Rather cheap flagyl generic antimicrobial undershirt, the competence and communication skills of doctors appear to be more important to patients than the doctors’ gender (Bertakis & Azari buy cheap flagyl 500 mg on line antibiotics qt interval, 2012; Bourke purchase flagyl online antibiotic nitrofurantoin, 2002; Mavis, Vasilenko, Schnuth, Marshall, & Jeffs, 2005; Thempest et al. This finding is consistent with the results of the current study, with 13 out of 16 participants referring to 196 the importance of their doctors’ competence and communication skills in lieu of their doctors’ gender. The ability for doctors to communicate effectively with their patients is crucial to meeting their patients’ needs and expectations (Godager, 2012). Numerous studies have revealed that patients prefer doctors who listen attentively, answer their questions, and include them in decision making—practices that are characteristic of patient-centered approaches (Carlsen & Aakvik, 2006; Copeland et al. Research indicates that female doctors tend to use patient-centered approaches more often than male doctors, as evidenced by longer consultations and a greater psychosocial focus in their discussions (Beach, 2000; Bertakis, 2009; Bertakis & Azari, 2012; Firth Cozens, 2008b; Hall & Roter, 2002; Hall et al. Considering the aforementioned findings regarding patient-centered approaches, it was expected that the participants in the current study would express a preference for female doctors. The fact that the participants in the current study reported no preference for a specific doctor gender might be due to the fact that only four out of the 16 participants interviewed (Alicia, Autumn, Kari, and Karen) consistently had doctors who did not make them feel unheard, invalidated, dismissed, not empathized with, or disrespected (discussed previously in “Subtheme 2: Participant Self-Advocacy”). In other words, during the time of their interviews, the majority of the participants might have still been seeking doctors who use a patient-centered approach. If this is the case, the gender of the doctors ultimately chosen by participants remains unknown because at the time of 197 the interviews, participants were not asked whether or not they were seeking or considering seeking new doctors. Future studies might consider asking participants how many doctors they have had, the gender of those doctors, their reasons for seeking new doctors, and whether or not participants have decided to keep their current doctor. When asked if it mattered whether their doctors were male or female, three of the 16 total participants indicated a preference for female doctors. Because Kari reported feeling heard and being involved in the decision making process, it is likely that Kari’s doctor utilized a patient-centered approach. Regarding Kari’s comment about male doctors being “too arrogant in their education,” because Kari is 78 years old, it is likely that she experienced paternalistic doctor-patient relationships in the past. According to Carla, “Every woman doctor [she’s] had, all of 3, [have] been far more empathetic and able to listen. Jenna had reported feeling unheard, invalidated, and dismissed, as well as shared that she sought health information, refused treatment, and self-treated. Whether or not these experiences are related to her doctor’s gender cannot be determined. Jenna’s assumption that female doctors might be more “compassionate and understanding” could be due to her negative experience with her male doctor or based on a conventional view of women as nurturers (Bertakis & Azari, 2012; Hall, Roter, Blanch- Hartigan, Schmid Mast, & Pitegoff, 2015; Shields, 2007). According to Bertakis and Azari (2012), traditional gender role expectations among both patients and doctors may be unconsciously reinforced by gender differences in communication. Nine out of the 16 total participants indicated that being taken seriously influenced their ability to communicate with their doctors. Of these nine participants, Alicia and Diane were the only individuals who felt like their doctors took them seriously. Alicia explained, “Knowing that he takes me seriously helps me to feel comfortable sharing my symptoms with my doctor. More specifically, Emily and Anne indicated believing that both male and female 199 doctors are less likely to take women’s complaints as seriously as men’s complaints. Emily explained, “Sometimes I think men doctors don’t take some female symptoms seriously, but then I’ve had women doctors that also didn’t seem to be sympathetic to a formally [sic] skinny patient who quickly put on 20 pounds. I do tend to get emotional which I think makes doctors give less credence to my depiction of my symptoms. As a result, women often need to work harder in order to be perceived as credible patients. According to Soderberg, Olsson, and Skar (2012), it is a “violation of a person’s dignity” to not be taken seriously (p. Likewise, in Stenberg, Fjellman-Wiklund, and Ahlgren’s (2012) study of individuals being treated for neck and back pain, patients expressed that being taken seriously by their doctors was essential for feeling comfortable in communicating with their doctors. Participants who did not feel like they were taken seriously reported feeling 200 rejected and ashamed; and this experience was more common among female participants than male participants. Stenberg and colleagues argued that the pain levels of the female participants in their study may have been underestimated, and that this might be due to a stereotypical view of women as overly emotional and complaining. The authors likened the participants’ experiences of not being taken seriously to being disqualified as people (p. The participants indicated that, as a result of not being taken seriously, they felt like that had no influence in their communication with their doctors. According to Hedberg and Lynoe (2013), doctors who are considered to be competent by their patients listen to their patients, take them seriously, answer their questions, and invite them to participate in their care. In addition to being perceived as competent, doctors are perceived as trustworthy by their patients when they demonstrate sensitivity to their patients’ emotions (Skirbekk et al. By creating an environment in which patients feel safe in communicating about their illness experiences, doctors are better able to ask relevant questions and recognize potentially misdiagnosed or undiagnosed illnesses (Dean & Street, 2014; Hedberg & Lynoe, 2013). Three out of the 16 total participants indicated that showing emotion influenced communication with their doctors. More specifically, in Alicia’s experience, the presence of emotion prompted effective communication with her doctor. However, the presence of emotion appeared to be problematic for Anne’s and Leanne’s attempts to communicate effectively with their doctors. Anne explained, “I do tend to get 201 emotional which I think makes doctors give less credence to my depiction of my symptoms. Research indicates that men’s symptoms are more likely to be interpreted as biological by doctors, while women’s symptoms are construed to be psychosomatic—that is, that women’s symptoms are a result of a mental, rather than physical, illness (Chrisler, 2001; Hamberg et al. The issue of women’s symptoms being considered psychosomatic is discussed further in section “Theme 4: Culture of the Medical Profession. Alicia explained, “It was not until I broke down in tears with my radiation oncologist that he suggested metabolic testing…[and to] follow this up with my primary care physician. When doctors were not responsive to the women’s descriptions of bodily symptoms, the women then referred to authorities outside of themselves (e. Similar results were found in Werner and Malterud’s (2003) study of women who sought to obtain their doctors’ validation of their chronic 202 pain through using assertiveness and “surrendering” (i. According to Werner, Isaksen, and Malterud (2004), female patients need to utilize such strategies in order to fit in with normative, biomedical expectations of illness and be perceived as credible patients. Although Anne’s and Alicia’s experiences with demonstrating emotion seem to be on opposite ends of the spectrum (i. Research indicates that whether patients’ emotional cues are subtle or obvious, doctors often fail to acknowledge and validate their patients’ concerns using empathic communication (Epstein et al. Even if it was not their doctors’ intention, the patients felt patronized by their doctors and as if they were being accused of exaggerating their symptoms. Finset (2012) argued that doctors sometimes offer reassurance prematurely in response to their patients’ distress (e. As such, incorporating empathy-related communication techniques into medical training programs may help doctors to be better equipped to handle emotions in the clinical encounter (Finset, 2012) and to respond constructively. Theme 4: Culture of the Medical Profession Participant responses to interview questions indicated that their experiences with thyroid disease treatment were influenced by the culture of the medical profession.

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Firmicutes cheap 200mg flagyl otc infection you get in hospital, in particular Lactobacillus strains were dominant in the gut microbiotas of the outdoor piglets flagyl 200mg free shipping antibiotic for cellulitis, whereas the hygienic indoor piglets had reduced Lacto- bacillus and more potentially pathogenic phylotypes [127] purchase genuine flagyl on-line antimicrobial drugs are selectively toxic this means. The indoor piglets also had less diverse gut microbiota, and a more inflammatory pattern of gene 15 Microbiota, Immunoregulatory Old Friends and Psychiatric Disorders 333 Fig. Microbial biodiversity from the environment can modulate immunoregulation by (D) directly interacting with the immune system, or (A, B, C) by leading secondarily to altered microbiota. The environmental organism may cause secondary changes to the microbiota by (A) colonizing, or (B) antagonizing or competing with established microbiota or (C) modulating the host immune system-microbiota relationship expression in ileal biopsies [127]. Were these effects due to direct colonization by immunoregulation-inducing organisms from the outdoor environment [pathway (A) in Fig. Some organisms compete with, or antagonize established organisms [pathway (B)] and so alter the microbiota [128]. Others alter the immune system directly [pathway (D)], or modulate the immune system in ways that lead secondarily to a change in the host-microbiota relationship, which in turn leads to changes in the microbiota [pathway (C) in Fig. Genetic manipu- lations of the innate immune system that have profound effects on immune function (such as gene knockout) often operate indirectly by altering the gut microbiota. The phenotypic effects can then be transferred to wild-type mice that have not been genetically modified, by transferring the altered microbiota [129, 130]. It is the altered microbiota that is the proximate cause of the altered immunoregulation [129–133]. Is the Gut Still Involved in Immunoregulation by Organisms That Do Not Enter the Gut? Does this mean that all immunoregulation by “Old Friends” operates indirectly by modulating the immune system, and so secondarily causing changes in the gut microbiota? It is likely that such indirect effects occur, but there could be direct effects too. For example the skin microbiota has at least some immunoregulatory role independent of the gut [134]. Indeed components of the skin microbiota extend into the subepidermal compartments, suggesting subtle and unexplored mecha- nisms [135]. Moreover psychological stressors cause increased bacterial trans- location to lymphoid tissue from both the gut and the skin so the nature of the organisms present on skin is likely to be directly relevant to subsequent effects on immune function [136]. Interestingly, in the British field mouse (Apodemus), the burden of the louse Polyplax serrata correlated with the state of activation of the innate immune system in the spleen, implying that ectoparasites (fleas, lice, mites, ticks) might also have immunoregulatory roles [137, 138]. The blood nematodes are also of interest because these do not enter the gut at any phase of their life cycles, but they are powerfully immunoregulatory [9]. Nevertheless, in view of the experiments listed in the previous section, it is still possible that in addition to direct effects on the immune system [pathway (D) in Fig. There is also an increased frequency of the short allele of the serotonin transporter promoter that also has a marked proinflammatory effect [146]. As soon as the immunoregulation-inducing organisms are withdrawn by the modern lifestyle, or after immigration to a high-income country, these genetic variants lead to inflammatory overshoot. The proinflammatory variants become risk factors for chronic inflammatory disorders [143–146]. For instance, the recent claim to have discovered that the “cause” of Crohn’s disease is a genetically determined defect in the homing of neutrophils [147] is difficult to reconcile with the fact that 100 years ago the disease barely existed. But recent environmental changes could conceivably have caused this phenotype to become a risk factor. Two major issues were avoided in the discussion of the role of immunoregulation in determining stress resilience (Fig. First we did not discuss why stress causes release of inflammatory mediators, and secondly we did not discuss why such mediators trigger depression. How do these mechanisms com- bine to result in raised proinflammatory cytokine levels? Paracellular permeability is controlled by tight junctions, intermediate junctions and desmosomes, which constitute a size- and cation-selective filter for small molecules. The composition of the microbiota, particularly Lactobacillus strains and hel- minth “Old Friends” also modulate permeability. When idiopathic chronic diarrhea in rhesus monkeys was treated with the whipworm Trichuris trichiura, clinical improvement was accompanied by striking changes in the microbiota attached to the mucosa [159]. Indirect Effects of Psychosocial Stress via the Microbiota Stress induces changes in the composition of the microbiota of rodents [72], and induces bacterial translocation from gut and skin [136]. When sampled within hours of admission to the emergency room fecal bacterial counts were decreased 1,000-fold compared to control subjects, and obligate anaerobes and Lactobacillus species were significantly decreased [160]. Similarly, a large change in the microbiota after allogeneic bone marrow transfer was iden- tified as a risk factor for subsequent inflammation and graft-versus host disease [161], implying that stress alters immunoregulation at least partly by altering the microbiota. But this response was greatly attenuated by pre-treatment with an 15 Microbiota, Immunoregulatory Old Friends and Psychiatric Disorders 337 antibiotic cocktail to deplete the microbiota [72]. Stress Resilience and the Microbiota The microbiota might also be involved in the observation that poor stress resilience and an exaggerated cytokine response to environmental [31] or laboratory [22] stressors is characteristic of people who have suffered increased early life stress. This inter- pretation is in agreement with the observation that in a low-income country population the adults who had a high level of microbial exposure in infancy were resistant to the long-term proinflammatory effects of a very severe childhood stressor [32]. The mechanisms that cause inflammatory responses to alter behavior and cognition have been extensively reviewed recently [166] and are summarized briefly here. From an evolutionary point of view this link between immunity and psychiatry is explained by the fact that during an acute infection, withdrawal (to conserve resources, fight infection and heal wounds) and hypervigilance (to detect danger) are adaptive responses [167]. Withdrawal and hypervigilance probably result from inflammation-mediated signals to distinct parts of the brain. However these states are not sustainable and if prolonged, withdrawal becomes depression and hypervigilance becomes anxiety. This relationship between prolonged inflammatory stimuli and behavioral changes that resemble depression 338 G. Inflammation-associated depression and anxiety are more likely in situations where there is poor control of inflammation [169]. Similarly, depression and anxiety often accompany the chronic inflammatory disorders that are increasing in high-income countries. First, cytokines can enter the brain in areas such as the circumventricular organs where there is no blood-brain barrier. Perhaps these areas should be regarded as sensory organs of which one role is the detection of inflammation. Cytokines in the periphery can also signal via afferent fibres within the vagus and other sensory nerves. This has been called the “facsimile” mechanism, because the cytokine stimulating the peripheral nerve terminals may subsequently be synthe- sized de novo and released within the brain. However inflammation propagated to the brain by the pathways listed above can cause these cells to express inflammatory cytokines and to release reactive oxygen and nitrogen species [166].

When assessing monocular charts and Goldmann perimetry generic 400mg flagyl otc 3m antimicrobial oral rinse, fxation accuracy will also be considered trusted 200 mg flagyl antibiotics in food. Defect affecting central area only (Esterman within 20 degree radius of fxation) Only for the purposes of licensing Group 1 car and motorcycle driving: the following are generally regarded as acceptable central loss scattered single missed points a single cluster of up to 3 adjoining points discount flagyl online amex bacteria biofuel. Defect affecting the peripheral areas – width assessment Only for the purposes of licensing Group 1 car and motorcycle driving: the following will be disregarded when assessing the width of feld a cluster of up to 3 adjoining missed points, unattached to any other area of defect, lying on or across the horizontal meridian a vertical defect of only single-point width but of any length, unattached to any other area of defect, which touches or cuts through the horizontal meridian. Static visual feld defect For prospective learner drivers with a static visual feld defect, a process is now in place to apply for a provisional licence. Higher standards of feld of vision – bus and lorry drivers The minimum standard for the feld of vision is defned by the legislation for Group 2 bus and lorry licensing as: a measurement of at least 160° on the horizontal plane extensions of at least 70° left and at least 70° right extensions of at least 30° above and at least 30° below the horizontal plane no signifcant defect within 70° left and 70° right between 30° up and 30° down (it would be acceptable to have a total of up to 3 missed points, which may or may not be contiguous*) no defect is present within a radius of the central 30° no other impairment of visual function, including no glare sensitivity, contrast sensitivity or impairment of twilight vision. A total of more than 3 missed points, however – even if not contiguous – would not be acceptable for Group 2 driving because of the higher standards required. Note that no defects of any size within the letterbox are licensable if a contiguous defect outside it means the combination represents more than 3 missed points. The minimum standards set out for all The minimum standards for Group 2 drivers above must be met. Glare may counter an ability to pass Glare may counter an ability to pass the number plate test (of the minimum the number plate test (of the minimum requirements) even when cataracts requirements) even when cataracts allow apparently appropriate acuities. Exceptions for visual acuity allowed by older licences (‘grandfather rights’) The standards for Group 1 car and motorcycle licensing must be met before any of the following exceptions can be afforded to Group 2 bus and lorry drivers holding older licences. Visual acuity Exception 1 A driver must have been awarded a Group 2 bus and lorry licence before 1 March 1992, and be able to complete a satisfactory certifcate of experience, to be eligible. If the licence was awarded between 2 March 1992 and 31 December 1996, visual acuity with corrective lenses if needed must be at least 6/9 in the better eye and at least 6/12 in the other eye; uncorrected visual acuity may be worse than 3/60 in one eye only. Monocularity Exception 2 Must have been awarded a Group 2 bus and lorry licence before 1 January 1991, with the monocularity declared before this date. Exception 3 Drivers with a pre-1997 Group 1 licence who are monocular may apply to renew their category C1 (vehicles 3. They must be able to meet the minimum eyesight standards which apply to all drivers and also the higher standard of feld of vision for Group 2 (bus and lorry) drivers. Exceptionally, a stable uncorrected diplopia endured for 6 months or more may be licensable with the support a consultant specialist’s report of satisfactory functional adaptation. Driving may be licensed after individualDriving may be licensed after individualDriving may be licensed after individual Driving may be licensed after individualDriving may be licensed after individualDriving may be licensed after individual consideration, provided the standardsconsideration, provided the standardsconsideration, provided the standards consideration, provided the standardsconsideration, provided the standardsconsideration, provided the standards for visual acuity and feld above are met. Driving is not usually licensed if the Driving is not usually licensed if the condition is severe and affects vision, condition is severe and affects vision, even if treated. Driving may be licensed if the Driving may be licensed if the condition is mild, subject to return condition is mild, subject to return of satisfactory medical reports. Control of mild blepharospasm with Control of mild blepharospasm with botulinum toxin may lead to licensing botulinum toxin may lead to licensing if the treatment does not produce side if the treatment does not produce side effects that are otherwise disqualifying, effects that are otherwise disqualifying, such as uncontrollable diplopia. Such sequelae need reference to Such sequelae need reference to requirements under ‘Transient loss requirements under ‘Transient loss of consciousness’ (from page 21 of of consciousness’ (from page 21 of Chapter 1, neurological disorders). See also cough syncope in Chapter 1, See also cough syncope in Chapter 1, page 27. Obstructive sleep apnoea Refer to guidance concerning this condition under ‘excessive sleepiness’ (page 108) in Chapter 8, miscellaneous conditions. Subsequent licensing requires: satisfactory treatment success no brain scan evidence of intracranial metastases (refer to malignant brain tumours, page 35 of Chapter 1, neurological disorders). Group 1 Group 2 car and motorcycle bus and lorry Excessive sleepiness Must not drive. The effects of any cancer treatment The effects of any cancer treatment must also be considered – the generally must also be considered – the generally debilitating effects of chemotherapy debilitating effects of chemotherapy and radiotherapy in particular. In-car, on-the-road assessments (Appendix G, page 133) are an invaluable way of ensuring, in valid licence holders, there are no features liable to present a high risk to road safety, including these examples: visual inattention, notable distractibility, impaired multi-task performance. The following are also important in showing there is no impairment likely to affect driving: adequate performance in reaction times, memory, concentration and confdence. Impairment of cognitive functioning is Impairment of cognitive functioning is not usually compatible with the driving not usually compatible with the driving of these vehicles. Mild cognitive disability may be compatible with safe disability may be compatible with safe driving – individual assessment will driving – individual assessment will be required. Licence holders wishing to drive after surgery should establish with their own doctors when it would be safe to do so. Any decision regarding returning to driving must take into account several issues, including: recovery from the effects of the procedure anaesthetic recovery from the effects of the procedure any distracting effect of pain analgesia-related impairments (sedation or cognitive impairment) other restrictions caused by the surgery, the underlying condition or any comorbidities. Drivers have the legal responsibility to remain in control of a vehicle at all times. Such a judgement may be necessary for any of a range of conditions that may temporarily affect driving, including, but not limited to: postoperative recovery (see ‘Driving after surgery’, page 112) severe migraine limb injuries expected to show normal recovery pregnancy associated with fainting or light-headedness hyperemesis gravidarum hypertension of pregnancy recovery following Caesarean section deep vein thrombosis or pulmonary embolism. Drivers taking prescribed drugs subject to the drug-driving legislation will need to be advised to carry confrmation that these were prescribed by a registered medical practitioner. Some prescription and over-the-counter medicines can affect driving skills through drowsiness, impaired judgement and other effects. Prescribers and dispensers should consider any risk of medications, single or combined, in terms of driving – and advise patients accordingly. Advice for individual driving safety should be considered carefully for all antidepressants antipsychotics – many of these drugs will have some degree of sedating side effect via action on central dopaminergic receptors. Older drugs (chlorpromazine, for example) are highly sedating due to effects on cholinergic and histamine receptors. Newer drugs (olanzapine or quetiapine, for example) may also be sedating; others less so (risperidone, ziprasidone or aripiprazole, for example) opioids – cognitive performance may be reduced with these, especially at the start of use, but neuro-adaptation is established in most cases. Driving impairment is possible because of the persistent miotic effects of these drugs on vision. Also refer to Chapter 4, psychiatric disorders (page 79), and Chapter 5, drug or alcohol misuse and dependence (page 88). According to Section 92 of the Road Traffc Act 1988: A relevant disability is any condition which is either prescribed (by Regulations) or any other disability where driving is likely to be a source of danger to the public. A driver who is suffering from a relevant disability must not be licensed, but there are some prescribed disabilities where licensing is permitted provided certain conditions are met. A driver with a prospective disability may be granted a driving licence for up to 5 years, after which renewal requires further medical review. Sections 92 and 94 of the Road Traffc Act 1988 also cover drivers with physical disabilities who require adaptations to their vehicles to ensure safe control. See Appendix F, disabilities and vehicle adaptations (page 132) and Appendix G, Mobility Centres and Driving Assessment Centres (page 133). A serious neurological disorder is defned for the purposes of driver licensing as any condition of the central or peripheral nervous system that has led, or may lead, to functional defciency (sensory, including special senses, motor, and/or cognitive defciency), and that could affect ability to drive. A short-term licence for renewal after medical review is generally issued whenever there is a risk of progression. Further information relating to specifc functional criteria is found in the following chapters: Chapter 1, neurological disorders (page 16) Chapter 4, psychiatric disorders (page 79) Chapter 6, visual disorders (page 96) Chapter 8, miscellaneous conditions – excessive sleepiness (page 108). The following two boxes extract the paragraphs of the Motor Vehicle (Driving Licences) Regulations 1999 (as amended) that govern the way in which epilepsy is ‘prescribed’ as a ‘relevant’ disability for Group 1 or Group 2 drivers (also see Appendix A, the legal basis for the medical standards, page 115). Group 1 car and motorcycle (2) Epilepsy is prescribed for the purposes of section 92(2) of the Traffc Act 1988 as a relevant disability in relation to an applicant for, or a holder of, a Group 1 licence who has had 2 or more epileptic seizures during the previous 5-year period.

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A definitive diagnosis of thyroid disease requires a physical examination and thorough history of the patient (Goolsby & Blackwell 400mg flagyl overnight delivery antibiotics for uti guidelines, 2004) purchase flagyl 250mg on line treatment for dogs bite. Diagnosis Making a definitive diagnosis of thyroid disease has shown to be challenging due to a number of factors generic flagyl 500 mg line virus x 2010. In addition, although approximately 13 million Americans with thyroid disease remain undiagnosed (Goolsby & Blackwell, 2004), the U. Preventive Services Task Force indicated a lack of evidence for recommending for or against routine screening for thyroid disease in adults, thus leaving the use of this potentially beneficial diagnostic measure to the discretion of individual practitioners (Helfand, 2004). Even further, thyroid disease is often mistaken for other conditions due to the similarity in its symptoms to other disorders such as major depression, bipolar depression (Aslan et al. Thus, a thorough assessment, including a physical examination and complete history of the patient, is vital for ensuring proper diagnosis and treatment of an individual with thyroid disease (Goolsby & Blackwell, 2004). However, remission rates are variable and relapses are frequent when antithyroid drugs are used alone (Goolsby & Blackwell, 2004). Some experts recommend the addition of T3 (liothyronine; name brand Cytomel) for its antidepressant effects (Dayan, 2001; Joffe, 2006). Effective treatment of thyroid disease depends upon an accurate diagnosis of hyperthyroidism or hypothyroidism (Cappola & Cooper, 2015; Goolsby & Blackwell, 2004; Heinrich & Grahm, 2003; McDermott & Ridgway, 2001). Regular monitoring of the thyroid patient’s symptoms and interpreting blood work are necessary for determining treatment effectiveness. Thus, in cases in which physicians do not use all three main thyroid function tests, thyroid patients often experience chronic or worsening symptoms (Bunevicius & Prange, 2006; Heinrich & Grahm, 2003; McDermott & Ridgway, 2001). Diagnostic and treatment challenges related to thyroid disease underscore the importance of an effective doctor-patient relationship (Copeland et al. Female thyroid patients’ experiences of treatment and the doctor- patient relationship might be best understood through the lens of social constructivism and feminism, as both worldviews emphasize individuals’ experiences in social contexts (Hearn, 2009; Docherty & McColl, 2003). Conceptual Framework In this study, data interpretation was guided by social constructionism and feminist theory. Themes related to the culture of the medical profession, diagnostic bias, and gender differences in communication—all of which are discussed later in this 29 chapter—were identified. Social Constructionism Lupton (2003) and Martin and Peterson (2009) described the trajectory in medical thought by which social constructionism arose as a response to the biomedical model (p. This model located disease in specific parts of the body and reduced medical concerns to mechanistic processes. In the 1950s, as a response to the biomedical model, Talcott Parsons developed the functionalist perspective, in which the role of a sick individual is seen as a social response to the deviant place in society occupied by persons with poor health (Martin & Peterson, 2009). In the functionalist perspective, patients desire to be accepted by society and therefore seek verification from doctors that they are not malingering (Lupton, 2003). Although Parson’s work is acclaimed for identifying the role of society in understanding illness, the functionalist perspective has been criticized for characterizing patients as passive and grateful, while doctors were portrayed as universally competent and altruistic. In addition, according to Lupton (2003), the functionalist viewpoint did not take into consideration the potential for conflict within the doctor-patient relationship. The social constructionist model emerged in the 1980s in response to these criticisms. In this perspective, all medical issues, including health, chronic illnesses, and medical care, are socially constructed facts that are subject to varying degrees of consensus and interpretation due to cultural factors and social norms (Docherty & McColl, 2003; Fernandes et al. In other words, in the management of illness, both the patient and the doctor are influenced by their individual beliefs and experiences and the society in which they live. Thus, the social constructionist perspective is appropriate to the qualitative study of health and disease, which takes as its data the personal experiences, perceptions, observations, and narratives of individuals (Creswell, 2007; Hearn, 2009). The logical positivist perspective, commonly used in quantitative research, involves an assumption that there are stable, social facts with a single reality, separated from the feelings and beliefs of individuals (Creswell, 2007). In other words, regardless of how an individual perceives an event, only one interpretation of that event is considered to be appropriate or based on “truth” (Patton, 2002). For example, if an individual is diagnosed with a chronic illness and the medical profession contends that such a diagnosis should have a minimal emotional impact on the individual, for him or her to react in any other manner (e. In contrast, social constructionism, commonly used in qualitative research, is based on the belief that multiple realities are socially constructed through individual (constructivism) and collective (constructionism) perceptions of the same situation 31 (Patton, 2002). For example, on the individual (constructivist) level, one person might view a chronic illness diagnosis as manageable, while another person might view that same diagnosis as emotionally devastating. These individual perceptions are influenced by the collective (constructionist) framework (e. Within the social constructionist perspective, both of these interpretations would be considered valid. Docherty and McColl (2003) noted that a social constructionist approach takes patients’ interpretations of their illness experience into account. These interpretations are relevant because they influence the patients’ feelings, reactions, and behaviors. Thus, the female body and bodily illnesses take on certain meanings in a social context, and these meanings influence patients’ interpretations of the illness experience (Fernandes et al. Findlay (1993) also argued that social construction is an important source of knowledge in the fields of science and medicine. However, according to Findlay, the technical nature of scientific and medical knowledge often results in perspectives that neglect the social contexts and construction of this knowledge. More specifically, diagnostic and treatment decisions tend to be based on “objective evidence” of disease 32 (e. Furthermore, competing perspectives among pharmaceutical, medical, and insurance companies influence diagnostic and treatment decisions (Hearn, 2009). In order to underscore the social and political aspects of medical knowledge and practice, Findlay (1993) argued that biomedicine defines disease as a deviation from a particular standard viewed as biological normalcy. The implications of this can be seen, for example, in the way in which physicians treated female fertility issues in the 1950s, which often assumed a specific, socially constructed set of values (Findlay, 1993). Findlay cited descriptions of the hormonal systems of males and females from this period, noting that libido was emphasized in males and reproduction was emphasized in females, and argued that acknowledgment of hormones in females was restricted to those directly related to reproduction. Feminists contend that women continue to be viewed by the medical profession as being at the mercy of their reproductive hormones (Fernandes et al. This perception could have a significant impact on women with thyroid disease because of the psychological symptoms resulting from the hormone imbalances involved in thyroid dysfunction (Shimabukuro, 2008). According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Thext Revision (American Psychiatric Association, 2000), several of the most common cognitive, mood, anxiety, and psychotic disorders might be best explained by thyroid dysfunction. Yet, there are pervasive beliefs among physicians that women over-report pain and that vague 33 symptoms are the results of mental, rather than physical, illness (Chrisler, 2001; Hoffmann & Tarzian, 2001). Viewed from a social constructionist perspective, these examples show how socio-cultural constructs, perspectives, and attitudes can influence the field of medicine. Feminism Despite efforts to incorporate gender-sensitive practices into the field of medicine, historically-based knowledge and beliefs about women persist (Chrisler, 2001; Hoffmann & Tarzian, 2001; Sherwin, 1999).

From the central great room discount 200 mg flagyl with visa antimicrobial rinse, with its grand piano and game tables discount flagyl 500 mg amex virus upload, a wide corridor loops around the building buy cheap flagyl antibiotic prophylaxis dental, lit by sconces rather than overhead fuorescent light, and lined with rooms of every sort: exercise, meditation, art therapy, music therapy, teen lounge, children’s playroom; patient rooms with garden-side terraces and oxygen equipment Community Partnership for Arts and Culture 27 Creative Minds in Medicine Hospice of the Western Reserve 17876 St. Rollaway beds and rocker recliners are also in each patient room for those who wish to stay near their loved ones. Corridors are indented with “garages,” deep alcoves that hide parked wheelchairs and carts from view. Deceased patients and their families have a dignifed exit area accessible to vehicles and out of sight of the main entrance, to protect privacy and everyone’s feelings. Staff members can walk an outdoor section of corridor or rest in their special staff lounge for needed breaks. Every door is wide enough to push a bed through, ensuring that patients at Ames House can go everywhere they want – outside, to do artwork, help bake cookies – whether they can walk or sit up or not. So do the roles of design and art in making the end of life as comforting as possible. He calls it an essential part of helping people go through a profound change he compares to a caterpillar turning into a butterfy. Over the course of human development, arts and culture activities have been valued for their utility in codifying traditions and uniting communities through activities that “facilitate[d] the need for belonging, fnding and making meaning” while contributing to the development of physical skills. In addition,87 arts and culture activities have provided outlets for expression of emotion, self-refection and Key Benefts personal discovery. These perspectives have merged and expanded over time to form a much more transformative view of the role arts and Research has demonstrated that participation culture can play in the lives of individuals and their communities. Arts and culture experiences can in arts and culture activities and/or expressive support outcomes that “redefne the self, build arts therapies help patients: 88 community, and address civic issues. An important distinction can be • Raise levels of self-esteem made between “expressive arts therapies” and the • Improve measures of specifc clinical outcomes “therapeutic use of arts and culture”: Expressive such as motor functioning, memory recall and arts therapies are provided in clinical healthcare vital signs settings by “trained health care [sic] professionals to heal or ameliorate the effects of disease and disability,” while the therapeutic use of arts and culture in healthcare settings includes artist-in- residence programs through which professional artists carry out arts and culture activities to promote health and wellness. This chapter looks90 at how participation in expressive arts therapies, as well as in arts and culture activities, is taking place in Cleveland. Community Partnership for Arts and Culture 30 Creative Minds in Medicine Participatory Arts and Health Expressive Arts Therapies Today, expressive arts therapies apply the disciplines of visual art, music, dance, literature and theater for the health benefts of participants. For example, visual and literary arts help grieving91 children and adolescents express their emotions following loss; music therapy decreases92 pain, anxiety, depression, and shortness of breath, and it improves mood in palliative medicine patients; dance allows veterans to tell their stories nonverbally and cope with post-traumatic93 stress disorder; writing and reciting poetry assists those with Alzheimer’s disease and related94 dementia to recall memories; and drama therapy lifts mood and reduces pain levels for95 dialysis patients undergoing treatment. Expressive arts therapies have also yielded measurable96 outcomes such as stress reduction, pain management and improved motor and social functioning for groups such as veterans, autistic youth and stroke survivors. A minimum of a bachelor’s degree or equivalent is required to become a board certifed music therapist, while a master’s degree is required to become a board certifed art therapist. Locally, the Cleveland Music Therapy Consortium, which was formed in 1976, brings together the music therapy programs of the Baldwin Wallace University Conservatory of Music and the Music Department of the College of Wooster. The collaborative arrangement allowed a music therapy degree to be offered for the frst time in Northeast Ohio. The region also provides Ohio’s only98 source of Masters in Art Therapy and Counseling degrees, at Ursuline College in Pepper Pike. Arts and culture nonprofts use expressive make up one set of organizations that offers a wide range of such programs throughout the Cleveland area. The arts therapies Music Settlement, for example, was a pioneer in the music therapy feld, developing its Center for Music Therapy in to benefit 1966. Currently, the center offers therapy sessions for individuals with mental illness, terminal illness, learning patients by disabilities and other social or behavioral disorders. It also provides music therapy programming in educational helping them settings to enhance core curriculum standards being taught to children in social services settings such as the Salvation channel Army’s Harbor Light complex for those who were formerly incarcerated, homeless and/or are recovering addicts; for emotions, adults in day programming at the United Cerebral Palsy Association; in medical settings such as the burn unit at recover MetroHealth Medical Center; in the palliative-medicine from trauma department at the Cleveland Clinic; and at the Cleveland Sight Center. Cleveland’s Art Therapy Studio enhances the quality of life for those with physical, cognitive or emotional challenges through the therapeutic use of visual art. The organization was established in 1967 as a joint partnership with HighlandView Hospital, which is now MetroHealth Medical Center, a partnership that continues today. It also coordinates employee wellness workshops for local businesses, as well as professional development opportunities for practicing art therapists. This program uses music therapy to improve the socialization, literacy and language skills of Cleveland’s underserved three- to fve-year olds. The Cleveland Clinic Arts and Medicine Institute has dedicated art and music therapists who work throughout the hospitals with individual patients at bedside, in groups, and in public areas with patients and families. The largest programs are with adult cancer, cardiovascular, and transplant patients and pediatric inpatients. For example, the art therapy program in the Taussig Cancer Institute helps individuals explore their emotions as they undergo treatment, and music therapy is provided to patients undergoing bone marrow transplant to help alleviate pain and anxiety during their hospital stay. Studio therapists also conduct out-patient art groups, an is provided open studio, and an art and occupational therapy group for spinal cord injured patients. Patients make art during their dialysis treatments as a help alleviate way to cope with treatments, restrictive lifestyles (i. Hospice of the Western Reserve offers a series of Healing Arts Workshops led by art therapists to help participants Community Partnership for Arts and Culture 32 Creative Minds in Medicine Participatory Arts and Health cope with grief through arts and culture activities such as the creation of remembrance quilts, craft objects and paper clay sculptures. Artists are sharing projects and engaging others in their work through arts-by-the-bedside programs and as artists-in-residence. Arts-by-the-bedside programs bring customized performances directly to patients’ bedsides. Artist-in-residence programs bring artists into healthcare settings in a more structured way for specifed periods of time, allowing for the artist to become more integrated into the hospital environment and deepen relationships with those they serve. Whereas expressive arts therapies work toward treating the physical and psychological reactions associated with disease, the interaction of the artist with a patient or the interaction of the patient with a particular artistic medium are seen as ends in themselves. The program welcomes world-class performers featured on the University of Florida Performing Arts’s season schedule into the hospital for residencies and performances. Over time, viewing sessions with patients yield increasingly refned image searches and selections based on each patient’s preferences. One of these, the Cleveland Clinic Arts and Medicine Institute, flls the hospital environment every day of the week with live performances from local musicians and arts and culture organizations. Its recently created Musicians-in-Residence program integrates a core group of local musicians into the hospital environment with regular performances in public spaces. For example, the Cleveland Museum of Art, the Alzheimer’s Association and the Cleveland Clinic offer “Art in the Afternoon” tours for individuals with memory loss and their care partners. Through partnerships with the Cleveland Institute of Art, the Cleveland Institute of Music, the Cleveland Orchestra and individual artists, Access to the Arts provides arts and culture programming to the ill and the elderly living in a range of healthcare facilities including nursing homes, hospitals, senior centers and retirement communities. The Cleveland International Piano Competition partners with the Cleveland Clinic, assumes Access to the Arts and the Golden Age Centers to give its contestants opportunities to perform recitals in area particular nursing homes, hospitals, hospices, senior centers and retirement communities. Community Partnership for Arts and Culture 34 Creative Minds in Medicine Participatory Arts and Health and the Elisabeth Severance Prentiss Center for Skilled Nursing Care at MetroHealth. At Eliza BryantVillage, residents create quilts to share memories and traditions and, through partnerships with organizations such as the Fatima Family Center, share them with the community. Judson, a nonproft retirement community in Cleveland’s University Circle area, has brought relationships its residents together with local students to form an ensemble that performs show tunes. Such activities are structured to meet the needs of each individual participant and are developed based on mutually agreed upon goals. Cleveland organizations use a wide variety of expressive arts therapies to bring about positive clinical outcomes for patients.

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Accordingly buy flagyl with amex antibiotics for pink eye, along with some drugs and minor surgery cheapest generic flagyl uk antimicrobial infection, following the nonnaturals was critical therapy order flagyl 200mg amex killer virus. Galen, who borrowed much from ments including gout, dyspepsia, and consumption, among others, the primary use of exercise was for prophylaxis (3). The classical Western medical notion that one could im- prove one_s health through one_s own actions V for example, Address for correspondence: Jack W. Ancient medicine made it clear to physicians and Current Sports Medicine Reports Copyright * 2010 by the American College of Sports Medicine laypeople alike that responsibility for disease and health was 1 Copyright @ 2010 by the American College of Sports Medicine. Every person, Treatment of Disease, Tissot argued for the importance of both either independently or in counsel with their physician, had active and passive exercises as well as the centrality of exercise the opportunity to attain and preserve health. Middle Ages gave way to the Renaissance, with its individu- In antebellum America, the ‘‘six things nonnatural’’ alistic perspective and its recovery of classical humanistic became known as the ‘‘Laws of Health and were put forward ideals, this notion of personal responsibility for health along with herbs and water cures as alternatives to the acquired even greater attention, and it was understood gen- ‘‘heroic’’ healing practices of drugging, bleeding, and purging erally that ‘‘we die by the way we live (6). He noted that he often saw people ‘‘whose inclination, situation, or employment does not admit of ex- Examples of a continuation of the nonnatural tradition and ercise, soon become pale, feeble, and disordered’’ and warned the necessity of exercise for good health abound in the med- that ‘‘idleness and luxury create more diseases than labour ical literature. It was an era when sleep and vigil, movement and rest, and the passions of the many laypeople and physicians alike had much faith in na- soul and alteration of the air’’ (37). In fact, the term ‘‘natural’’ was used in we use exercise under the conditions which we will describe, medical writing to signify a state of well being. And it is im- it deserves lofty praise as a blessed medicine that must be kept portant to understand that the Greek ‘‘physis’’ meant ‘‘nature’’ in high esteem (37). For cating the public on living habits all received attention in the some physicians in the 1700s, though, such intervention medical literature. In London, in the early 1700s, physician Francis Fuller The ‘‘Laws of Health,’’ or the nonnatural tradition itself, published Medical Gymnastics: A Treatise Concerning the Power found further expression in pre-Civil War America through a of Exercise. In his most poignant discussion of the role of new literature and profession devoted to ‘‘physical educa- exercise as medicine, he stated: tion. Its subject matter was obtain little Credit with most People, who tho_ they will give devoted to maintaining health (3). Books like Thoughts on a Physician that hearing when he recommends the frequent Physical Education by Transylvania medical school physician use of Riding, or any other sort of Exercise; yet at the bottom Charles Caldwell in 1834 (11) and Physical Education and look upon it as a forlorn method, and the Effect rather of Preservation of Health by Harvard medical school physician his Inability to relieve _em, than of his belief that there is John Warren in 1845 (50) helped birth the ‘‘physical educa- any great matter in what he advises: Thus by a negligent tion’’ movement in America. It was Warren who explained Diffidence they deceive themselves and let slip the Golden that it was ‘‘a general law, that health may be preserved to a Opportunities of recovering, by a diligent Struggle, what late period of life by the use of those things, which are could not be procured by the Use of Medicine alone (20). Most Similarly, in Scottish physician William Buchan_s highly diseases are the consequences of violations of the laws of popular Domestic Medicine, first published in 1769, he sug- nature, sometimes the result of ignorance, more frequently of gested that ‘‘of all the causes which conspire to render the life inattention’’ (50). He also explained that formation of the American Association for the Advancement ‘‘exercise alone would prevent many of those diseases which of Physical Education, a professional group founded by, domi- cannot be cured, and would remove others where medicine nated by, and presided over, by M. Later that century in Paris, French pointments at major universities like Johns Hopkins, Yale, physician Clement Tissot wrote Medical and Surgical Gym- and Harvard. With the subtitle of Essay on the Usefulness of Further, 12 of the 16 members of the Society of College Movement, or Different Exercises of the Body, and of Rest, in the Gymnasium Directors were M. In addition, the following year, 15 out of the 20 and those who were did not look at ‘‘physical education’’ as a members of the American Physical Education Association_s field of potential employment or one where their expertise National Council were physicians, including the President would be best utilized or appreciated. Most of the physicians who taught began to lose the attention previously displayed by many ‘‘physical education’’ took anthropometric measurements, pre- physicians. William White, a faculty member at At about this same time in the early 1900s, ‘‘physical edu- the University of Pennsylvania, wrote in Lippincott_s magazine cation’’ was beginning to experience a shift in emphasis from in 1887: ‘‘Let it be understood that the main object and idea body development and health instruction to games and sports. As such, basketball joined ical fitness’’ as we know it today, was Health, Strength & football, baseball, track and field, swimming, and tennis, Power, written by Harvard M. Now, to teach and exercise, health, and medicine was another University of coach these new games, schools and colleges needed men and Pennsylvania physician and physical educator_s book, Exercise women with expertise in one or more sports, not physicians. The new role of physical By the early 1900s, the field of medicine in the United education in high schools and colleges became viewed as States began to undergo significant changes. Priority was given to fighting infectious dis- America, and research in education, psychology, sociology, eases like yellow fever, smallpox, influenza, diphtheria, and anthropology, the moral and educational benefits of typhus, cholera, and tuberculosis, and to finding effective playing games overshadowed their health promotion values vaccines. Physical education became a sports skills curriculum and power and control, it became evident that hundreds of forged direct relationships with intramural, interscholastic, physicians were being trained at subpar colleges of medicine. And, as games and sports became This alarming trend was made more public by the Carnegie central to physical education classes, their competitive nature Foundation Report on Medical Education in 1910. Its author, catered to those students more highly skilled and neglected Abraham Flexner, recommended closing 120 of 155 medical the majority who were not athletically inclined. The problem schools as ‘‘worse than useless’’ and leveled a scathing blow on with using football, basketball, or softball as the subject mat- the profession (18). It Health’’ and began to promote his ‘‘Physical Culture Creed’’ was at this time too, that many in the medical community in the 1930s (16). Except for having seven ‘‘laws’’ instead of viewed competitive sports as being harmful or potentially six, Macfadden_s ‘‘creed’’ was identical to the ancient non- dangerous because the level of exertion generally exceeded naturals. Further evidence of the failure of the ‘‘new physical the rule of moderation basic to the ‘‘Laws of Health. That phys- that showed the poor fitness of American boys and girls when ical education had changed to accommodate sports started compared with those in Austria, Italy, and Switzerland. In another Carnegie Report, startling findings led to direct federal government inter- American College Athletics published in 1929, investigator vention with the formation of the President_s Council on Howard Savage found that only 23 out of the 177 college Youth Fitness in 1956 (4,27). This prompted Savage to state: ‘‘Of all the field of higher Like medicine in the early 1900s, the physical education education, physical education shows the largest number of profession came under more scrutiny in the early 1960s. In his members with the rank of professor who have only a bach- book The Miseducation of American Theachers in 1963, James elor_s degree or no degree whatever’’ (31). Savage concluded Koerner criticized the inferior intellect of faculty, said stu- by criticizing educators for redefining the purpose of physical dents in training spent too much time in methods courses, education, granting coaches faculty appointments, and pre- and lamented nonacademic subjects like physical education paring coaches to fill positions as physical educators. That same year, in yet similar study of high school sports in the early 1930s, it was another Carnegie Foundation Report, The Education of found that in 90% of the 760 schools surveyed, the physical American Theachers, author James Conant criticized under- education director and football coach were the same person graduate programs for offering courses in football funda- (31). The ‘‘Sports Creed’’ emphasizing citizenship, teamwork, mentals and advanced basketball, but was harsher when he character, democratic living, and sportsmanship had replaced discussed graduate education. He wrote: ‘‘If I wished to portray the ‘‘Laws of Health’’ as the focal point for physical education the education of teachers in the worst terms, I should quote (15). And, as that took place, the new physical education from the descriptions of some graduate courses in physical curriculum focusing on competitive sports required the hiring education’’ (12). Conant went on to conclude: ‘‘To my mind, a of coaches, not physicians, and favored those students blessed university should cancel graduate programs in this area’’ (12). Deans and department chairs of several Big 10 come apparent as early as World War I when one third of the universities who had come to the same conclusions as Con- 3 million drafted were deemed physically unfit, and those ac- ant, albeit 10 yr earlier, agreed with Henry and reacted with a cepted had to be taught the basic rudiments of hygiene and flurry of changes in the late 1960s. There also were those within physical education, admission standards, departmental reorganization, and an like professor Charles McCloy, an exercise physiologist at emphasis on research were examples. More importantly, the State University of Iowa, who believed his colleagues though, the call for more rigorous programs led to a search for had gotten carried away with sports and games and argued in a legitimate field of study. How could physical education the professional literature for a return to the goals of bodily become an academic discipline?