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The beam forcing the pioneers to innovate (seated position purchase zoloft 25 mg on line, emittance could be in the range 2 to 5 pi zoloft 25 mg visa. The beam is switched from one In the 1990s the frst full 360 solution appeared buy generic zoloft 50 mg online, room to another via a dipole; the beam is thus only called gantry, a big mechanical structure rotat- available for one room at a time. This constraint is ing around the patient (weighing between 80 and acceptable during treatment hours because the time 150 tons). The limits of this technique are that it is not optimal in terms of the conformity of 4. The scatterers spread by modifying the energy of the beam (directly for the originally Gaussian beam into a wide homo- synchrotrons or through energy selection system for geneously distributed beam that is shaped to the cyclotrons) for the diferent slices of the tumour. The dose- The scanning technique is a kind of 3D scanning of depth curve (the so-called Spread-Out Bragg Peak, the treated volume. Constraints are, however, the complexity (speed, number of checks) and the sensitivity towards organ motion. In both methods, non-invasive instrumentation, mainly ionisation chambers, is used to count and monitor the beam. Displacement from the planned position of the mean recorded position for each spot position and mean displacement the lateral and distal penumbras of the beams are from the planned position for all recorded spots at one specifc 26 the important criteria. But these References performances must also be linked with the associ- ated system and procedures: Treatment Planning [1] J. Use of treatment log fles particle interactions in the beam delivery system in spot scanning proton therapy as part of or upstream, and safety and reliability. Magnetic scanning opment of particle therapy [5]; the charge particle system for heavy ion therapy, Nucl. But the promised Eldorado has to confront certain compromises: very thin and fast beams vs uncertainties of physiological and moving organs, advanced and innovative techniques vs high expectations in patients throughput linked with the cost of the facilities, systems developed and set by the industry vs research & development by academic institutions. Frequently, the active volume In order to standardise the reference dosimetry of ionisation chambers is flled with air and the between diferent therapy centres international pro- response is corrected for the atmospheric pressure. In general no conversion is not only the reference dosimetry but also delivery coefcients or correction factors are required in of tools for acceptance, testing and commissioning measurements since it is only the comparison of of treatment beam lines and treatment planning sys- two dosimeter readings, one of them being in ref- tems, periodic quality assurance checks and fnally erence conditions. This can be performed by scanning with a detector along the z-axis in a water phan- 5. One solution is a set tigate the signifcance of secondary and scattered of plane-parallel chambers (multi-layer ionisation radiation additional tools may be necessary; espe- chamber), separated by the absorbing layers in such cially if the goal is to assess the contribution from a way that the entire structure has efectively the diferent types of secondary radiation. In hadron- same stopping power (range) as the corresponding therapy the production of neutrons (and heavier water phantom. An alternative quantify for each specifc beam line and collimator 28 solution for quick depth dose measurements is setting. In passive The sharp gradient of depth dose distributions beam delivery systems there are a number of flters and the application of scanning beams stimulated and collimators in which secondary radiation is the development of two and three dimensional produced, while in active scanning systems, beam dosimetry (2D and 3D) systems. One of the interactions with the patients themselves are in important tools for scanning beams is a matrix of principle the only signifcant source of secondary ionisation chambers, able to work as beam profle radiation. The out-of-feld doses can vary by several monitors or for 2D dose distribution in water. The sensitive area scintillators for timing signals in combination of the detector is 160 x 160 mm2, with the anode with a BaF -detector. For in-phantom measure- 2 segmented in 1024 square pixels arranged in a 32 x ment quantifying the neutron dose and out-of-feld 32 matrix; the area of each pixel is 5 x 5 mm2. More advanced (but more and to measure the stability and reproducibility of bulky) neutron detector systems include Bonner the delivery system. New develop- ments based on ionisation chambers with a micro pattern readout (Micro Pattern Gaseous Detectors, 5. Extremely high-granularity determine profles of charged particle beams since tracking calorimeters for the detection of charged the beginning of the use of accelerators. Such a compact detector will be a single device performing tracking, particle identifcation and energy (range) measurements simultaneously. It consists of many (~50) layers of thin Si-pixel sensors sandwiched between absorbing layers. Because of the extremely large number of cells (~1014) the device will be able to cope with a large particle fux without saturation efects. References [1] International Atomic Energy Agency, Absorbed Dose Determination in External 29 Beam Radiotherapy, Technical Report Series No. Also lateral motion can change the radiological depth when dif- Cancer of organs afected by breathing motion such ferent tissues have to be traversed by the beam to as lung or liver causes a large fraction of all deaths by reach the target. This efect is especially severe in the cancer, and typically these cancers also show a very lung, where low-density lung tissue can be replaced poor prognosis. The time scale of this motion is sec- by sof tissue of either tumour or adjacent organs. This For successful treatment of moving organs, the causes severe, highly variable deviations of the deliv- motion has to be assessed through volumetric imag- ered dose. The patient is positioned and his breathing motion monitored (C); the dose is delivered with a motion compensation scheme, C D here shown for tracking (D). Current studies are limited to the opti- repeated imaging, other modalities would be of use. A widely applied strategy for tumour motion detec- Point-based and surface-based external localisation tion relies on implanted markers, which are detected has been used for motion detection and continuous by single or multiple X-ray imaging for localisation localisation of internal moving structures. Achievable accuracy is a few mil- abdominal motion is well correlated with the supe- limetres, especially if multiple views are used. A rior inferior motion of inner anatomical structures non-ionising, real-time alternative uses implanted due to breathing. Surface detection techniques to transponders, continuously detected by external capture the whole thoraco-abdominal skin surface electromagnetic receivers. Although typical appli- in a snapshot provide redundant information from cations are in prostate cancer radiotherapy,the use which robust tumour motion can be achieved. The polynomial correlation as well as machine learning dense markers lead to difcult-to-compensate range methods have been proposed with diferent level of deviations, with documented critical dosimetric complexity. Low atomic number mate- patient-specifc and time-dependent, thus requir- rials together with specifc implantation criteria ing a frequent verifcation of model estimation and (perpendicular to the beam axis) may reduce dose on-line adaptation of correlation parameters to perturbation, but markers raise serious concerns, encompass intra-fraction breathing irregularities. In contrast to photon therapy, the above- Non-ionising alternatives include ultrasound for mentioned range changes also have to be included real-time detection with millimetre accuracy. The in the margins, for which several strategies have main drawback is that image quality is operator- been explored. Time-resolved dose calculation requires several A diferent approach also resulting in a reduced input parameters available ofen only afer irra- residual motion is gating. The timing and beam positions of dose only if the target is within a pre-defned range, the delivery has to be correlated to actual, measured so-called gating window. This kind of of the gating window only a certain fraction of the precise re-calculations can be helpful for adaptive breathing cycle is available for irradiation. Robustness of both motion compensation and A promising alternative, but still in early stages of monitoring remains an issue of ongoing research. References This potentially results in conformal target cover- age also for complex motion patterns that are not [1] C. The rescanning also increases the robustness of the method, as other variable errors are also averaged. Similar to rescanning, fractionation also leads to averaging of random dose errors, though inhomo- geneous fraction doses have to be accepted. Tese studies show that densely Biologically-optimised treatment plans are ofen ionising radiation induces a high fraction of clus- discussed in radiotherapy [1]. Tese efects are now the mainstream optimisation of the physical treatment plan for a research topic in particle radiobiology [2]. Clinical implementation of biologically-optimised plans is ofen hampered by the uncertainties in radiobiology. The inset shows a zoom of the distal penumbra, and the green line the increased range predicted by the biological model. Recent in vascular endothelial cell apoptosis is rapidly acti- vitro studies show indeed that carbon ions are more vated above 10 Gy per fraction [3], and that the efective than X-rays in killing stem cells from colon ceramide pathway orchestrated by acid sphingo- and pancreas cancers. Moreover, preliminary results myelinase is a major pathway for the apoptotic indicate an increased efectiveness of low-energy response.

This woman had an endoscopy which showed oesophagitis purchase 100mg zoloft with mastercard, and treatment with omepra- zole and an alginate relieved her symptoms zoloft 100mg line. These headaches have been present in previous years but have now become more intense buy 50mg zoloft free shipping. She also complains of loss of appetite and difficulty sleeping, with early morning wak- ing. She has had eczema and irritable bowel syndrome diagnosed in the past but these are not giving her problems at the moment. Examination of the cardiovascular, respiratory and gastrointestinal systems, breasts and reticuloendothelial system is normal. The headache is usually bilateral, often with diffuse radiation over the vertex of the skull, although it may be more localized. Patients may show symp- toms of depression (this woman has biological symptoms of loss of appetite and disturbed sleep pattern). Sufferers may reveal sources of stress such as bereavement or difficulty with work. There may be an element of suggestion as in this case, with concern that she may have inherited a brain tumour from her mother. Major differential diagnoses of chronic headaches Classic migraine: characterized by visual symptoms followed within 30 min by the onset of severe hemicranial throbbing, headache, photophobia, nausea and vomiting lasting for several hours. The onset is usually in early adult life and a positive family history may be present. It characteristically occurs 1 2h after sleeping, and lasts 1 2h and recurs nightly for 6 8 weeks. There will often be other signs, including personality change and focal neurological signs. It is important to come to a clear diagnosis and to address the patient s beliefs and con- cerns about the symptoms. The question of depression needs to be explored further and may need treating with antidepressants. Two months earlier he had been admitted with a productive cough and acid-fast bacilli had been found in the sputum on direct smear. He was found a place in a local hostel for the homeless and sent out after 1 week in hospital on antituberculous treatment with rifampicin, isoniazid, ethambutol and pyrazinamide together with pyridoxine. His chest X-ray at the time was reported as showing probable infiltration in the right upper lobe. This might have occurred because he had a resistant organism or, more likely, because he had not taken his treatment as prescribed. Other possi- bilities would be liver damage from the antituberculous drugs and the alcohol, although clinical jaundice would be expected, or electrolyte imbalance. If these are not present a lumbar puncture would be indicated, provided that there is no sign to suggest raised intracranial pressure. It is now 2 months since the initial finding of acid-fast bacilli in the sputum and the cul- tures and sensitivities of the organism should now be available. These should be checked to be sure that the organism was Mycobacterium tuberculosis and that it was sensitive to the four antituberculous drugs which he was given. The urine will be coloured orangy-red by metabolites of rifampicin taken in the last 8 h or so. Comparison with his old chest X-rays showed extension of the right upper-lobe shadow- ing. It is difficult to be sure about activity from a chest X-ray but extension of shadow- ing is obviously suspicious. A direct smear of the sputum showed that acid-fast bacilli were still present on direct smear. The breathlessness persisted over the 4 h from its onset to her arrival in the emergency department. There is no relevant previous medical history except asthma controlled on salbutamol and beclometa- sone. She works as a driving instructor and had returned from a 3-week holiday in Australia 3 weeks previously. The phys- ical signs of tachypnoea, tachycardia, raised jugular venous pressure and pleural rub would fit with a diagnosis of a pulmonary embolus. The peak flow of 410 L/min indicates that asthma does not explain her breathlessness. The differential diagnosis would include pneumonia, pneumothorax and pulmonary embolism. Possible predis- posing factors for pulmonary embolism are the history of a long aeroplane journey 3 weeks earlier, oral contraception and her work involving sitting for prolonged periods. Other signs such as transient right ventricular hypertrophy features, P pulmonale and T-wave changes may also occur. A ventilation perfusion lung scan could be done looking for a typical mismatch with an area which is ventilated but not perfused. A pulmonary arteriogram has been the gold standard for the diagnosis of embolism but is a more invasive test. In cases with a normal chest X-ray and no history of chronic lung disease, equivocal results are less common and it is not usually necessary to go further than the lung scan. This showed a filling defect typical of an embolus in the right lower lobe pulmonary artery. A search for a source of emboli with a Doppler of the leg veins may help in some cases, and the finding of negative D-dimers in the blood makes intravascular thrombosis and embolism unlikely. The anticoagulation can then transfer to warfarin, continued in a case like this for 6 months. Alternative modes of contraception should be discussed and advice given on alternating walking or other leg movements with her seated periods at work. Thrombolysis should be considered when there is haemodynamic compromise by a large embolus. The pain is in the centre of the chest and has lasted for 3 h by the time of his arrival in the emergency department. He has been treated with aspirin and with beta-blockers regularly for the last 2 years and has been given a glyceryl trinitrate spray to use as needed. His father died of a myocardial infarction aged 66 years and his 65-year-old brother had a coronary artery bypass graft 4 years ago. Examination He was sweaty and in pain but had no abnormalities in the cardiovascular or respiratory systems. He was given analgesia and thrombolysis intravenously and his aspirin and beta-blocker were continued. On examination, now his jugular venous pressure is raised to 6 cm above the manubrioster- nal angle. On auscultation of the heart, there is a loud systolic murmur heard all over the praecordium. In the respiratory system, there are late inspiratory crackles at the lung bases and heard up to the mid-zones. The late inspiratory crackles are typical of pulmonary oedema and the chest X-ray confirms this showing hilar flare with some alveo- lar filling, Kerley B lines at the lung bases and blunting of the costophrenic angles with small pleural effusions. The first four of these could produce pulmonary oedema and a raised jugular venous pressure as in this man. Pulmonary embolism would be compatible with a raised jugular venous pressure but not the findings of pulmonary oedema on examination and X-ray. Acute mitral regurgitation from chordal rupture and ischaemic perforation of the inter- ventricular septum both produce a loud pansystolic murmur. The site of maximum inten- sity of the murmur may differ being apical with chordal rupture and at the lower left sternal edge with ventricular septal defect, but this differentiation may not be possible with a loud murmur. The management of acute ventricular septal defect or chordal rupture would be similar and should involve consultation with the cardiac surgeons. Milder degrees of failure with a pansystolic murmur may occur when there is ischaemia of the papillary muscles of the mitral valve. This is managed with anti- failure treatment, not surgical intervention, and can be differentiated by echocardiography. He has complained of general pains in the muscles and he also has some pains in the joints, particularly the elbows, wrists and knees. Three weeks earlier, he fell and hit his leg and has some local pain related to this.

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In severe alkalosis purchase 50mg zoloft amex, which is compensated for by renal excretion overdose disorders of consciousness occur progressing of bicarbonate and potassium generic zoloft 100mg with amex. Thecombinationofthemetabolicandrenaleffects Cerebral oedema and pulmonary oedema cheap zoloft 25 mg free shipping, which may be result in a metabolic acidosis. Investigations Blood glucose, blood gases, U&Es, prothrombin time Clinical features and bicarbonate levels should be measured. Treatment Patients may appear asymptomatic even in the pres- is based on plasma salicylate levels (>500 mg/L (3. Gastrointesti- Activated charcoal may be considered in conscious pa- nal haemorrhage may require blood replacement and tientswithin1hourofingestionandconsumptionabove metabolic acidosis should be corrected. Symptomatic patients with moderate (3 5 mg/L or Haemodialysis is used if plasma salicylate level is 700 55 90 mol/L) or severe (>5 mg/L or 90 mol/L) mg/L (5. Patients who have not developed symptoms by 6 hours following ingestion are unlikely to have had a signicant overdose and do not require further Iron overdose monitoring. Aetiology Iron poisoning is usually seen in childhood and results Tricyclic antidepressant overdose from accidental ingestion of iron-containing medica- Denition tions such as vitamin preparations mistaken for sweets. Patients may de- Incidence/prevalence velop nausea, vomiting, abdominal pain and diarrhoea. Late signs in severe overdose include hypotension, coma, hy- Pathophysiology poglycaemia and hepatocellular necrosis. Tricyclic antidepressants have anticholinergic, alpha- adrenergic blocking, and adrenergic uptake inhibiting Investigations properties. They also have a quinidine like effect on the Aserum iron level (ideally at 4 hours after ingestion) is myocardium. Clinical features Araised neutrophil count and serum glucose suggests r Common features include hot, dry skin, dry mouth, toxicity. There may r In severe poisoning (unconscious or hypotension) be increased tone, increased deep tendon reexes and intravenous uids and desferrioxamine (a chelating extensor plantar responses. If the patient is comatose, agent for iron) should be commenced immediately all reexes may be absent. Lithium overdose r Confusion, agitation and visual hallucinations may Denition occur during recovery. Lithium poisoning usually results from chronic drug ac- cumulation, accidental or deliberate overdose of lithium Complications carbonate. Aetiology/pathophysiology Investigations Lithium has a narrow therapeutic index (the levels at Arterial blood gases to check both pH and bicarbonate which it becomes toxic are only marginally higher than levels. U&Es and urine output duce toxicity, as may concomitant use of nonsteroidal should be monitored. Management Clinical features r Patients should be stabilised with management of air- Thereisgoodcorrelationbetweensymptomsandplasma way, breathing and circulation as required. Intravenous lidocaine may be Investigations of benet in treatment of cardiac arrhythmias; how- Serum lithium levels should be measured if chronic toxi- ever, it may precipitate seizures. Refractory should be taken 6 hours post-ingestion and 6 12 hourly seizures require intubation, ventilation, paralysis and thereafter. Persisting hypotension may require intravenous u- ids, glucagon bolus and infusion (corrects myocardial depression) and in severe cases inotropes. Management In chronic accumulation, stopping lithium is often all Prognosis that is needed to alleviate symptoms; however, patients Tricyclic antidepressant overdose carries a high mor- may require other treatments for bipolar disorder. All patients should be surviving patients most cardiac complications resolve observed for a minimum of 24 hours post-ingestion. The mortality in chronic poisoning is 9%, but as high r In severe poisoning the treatment of choice is as 25% in acute overdose. Clinical symptoms may per- haemodialysis which is considered if there are any sist after the serum lithium levels have fallen and 10% of neurological features or if very high plasma levels are patients with chronic poisoning have long-term neuro- detected. Index Note: page numbers in italics refer to gures, those in bold refer to tables. Until now, Life Extension could cite only isolated statistics to make its case about the dangers of conventional medicine. A group of researchers meticulously reviewed the statistical evidence and their findings are absolutely shocking. This fully referenced report shows the number of people having in-hospital, adverse reactions to prescribed drugs to be 2. The number of unnecessary antibiotics prescribed annually for viral infections is 20 million per year. The number of unnecessary medical and surgical procedures performed annually is 7. The most stunning statistic, however, is that the total number of deaths caused by conventional medicine is an astounding 783,936 per year. The article uncovered so many problems with conventional medicine however, that it became too long to fit within these pages. We placed this article on our website to memorialize the failure of the American medical system. By exposing these gruesome statistics in painstaking detail, we provide a basis for competent and compassionate medical professionals to recognize the inadequacies of today s system and at least attempt to institute meaningful reforms. Natural medicine is under siege, as pharmaceutical company lobbyists urge lawmakers to deprive Americans of the benefits of dietary supplements. Drug-company front groups have launched slanderous media campaigns to discredit the value of healthy lifestyles. These attacks against natural medicine obscure a lethal problem that until now was buried in thousands of pages of scientific text. In response to these baseless challenges to natural medicine, the Nutrition Institute of America commissioned an independent review of the quality of government-approved medicine. The startling findings from this meticulous study indicate that conventional medicine is the leading cause of death in the United States. The Nutrition Institute of America is a nonprofit organization that has sponsored independent research for the past 30 years. What you are about to read is a stunning compilation of facts that documents that those who seek to abolish consumer access to natural therapies are misleading the public. A definitive review of medical peer-reviewed journals and government health statistics shows that American medicine frequently causes more harm than good. Besser spoke in terms of tens of millions of unnecessary antibiotics prescribed annually. Any invasive, unnecessary medical procedure must be considered as part of the larger iatrogenic picture. The figures on unnecessary events represent people who are thrust into a dangerous health care system. Working with the most conservative figures from our statistics, we project the following 10-year death rates. Table 3: Estimated 10-Year Death Rates from Medical Intervention 10-Year Condition Author Deaths Adverse Drug Reaction 1. Our projected figures for unnecessary medical events occurring over a 10-year period also are dramatic. Medical science amasses tens of thousands of papers annually, each representing a tiny fragment of the whole picture. To look at only one piece and try to understand the benefits and risks is like standing an inch away from an elephant and trying to describe everything about it. Each specialty, each division of medicine keeps its own records and data on morbidity and mortality. We have now completed the painstaking work of reviewing thousands of studies and putting pieces of the puzzle together. Because of the extraordinarily narrow, technologically driven context in which contemporary medicine examines the human condition, we are completely missing the larger picture. Medicine is not taking into consideration the following critically important aspects of a healthy human organism: (a) stress and how it adversely affects the immune system and life processes; (b) insufficient exercise; (c) excessive caloric intake; (d) highly processed and denatured foods grown in denatured and chemically damaged soil; and (e) exposure to tens of thousands of environmental toxins. The huge disservice of this therapeutic strategy is the result of little effort or money being spent on preventing disease. Underreporting of Iatrogenic Events As few as 5% and no more than 20% of iatrogenic acts are ever reported. In 1994, Leape said his figure of 180,000 medical mistakes resulting in death annually was equivalent to three jumbo-jet crashes every two days.

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We know that physicians order 25 mg zoloft overnight delivery, as a group generic zoloft 50 mg amex, do not avail themselves of a regular source of health care purchase 50mg zoloft. When feeling stressed and overwhelmed, physicians may turn to the use of substances as a means of coping. Physicians feel unable to access help either for the originating problem, or for the resulting dependency without feeling ashamed and humili- ated. Parsons emotional or mental health problem during residency, Objectives and This section will 36 per cent reported that they did not have a family examine the importance of physician health to the quality physician (Cohen 2004). This has come to the atten- pecting it all, tion of the program director through preceptors, who have excessive workload and too little control of work both been practising medicine for over 25 years. These threats can contribute to of Neurosciences, Mental Health and Addiction, showed the job stress. The risks for disease and injury are as high or link between work organization and mental health problems higher for physicians as for other workers. Brian Day has stated, The health of Canada s The economic benefts of promoting physician health should doctors is crucial to the provision of high-quality health care not be overlooked. In 2003 04, 34 per cent of the almost 2000 resident physicians Patient safety who participated in the Happy Doc pilot survey reported that Of obvious concern in relation to physician health and wellness their daily lives were quite a bit to extremely stressful. Physicians who are struggling with of respondents said they would pursue another career if they unmanaged mental or physical problems put both themselves could, and 53 per cent said that they had experienced intimida- and their patients at risk. Thus, an important stressor for physicians is The resident discussed with the program director family concern about their ability to provide optimal care for their stresses combined with a heavy clinical workload which patients (Wallace et al 2007). The director recommended a visit to the family management at McMaster University, Exhaustion and illness doctor for assessment. No physical or mental illness was in the workplace can lead to errors in judgment, diffculty in detected. The family doctor recommended a balanced making decisions, increased social friction because of irritability diet, exercise and spending time with family. Andrew Padmos, chief executive offcer of the Royal of the Poststaff Health Organization). One month later College of Physicians and Surgeons of Canada, has stated that the resident is performing at their best and receives an At the foundation of everything we do is one simple aim: to excellent evaluation on their rotation. According to the framework, is the ability to achieve balance between work and personal the six core domains shared by all health care professionals are life. Younger physicians have indicated to: that they prefer to have good physical health rather than being contribute to a culture of patient safety, stressed and tired out. Clear instructions Generational and gender differences during the orientation process help them to become more Recent research shows that baby-boomer and Gen-X effcient and confdent, translating into better teamwork and physicians work, on average, the same number of hours encouraging collegiality. Young physicians also express a desire 61 per week and have a roughly equal level of commitment for a positive work culture, along with a wish to avoid being to patients. The biggest difference is that although Gen-Xers drawn into any existing pockets of cynicism. They agree that physicians feel that their medical careers are important, they any threat to their professional standards or that of a hospital do not necessarily place [their work] at the forefront as the is potentially stressful and can affect their relationship with pa- only aspect of who they are. A culture of openness can help to mitigate these threats, younger cohort seeks a well-rounded and balanced life can be and a healthy sense of community among the physicians can interpreted by baby boomers as a lack of commitment (Jovic help physicians to cope with stressful situations. Bill Wilkerson, co-founder of the Global Business and The number of female physicians has increased 36. In the 2007 National Physician Survey, 80 per cent of physi- What is the solution in the workplace? Wilkerson puts it this cians indicated that the complexity of their patient caseload as way: The solution is the cornerstone of good old-fashioned the biggest factor affecting their time. Given an ever-increasing management, which is based on human decency, clear think- proportion of our aging population is affected by chronic dis- ing, open communications. The other cornerstone is clarity of ease and comorbidities, the average physician s workload will purpose and function. CanadianMedicalAssociation Of the medical students who responded to the 2007 National Launches First Check-up of Doctors Health. Society grants physicians status, respect, autonomy in practice, ability to self-regulate and fnan- cial compensation. A number of patient visits are professional role physicians must make their patients well- rescheduled, and students and residents are assigned to being their frst priority, this commitment must include a caveat other supervisors. Physicians should bear in mind the advice ents the following week but begins the clinical encounter given to airline passengers in case of a depressurization: put by expressing dissatisfaction, anger and frustration that on one s own oxygen mask before assisting others. We must the postponement of the appointment resulted in losing maintain our own health in order to be ft to care for society. The physician feels regretful and guilty at having taken the day off, but at the same time is frustrated by the patient s demanding tone. Refection for educators At the beginning of your residents rotation, have them keep a journal of the challenges they encounter with Introduction respect to meeting the expectations of their patients and Society is quite aware of basic lifestyle choices that promote maintaining their own health. You may wish to provide good health, such as maintaining a healthy diet, exercising your own example of challenges you have experienced. In regularly, avoiding smoking and street drugs, and limiting addition, you can keep your own journal of such physician alcohol use. Most Canadians also recognize the importance of health challenges and have a formal discussion half-way working with their primary care physician for health concerns, through the rotation on how you and your residents dealt follow-up and appropriate screening at different stages of life. At their regular evaluation However, how often do patients consider the health needs of meetings program directors can discuss with residents the their own doctors? The journal will provide clear examples of how the residents understand Healthy physician, healthy patient the key issue. Residents may also consider incorporating Some patients infuence the mental health of their physicians such discussions into their half-day educational sessions by virtue of challenging personality traits, the denial of their or at their regular retreats. Physicians may choose to prescribe unneces- sary antibiotics for a viral illness to pacify the expectations of a patient who wants a quick resolution of their ailment. However, while these physicians are well aware of the lack of effcacy of antibiotics in these situations and the potential to promote new strains of resistant bacteria, they may feel they lack the time or energy to go through the process of proper patient education. The evolution of medicine into the computer era has also contributed to the complexity of the physician patient relationship where physician health is concerned. Although one rarely hears of a house calls nowadays, e-mail is today s equivalent of yesterday s housecall. Patients can now follow doctors home, on vacation, or literally anywhere technology may go. What about the concept that patients need to be seen in person for a physician to make clinically informed deci- sions about their care? Today s society expects medicine to be a convenient service, similar to the fast-food industry which likely contributed to the development of the walk-in clinic. The patient appreciates the bedside: social expectations and value triage in medical practice. Many of these elements can readily contribute acknowledge that individual physicians have an opportunity to personal health and sustainability. Emerging evidence suggests that the development readers can readily access to enhance their understanding and of skills in each of these areas is associated with improved practise of leadership. There is no doubt that many other facets of health and sus- Personal awareness tainability are of relevance to physicians. Starting with the perspective of search for information and practical ways to move forward Mahatma Gandhi, it considers what is meant by values, be- with your own personal health and professional sustainability liefs and knowledge. Through exercises and refec- Key references tion, readers will have an opportunity to consider how best www. Other professions and disciplines have long valued self- assessment, critical appraisal of the self, and introspection. Offering interactive exercises enhance professional development, improve personal health, focused on the development of insight and skills, it blends and promote patient care. The second chapter in this section many of the skills of this section of the guide and offers prac- introduces the basic principles of refective practice, offering a tical methods to enhance the health care workplace. Referring to the work of thinkers such as Howard Gardiner, Peter Salovey, John Mayer and Daniel Goleman, the third chapter in this section suggests that models of emotional intel- ligence have much to offer the medical profession.

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