اهلا و سهلا

السلام عليكم و رحمة الله و بركاته
اهلا بكم اصدقائى الاعزاء .....اسعدنى تشريفكم لى و ارجو ان تجدوا كل ما يفيد
طب و علوم...صحة و جمال..رجيم و رشاقة

الثلاثاء، 31 مايو 2011

مجموعة مستشفيات ائتلاف اطباء مصر

 
المهمة
مشروع لكل الاطباء بدل ماحنا عواطلية زي ماحمدي بيقول
وبدل ما وزير الصحة بيقول اننا ندورلنا علي صنعة عشان نكسب منها احسن من شغلنا كأطباء
وبدل ماحنا حاسسين اننا بنشحت من اللي مايسواش
وهما قاعدين يستفوا في فلوس من مستشفياتهم الخاصة هو والكبار اللي زيه واللي من مصلحته خراب وزارة الصحة وبدل مانسافر بره ونتغرب
احنا نقعد علي قلبهم و نقاسمهم في لقمه عيشهم وبما ان الحكومة والشعب مش مقتنعين بمطالبنا نستغني عنهم ونعمل مشروع لكل الاطباء
ويضمن لينا علاج مجاني محترم يحفظ كرامتنا
ومكان نشتغل فيه باجر محترم بجاني ارباح من العمل
هنعمل دراسة جدوي عن المشروع ده ومش هيكلفنا اكتر من ٥٠٠ جنيه شهريا لمده عشرين شهر ويبقي عندك سهم في المجموعه وكمان هتشتغل فيها وياسلام لما تشتغل في ملكك
لو وصلنا لعدد ١٠ الاف مشترك يبقي وصلنا لرأس مال وقدره ١٠٠ مليون جنيه يكفي لافتتاح مجموعة من عشر مستشفيات علي مستوي الجمهورية يعمل بها الاطباء المساهمين وتدر ارباح لهم وفي نفس الوقت يتكفل بعلاج الاطباء مجانا بالاضافة للعمل الاستثماري
وان شاء الله هنوصل لاكبر مجموعة مستشفيات استثماريه في مصر وهتكون فعلا على اساس شركه مساهمه مصريه يكون لكل طبيب نصيب من رأس المال طبقا لمساهمته فيه بنسبه مئويه
كل اللى تعجبه الفكرة ينضم للصفحة الخاصة بالمجموعة على الفيس بوكhttp://www.facebook.com/pages/%D9%85%D8%AC%D9%85%D9%88%D8%B9%D8%A9-%D9%85%D8%B3%D8%AA%D8%B4%D9%81%D9%8A%D8%A7%D8%AA-%D8%A7%D8%A6%D8%AA%D9%84%D8%A7%D9%81-%D8%A7%D8%B7%D8%A8%D8%A7%D8%A1-%D9%85%D8%B5%D8%B1/123583891057414?sk=info

رجيم خفيف وسريع النزول.

.......الفطور 2 بيضة وكوب شاى بلبن بدون سكر ونصف رغيف.....او بدل البيض 4 ملاعق فول بالليمون وملعقة زيت زيتون او زيت حار....او بدل البيض والفول قطعة جبنة قريش... بين الفطور والغداء باكو بسكويت او شيكولاتة قطعة صغيرة ..الغداء ربع فرخة مشوية او مسلوقة مع سلطة وفنجان ارز مسلوق وطبق خضار ....او قطعة لحمة بحجم الكف مشوية او مسلوقة مع سلطة وطبق مكرونة مسلوقة وسلطة .....او 2 سمكة مشوية مع السلطة ونصف رغيف وخضار اخضر ....بعد الغداء بساعتين 2 ثمرةفاكهة من نوع واحد .......العشاء 2 كوب زبادى مع 2 تفاحة او قطعة لانشون مع خس ورغيف سن او رغيف سن مع قطعة جبن قليل الدسم مع خس او كوب شاى بلبن بدون سكر مع 3 بقسماط سن ........انا عملتها ونزلت 3 كيلو بالاسبوع والله الموفق.....ملحوظة ممكن شرب شاى قهوة نسكافية ....وليكى 2 ملعقة سكر .....ممنوع الملح استبددلى بالليمون وممكن شرب سفن اب دايت او سبرايت.......3 بالاسبوع وكمان اشربى عصائر بدون سكر .....

How To Stay Calm When Life Isn't

No matter what is happening in the world around us, it is never necessary to become caught in depression, fear or other negativity. We are not the victims of the world we see, but have the ability to mobilize ourselves and take charge of the way we respond. There are simple steps to take which when practiced easily turn our state of mind around – and effect the world outside as well.

It is very important to both learn and take these steps. Depression and fear can easily become addictive. The longer we stay in negative states of mind, the more difficult it can become to leave them ..Our world then grows smaller and we begin to develop catastrophic expectations. We lose touch with our own power to take charge, to choose actions and perceptions which counteract the negativity. However, it is the right and responsibility of every mature adult, to steer their lives in the direction of their own choosing. The tools offered both in this article and program make it easy to do. They all result in a process of Centering. The more we practice these steps, the stronger we grow, and the more we can see negativity for what it is, something that has no power other than that which we give it.Centering
This practice of Centering is universal. Many forms of exercise, martial arts and meditation are ways of achieving centering and balance. They are ways of tapping into the fundamental strength and courage all individuals are endowed with. In Zen they say, "Open the treasure house within." This reminds us that we are endowed with gifts which are far greater than we currently realize or employ.

In this article, some Centering practices will be offered. While these are simple, they are very powerful. When they are taken on and practiced daily, an individual calms down and changes will soon be seen.



Attention

We are what we think about.. Morita, a Japanese psychiatrist, the founder of Morita Therapy, states that all neurosis comes from frozen attention that has gotten stuck and fixed upon recurring negative thoughts. The more we give attention to that which is destructive, the more strength it has to rule our lives. This can be counteracted rather easily.

Take back your attention. Do not let it be absorbed by all that is presented to it. The power of focus is the power of life. Spend time each day developing focus and concentration. Withdraw yourself from the chaotic external world for a period of time each day, and pull your attention back within. Sit with a straight back, do not move and concentrate upon your breath. Let random thoughts come and go. Do not suppress them, but do not let them grab your attention away. At first you may be besieged by many surprising thoughts and feelings, but if you simply notice them and then return your attention to your breathing, these will soon die down.


Count your breath from one to ten, then all over again. Do this for at least ten to fifteen minutes without moving. By not moving we are stopping what is called the monkey mind, the mind, which jumps from one thing to the next, fears, demands, grabs and sabotages our lives. It is the monkey mind, which causes our sorrow and fear. But it is only a part of us, it cannot take over our lives, when we take our attention back. By doing this daily, we are strengthening new parts of ourselves, which can guide and lead us in a new direction, one of meaning, and well-being 
This wonderful time spent with oneself is a simple way to attain perspective, become able to see clearly and be rooted in the larger truth. This time becomes a fortification against many storms, which naturally besiege us. We develop a place within ourselves, which we can always return, for wisdom, strength and comfort. When we allow the external world to consume us, we are simply giving our natural treasures away.

Rather than struggle to analyze and undo our patterns, we work directly with our attention. The question before us always is: What am I focusing on this moment? Am I present to the breathing, or lost somewhere in a dream, dwelling upon the pains and wrongs I think have others have done me, or the terrible things that can happen someday?

Reality continually renews and confronts us with new tasks, challenges, opportunities and solutions, day after day. Are we in touch with this ever flowing reality? Are we asking ourselves what is available now, what gifts we are receiving and what we can give to others, or are we dwelling upon how wronged, threatened or deprived we've always been?

Gratitude
As we do this faithfully, the second step of Centering appears. At a certain moment we become aware that depression and gratitude cannot co-exist in the same person at the same time. When our focus and life are primarily self absorbed, revolving around self-centered dreams, what we need and what others are thinking of us, we live in a prison without bars. Underlying feelings of worthlessness emerge, producing additional depression, hostility and stress.

In Centering as we become aware and grateful our focus naturally changes to all that we are receiving, to what others need, what we can give, what has to be done. And then we do it. We take action. We do not hesitate. When our focus is placed upon simple daily actions, and upon doing "deeds of service", the monkey mind is dismantled and passing emotions do not take center stage.

As we Center we learn to do each action with full attention, (no matter how small or large). We do not dwell upon the outcome. Our joy and satisfaction comes from acting with a whole heart and mind. Results and consequences are secondary, and take care of themselves. When we are not absorbed by concern for outcomes, how much anxiety can we ever have?

The most powerful antidote to psychological suffering is an individual's sense of self worth. When we are taking actions that are meaningful to us, self-respect develops naturally. When our behavior arises out of a grateful mind, each individual inevitably finds a personal alignment between their daily actions and highest values. As they become more and more occupied with that which is valuable, and life giving, their resourcefulness increase as does their sense of worth. They can then handle any difficult situation and give what is needed to all. Living in this manner, life feels like a gift they are constantly receiving, and they become a gift to life as well.

Having A Weight Loss Plan

Very strange indeed! You have heard plans for gaining! Here you are thinking about a loss plan! And you are very serious about this loss! You have a loss-sharing buddy, you congratulate each other over the losses you have 'gained' in the period under review! Any reduction in the loss is not to your mutual liking!

Any weight loss plan that does not take the diet aspect into consideration, is no plan at all! Who are the starred generals in the weight loss plan that are expected to give sterling performances? Of course, the old war-horses! They are: Exercise and Diet!

How to get results from the weight loss plan? Whatever methods you use, they must perform two functions-stimulate metabolism which do the job of fat burning and continuously assist you in the process of loss, without intermission! Any plan or any ingredient that is appetite-suppressant without causing any side effects, is suitable for your weight loss plan. It must lessen your struggle with weight on various parts of your body. It must trim the excess fat around the waist and buttocks.

Relentless research is going on in this million-dollar weight loss project. The whole idea is to find sensible and sustainable ways for overweight patients to lose weight, and to maintain that gained position of weight loss over a long period. It is the most frustrating experience to gain weight after so much of trials and tribulations, after having once lost it!< 
The importance of exercises is emphatic. Nobody has ever said- I did exercise and I gained weight! The various yoga asanas and Ashtanga Yoga & Bikrama Yoga are very useful. The overweight and obese specialists emphasize on one thing even after prescribing medication-understand the importance of exercise for all successful weight loss programs. Physical activity is key to staying healthy.

You are fat because you are lazy. Now, you are moving in the right direction, because now you know the value of right nutrition. It goes without saying that when you talk about right nutrition, all items of wrong nutrition need to be avoided at all costs. Even for the sake of temptation, those should not be given a chance to enter into your system. They have created enough havoc in the past. Let them take the well-deserved rest now.

Keep a careful calorie count. There should be awareness in you about what should be done and what should not! You know what is your problem, you have understood the cause of your problem and therefore you will find the answer for your problem-definitely!
 

A More Convenient Approach To Heart Health

Here's news many Americans can take to heart. In addition to diet and exercise, there is a new heart health product with aspirin available to help reduce heart disease risk factors.

Cardiovascular disease poses a major health threat to both men and women in the U.S. According to the American Heart Association, more than 71 million adults in the U.S. have at least one type of cardiovascular disease. These include dysfunctional conditions of the heart, arteries and veins that supply oxygen to life-sustaining areas of the body such as the brain, the heart itself and other vital organs.

These conditions can be caused by a buildup of fatty deposits in the arteries, elevated cholesterol, high blood pressure and poor circulation. Patients with cardiovascular disease are at increased risk for heart attacks, strokes and death.

A healthy diet and regular exercise are important steps in the prevention of cardiovascular disease. In addition, a new and complete heart health product has been developed that combines the known benefits of doctor-recommended, low-dose aspirin with heart health vitamins and other supplements. These ingredients have been clinically shown to reduce the chances of heart attack and stroke, and may help lower blood pressure and cholesterol levels and help manage other cardio risk factors.

Called CardioEA™ Enhanced with Aspirin, each safety-coated caplet contains 81 mg of doctor-recommended, low-dose aspirin plus a complex of vitamins B6, B12, Folic Acid, L-Arginine and Aged Garlic Extract™ (AGE). It provides heart health-conscious consumers with the opportunity to help manage many of the risk factors that contribute to heart disease with a single daily caplet instead of taking various supplements and aspirin every day.

This is the first in a new category of preventive and wellness products called OTCeuticals™, manufactured by the Alan James Group, a health care-focused consumer products company based in Boca Raton, Florida. OTCeuticals are vitamins, minerals, herbs and other supplements that are combined with FDA-monographed, Category 1 USP-grade ingredients in rational, safe, effective and convenient combinations.

In addition to CardioEA Enhanced with Aspirin, the Alan James Group's OTCeuticals pipeline includes products for bone & joint and gastrointestinal health, among others.

CardioEA Enhanced with Aspirin is available in the vitamin section at most major supermarkets, chain drug and discount retailers.

Baby Sleep Tips - Some Tricks For The Transition

Baby Sleep Tips - Some Tricks For The Transition



As a new parent, one of your priorities will be to establish good sleeping habits with your newborn. Your baby needs to learn to sleep on his own; the transition from sleeping with his mother to sleeping by himself takes some time. Of course, as add added bonus, if you get your baby to learn to sleep on his own you will also get some much needed rest yourself. To instill good sleeping habits in your baby, research and try to employ different baby sleep tips: try a lot of things and see what works for you, and don't be afraid to trust your instincts.

Many baby sleep tips center on the idea of establishing routines and associations for your child between nighttime and sleep. The sooner you child begins to associate bedtime with sleep, the more likely he is to be able to go to sleep without a fuss. A period that is often overlooked, however, in establishing day vs. night associations, is the period of "transition" - that is, the one between being awake and falling asleep. Here are some transitioning techniques to try:

Try what is sometimes called "fathering down." Just before placing the baby into bed, the father should cradle the baby in such a way that the baby's head rests on the father neck. The father should then talk gently to the child. Because the male's voice is much deeper than the female's, babies are often more soothed by it, and will fall asleep more easily after being exposed to it for some time.

You can also try what is sometimes referred to as "wearing down." This is effective if your baby has been active throughout the day and is too excited to go to bed easily. All you have to do is place your baby in a sling or carrier - "wear him" in other words - for about half an hour before his bedtime. Simply go about your regular household activities: being close to a parent and slowly rocked about before bedtime will provide your child with an easier transition from being awake to being asleep
Finally, if you've exhausted other options, you can go for the tried and true method of "driving down." Most parents are probably familiar with this as a last resort: place your baby in the car and drive around for awhile until he falls asleep. This one, while inconvenient, usually works every time, and if you desperately need some sleep it can be a godsend.

Obviously, you don't want to do things like drive around every night to get your child to sleep. Nor do you want to have to carry him around in a sling. The idea, though, is to start with these more drastic techniques and then slowly ease out of them. Keep in mind what a major transition your baby is going through when he is tiny: he's never slept on his own before. He simply doesn't know how to transition himself from being awake to being asleep. By employing these transition techniques you will be slowly teaching him how to do so, and as they are gradually removed your baby will learn good sleeping habits, which will ensure that both you and your child get a good night's rest.

 


cranial nerves examination

Eye: History, Examination
  1. History
  2. Inspection
  3. Visual acuity
  4. Visual fields
  5. Ophthalmoscopic (fundi)
  6. Pupils
  7. Corneal reflections
  8. Eye movements
  9. Corneal reflex
History 
  • Presenting complaint:
    • Onset: gradual vs. sudden vs. asymptomatic.
    • Duration: brief vs. continuous.
    • Location: focal vs. diffuse, unilateral vs. bilateral.
  • Eye Hx: squint, amblyopia, glasses, glaucoma.
  • Family Hx: squint, lazy eye, glasses, glaucoma, cataract (young person).
  • Past medical Hx: especially vascular (diabetes, hypertension).
  • Medications: current meds, Hx of drugs affecting eye.
    • Is pt on or been on eye drops.
  • Social Hx: relevant post-op (to put eye drops in).
Inspection
In all, looking for asymmetry, deformities, discoloration, redness, discharge, lesions.
  • Diagnostic facies.
  • Orbit, rim: palpate for lumps.
  • Brow: lost sweating (Horner's).
  • Eyelids: xanthelasma, ectropian, entropian.
  • Eyelids: pus on lids (blepharitis).
  • Ptosis.
  • Exophthalmos.
  • Iris: colour, defects.
  • Cornea: transparent vs. opaque, corneal arcus, band keratopthy, Kayser-Fleischer rings, lesion, scars.
  • Ask the patient to look up and pull down both lower eyelids to inspect the conjuntiva and sclera.
    • Conjunctiva: clear/infected. If conjuntivitis, wash hands immediately: viral form contagious.
    • Sclera: jaundice, pallor, injection.
  • Spread each eye open with Dr's thumb, index finger. Ask pt to look to each side and downward to expose entire bulbar surface.
    • Eyeball tenderness.
Visual acuity
If  eye pain, injury, visual loss, check visual acuity before rest of the exam or inserting medications into eyes [so don't get sued].
  • Let pt to use glasses, contacts if available.
  • Put pt 20 feet from Snellen eye chart, or hold Rosenbaum pocket card 14 inches away.
  • Pt. covers an eye at a time with a card, reading smaller letters till stop.
  • Record smallest line read, eg 20/40.
Visual fields
  • Stand 2 feet in front of pt, who looks in Dr's eyes at eye-level.
  • Dr's hands to side half way between Dr and pt, wiggle fingers, ask which they see move.
  • Repeat 2-3 to test both temporal fields.
  • If suspect abnormality, test 4 quadrants of each eye while card covers other.
Ophthalmoscopic (fundi)
  • Darken room, adjust scope so light is no brighter than necessary.
  • Adjust aperture to a plain white circle.
  • Set diopter dial to zero, unless have a preferred setting.
  • Dr. uses left hand and left eye to examine the patient's left eye.
  • Dr's free hand onto the pt's shoulder or forehead for control.
  • Tell pt to stare at wall.
  • Look through scope, shine light into pt's eye from 2 feet away at a 45º angle.
  • See the retina as a "red reflex.". Reflex: clear vs. opaque (cataract). Follow red color to move within a few inches from pt's eye.
  • Adjust diopter dial to bring the retina into focus. Find a blood vessel and follow it to the optic disk, use this as a point of reference.
  • Inspect optic disk:
    • Colour of disc: pink vs. pale.
    • Margins clear.
    • State of cup.
  • Inspect vessels: all 4 quadrants, veins are darker than arteries:
    • Bleeding, exudate.
    • Pigmentation, occlusion.
  • Inspect macula, by moving the scope nasally:
    • Foveal light reflex
    • Bleeding, exudate.
    • Edema, drusen.
Pupils
  • Shape, relative size.
  • Light reaction: dim lights if needed.
    • Pt looks in distance, shine light in from side to gauge pupil's light reaction. Record size, irregularity.
    • Assess both direct (same eye) and consensual (other eye) responses.
  • Assess afferent pupillary defect by moving light in arc from pupil to pupil, and if L eye light makes R eye dilate, not constrict (Marcus Gunne). Optionally: as do arc test, have pt place a flat hand extending vertically from his face, between his eyes, to act as a blinder so light can only go into one eye at a time. 
  • Accommodation: pt alternates between looking into distance, and a hat pin 30cm from nose.
Corneal reflections
  • Shine a light from directly in front of the pt.
  • Corneal reflections should be centered over pupils.
  • Assess asymmetry (extraocular muscle pathology).
Eye movements
  • "Follow finger with eyes without moving head": test the 6 cardinal points in an H pattern. Assess:
    • Failure of movement.
    • Nystagmus [pause to check it during upward, lateral gaze]).
  • Convergence by moving finger towards bridge of pt's nose.
  • Gaze palsies (supranuclear lesions).
  • Fatiguability (myasthenia).
Corneal reflex
  • Corneal reflex: patient looks up and away.
  • Touch cotton wool to other side.
  • Look for blink in both eyes, ask if can sense it.
  • Repeat other side. [Tests V sensory, VII motor].

MODELS OF THE CONSULTATION


A summary of models that have been proposed over the last 20 years

There have been a number of helpful models of the consultation which have been produced over the last 30 years. Some are task-orientated,  process or outcome-based; some are skills-based, some incorporate a temporal framework, and some are based on the doctor-patient relationship, or the patient’s perspective of illness. Many incorporate more than one of the above.

Models of the consultation give a framework for learning and teaching the consultation; the toolbox is a useful analogy. Models enable the clinician to think where in the consultation they are experiencing the problem, and what they and the patient aiming towards. This is helpful in then identifying the skills that are needed to achieve the desired outcome. A particularly useful general book on Understanding the Consultation by Tim Usherwood (see the book list at the end of this document) describes a number of the models below in more detail, and also includes psychological concepts such as projection, transference and counter-transference.


1.         ‘Physical, Psychological and Social’ (1972)

The RCGP model encourages the doctor to extend his thinking practice beyond the purely organic approach to patients, i.e. to include the patient’s
            emotional, family, social and environmental circumstances.

2.         Stott and Davis ( 1979)

            “The exceptional potential in each primary care consultation” suggests that    four areas can be systematically explored each time a patient consults.

            (a)        Management of presenting problems
            (b)        Modification of help-seeking behaviours
            (c)        Management of continuing problems
            (d)        Opportunistic health promotion

3.         Byrne and Long (1976)

            “Doctors talking to patients”. Six phases which form a logical structure to the            consultation:

            Phase   I           The doctor establishes a relationship with the patient

            Phase  II           The doctor either attempts to discover or actually discovers the                                              reason for the patient’s attendance

            Phase  III         The doctor conducts a verbal or physical examination or both

            Phase  IV         The doctor, or the doctor and the patient , or the patient (in that                                              order of probability) consider the condition

            Phase    V        The doctor, and occasionally the patient, detail further treat-
                                    ment or further investigation

            Phase   VI        The consultation is terminated usually by the doctor.

Byrne and Long’s study also analysed the range of verbal behaviours doctors used when talking to their patients. They described a spectrum ranging from         a heavily doctor-dominated consultation, with any contribution from the patient as good as excluded, to a virtual monologue by the patient untrammelled by any input from the doctor. Between these extremes, they described a graduation of styles from closed information-gathering to non-directive counselling, depending on whether the doctor was more interested in developing his own line of thought or the patient’s.



4.         Six Category Intervention Analysis (1975)

            In the mid-1970’s the humanist Psychologist John Heron developed a simple but      comprehensive model of the array of interventions a doctor (counsellor or
therapist) could use with the patient (client). Within an overall setting of concern       for the patient’s best interests, the doctor’s interventions fall into one of six
            categories:

            (1)        Prescriptive    -  giving advice or instructions, being critical or directive

            (2)        Informative     -  imparting new knowledge, instructing or interpreting

            (3)        Confronting    -  challenging a restrictive attitude or behaviour, giving
                                                   direct feedback within a caring context

            (4)        Cathartic        -  seeking to release emotion in the form of weeping,
                                                    laughter, trembling or anger

            (5)        Catalytic         -   encouraging the patient to discover and explore his own                                             latent thoughts and feelings

            (6)        Supportive      -   offering comfort and approval, affirming the patient’s
                                                    intrinsic value.

            Each category has a clear function within the total consultation.


5.         Helman’s  ‘Folk Model’  (1981)

            Cecil Helman is a Medical Anthropologist, with constantly enlightening insights
            into the cultural factors in health and illness. He suggests that a patient with a
            problem comes to a doctor seeing answers to six questions:

            (1)        What has happened?
            (2)        Why has it happened?
            (3)        Why to me?
            (4)        Why now?
            (5)        What would happen if nothing was done about it?
            (6)        What should I do about it or whom should I consult for further help?

6.         Transactional Analysis  (1964)

            Many doctors will be familiar with Eric Berne’s model of the human psyche as
            consisting of three ‘ego-states’ - Parent, Adult and Child. At any given moment
            each of us is in a state of mind when we think, feel, behave, react and have
            attitudes as if we were either a critical or caring Parent, a logical Adult, or a
            spontaneous or dependent Child. Many general practice consultations are
            conducted between a Parental doctor and a Child-like patient.  This transaction
            is not always in the best interests of either party, and a familiarity with TA
            introduces a welcome flexibility into the doctor’s repertoire which can break
            out of the repetitious cycles of behaviour (‘games’) into which some
            consultations can degenerate.



7.         Pendleton, Schofield, Tate and Havelock (1984, 2003)

            ‘The Consultation -   An Approach to Learning and Teaching’ describe seven            tasks which taken together form comprehensive and coherent aims for any
            consultation.

            (1)        To define the reason for the patient’s attendance, including:

                        i)          the nature and history of the problems
                        ii)         their aetiology
                        iii)        the patient’s ideas, concerns and expectations
                        iv)        the effects of the problems

            (2)        To consider other problems:

                        i)          continuing problems
                        ii)         at-risk factors

            (3)        With the patient, to choose an appropriate action for each                                      problem

            (4)        To achieve a shared understanding of the problems with the                                               patient

            (5)        To involve the patient in the management and encourage him to                             accept appropriate responsibility

            (6)        To use time and resources appropriately:

                        i)          in the consultation
                        ii)         in the long term

            (7)        To establish or maintain a relationship with the patient which                                 helps to  achieve the other tasks.

The authors’ 2nd edition, “The new consultation” includes recent relevant research material and a wealth of experience accumulated by the authors since their first publication. The first part of the book covers the consultation; the “central act of medicine”, and puts both the perspectives of the doctor and the patient, and the outcomes that both are looking for at the heart of the process of the medical interview. The second half of the book is concerned with learning and teaching effective consulting.

8.         Neighbour (1987)


Five check points: ‘where shall we make for next and how shall we get there?’

            (1)        Connecting        -         establishing rapport with the patient

            (2)        Summarising   -           getting to the point of why the patient has come
                                                            using eliciting skills to discover their ideas,                                                                 concerns, expectations and summarising back to
                                                            the patient.

            (3)        Handing over   -         doctors’ and patients’ agendas are agreed.
                                                            Negotiating, influencing and gift wrapping.

            (4)        Safety net          -         “What if?’: consider what the doctor might do in
                                                            each case.

            (5)        Housekeeping  -          ‘Am I in good enough shape for the next                                                                    patient?’


9.         The Disease - Illness Model  (1984)

McWhinney and his colleagues at the University of Western Ontario have proposed a “transformed clinical method”. Their approach has also been called “patient-centred clinical interviewing” to differentiate it from the more traditional “doctor-centred” method that attempts to interpret the patient’s illness only from the doctor’s perspective of disease and pathology.

The disease-illness model below attempts to provide a practical way of using these ideas in our everyday clinical practice. The doctor has the unique responsibility to elicit two sets of “content” of the patient’s story: the traditional biomedical history, and the patient’s experience of their illness.





 Patient presents problem

Gathering information

Parallel search of two frameworks









Weaving back
and forth between the two frameworks
          Disease framework                                                                                     Illness framework                                                                                         
        The biomedical perspective                                                                     The patient’s perspective                                                                            



        Symptoms                                                                                                     Ideas     
        Signs                                                                                                               Concerns
       Investigations                                                                                               Expectations                                                                                                 Feelings and thoughts
        Underlying pathology                                                                                Feelings and thoughts      
                                                                                                                                 Effects on life
       

        Differential diagnosis                                                                                                Understanding the patient’s
                                                                                                                                 Unique experience of the
                                                                                                                                 illness

                                                                 Integration of the two frameworks
                                                                
                                                                 Explanation and planning
                                                                 Shared understanding and decision-making

        After Levenstien et al in Stewart and Roter (1989) and Stewart et al (1995 & 2003)                                                  



Levenstein JH, Belle Brown J Weston WW et al (1989) Patient-centred clinical interviewing. In Communicating with medical patients (eds M Stewart and D Roter) Sage Publications, Newbury Park, CA.
Stewart M. (2001) Towards a global definition of patient centred care. BMJ.  322(7284):444-5,




10.       The Three Function Approach to the Medical Interview (1989)

            Cohen-Cole and Bird have developed a model of the consultation that has    been adopted by The American Academy on Physician and Patient as their      model for teaching the Medical Interview.

            (1)        Gathering data to understand the patient’s problems

            (2)        Developing rapport and responding to patient’s emotion

            (3)        Patient education and motivation


            Functions                                            Skills

            1.         Gathering data             a)         Open-ended questions
                                                                        b)         Open to closed cone
                                                                        c)         Facilitation
                                                                        d)         Checking
                                                                        e)         Survey of problems
                                                                        f)         Negotiate priorities
                                                                        g)         Clarification and direction
                                                                        h)         Summarising
                                                                        i)          Elicit patient’s expectations
                                                                        j)          Elicit patient’s ideas about
                                                                                    aetiology
                                                                        k)         Elicit impact of illness on                                                                                            patient’s quality of life


            2          Developing rapport                  a)         Reflection
                                                                        b)         Legitimation
                                                                        c)         Support
                                                                        d)         Partnership
                                                                        e)         Respect

            3          Education and motivation        a)         Education about illness
                                                                        b)         Negotiation and maintenance of a                                                                               treatment plan
                                                                        c)         Motivation of non-adherent                                                                                         patients


In 2000 the authors published a second edition, where they altered the order of the three functions of effective interviewing, putting “Building the relationship” in front of “Assessing the patient’s problems”,  and “Managing the patient’s problems”.

The authors have included three excellent chapters on :
  • Understanding the patient’s emotional response
§         Managing communication challenges
  • Higher order skills
The section on overcoming cultural and language barriers and troubling personality styles and somatisation are particularly helpful.

11.       The Calgary-Cambridge Approach to Communication Skills Teaching
                                                                                                                        (1996)

            Suzanne Kurtz & Jonathan Silverman have developed a model of the            consultation, encapsulated within a practical teaching tool, the Calgary      Cambridge Observation Guides. The guide is continuing to evolve and now   includes Structuring the consultation. The Guides define the content of a communication skills curriculum by delineating and structuring the skills that have been shown by research and theory to aid doctor-patient communication. The guides also make accessible a concise and accessible summary for facilitators and learners alike which can be used as an aide-     memoire during teaching sessions

            The following is the structure of the consultation proposed by the guides:

            (1)        Initiating the Session
                        a)         preparation
                        b)         establishing initial rapport
                        c)         identifying the reason(s) for the consultation

            (2)        Gathering Information

                        exploration of of the patient’s problems to discover the:
                        a)         biomedical perspective
                        b)         the patient’s perspective
c)         background information - context

            (3)        Building the Relationship

                        a)         using appropriate non-verbal behaviour
                        b)         developing rapport
                        c)         involving the patient

            (4)        Providing structure

                        a) making organisation overt
                        b) attending to flow

            (5)        Explanation and Planning

                        a)         providing the correct amount and type of information
                        b)         aiding accurate recall and understanding
                        c)         achieving a shared understanding: incorporating the patient’s                                                 perspective
                        d)         planning: shared decision making

            (6)        Closing the Session

                        a) ensuring appropriate point of closure
                        b) forward planning


12.       Comprehensive Clinical Method/Calgary-Cambridge Guide Mark 2.  (2002)
This method combines the traditional method of taking a clinical history including the functional enquiry, past medical history, social and family history, together with the drug history, with the Calgary-Cambridge Guide.  It places the Disease-Illness model at the centre of gathering information. It combines process with content in a logical schema; it is comprehensive and applicable to all medical interviews with patients, whatever the context.
Below is an example of the skills required to elicit the disease, the illness and the background content when gathering information.







Gathering Information



process skills for exploration of the patient’s problems  
                   (the bio-medical perspective and the patient’s perspective)

  • patient’s narrative
  • question style: open to closed cone
  • attentive listening
  • facilitative response
  • picking up cues
  • clarification
  • time-framing
  • internal summary
  • appropriate use of language
  • additional skills for understanding patient’s perspective


                                                                content to be discovered:


 the bio-medical perspective                                                                             the patient’s perspective
           (disease)                                                                                      (illness)

sequence of events                                                                                                     ideas and concerns
symptom analysis                                                                                                                       expectations
relevant functional enquiry                                                                                     effects
                                                                                                                                       feelings and thoughts



essential background information

past medical history
drug and allergy history
social history
family history
functional enquiry




13.  BARD 2002 Ed Warren (2002)
The BARD model attempts to consider the totality of the relationship between a GP and a patient and the roles that are being enacted. The personality of the doctor will have considerable influence on the doctor-patient encounter, as will the doctor’s previous experience of the patient. The model attempts to include how the doctor’s personality can be used to best effect, and looks specifically at the doctor and patient roles in the medical encounter. It aims to “encompass everything that happens during a consultation” and encourage reflection. It is important that GPs play to their strengths, and use their role and personality and behaviour positively for the benefit of the patient.

The four proposed avenues for analysis are:
Behaviour
Aims
Room
Dialogue


Behaviour
A doctor has many alternatives in how they present to a patient, and these choices will reflect the needs of the patient and the personality of the GP. It includes non-verbal and verbal skills as well as confidence, “lightness of touch”, and behaviours which feel “just right”. The key is for the doctor to choose the most appropriate behaviour with each patient in front of them

Aims
It is important for the aims of a consultation to be clear in order to help the doctor and the patient to head in the right direction. However not all the aims will necessarily need to be achieved in one consultation, and priorities have to be clarified.

Room
The consultation will be affected by the environment in which the doctor works, as well as for example, where the doctor sits, or whether a side room is used for the examination.

Dialogue
How you talk to the patient is crucial. Tone of voice, what you say, language, the ability to confront or challenge needs thought. How can you be sure that both you and the patient are talking the same language?



14. Balint 1986
Michael Balint and his wife Enid, who were both psychoanalysts, started to research the GP/patient relationship in the 1950s, and over many years ran case-discussion seminars with GPs to look at their difficulties with patients. The groups’ experiences formed the basis for a very important contribution to the general practice literature; The doctor, the patient and the illness. In exploring the doctor-patient relationship in depth, Balint helped generations of doctors to understand the importance of transference and counter-transference, and how the doctor himself is often the treatment or drug. Balint groups are still popular, and are usually run on psychodynamic lines and often one of the group leaders is a psychotherapist. Balint’s tenet was that doctors decide what is allowable for discussion from the patient’s offer of problems, and that doctors impose constraints on what is acceptable to explore in the consultation, often unconsciously.  This selective neglect or avoidance is often related to something in the doctors life which is threatening. For example a doctor may not wish to explore alcoholism in a patient if he or she either drinks to excess themselves, or someone close to the doctor has an alcohol problem. It the patient is also reluctant to discuss the issue then this can lead to collusion.

Balint groups commonly begin with “has anyone a case today?” A doctor then tells the story of a patient who is bothering him and the group will help the doctor to identify and explore the blocks which are constraining exploration and management of the patient’s problem.

15. Narrative-based Medicine
Launer J (2002)
Narrative studies explore the way people tell stories. The modernist approach had been to be attentive to these stories and the particular approach described in this book is a specific one, developed by a team of teachers at the Tavistock Clinic in London. In primary care we have an option not only to reflect on these stories, we can respond to and even challenge them. Thus the post-modern and more radical view would be that a clinical interaction is one in which two parties bring their own individual contexts and preferences, to create what is a unique and developing conversation. For example, in the context of the consultation between a patient and the GP, there is often no “ultimate truth” to the answer to the question “why has the patient attended”, or what the patient is hoping for from the doctor, because in an attempt to explore these important questions, even more important questions and ideas will emerge.

Skills which help the patient to understand better what is happening to them not only include the basic skills of listening, and empathising. Question style is crucial; appropriately timed questions asked with respect and in the spirit of caring about the eventual outcome for the patient can be used with great effect in contexts where the clinician is trying to help the patient look at a problem from a different point of view, and encourage behaviour change. They might be compared with to Socratic questioning, and form the basis of narrative-based interviewing and originally come from family systems therapy.
The six key concepts are:
  • conversations
  • curiosity
  • circularity
  • contexts
  • co-creation
  • caution

Some examples:
“When you get home, what do you think your husband might say when you tell him what we have been talking about?”
“Who in the family thinks you are depressed as well as your husband?”
“If we can’t get to the bottom of your problem, what do you think you might do next?”

Constructing a genogram with the patient is a good example of one of the other techniques used in narrative-based medicine.