ensuring timely pathologic diagnosis, staging and access to effective treatment with routine evaluation to improve the process (Table 1) (10). A screening programme encompasses the process from invitation to treatment and requires plan- ning, coordination and monitoring and evaluation. When discussing the availability and/or use of a testing modality for early diagnosis and screening, it is important to distinguish its use as a diagnostic test (early diagnosis) or as a screening test. For example, for a patient who has developed a breast lump, a mammogram functions as a diagnostic test in cancer early diagnosis. Alternatively, mammography might be used as part of a breast cancer screening programme for a target population who generally do not have symptoms. An evidence-informed assessment of current capacity and potential harms versus benefts must be performed before introducing or scaling a programme for cancer early diagnosis or screening. Guide to cancer early diaGnosis | 9 Table 1. When linked to treatment reduction in cervical and colorectal cancers) mortality generally evident in three to reduction in stage of disease at diagnosis in target fve years population (generally earlier stage than early diagnosis) reduction in mortality when screening delivered effectively and linked to treatment, but not for many years (often >10 years) Potential for harm low: testing limited to only those who Potentially high as test applied to an entire target have signs and symptoms populationb Generally, most who screen positive will not have cancer or precancerous abnormalities, but require additional tests and procedures that can potentially lead to complications, psychological distress and utilization of resources some may be overdiagnosed and overtreated Applicability and current accepted core component of health Benefts documented in high-resource settings for scientifc evidence services to improve timely diagnosis limited number of cancers (e. For example, given the resource requirements and complexities, breast cancer screening with mammography is not recom- mended in countries with weak health systems (11). Ensuring that there is suffcient capacity for early diag- nosis and treatment is critical before planning to initiate or expand screening services. This approach allows for maximal effciency and greater equity in services, provid- ing access to care for individuals with cancer, particularly in low-resource settings. Additionally, barriers to early diagnosis are generally analogous to those in the cancer screening process and include limited access to diagnostic tests and pathology; poor follow-up and coordination; inaccessible high-quality, timely treatment; and fnan- cial obstacles. Policies and programmes to overcome these barriers should focus on improving early diagnosis, prior to implementing cancer screening when possible. The assessment can include effectiveness and costs of current cancer control strategies, current population coverage of services, obstacles to care including delays, fnancial protection and quality of care. Wherever possible, data should be analysed by sex, geographic location, ethnicity and socioeconomic status to identify inequities that can be redressed when planning and allocating resources. The situation analysis can identify gaps in services and inform policy decisions based on accurate resource availability (12). If current capacity for early diagnosis is limited, then prioritizing cancer screening will generally not be impactful (Figure 3). The overall status of early diagnosis and screening programmes can be assessed in the distribution Figure 3. Planning early diagnosis and screening according to current capacity Perform situation analysis of existing cancer services Early diagnosis capacity limited Early diagnosis capacity limited Early diagnosis capacity strong Screening absent Unorganized or ineffective screening present Unorganized or ineffective screening present • Provide basic diagnostic tests and treatment • Focus on early diagnosis capacity • devise programme to strengthen screening • Focus on early diagnosis capacity • reduce delays in care services focusing on regions with demonstra- • improve awareness • improve coordination between health facilities tion projects • ensure prompt diagnosis and referral • consider limiting screening activities to one • Focus on meeting criteria for organized demonstration project or stopping screening screening and high participation rates • consider focus on cervical cancer screening depending on burden and resource availability Note: Countries with weak health systems or low resources are likely to have limited early diagnosis capacity and absent or ineffective national screening programmes. Guide to cancer early diaGnosis | 11 of cancer stage at diagnosis and trends over time. For example, a region that has high incidence rates of advanced cancers is likely to have limited early diagnosis capacity. In the United Kingdom of Great Britain and Northern Ireland, over 50% of the decrease in breast cancer mortality in women under age 65 was due to improved early diagnosis and the provision of effective treat- ment (14). Similar improvements in breast cancer mortality were seen in other countries prior to the introduction of screening because of improved early diagnosis (Figure 4) (15). It is also well established that reducing delays in care can have a signifcant impact on improving outcomes. In one study, patients who experienced a short delay (<3 months) experienced an absolute 7% greater likelihood of survival from breast cancer compared with those who had moderate delays (3–6 months) in care (16,17). This magnitude in survival beneft was similar or greater than the beneft achieved by chemotherapy (16). While improving early diagnosis generally improves outcomes, not all cancer types beneft equally. Cancers that are common, that can be diagnosed at early stages from signs and symptoms and for which early treatment is known to improve the outcome are generally those that beneft most from early diagnosis (5). A high mortality-to-incidence ratio is a general estimate that a high proportion of people diag- nosed with cancer are dying from it. Before the introduction of mammography and adjuvant therapy, there was a signifcant improvement in breast cancer survival due to early diagnosis. These steps correspond with the standard patient-initiated health-seeking pathway across diseases: awareness and health-seeking, diagnosis and initiating treatment. While various terms have been used to describe the early diagnosis steps, consistent terminology is important to com- municate fndings and promote standards across different settings (Table 2) (18–21).

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She had crawled painfully out of bed with her grandmother’s help and been sitting crying in a wheelchair for half an hour cheap 20 mg vardenafil overnight delivery, with nothing to support her swollen leg vardenafil 10mg on line, before the news came. Virtual teams – such as specialists linked to gen- eral practitioners by telephone – are increasingly common in rural or remote settings. Ministries of health should work with ministries of education and professional societies to ensure that the health workforce is taught the right skills to prepare them adequately for chronic disease prevention and management. Continuing professional education allows the health workforce to develop skills after completion of training. Educational activities include courses, on-site follow-up and coaching, and regular assessments and feedback on progress. Medical, nursing and other health professional societies are valuable partners in the provision of continuing medical education. The stepwise » The private sector is a natural partner in chronic disease framework initiated by prevention and control governments can be best » Civil society plays a role that is implemented by working distinct from that of governments with some or all of the and the private sector, and adds private sector, civil soci- human and financial resources to a wide range of chronic disease ety and international or- prevention and control issues ganizations. This chapter » International organizations and outlines the ways in which donors have important roles to such cooperation can be play in the response to chronic disease put into practice. They offer all sectors new opportunities to work together in order to advance the greater public good. In order to be as effective as possible, they should work within the overall framework for prevention and control determined by the government (see previous chapter). Working in partnership ensures synergies, avoids overlapping and duplication of activities, and prevents unnecessary or wasteful competition. The partnership has recently released a strategic framework for are implemented with the full agreement of all action, and work is under way on parties. Developing and managing a successful partnership Transparent linkages are being requires an appropriate organizational structure. Possibilities for partnerships with pharmaceutical companies are also being explored (8). It to improve health in the Americas by reducing risk factors aims to create a dynamic inter- for chronic diseases. The main focus has been primary pre- national forum where health- vention of risk factors such as tobacco use, poor diet and care providers, researchers, physical inactivity. The research as well as clinical and network serves as a forum for advocacy, knowledge dis- public health information, thus semination and management, and technical support and as ensuring the high scientific an arena where directions, innovations and plans are made quality of the discussion (for for continuous improvement of chronic disease prevention more information see http:// initiatives in the Americas. Most adults spend a significant portion of their time in a work environment and are often surrounded by peers who may influence their behaviour and attitudes. Mobility India created the tems kept clean and tobacco- Millennium Building on Disability – the Mobility India free, assistive devices installed, Rehabilitation Research & Training Centre – as a model and physical activity promoted. The building is or if more resources are avail- friendly to all types of disabilities, and 40% of the staff able, employers can move on to have a disability. Braille signs; tile floors with varied surfaces to guide people with visual impairments; accessible bathrooms, switchboards, and washbasins; a lift with auditory sig- nals and an extra-sensitive door sensor; adequate and earmarked parking spaces; highly accessible hallways and workspaces with furniture kept in unchanged loca- tions; and contrasting colour schemes and natural light for people with low vision. The fact that Mobility India staff with personal experi- ence of disabilities and chronic conditions are working in an accessible building has created a productive environ- ment in which to work with confidence and dignity (9). The success of the Mectizan® (ivermectin) to prevent Mectizan® donation programme (see spotlight, onchocerciasis, or river blindness, in left) is one example of such a programme. In 1987, it decided to donate as much as is needed to every- one who needs it for as long as it takes to eliminate the disease worldwide. Mectizan® cannot restore lost sight but if it is taken early enough, it protects remaining vision. It kills the larvae responsible, and elimi- nates itching and damage to the eyes with just one dose per year, although infected people need to take Mectizan® for around 20 years. The Mectizan® donation programme has been a highly effective public health programme and serves as a possible model for tackling some future problems in international health. The private sector has a significant role to play in closing these gaps, as do public–private partnerships, which can invest strategically to accel- erate progress with regard to specific diseases. Current annual produc- Alternatives to insulin delivery tion of hearing aids provides approximately 33% of those technologies, such as nasal needed in high income countries, but less than 3% of those sprays, could reduce the need needed in low and middle income countries. Afford- reluctant to provide affordable hearing aids on a large able hearing aids (see spotlight, scale because of their perceived lack of a sustainable left) are another public health market, and the lack of infrastructure to provide them. Providing appropriate and affordable hearing aids and services worldwide would be a highly effective and cost- effective way to make a positive impact. Sustainable provision on a sufficiently large scale in low and middle income countries would also be crucial in terms of improv- ing equity and access. The guidelines state that public–private partnerships between the governments of developing countries and hearing aid manufacturers are necessary. All signatory food producers, dis- to the food and drink industries tributors, retailers, marketers, advertisers and media out- include the following: lets have acknowledged or publicized the fact that obesity is a major risk to public health, that the food industry has a limit the levels of saturated role to play in tackling obesity, and that they will meet key fats, trans-fatty acids, free objectives, such those aimed at reducing obesity, improv- sugars and salt in existing ing nutrition, and increasing physical activity. Actions and products; commitments resulting from the Food Industry Accord are continue to develop and being independently evaluated (10). Many companies have already made some modifications to product composition by lowering portion sizes and altering contents. Some have introduced low/reduced fat and low salt products, as well as offering fruit and salads in fast food outlets.

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