By H. Milok. Lee College.
Policy responses at the first level were ‘aimed at strengthening individuals in disadvantaged circumstances buy serophene 50 mg on-line breast cancer walk nyc, employing person- based strategies’ (Benzeval et al generic serophene 25mg overnight delivery breast cancer merchandise. Examples provided included ‘stress management education for people working in monotonous conditions, counselling services for people who become unemployed to help prevent the associated decline in mental health and supportive smoking cessation clinics for women with low incomes’. According to David Wainwright’s perceptive critique of this report, ‘the objection should not be that such initiatives blame the individual, but that they reinforce his/her low expectations concerning social change’ (Wainright 1996). Furthermore, ‘by encouraging the individual to adapt to adverse conditions, to be a “survivor”, such initiatives reinforce the belief that any form of social action is unlikely to succeed, that one should just accept one’s alienation’. He challenged the notion that using such ‘cheap psychological tricks’ could contribute to ‘empowerment’, observing that the ‘colonisation of the individual’s life-world’ involved in these schemes was the ‘ultimate in disempowerment’. Policies aimed at the level of the community were ‘focused on how people in disadvantaged communities can join together for mutual support and in so doing strengthen the whole community’s defence against health hazards’ (Benzeval et al. The first three targets proposed for community mobilisation were as follows: • social control of illegal activity and substance abuse; • socialisation of the young as participating members of a community; • limiting the duration and intensity of youthful ‘experimentation’ with dangerous and destructive activity 94 THE POLITICS OF HEALTH PROMOTION Though it is not at all clear how such initiatives would reduce health inequalities, the attempt to use policies presented in the guise of health promotion as a means of social control is obvious. Tackling health inequalities has become redefined as community policing to deal with problems of drugs, crime and even youthful exuberance (now known as ‘anti-social behaviour’). The authors’ statement that ‘these policies recognise the importance to society of social cohesion, as well as the need to create the conditions in deprived neighbourhoods for community dynamics to work’ provides considerable insight into their own preoccupations (which are no doubt widely shared in the medical and political establishments). Since the election of New Labour to government and the elevation of health inequalities and social exclusion to the centre of policy, interventions targeted at individuals and communities of the sort earlier promoted by the Kings Fund have become commonplace. In an updated set of recommendations, Michaela Benzeval and her colleagues suggested, as one example of an initiative to combat health inequalities, ‘home visiting by health visitors, GPs and trained community peers to reinforce preventive health measures’ (Benzeval, Donald 1999:94). Confiscate cigarettes, count up household alcohol units and dispose of any excess to basic weekly requirements, inspect the fridge for high fat foods and confiscate cream buns, organise a brisk jog around the block? The activities of the Social Exclusion Unit around issues like homelessness and teenage pregnancy do nothing to reduce inequality, but aim to foster a therapeutic relationship between the state and recipients of welfare benefits. Programmes like Sure Start, which aims to promote the parenting skills of young families also aim to provide new points of contact between isolated individuals and the state. Meanwhile the activities of health action zones and healthy living centres also aim to foster the social cohesion for which New Labour yearns. Under the banner of health inequalities New Labour has turned health promotion into a sophisticated instrument for the regulation, not only of individual behaviour, but that of whole communities. The treatment of drug addicts is one example of this trend, which is leading to a transformation in the nature of medical practice as GPs take on some of the concerns of the criminal justice system. The expanding scope of general practice extends into the field of mental health, a territory that has itself expanded through the annexation of more and more areas of personality and behaviour under psychiatric disease labels. We focus here on the expansion of the concept of addiction and at the way this has contributed to the growing medicalisation of society. We look finally at the treatment of these problems in general practice, through counselling and medication and at the consequences of these developments for both doctors and patients. Drug squad general practice In the 1980s and early 1990s I gained some experience in the medical approach to treatment of drug addiction in general practice. The occasional heroin user would turn up, usually in a stereotypically ‘strung-out’ condition, saying that they wanted to come off drugs and asking for a prescription for methadone. Following the approach recommended in various text-books and official publications, I would try to assess their motivation to get off drugs and if this seemed positive, I would agree to prescribe methadone and refer them to the drug dependency unit at the local hospital, for specialist counselling (Advisory Council on the Misuse of Drugs, 1982, 1984). I would work out how much heroin they were using and calculate the appropriate dose of methadone and negotiate 96 THE EXPANSION OF HEALTH a programme of withdrawal over a period of weeks or months, according to what appeared realistic. We would then arrange to meet weekly to renew prescriptions and review progress. My experience of this technique over several years was of approximately 100 per cent failure. Sometimes the withdrawal programme appeared to be going well for while, but then things would start to fall apart. Sometimes the patient simply disappeared, only to return months later, even more strung-out, wanting to start the whole process again. Sometimes they would turn up, invariably late and often in an agitated state, with a variety of explanations often of remarkable ingenuity, which all culminated in a demand, more or less aggressively delivered, for further prescriptions of methadone or other medications. Sometimes they would reach the end of the withdrawal phase and simply request to continue on a substantial dose of methadone into the indefinite future. Reflecting on this experience, I recognised two fundamental problems with the substitute medication approach, one relating to motivation, the other to addiction.
Frank Stinchﬁeld’s memory is immortal- in the care of wounded ex-servicemen purchase serophene 100 mg mastercard womens health 33511, and during ized in his contributions to orthopedics and medi- the Second World War was orthopedic surgeon to cine cheap serophene 50mg with mastercard pregnancy 5 weeks 4 days. He gained a Blue for orthopedic community owes much of its infor- hockey and was always interested in sport. Woe mation and advancements to his commitment and betide his house surgeon if he could not immedi- talent. His family, students, and patients owe ately give him on arrival at a hospital the latest much of their hope, passion, knowledge, and best score in the current Test series. He was a man of the mountains and the outdoors, and the Cuillin of Skye was his haven for many years, but he loved all Scotland. Traveling with him anywhere in Britain, but particularly in Scot- land, was fascinating, for one was regaled with endless tales and legends of the country traveled through. He used to read far into the night and the diversity and extent of his reading was extraordinary. The two men were in many ways similar and Stirling acquired an admiration and devotion for his chief. In 1929 he was awarded a 325 Who’s Who in Orthopedics Traveling Fellowship of the English College of One of Stirling’s earliest appointments was that Surgeons, which allowed him to visit the United of surgeon in charge of accident services in Fife, States, Canada and Europe. To his dismay, the occa- met many orthopedic surgeons and developed a sion was never to come. For the sick, his time and special and long-lasting friendship with Steindler patience were endless. No one was ever turned away Back in Edinburgh, he was appointed an assis- from his clinics; in consequence these were very tant surgeon to the Royal Hospital for Sick prolonged. The last ferry from Fife to Edinburgh Children and began an association with W. Cochrane had an immense enthusiasm returned to the quay when his well known car for the care of the crippled child. He had was to become the Princess Margaret Rose the capacity for a great, continuing but quiet hap- Orthopaedic Hospital were already on the piness. The concept conceived by Robert Some of his happiest times were spent with the Jones and developed at Oswestry was to be Monks of St. The orthopedic hospital is on the dines in monks’ habit on beer and sausages, regal- edge of the city, surrounded by trees, facing south ing each other with tales and humorous verse. He over the Pentland Hills, and is perhaps the loveli- was in all ways a gentle man, aware of the human est site of any orthopedic hospital in Britain. It dignity of his patients, even the most fractious or has now grown to nearly 300 beds. In his early years he wrote a book of though a traditionalist and conservative to the fairy stories. In Wyn he of orthopedics, if one could argue to his satisfac- found a completion to his life, a fulﬁlment of his tion that it was necessary. He had seemed a conﬁrmed bachelor; was held by his colleagues was reﬂected in his in reality he was an idealist who was prepared to election as vice president of the British Orthope- wait. Having all his life per- leagues tirelessly traveled over the many counties suaded the crippled that disablement was not a brought into their ambit. At one time, 95 clinics disability, as one might expect, he learned to walk were in being in southern Scotland. He became a appearance of tuberculosis, poliomyelitis, rickets nimble septuagenarian, drove his car, became an and many other crippling diseases of children and enthusiastic gardener and attended public dinners. Derick Strange was an articulate and enthusi- astic teacher, an original thinker rather than a regurgitator of the views of others. His initiative resulted in the beginning of postgraduate teach- ing at the Kent and Canterbury Hospital and the eventual opening of the Kent Postgraduate Medical Centre. His most important contribution to the devel- opment of orthopedic surgery was probably the publication, in 1965, of his monograph entitled The Hip. It ran to only 284 pages, but Norman Capener, in his review of it in The Journal of Bone and Joint Surgery, said that “in a special way, this book... Clair Strange’s ability to convey complex ideas simply by his own drawings. He was a member of the STRANGE original group of ABC Traveling Fellows, and, at 1911–2002 86 years of age, published The History of the ABC Club of Traveling Fellows.
Curriculum design standard” in curriculum design proceeds by working “backwards” from outcomes to the other elements (content; teaching and learning experiences; assessment; and evaluation) discount serophene 25mg mastercard menstruation tissue. The use of outcomes is becoming more popular in medical education cheap serophene 25 mg otc menopause 8 months no period, and this has the important effect of focusing curriculum designers on what the students will do rather than Desired what the staff do. Care should be taken, however, to focus only outcomes (students Content • Teaching Assessment Evaluation on “significant and enduring” outcomes. An exclusive concern • Learning will be with specific competencies or precisely defined knowledge and able to... Although debate may continue about the precise form of these statements of intent (as they are known), they constitute Outcomes based curriculum (defining a curriculum “backwards”—that is, an important element of curriculum design. It is now well from the starting point of desired outcomes) accepted that curriculum designers will include statements of intent in the form of both broad curriculum aims and more specific objectives in their plans. Alternatively, intent may be Example of statements of intent expressed in terms of broad and specific curriculum outcomes. Aim The essential function of these statements is to require x To produce graduates with knowledge and skills for treating curriculum designers to consider clearly the purposes of what common medical conditions they do in terms of the effects and impact on students. Objectives x To identify the mechanisms underlying common diseases of the circulatory system Descriptive models x To develop skills in history taking for diseases of the circulatory system An enduring example of a descriptive model is the situational Broad outcome model advocated by Malcolm Skilbeck, which emphasises the x Graduates will attain knowledge and skills for treating common importance of situation or context in curriculum design. In this medical conditions x Students will identify the mechanisms underlying common diseases model, curriculum designers thoroughly and systematically of the circulatory system analyse the situation in which they work for its effect on what x Students will acquire skills in history taking for diseases of the they do in the curriculum. The impact of both external and circulatory system internal factors is assessed and the implications for the curriculum are determined. Although all steps in the situational model (including situational analysis) need to be completed, they do not need to Situational analysis* be followed in any particular order. Curriculum design could begin with a thorough analysis of the situation of the External factors Internal factors x Societal expectations and x Students curriculum or the aims, objectives, or outcomes to be achieved, changes x Teachers but it could also start from, or be motivated by, a review of x Expectations of employers x Institutional ethos and content, a revision of assessment, or a thorough consideration x Community assumptions structure of evaluation data. What is possible in curriculum design and values x Existing resources depends heavily on the context in which the process takes x Nature of subject x Problems and place. They are x Nature of support systems curriculum x Expected flow of resources not separate steps. Content should follow from clear statements of intent and must be derived from considering external and *From Reynolds J, Skilbeck M. But equally, content must be delivered by 6 Curriculum design appropriate teaching and learning methods and assessed by relevant tools. No one element—for example, assessment— Situational should be decided without considering the other elements. They also display the essential features of the curriculum in a clear and succinct Organisation and Programme building manner. They provide a structure for the systematic implementation (content) organisation of the curriculum, which can be represented diagrammatically and can provide the basis for organising the curriculum into computer databases. Programme building Programme building The starting point for the maps may differ depending on (assessment) (teaching and learning) the audience. A map for students will place them at the centre and will have a different focus from a map prepared for teachers, administrators, or accrediting authorities. They all have The situational model, which emphasises the importance of situation or context in curriculum design a common purpose, however, in showing the scope, complexity, and cohesion of the curriculum. Curriculum maps with computer based graphics with “click-on” links are an excellent format. The maps provide one way of tracing the links between the curriculum as planned, as Situation delivered, and as experienced. But like all maps, a balance must Content • Backgrounds be achieved between detail and overall clarity of representation. Outcome based education: part 1—an introduction to outcomes-based education. Explicit organisation Appropriate Organisation • Blocks • Scope, sequence Content x Harden R. Curriculum mapping: a tool for transparent and • Units • Related to aims • Timetables • Related to practice authentic teaching and learning. Clear blueprint self direction • Formative • Learning in real • Summative life settings Assessment Teaching and learning Example of a curriculum map from the students’ perspective.
Louis on October 10 buy discount serophene 100 mg line menopause 19, attracted residents and faculty from the entire 1986 safe 100mg serophene menopause breast changes, from carcinoma of the pancreas. He retired as chairman in 1972 and to Phyllis, he left three children: Mary Ann Krey, became professor emeritus in 1976. Reynolds Chair of Orthopedic Surgery was created at Washington University in 1979 from contributions by his friends, students and patients. Fred became active in the American Academy of Orthopedic Surgeons, serving as chairman of the Instructional Course Committee from 1959 to 1961, chairman of the Committee on Graduate Education from 1961 to 1964, and editor of the Instructional Course Lectures and president in 1965. He was president of the Clinical Orthope- dic Society in 1960, and he was elected to the American Orthopedic Association. In addition to being a member of the American Board of Ortho- pedic Surgery and of state and local orthopedic and surgical societies, Fred was president of the St. Louis Orthopedic Society and of the Clinical Orthopedic Society and served on study sections of the National Institutes of Health and the editorial board of The Journal of Bone and Joint Surgery, and was a founder and ﬁrst president of Frederic W. His father was an Episcopalian Fred considered his major responsibility to minister who became the bishop of Pennsylvania. His greatest Washington, DC, where he received a rigorous quality as a teacher was his uncompromising classical education. He was his own severest degree from Harvard University in 1928, he critic, a quality he taught by example to those attended Oxford University, which awarded him around him. He had no patience for stupidity or an additional bachelor’s degree and a master’s laziness. Fred’s advice to residents, whether they degree from the school of medicine. He then entered military service (an experience he thought returned to the United States and obtained his would be valuable) or practice, was the same: medical degree from Harvard University in 1934. His postgraduate training embraced a broad Fred was a master surgeon and a careful and experience in research and the basic sciences and thoughtful physician. In 1941, he joined the faculty of superﬁcially, he was a crusty, grumpy, taciturn Harvard University Medical School, where he man. But those who were privileged to be asso- remained until 1947, with a hiatus as a medic in ciated with him knew him as a caring, compas- World War II. While in the service, Rhinelander sionate, highly skilled physician, teacher, and became chief of orthopedics at the Letterman friend. His wish for his residents was that they General Hospital in San Francisco. His experi- should be better physicians, surgeons, scholars, ence with the use of iliac bone grafts in the treat- 287 Who’s Who in Orthopedics ment of ununited fractures was substantial. After attending Harvard University, Boston, MA, he leaving the service, he entered private practice in studied medicine at the College of Physicians and San Francisco and had a clinical appointment on Surgeons, in New York City. After receiving his the faculty of the University of California in San medical degree in 1939, he interned and served a Francisco. In 1955 he joined the faculty of Case year of general surgery residency in the Brooklyn Western Reserve University School of Medicine, Hospital. Shortly after beginning his orthopedic where he remained, retiring as professor emeritus residency at the Presbyterian Hospital in New in 1972. It was while he was in Cleveland that York City, his training was interrupted by World Rhinelander did his intensive study of the micro- War II. Robinson served in army hospitals in the circulation in bone and the effects of operative United States and in the South Paciﬁc. After his retire- of his discharge he was the commanding ofﬁcer ment, he moved to Little Rock, AR, where he and chief of surgery of the 90th Field Hospital served on the faculty of the University of in Leyte, Philippine Islands. In 1979, Rhinelander returned to in 1946, he resumed his orthopedic training at California, where he was appointed research pro- Strong Memorial Hospital in Rochester, NY. It was his The quality of Rhinelander’s work on the experience in England that ﬁrst stimulated his microcirculation of bone was recognized by the interest in surgery of the spine. American Academy of Orthopedic Surgeons, On his return to the United States, Robinson from which he received the Kappa Delta Award joined the faculty of the University of Rochester in 1974.
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