By T. Wilson. Simmons College.

Compromise is certainly accept- uninitiated members of the lay public and gradually acquire able on occasion buy sinemet 125 mg without prescription medicine lyrics, and for good reason sinemet 125 mg without prescription treatment emergent adverse event. This happens in parallel frst” becomes a pattern of behaviour, the health of the with the transformation from non-expert to expert clinician. This issue In recognition of this, there are different expectations for phy- must be addressed openly during training. As stu- fact that limits must be placed on the expectations of all dents and residents accept increasing levels of responsibility parties to the social contract. Expectations and obligations: situations that arise, and that they can make the often diffcult professionalism and medicine’s social contract with society. Training programs bear a heavy responsibility in ensuring that unreasonable demands are not chronically imposed upon residents, and that tensions concerning professional versus personal priorities are discussed openly throughout a resident’s training. Behavioural patterns that are detrimental to a healthy lifestyle are often set during residency training. On a more positive note, being aware of the tensions that inevitably arise in practice, and having an opportunity to refect on them in a supportive environment, can help to establish patterns of behaviour that both preserve the professionalism of medicine and lead to healthy patterns of living. The impact of long duty hours Working around the clock can be socially, physically and psy- Case chologically challenging. Long duty hours can lead to isolation A frst-year resident feels life is like a runaway train. They from friends and support networks, straining relationships and feel tired and irritable all the time, and their world is over- preventing physicians from maintaining former activities and fowing with medicine (facts, patients, readings, rounds, connections. Extensive time at work can tax one’s energy and procedures, test results, assignments and call). The resident lead to irritability, depressed mood, substance abuse and other misses their family, cooking a good meal, and having time mental health problems. They can’t re- around the clock are a risk factor for weight gain, immune dys- member their last workout. The resident could use a good function, infertility, diabetes, gastrointestinal complaints and night of sleep, too, but they are on call again tonight and coronary artery disease. The resident is starting duty hours such as years of shiftwork involving night shifts to fnd patients and their complaints annoying. When they and sleep loss have been equated with smoking a pack of ciga- observe their supervisor they are working with today, the rettes per day. Working outside of regular business hours, as in resident notices the supervisor looks just as tired. The doing call or shiftwork, disrupts the circadian rhythms critical resident wonders if they are cut out for medicine. Introduction That medical practice is characterized by intense and long Work hours and fatigue work hours is an understatement. Patients do not choose the Traditionally, fatigue was thought to be a simple equation: fa- hour they become ill, and twenty-frst century medicine is a tigue = hours of work. Physician shortages, an aging population, fatigues one person one day might not have the same impact and diffculties accessing health care mean that the patients on someone else, or even on the same person in other circum- physicians see have increasingly complex needs and are sicker. Fatigue is perhaps better thought of as a function of The exponential growth in medical knowledge and technology an interaction of different factors (see textbox): the individual also place greater demands on physicians, and physicians-in- (e. In the 2007 Canadian National Physician Survey, work, and this can lead to inattention or medical error, putting the mean reported time spent on professional duties, before patients at risk (Crosskerry 2008). Over the longer term, physi- call, was about 51 hours per week across all specialties, practices cian fatigue can lead to mental or physical health problems, and ages. Sixty-one percent of physicians also reported work- burnout, and exit from practice. Physicians-in-training, with Strategies to cope with long work hours a few short years to prepare for practice, typically spend 60, 80 What can a physician do to mitigate the effects of long work or more hours on duty every week, depending on the specialty hours? These long hours of duty put physicians numbers of physicians, and cures for diseases, medicine will at risk for a number of negative consequences. However, the fve general strategies described below can support healthy work habits, counteract the effects of fatigue, promote safe practice, and avert burnout (see chapter 11-E).

In this equation order sinemet 300 mg with amex symptoms diagnosis, xi is the numeri- cal value of the i th data point and n is the total number of data points cheap 110mg sinemet visa symptoms 6 weeks pregnant. These are extreme numbers on either the high or low end of the distribution that will produce a high degree of skew. There will not be a truly representative central value if the data are highly skewed and the mean can misstate the data. It makes more sense to 100 Essential Evidence-Based Medicine Fig. The mean should not be used for ordi- nal data and is meaningless in that setting unless the ordinal data has been shown to behave like continuous data in a symmetrical distribution. This is a common error and may invalidate the results of the experiment or portray them in a misleading manner. It should be used when deal- ing with ordinal variables or when the data are highly skewed. The mode is the most common value or the one value with the largest number of data points. It is used for describing nominal and ordinal data and is rarely used in clinical studies. The stan- dard error of the mean is a measure that describes the dispersion of a group of samples. It should be given whenever there is either a large spread of data values with many outliers or when the range is asymmetrical about the value of central tendency. The lowest quarter of values lie below the lower quartile or 25th percentile, the Review of basic statistics 101 lower half below the 50th percentile, and the lowest three-quarters below the upper quartile or 75th percentile. The interquartile range is the range of values from the 25th to the 75th percentile values. It is the average of the squares of the difference between each value and the mean or the sum of the squares of the difference between each value and the mean divided by n (the number of data points in the sample). Populations and samples A population is the set of all possible members of the group being studied. The members of the population have various attributes in common and the more characteristics they have in common, the more homogeneous and therefore restrictive the population. An example of a fairly restricitive population would be all white males between 40 and 65 years of age. With a restrictive population, the generalizability of the population is often a problem. The less the members of the sample have in common, the more generalizable the results of data gath- ered for that population. For example, a population that included all males is more generalizable than one that only includes white males between 40 and 65 years of age. An example could be all white males available to the researcher on a given day for a study. Reasons to use a sample rather than the entire population include convenience, time, cost,andlogistics. The sample may or may not be representative of the entire population, an issue which has been discussed in the chapter on sources of bias (Chapter 8). Histograms or frequency polygons show how many subjects in a sample or population (the y-axis) have a certain characteristic value (the x-axis). When plotted in this manner, we call the graph a distribution of values for the given sample. By definition, a symmet- rical distribution is one for which the mean, median, and mode are identical. They are said to be skewed to the right (positive 102 Essential Evidence-Based Medicine Fig. Skew should be discussed when presenting and evaluating data and the range of the data given in addition to the standard measures of central tendency and dispersion.

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Of adults with acute hepatitis B discount sinemet 110mg fast delivery treatment pneumonia, 61% reported having missed an opportunity for vaccination (Williams et al cheap 110 mg sinemet visa treatment leukemia. Low coverage of high-risk adults is attributed to the lack of dedicated vaccine programs, limited vaccine supply, inadequate funding, and noncompliance by the involved populations (Mast et al. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. In-Figure 4-1, editable terventions are more cost-effective as one moves down (lower age) and to the right (higher incidence). The researchers collected data on patient visits and hepatitis B vaccinations for Copyright © National Academy of Sciences. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Possible reasons for the decline include fscal constraints and increasing rates of prior vaccination. Thus, foreign-born adults may be at high risk for acquiring hepatitis B, and women may transmit the virus to their newborns. Foreign-born adults would beneft from laboratory testing to determine their infection status and subsequent hepatitis B vaccination of susceptible people. Vaccine uptake was highest when it was provided on site and during the initial study visit (Campbell et al. A New Haven mobile health van at a needle-exchange program found that 66% of those initially offered the hepatitis B vaccine completed all three doses (Altice et al. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Studies of vaccine protocols show that completion rates are substantially higher when vaccination is offered at such a location as a needle-exchange program. The study also found an unexpect- edly high rate of chronic hepatitis B infections (3. Four of those states require vaccination of all inmates, and 16 require only that juvenile inmates be vaccinated. Several studies reported that if offered the hepatitis B vaccine, most inmates (60–93%) would agree to be vaccinated (Rotily et al. In a study of inmates in Denmark, 63% completed the hepatitis B vaccination series on an accelerated 3-week schedule compared with 20% of those on a 6-month schedule (Christensen et al. Thus, immunization of incarcerated people could potentially prevent nearly one-third of all acute hepatitis B cases in the United States. Although most prison systems in the United States do not provide universal hepatitis B vaccination for inmates, Charuvastra et al. Although the length of stay is shorter in jails than in prisons, offering hepatitis B vaccination to jail inmates is feasible and provides a beneft to the community after the inmates are released. Substantial protec- tion is provided after even one or two of the three doses of the series. It is important to have a health-record system that tracks immunizations so that the vaccine series can be continued if later incarcerations occur. Ideally, im- munizations administered in jails will be captured in an adult immunization registry (see discussion on immunization-information systems below) so Copyright © National Academy of Sciences. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. The committee did not fnd data on rates of hepatitis B vac- cination of institutionalized developmentally disabled people. Identifying At-Risk Adults As discussed above, recommendations regarding childhood hepatitis B vaccination are aimed at achieving universal coverage, and recommenda- tions regarding adult vaccination focus on the identifcation of risk popula- tions for targeted immunization efforts.

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Case As seductive as the practise of medicine can be generic 110mg sinemet with visa symptoms ibs, Michael Myers A resident requests a meeting with their supervisor over reminds us to “say yes to the relationship and practise say- coffee 125mg sinemet for sale medicine 377. The resident becomes distraught while disclosing ing no to other offers” (Myers 2001). Spend a minimum of that she miscarried her frst pregnancy three weeks ago twenty minutes alone with your spouse each day and plan a and that her partner, a more senior resident, is preoccu- date together every week. The resident acknowledges that her partner has tried Monica Hill and Nancy Love quote the novelist Henry James to be supportive, but feels that “he just doesn’t get it. Unbalanced criticism, defensiveness, Successful marriages and similar partnerships are built on ridicule, a posture of superiority, and “shutting off ” are poi- knowledge, friendship, fondness and admiration (Gottman sonous to this process (Hill and Love 2008). For physicians as for anyone else, this means having population, domestic violence and abuse occurs in medical time together to develop the essential advantage of such rela- families too. It includes affection, expressiveness, sexuality, cohesion, compatibility, autonomy Dual-physician relationships and confict resolution (Myers 2001). Confict between work and familial roles is inevitable at times, whether one or both partners are physicians. Classically, role Work and family life strain has been more frequently noted among female physi- The issue of deferring intimacy in favour of medical work has cians, but in reality male physicians experience it as well. Half been described in the literature on medical marriages (Myers of married women physicians are married to other physicians 2001 and Gabbard 1989). Dual-physician relationships bring sional advancement over the nurturing of intimate relation- certain challenges, such as complicated schedules and career ships, working long hours at the expense of their home lives. Careers postpone their investment in the “emotional bank account” of can be shaped, reshaped and salvaged more easily than rela- their families or in some cases, avoid admitting that they in fact tionships and families. Paradoxically, however, “the marital interests can be satisfying, which can lead to greater mutual relationship is the main source of coping with the stress of understanding, support and shared parenting (Schrager et al medical practice” (Gabbard 1989). It would seem, however, whether by preference, mutual decision or default, that women physicians continue to take Physicians who enjoy successful intimate partnerships learn more responsibility on the home front than their male counter- early that certain attributes that serve them well at work are parts. For example, while physicians of female physicians being the primary or sole income earner are accustomed to their role as experts and expect to be in in their households. In contrast to Protecting and nurturing our intimate relationships may require most physicians’ experience of medical education, marriage is a re-examination of our professional responsibilities and work non-competitive. As you develop your resident group or consider Relationships, however, do require work in realtime, a sense of your eventual practice setting, keep these questions in mind: humour, and a degree of luck. John Gottman, a respected re- • Does your group discuss shock-absorber systems for searcher in marriage and relationships, stresses the importance parental leaves and urgent family issues? She had speculated that a child would keep geographical triangle: home, school and workplace. Keeping her relationship together, given her partner’s attraction to logistics as simple as possible will beneft your marriage and “more medicine” and achievement. He expresses fear of giving in Raising children together to his feelings lest they derail his career focus. With the For many women physicians, the question of when to plan counsellor’s help, they review their priorities with regard childbearing is especially challenging when training demands to career plans and the timing of child-bearing. Supportive sessions lead to a better understanding of their mutual colleagues and training programs are nearly as important as a objectives, and of the supports available to them to help supportive partner. Furthermore, resi- dency training directors never accompany graduated residents impact on your family, whose sleep is being disturbed by the to the infertility clinic. The concept that it takes a village to raise a child applies to medical families, too. Women physicians are particularly aware Vacations are one of the non-urgent but important elements that the more they work, and the greater number of children of time management. Vacations in which play and fun—and they choose to have, the greater the chance that they will need not perfection—are modelled, where being rather than doing to rely on child care arrangements beyond the family. Many are valued and pleasure for its own sake is enjoyed, are healthy women physicians and dual-career couples fnd live-in help with for the whole family (Maier 2005) regard to child care invaluable. External assistance with regard to other household duties can also be a time-management tool Summary that benefts everyone. Managing the expectations of our partners and others can be problematic in medical relationships. Some of these expecta- Two points to remember when your medical relationship is tions may be fnancial, arising from assumptions about what blessed with children are these: the lifestyles of physicians will be.

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