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American Dietetic Association._ Elliott, Laura_ McCallum, Paula Davis_ Molsee...MarthyRavello1
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2) The document outlines various ways family doctors can help with risk assessment, communication, and management including sharing guidelines, communicating with specialists, collecting patient exposure histories, and involving patients in decision making.
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This document presents a preliminary framework for understanding accessibility in the Canadian health care system. It conducted an environmental scan of literature, key informant interviews, and a workshop to develop the framework. The framework aims to broaden the discussion around accessibility beyond wait times for surgeries. It recognizes that access depends on social and economic factors, patient needs and resources, mediating factors like affordability and accommodation, trends in public and private sectors, and provider issues. The framework models how these influence availability of care, and then system, provider and health outcomes. It identifies gaps in knowledge and calls for a more holistic approach to measuring accessibility across different health services and sectors.
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This document provides an overview of the second edition of "The Clinical Guide to Oncology Nutrition" published by the American Dietetic Association. It discusses topics covered in the guide including cancer statistics, screening methods, changes in metabolism from cancer and cancer treatment, diet and cancer prevention, medical nutrition therapy, nutrition support, management of side effects, complementary therapies, nutrition for survivors and in palliative care, and clinical management in oncology settings. The guide serves as a comprehensive reference for dietitians and other health professionals working in oncology.
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This report discusses the place of E-Health initiatives in the Australian Health care system,
the need for IT in the reform agenda and the case for change.
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This document summarizes a journal article that reviews studies from cystic fibrosis patient registries related to disease incidence, genetics, microbiology, pregnancy, clinical complications, lung transplantation, and other topics. The summary discusses key findings from registry studies on disease incidence rates that vary significantly between countries and regions. Studies on genetics examine genotype-phenotype correlations and the predictive value of CFTR mutations. Papers on microbiology describe the clinical relevance of different pathogens. Studies on clinical complications discuss the prevalence of issues like haemoptysis and diabetes. Papers on lung transplantation focus on models to improve transplant candidate selection and factors linked to post-transplant survival.
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1. The document provides the views of members of the public and doctors on the standards of care and practice expected of doctors as set out in Good Medical Practice.
2. Participants generally agreed with the key duties in Good Medical Practice, but had differing views on concepts like "partnership" and expectations of doctors' probity.
3. Both groups recognized the importance of technical competence and communication skills, though the public was more skeptical about doctors reporting their own shortcomings while doctors focused on challenges like a lack of support for whistleblowers.
Rischio Radiologico (Ernesto Mola e Giorgio Visentin)csermeg
1) The document discusses the responsibilities of family doctors in regards to justification and optimization of medical imaging according to the European BSS 2013 guidelines. It describes how family doctors can contribute to ensuring imaging examinations are justified based on clinical need and protocols are optimized to reduce radiation exposure.
2) The document outlines various ways family doctors can help with risk assessment, communication, and management including sharing guidelines, communicating with specialists, collecting patient exposure histories, and involving patients in decision making.
3) WONCA commits to cooperation across stakeholders to promote radiation protection culture through education and establish clear justification processes and clinical imaging guidelines.
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Increasingly medical practice is coming under intense scrutiny as to what is appropriate and affordable care, including serious considerations of patient safety issues and protection. Medical professionalism must be consciously adhered to as we try and find the best health care for our patients at the best value and outcomes for our patients themselves, and also for society at large. In view of escalating health care costs, physician autonomy to practice as he or she likes or deems fit has now come under siege with more and more performance monitoring, not just for appropriateness, but also for outcomes, necessity and cost-effectiveness. Physician' vested interests must be tempered with evidence-based benefits or at least be associated with no increase in harm or incur affordability issues. Fraudulent physician malfeasance are now being uncovered via whistle-blowers, or through greater more meticulous audit of various validated performance measures, and those physicians found to have flouted these due to pecuniary self-interests, overuse of tests or procedures have been found guilty and sanctioned with heavy fines, return of reimbursements as well as imprisonment, and erasure from medical registries and the removal of license to practice.
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Accordingly, researchers at the Milken Institute undertook a comprehensive, quantitative documentation of medical technology's impact on the economic burden of disease. The study also projects how future innovation in this sector would affect the health care system and the larger economy -- a positive benefit of more than $23 billion a year for the United States.
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1) EHRs can help schools better manage student emergencies by providing important health information quickly.
2) Chronic disease management systems linked to EHRs can help students manage conditions like diabetes.
3) EHRs can facilitate individualized health education and wellness promotion to students via links, counseling referrals, and automated reminders on mobile phones.
4) EHR data analysis may help public health agencies understand disease prevalence and formulate policies through systematic surveillance of student health across schools.
5) Technology can
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This document is a doctoral dissertation submitted by James T. Tufano to the University of Washington in partial fulfillment of the requirements for a Doctor of Philosophy degree. The dissertation explores provider perspectives on the roles, importance, and effects of healthcare information and communication technologies in the context of patient-centered healthcare redesign. Three qualitative observational studies were conducted at Group Health Cooperative to understand provider experiences with implementing and using various technologies as part of two distinct care redesign initiatives. The dissertation contributes new knowledge about sociotechnical approaches to technology-enabled healthcare transformation and quality improvement.
Initial Post (250 words)Read and interpret the short story .docxannettsparrow
Initial Post (250 words)
Read and interpret the short story "Damien's Shoes" by Ret'sepile Makamane. What logical inferences can you make based on its details? What can you infer about the narrator in this story, the narrator's son, and the setting of this story? What details suggest this? What other logical inferences can you make about this story? (Length: 250 words)
Two Replies
Respond to the posts of two of your peers by acknowledging their ideas and adding on to them with additional commentary, supporting detail or fact (such as a quote, detail referenced, or scenario from the story), and/or an new or different perspective or logical inference.
Damien’s Shoes
by Ret’sepile Makamane
My son (Links to an external site.)
, Damien, makes fires that flicker throughout rainy June nights. He moves about the shores of Lake Muhazi, lighting a new fire on a new spot every night. People who travel to Kayonza come back to Kigali with stories of having seen him during the rainy season as the smokes of his fires constantly go up to the skies, like a man cast away and looking for rescue. Those who have travelled and visited relatives with houses on the hills around Lake Muhazi in recent years to observe his activities say that my son sails up and down the lake during the day, busy ferrying passengers with completely covered faces to the other side. Others even claim that they have seen him up close, and that unlike other undead dead people he does not run away or conceal his face when you approach him. He has remained ten years old throughout the years, only bits of his hair are beginning to grey now.
When his boat work is done in the evenings, he plays his flute into the night, calming Lake Muhazi into even more stillness. He plays the flute so dedicatedly, earnestly, its melody so piercing, with sorrow so intense – a child blowing all his young soul into a musical instrument just so our land can heal. His flute wakes God from his deep sleep, – since Damien has already given God a few warnings, I hear – saying to God, “Thou Shalt Not Sleep, never. Not here in Rwanda, not anymore! Find yourself another bedroom.” Because God used to sleep here in Rwanda, you know. Lately, God stays awake at night looking intently at the world map, planning to migrate.
I carry with me Damien’s one shoe. He is barefoot, Damien, my boy, that is why he has to make these random fires when it rains in June – to warm his feet. I rescued this shoe from the mouth of a stray dog which made me run and chase it until I was panting like a hound myself. That was back in ninety-four. I was still a young man in those days. Oh, but that dog was not the end of my troubles. I have aged double while walking these hills and valleys with acacia and guava and mango trees, without even seeing their beauty anymore. Walking with a tormented soul, looking for Damien to put on his shoe on the other foot. Blaming myself, sixteen years moiling and roiling through these mangroves and swamp.
initial post one paragraph intext citation and reference Require.docxannettsparrow
This document provides instructions for an assignment on literary movements. Students are asked to choose one literary movement from the week's readings and discuss either:
1) The historical and political influences on the movement and a one paragraph summary of a specific work.
2) How a specific artwork captured the subject or story of a literary work, using examples like paintings influenced by poems or myths.
Students must use at least one additional scholarly source to discuss the influences on the chosen movement.
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Initial Post (250 words)Read and interpret the short story .docxannettsparrow
Initial Post (250 words)
Read and interpret the short story "Damien's Shoes" by Ret'sepile Makamane. What logical inferences can you make based on its details? What can you infer about the narrator in this story, the narrator's son, and the setting of this story? What details suggest this? What other logical inferences can you make about this story? (Length: 250 words)
Two Replies
Respond to the posts of two of your peers by acknowledging their ideas and adding on to them with additional commentary, supporting detail or fact (such as a quote, detail referenced, or scenario from the story), and/or an new or different perspective or logical inference.
Damien’s Shoes
by Ret’sepile Makamane
My son (Links to an external site.)
, Damien, makes fires that flicker throughout rainy June nights. He moves about the shores of Lake Muhazi, lighting a new fire on a new spot every night. People who travel to Kayonza come back to Kigali with stories of having seen him during the rainy season as the smokes of his fires constantly go up to the skies, like a man cast away and looking for rescue. Those who have travelled and visited relatives with houses on the hills around Lake Muhazi in recent years to observe his activities say that my son sails up and down the lake during the day, busy ferrying passengers with completely covered faces to the other side. Others even claim that they have seen him up close, and that unlike other undead dead people he does not run away or conceal his face when you approach him. He has remained ten years old throughout the years, only bits of his hair are beginning to grey now.
When his boat work is done in the evenings, he plays his flute into the night, calming Lake Muhazi into even more stillness. He plays the flute so dedicatedly, earnestly, its melody so piercing, with sorrow so intense – a child blowing all his young soul into a musical instrument just so our land can heal. His flute wakes God from his deep sleep, – since Damien has already given God a few warnings, I hear – saying to God, “Thou Shalt Not Sleep, never. Not here in Rwanda, not anymore! Find yourself another bedroom.” Because God used to sleep here in Rwanda, you know. Lately, God stays awake at night looking intently at the world map, planning to migrate.
I carry with me Damien’s one shoe. He is barefoot, Damien, my boy, that is why he has to make these random fires when it rains in June – to warm his feet. I rescued this shoe from the mouth of a stray dog which made me run and chase it until I was panting like a hound myself. That was back in ninety-four. I was still a young man in those days. Oh, but that dog was not the end of my troubles. I have aged double while walking these hills and valleys with acacia and guava and mango trees, without even seeing their beauty anymore. Walking with a tormented soul, looking for Damien to put on his shoe on the other foot. Blaming myself, sixteen years moiling and roiling through these mangroves and swamp.
initial post one paragraph intext citation and reference Require.docxannettsparrow
This document provides instructions for an assignment on literary movements. Students are asked to choose one literary movement from the week's readings and discuss either:
1) The historical and political influences on the movement and a one paragraph summary of a specific work.
2) How a specific artwork captured the subject or story of a literary work, using examples like paintings influenced by poems or myths.
Students must use at least one additional scholarly source to discuss the influences on the chosen movement.
Initial Post InstructionsTriggers are ethnocentric responses to .docxannettsparrow
Initial Post Instructions
Triggers are ethnocentric responses to differences and defensive reactions to ethnocentrism. Any number of things can serve as triggers, but they generally fall into the following categories: voice, appearance, attitude, and behavior. For example, a person of color may become anxious when driving through a small rural town. They may fear being stopped because of looking out of place. Another example would be to react to the smell of curry and spices when walking into an Indian home. The reaction could be either negative or positive depending on your experiences, but you immediately react to the stimulus.
For the initial post, address the following:
Describe a trigger that you have responded or been a witness to in the past, even if it was only a fleeting mental thought.
What was the result of your/their response?
If you/they had a negative response, how could your/their response to the situation been better or different?
What barriers did you/they need to overcome?
.
Initial Post InstructionsFor the initial post,consider thr.docxannettsparrow
Initial Post Instructions
For the initial post,
consider three (3)
of the following events: Treaty of Versailles
Rise of fascism, militarism and imperialism
Failure of the League of Nations Based on your three selections,
choose two (2)
of the following and craft a response for your selections:
Assess if the United States foreign policy during the 1930s helped to promote World War II. Could the United States have prevented the outbreak of World War II? If so, how? If not, why not?
Explain if the United States, despite neutrality, aided the Allies against the Axis powers.
.
Initial Post InstructionsFor the initial post, choose and ad.docxannettsparrow
Initial Post Instructions
For the initial post, choose and address one of the following options:
Option 1:
In the 19th century, the camera was a revolutionary invention, and many artists were concerned about the effect that photographs would have on the art world.
Did the invention of the camera change the arts? Why or why not?
Choose an artistic movement that you believe was influenced by the camera and discuss how the movement was affected.
Include at least one example of an artist and artwork in your response.
Include a statement from a current photographer or critic to support your points.
Option 2:
In the 21st century, the smartphone camera changed the way we use and view photography. In addition, apps and social media have changed the way we share photography.
How has the invention of the smartphone camera changed photography?
How have apps and social media changed the way we share photos? Are they positive and/or negative changes? Explain.
Include a statement from a current photographer or critic to support your points
.
Writing Requirements
Minimum of 1 page
Minimum of 2 sources cited (assigned readings/online lessons and an outside source)
APA format for in-text citations and list of references
.
Initial Post InstructionsDiscuss the differences and similaritie.docxannettsparrow
Initial Post Instructions
Discuss the differences and similarities between the presidential and parliamentary systems, including the executive and legislative branches. Which system do you feel serves its citizen better? Why? Use evidence (cite sources) to support your response from assigned readings or online lessons,
and
at least one outside scholarly source.
Follow-Up Post Instructions
Respond to at least one peer. Further the dialogue by providing more information and clarification. Minimum of 1 scholarly source which can include your textbook or assigned readings or may be from your additional scholarly research.
Writing Requirements
Minimum of 2 posts (1 initial & 1 follow-up)
Minimum of 2 sources cited (assigned readings/online lessons
and
an outside scholarly source)
APA format for in-text cita
.
Initial Post InstructionsAs we jump into the world of Alge.docxannettsparrow
Initial Post Instructions
As we jump into the world of Algebra, it is important to discuss how math, specifically Algebra, is used in the real-world.
Search for videos from Ted Ed showing the real-world value of mathematics. Choose a video to watch and then provide a one-paragraph summary (3-4 sentences) of the video in your own words. Be sure to discuss the math concept used.
Follow-Up Post Instructions
Respond to at least two peers in a substantive, content-specific way. Further the dialogue by providing more information and clarification.
Writing Requirements
Minimum of 3 posts (1 initial & 2 follow-up) with first post by Wednesday
APA format for in-text citations and list of references
.
Initial Post InstructionsFor the initial post, respond to one .docxannettsparrow
Initial Post Instructions
For the initial post, respond to one of the following options, and label the beginning of your post indicating either Option 1 or Option 2:
Option 1:
List the ways in which contemporary presidential campaigns have used social media as a campaign tool. Do you consider social media as a successful tool? Explain your answer. Do you see social media as an unsuccessful tool? Explain your answer and provide examples.
Option 2
: There are numerous discussions involving the Electoral College. There are some people that want to abolish the electoral college while others want to keep it. What do you think? Keep the electoral college or abolish it? Explain the reasons for your choice.
Be sure to make connections between your ideas and conclusions and the research, concepts, terms, and theory we are discussing this week
Writing Requirements
Minimum of 2 sources cited (assigned readings/online lessons and an outside source)
APA format for in-text citations and list of references
.
Initial Post InstructionsAgenda setting can be a difficult t.docxannettsparrow
Initial Post Instructions
Agenda setting can be a difficult task in government. Why? Who do you consider an important agenda setter in government? How does this participant help set the agenda? Give an example of an attempt at agenda setting in government. Was it successful? Why or why not? Consider how factors such as culture, political positions, etc. might impact your own, or the agenda setters' priorities.
Use evidence (cite sources) to support your response from assigned readings or online lessons, and at least one outside scholarly source.
.
Initial Post Identify all the components of a cell. Describe the fu.docxannettsparrow
Initial Post: Identify all the components of a cell. Describe the function of each of these components.
Response #1: Add to your own initial post: Describe cellular metabolism membrane transport and cellular reproduction
Response #2: Add to your own initial post and response #1: Describe the aging process. Identify the pathophysiologic process for 3 underlying principles of aging. Example: oxidative process.
please use APA format
.
Initial Discussion Board Post Compare and contrast life for col.docxannettsparrow
Colonial women in Virginia and Massachusetts colonies faced different expectations and opportunities based on class and status. Women in Virginia had more defined social roles and less opportunities compared to Massachusetts where women could own property. Margaret Brent was unique as she purchased land directly from Native Americans in Plymouth as a wealthy woman, showing how status could provide more freedom, though women overall had limited rights in both colonies.
Inital post please respond for the above post question one page with.docxannettsparrow
Inital post please respond for the above post question one page with intext citation and reference.
Required Resources
Read/review the following resources for this activity:
Minimum of 1 primary or scholarly source (from photographer or critic – either will count as your scholarly source requirement for discussions)
Initial Post Instructions
For the initial post, address one of the following options:
Option 1:
In the 19th century, the camera was a revolutionary invention, and many artists were concerned about the effect that photographs would have on the art world.
Did the invention of the camera change the arts? Why or why not?
Choose an artistic movement that you believe was influenced by the camera and discuss how the movement was affected.
Include at least one example of an artist and artwork in your response.
Include a statement from a current photographer or critic to support your points.
Option 2:
In the 21st century, the smartphone camera changed the way we use and view photography. In addition, apps and social media have changed the way we share photography.
How has the invention of the smartphone camera changed photography?
How have apps and social media changed the way we share photos? Are they positive and/or negative changes? Explain.
Include a statement from a current photographer or critic to support your points.
.
Infornnation Technology
in Hunnan Resource
:An
Empirical Assessnnent
By Alok Mishra, PhD, and Ibrahim Akman, PhD
The present paper begins by introducing a number of observations on tiie
appiications ot information teciinoiogy (iT) in tiie field of human resource
management (HRM) in gênerai. Tiiis is due to tiie fact that iT and its wide range of
appiications have already made their presence feit in this area. This wiii be
foliowed by a report on the findings of a survey on the present trends in
organizations with in the different sectors in Turkey. Aithough the impact of iT on
IHRM has iong been attracting the interest of academics, no empiricai research has
ever been reaiized in this fieid in Turiiey, and few studies have been reported
eisewhere. The survey was conducted among the 106 iT managers and
professionais from various sectors, based on whose resuits, the data shows that iT
is used extensiveiy in the organizations to perform IHRM functions in Turicey's
dynamic economy. The results aiso indicated that, while IT has an impact on aii
sectors in terms of IHRM to certain extent, the types of iT used vary significantiy
between recruitment, maintenance, and deveiopment tasi(s. However, the empiricai
resuits here reveai that these organizations are not appiying these technoiogies
systematicaiiy and maturely in the performance of HRM functions.
Key words: human resource management (HRM), human resource management
system (HRMS), human resource (HR), information technoiogy (iT), ANOVAtest,
chi-square test
T
he HRM function in organizations has gained increasing strategic emphasis, and
the importance of its alignment HRM and business strategies is well-acknowl-
edged.^ In fact, effective HRM is vital in order to be able to meet the market
demands with well-qualified employees at all times.^
Technology and HRM have a broad range of influences upon each other, and HR
professionals should be able to adopt technologies that allow the reengineering of the
HR function, be prepared to support organizational and work-design changes caused
by technology, and be able to support a proper managerial climate for innovative and
knowledge-based organizarions.^ These technological advances are being driven
primarily by strong demands from human resource professionals for enhancement in
speed, effectiveness, and cost containment."*
Public Personnel Management Volume 39 No. 3 Fall 2010 271
Snell, Stueber, and Lepak^ observe that HRMSs can meet the challenge of
simultaneously becoming more strategic, flexible, cost-efficient, and customer-oriented
by leveraging information technology Many experts forecast that the PC will become
the central tool for all HR professionals.^ Virtual HR is emerging due to the growing
sophistication of IT and increased external structural options.^ IT is beginning to
enable organizations to deliver state-of-the-art HR services, and reduced costs have
enabled companies, regardless of the firm size-to purchase HR technologies.^.
INFORMED CONSENT LETTER Page 1 of 2 SELF CONSENT .docxannettsparrow
INFORMED CONSENT LETTER
Page 1 of 2
SELF CONSENT
I have been invited to take part in a research study titled:
This investigation is spearheaded by Yulak Landa: whose contact information includes:
[email protected] and (305)833-0053
I understand that my participation is voluntary and that I can refuse to participate or stop taking
part any time without giving any reason and without facing any penalty. Additionally, I have the
right to request the return, removal, or destruction of any information relating to me or my
participation.
I am aware that the participation in this research study is on a voluntary basis, and I am free to
object the invitation as well as to withdraw my involvement as I would deem fit without offering any
reason, getting victimized, or facing any legal suit or conviction. It is also my right to ask for the
withdrawal, return, or discarding of any of the information shared or collected following my
participation in the study.
PURPOSE OF STUDY
I understand that the purpose of the study is to:
Determining how efficient are both the respiratory mask as well as standard mask in preventing
healthcare providers from getting exposed to corona virus in the course of their work. Can they all
be relied to offer the same protection?
PROCEDURES
I understand that if I volunteer to take part in this study, I will be asked to:
Declare information related to chronic illness or preexisting conditions as well as my age. I will as
well be required to fully adhere to the recommended hygiene standards as well as to be fully
dressed with protective gears which include the designated face mask, prior to getting exposed to
SARS- COV – 2 viruses. Also, I will have to undertake a 14 day or more in quarantine as well as
undertake the COVID 19 test. I shall also be required to undertake necessary treatments in the event
I am exposed to the virus.
BENEFITS
I understand that the benefits I may gain from participation include:
I will get a chance to enhance the safety of healthcare providers' who continue to dedicate their
efforts to the treatment and care of COVID_19 patients and relies on face masks as one of their PPE.
For Official Use Only
Received on:
Reviewed on:
End date:
File Number:
mailto:[email protected]
INFORMED CONSENT LETTER
Page 2 of 2
I will assist them in understanding if they would still use the standard face masks, taking into
consideration the general shortage of respiratory masks. All the instruments to be used and
expenses incurred will be covered by the researcher together with any counseling and treatments in
case I am exposed to the virus.
RISKS
I understand that the risks, discomforts, or stresses I may face during participation include:
I understand that I may get exposed to the virus, become sick, or even die from the COVID 19
disease. Due to the gravity of the illness, I may also be psychologically affected..
This document outlines the structure for an informative presentation, including an introduction with an attention getter and establishing credibility, a body with three main points and supporting evidence, and a conclusion summarizing the three points. Transitions are used to connect each section. References from credible sources are required to be cited in APA style.
Informed Consent FormBy the due date assigned, submit the Inform.docxannettsparrow
Informed Consent Form
By the due date assigned, submit the Informed Consent Letter to the
Submissions Area
(please note that this is only an example and no data may be collected).
Informed Consent Letter
Procedure section is clear, described in detail, specific, and all inclusive. Written in lay language (as documented by reading level score). Includes risks and benefits relevant to study. Address assent (if applicable).
Informed Consent Letter Example
IRB Application
.
INFORMATION THAT SHOULD GO INTO PROCESS RECORDING FOR MICRO WORK.docxannettsparrow
INFORMATION THAT SHOULD GO INTO PROCESS RECORDING
FOR MICRO WORK
There are various formats for completing a process recording. The following is an outline that covers the major areas we want included within a process recording. Please utilize the template that follows for completing a process recording with an individual, couple or family client(s).
1. Description/Identifying Information: The social work student’s name, date of the interview and the date of submission to the field instructor should always be included. Identify the client, always remembering to disguise client name to protect confidentiality. Include the number of times this client has been seen (i.e., "Fourth contact with Mrs. S."). On a first contact include name and ages of the client(s) you have written about. If client is seen in location other then the agency say where client was seen.
2. Purpose and Goalfor the Interview. Briefly state the purpose of the interaction and if there are any specific goals to be achieved, the nature of the presenting issues and/or referral.
3. Verbatim Dialogue (in the table below). A word-for-word description of what happened, as well as the student can recall, should be completed. This section does not have to include a full session of dialogue but should include a portion of dialogue. The field instructor and student should discuss what portions should be included in the verbatim dialogue.
4. Assessment of the Patient/Client/Consumer. This requires the student to describe the clients’ verbal and nonverbal reactions throughout the session. Consider everything that is occurring such as body language, facial expression, verbal outburst, etc.
5. The Student's Feelings and Reactions to the Client System and to the Interview (in the table below). This requires the student to put into writing unspoken thoughts and reactions s/he had during the interview e.g. "I was feeling angry at what the client was saying, not sure why I was reacting this way…”. “ I wonder what would happen if I said such-and-such.”
6. Identify Skills and/or Theory/ Conceptual Frameworks used (in the table below). The student should be able to identify what skills they used in an interaction, and/or what theoretical framework came to mind as they dialogued e.g. “I used the strengths perspective “ “I used the skill of partializing”
7. Supervisor/field instructor comments (in the table below) This requires the field instructor to provide review and critique of the student’s dialogue with the client system, skill identification, and interpretation of the client interview.
8. A summary assessment/analysis of the student's impressions. This is a summary of the student's analytical thinking about the entire interview and/or any specific interaction the student is unsure about. Include any client action or non-verbal activity that the student may want to discuss. (See Guided Questions at the end of the template for this section A-M)
9. Future plans. The .
Information Technology Capstone ProjectIn this course, learners .docxannettsparrow
Information Technology Capstone Project
In this course, learners apply knowledge and skills from other courses as they develop a project that benefits an organization, community, or industry. Learners prepare a proposal that includes a project description, deliverables, completion dates, and associated learning. Upon approval from the instructor, learners execute the proposal, record their progress weekly using a project tracking website, and produce a final project report.
.
A workshop hosted by the South African Journal of Science aimed at postgraduate students and early career researchers with little or no experience in writing and publishing journal articles.
LAND USE LAND COVER AND NDVI OF MIRZAPUR DISTRICT, UPRAHUL
This Dissertation explores the particular circumstances of Mirzapur, a region located in the
core of India. Mirzapur, with its varied terrains and abundant biodiversity, offers an optimal
environment for investigating the changes in vegetation cover dynamics. Our study utilizes
advanced technologies such as GIS (Geographic Information Systems) and Remote sensing to
analyze the transformations that have taken place over the course of a decade.
The complex relationship between human activities and the environment has been the focus
of extensive research and worry. As the global community grapples with swift urbanization,
population expansion, and economic progress, the effects on natural ecosystems are becoming
more evident. A crucial element of this impact is the alteration of vegetation cover, which plays a
significant role in maintaining the ecological equilibrium of our planet.Land serves as the foundation for all human activities and provides the necessary materials for
these activities. As the most crucial natural resource, its utilization by humans results in different
'Land uses,' which are determined by both human activities and the physical characteristics of the
land.
The utilization of land is impacted by human needs and environmental factors. In countries
like India, rapid population growth and the emphasis on extensive resource exploitation can lead
to significant land degradation, adversely affecting the region's land cover.
Therefore, human intervention has significantly influenced land use patterns over many
centuries, evolving its structure over time and space. In the present era, these changes have
accelerated due to factors such as agriculture and urbanization. Information regarding land use and
cover is essential for various planning and management tasks related to the Earth's surface,
providing crucial environmental data for scientific, resource management, policy purposes, and
diverse human activities.
Accurate understanding of land use and cover is imperative for the development planning
of any area. Consequently, a wide range of professionals, including earth system scientists, land
and water managers, and urban planners, are interested in obtaining data on land use and cover
changes, conversion trends, and other related patterns. The spatial dimensions of land use and
cover support policymakers and scientists in making well-informed decisions, as alterations in
these patterns indicate shifts in economic and social conditions. Monitoring such changes with the
help of Advanced technologies like Remote Sensing and Geographic Information Systems is
crucial for coordinated efforts across different administrative levels. Advanced technologies like
Remote Sensing and Geographic Information Systems
9
Changes in vegetation cover refer to variations in the distribution, composition, and overall
structure of plant communities across different temporal and spatial scales. These changes can
occur natural.
हिंदी वर्णमाला पीपीटी, hindi alphabet PPT presentation, hindi varnamala PPT, Hindi Varnamala pdf, हिंदी स्वर, हिंदी व्यंजन, sikhiye hindi varnmala, dr. mulla adam ali, hindi language and literature, hindi alphabet with drawing, hindi alphabet pdf, hindi varnamala for childrens, hindi language, hindi varnamala practice for kids, https://www.drmullaadamali.com
Walmart Business+ and Spark Good for Nonprofits.pdfTechSoup
"Learn about all the ways Walmart supports nonprofit organizations.
You will hear from Liz Willett, the Head of Nonprofits, and hear about what Walmart is doing to help nonprofits, including Walmart Business and Spark Good. Walmart Business+ is a new offer for nonprofits that offers discounts and also streamlines nonprofits order and expense tracking, saving time and money.
The webinar may also give some examples on how nonprofits can best leverage Walmart Business+.
The event will cover the following::
Walmart Business + (https://business.walmart.com/plus) is a new shopping experience for nonprofits, schools, and local business customers that connects an exclusive online shopping experience to stores. Benefits include free delivery and shipping, a 'Spend Analytics” feature, special discounts, deals and tax-exempt shopping.
Special TechSoup offer for a free 180 days membership, and up to $150 in discounts on eligible orders.
Spark Good (walmart.com/sparkgood) is a charitable platform that enables nonprofits to receive donations directly from customers and associates.
Answers about how you can do more with Walmart!"
Chapter wise All Notes of First year Basic Civil Engineering.pptxDenish Jangid
Chapter wise All Notes of First year Basic Civil Engineering
Syllabus
Chapter-1
Introduction to objective, scope and outcome the subject
Chapter 2
Introduction: Scope and Specialization of Civil Engineering, Role of civil Engineer in Society, Impact of infrastructural development on economy of country.
Chapter 3
Surveying: Object Principles & Types of Surveying; Site Plans, Plans & Maps; Scales & Unit of different Measurements.
Linear Measurements: Instruments used. Linear Measurement by Tape, Ranging out Survey Lines and overcoming Obstructions; Measurements on sloping ground; Tape corrections, conventional symbols. Angular Measurements: Instruments used; Introduction to Compass Surveying, Bearings and Longitude & Latitude of a Line, Introduction to total station.
Levelling: Instrument used Object of levelling, Methods of levelling in brief, and Contour maps.
Chapter 4
Buildings: Selection of site for Buildings, Layout of Building Plan, Types of buildings, Plinth area, carpet area, floor space index, Introduction to building byelaws, concept of sun light & ventilation. Components of Buildings & their functions, Basic concept of R.C.C., Introduction to types of foundation
Chapter 5
Transportation: Introduction to Transportation Engineering; Traffic and Road Safety: Types and Characteristics of Various Modes of Transportation; Various Road Traffic Signs, Causes of Accidents and Road Safety Measures.
Chapter 6
Environmental Engineering: Environmental Pollution, Environmental Acts and Regulations, Functional Concepts of Ecology, Basics of Species, Biodiversity, Ecosystem, Hydrological Cycle; Chemical Cycles: Carbon, Nitrogen & Phosphorus; Energy Flow in Ecosystems.
Water Pollution: Water Quality standards, Introduction to Treatment & Disposal of Waste Water. Reuse and Saving of Water, Rain Water Harvesting. Solid Waste Management: Classification of Solid Waste, Collection, Transportation and Disposal of Solid. Recycling of Solid Waste: Energy Recovery, Sanitary Landfill, On-Site Sanitation. Air & Noise Pollution: Primary and Secondary air pollutants, Harmful effects of Air Pollution, Control of Air Pollution. . Noise Pollution Harmful Effects of noise pollution, control of noise pollution, Global warming & Climate Change, Ozone depletion, Greenhouse effect
Text Books:
1. Palancharmy, Basic Civil Engineering, McGraw Hill publishers.
2. Satheesh Gopi, Basic Civil Engineering, Pearson Publishers.
3. Ketki Rangwala Dalal, Essentials of Civil Engineering, Charotar Publishing House.
4. BCP, Surveying volume 1
it describes the bony anatomy including the femoral head , acetabulum, labrum . also discusses the capsule , ligaments . muscle that act on the hip joint and the range of motion are outlined. factors affecting hip joint stability and weight transmission through the joint are summarized.
Main Java[All of the Base Concepts}.docxadhitya5119
This is part 1 of my Java Learning Journey. This Contains Custom methods, classes, constructors, packages, multithreading , try- catch block, finally block and more.
ISO/IEC 27001, ISO/IEC 42001, and GDPR: Best Practices for Implementation and...PECB
Denis is a dynamic and results-driven Chief Information Officer (CIO) with a distinguished career spanning information systems analysis and technical project management. With a proven track record of spearheading the design and delivery of cutting-edge Information Management solutions, he has consistently elevated business operations, streamlined reporting functions, and maximized process efficiency.
Certified as an ISO/IEC 27001: Information Security Management Systems (ISMS) Lead Implementer, Data Protection Officer, and Cyber Risks Analyst, Denis brings a heightened focus on data security, privacy, and cyber resilience to every endeavor.
His expertise extends across a diverse spectrum of reporting, database, and web development applications, underpinned by an exceptional grasp of data storage and virtualization technologies. His proficiency in application testing, database administration, and data cleansing ensures seamless execution of complex projects.
What sets Denis apart is his comprehensive understanding of Business and Systems Analysis technologies, honed through involvement in all phases of the Software Development Lifecycle (SDLC). From meticulous requirements gathering to precise analysis, innovative design, rigorous development, thorough testing, and successful implementation, he has consistently delivered exceptional results.
Throughout his career, he has taken on multifaceted roles, from leading technical project management teams to owning solutions that drive operational excellence. His conscientious and proactive approach is unwavering, whether he is working independently or collaboratively within a team. His ability to connect with colleagues on a personal level underscores his commitment to fostering a harmonious and productive workplace environment.
Date: May 29, 2024
Tags: Information Security, ISO/IEC 27001, ISO/IEC 42001, Artificial Intelligence, GDPR
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Training: ISO/IEC 27001 Information Security Management System - EN | PECB
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Slideshare: http://www.slideshare.net/PECBCERTIFICATION
This document provides an overview of wound healing, its functions, stages, mechanisms, factors affecting it, and complications.
A wound is a break in the integrity of the skin or tissues, which may be associated with disruption of the structure and function.
Healing is the body’s response to injury in an attempt to restore normal structure and functions.
Healing can occur in two ways: Regeneration and Repair
There are 4 phases of wound healing: hemostasis, inflammation, proliferation, and remodeling. This document also describes the mechanism of wound healing. Factors that affect healing include infection, uncontrolled diabetes, poor nutrition, age, anemia, the presence of foreign bodies, etc.
Complications of wound healing like infection, hyperpigmentation of scar, contractures, and keloid formation.
How to Add Chatter in the odoo 17 ERP ModuleCeline George
In Odoo, the chatter is like a chat tool that helps you work together on records. You can leave notes and track things, making it easier to talk with your team and partners. Inside chatter, all communication history, activity, and changes will be displayed.
Exploiting Artificial Intelligence for Empowering Researchers and Faculty, In...Dr. Vinod Kumar Kanvaria
Exploiting Artificial Intelligence for Empowering Researchers and Faculty,
International FDP on Fundamentals of Research in Social Sciences
at Integral University, Lucknow, 06.06.2024
By Dr. Vinod Kumar Kanvaria
5. of care that would provide state of the art care in rural
areas, increase the access to care, generate services and
revenue for both the rural and academic center, train
health care professionals [5], and serve as a laboratory
for intervention. (Table 1).
The RCOP has grown from one program in 1988 to
five programs operating at five rural hospitals. Briefly,
the majority of cancer care is provided at the rural
hospital. A team of two – three oncologists and two
nurse practitioners or nurse clinical specialists travel to
each site weekly. While there, they see new consulta-
tions and patients under treatment. They work with
primary care doctors at the rural sites who have ex-
pressed an interest in care of cancer patients; this
typically includes two – three surgeons and two – four
primary care internists or family physicians. Nurses
from the rural site come to the academic center for
specialized cancer nursing, then receive annual updates.
Many of the rural nurses have become certified in
oncology nursing.
The program is administered by the Massey Cancer
Center of the Medical College of Virginia, Virginia
Commonwealth University, and each of the rural hos-
pitals. Support for this program comes from the Com-
monwealth of Virginia.
3. Program analysis
3.1. Impact of the program on the clinical care
pro�ided
We have analyzed three important index conditions
in our first two rural hospitals [6]. We chose these
6. conditions because there was documented wide varia-
tion in practice, and poor medical outcomes if optimal
process was not followed (Table 2). It was difficult to
Table 1
Goals of the rural cancer outreach program
Goal Comment
Virginia is typical rural USEstablish a model of care for
staterural Virginia
Deliver state of the art care in See what care could be
delivered at the rural site,rural areas
what should be centralized
Increase access to clinical trials Allow access to new drugs;
increase accrual to clinical
trials for the academic center
Train health care professionals Help recruit and retain
primary care and specialist
physicians and nurses for the
rural area. Provide a specialty
service that makes rural
practice more attractive
Link academic and rural Make regional policy, not
hospital against hospital, tohospitals in strategic alliance
solve problems of indigent
care.
Help support unprofitableHelp finances of both hospital
partners small rural hospitals.
Use the program for tobaccoServe as a entry point for
7. community based interventions and nutrition interventions if
desired by rural community.in prevention
L.J. Lyckholm et al. / Critical Re�iews in
Oncology/Hematology 40 (2001) 131 – 138 133
Table 2
Level before RCOPIndex condition Level after RCOP
Morphine use in chronic pain 0 +500%
60%�20%Breast conserving therapy
9Clinical trial accrual 0
Adjuvant therapy for early breast Unknown. Probably high for
affluent patients Offered to all patients regardless of ability
who could travel, low for the poor to paycancer
analyze the type of care because the volume of any
one condition, e.g. use of adjuvant chemotherapy in
Stage I – III breast cancer, was always low and usually
less than ten cases per year. However, the importance
of high quality care to those individuals is as impor-
tant as in other settings. There is often reluctance to
analyze care patterns if it is likely to show less than
optimal care; for instance, a hospital that reports ex-
cess mortality from routine myocardial infarction may
find that patients avoid that hospital for all cardiac
care, especially troublesome for a small hospital that
depends on retaining a large percentage of its market
for survival. Also, there is often no financing avail-
able to support an in depth look at practice patterns
and survival or recurrence.
8. The use of morphine for cancer pain was studied in
one hospital. In the preceding 3 years before RCOP,
there had been almost no morphine prescribed; within
2 years the amount of oral and intravenous morphine
increased by over 500%. In addition, the use of mepe-
ridine declined. Breast conservation, considered the
desired treatment for early stage breast cancer, had
been rarely used before RCOP. By the 3rd year of
operation at our first hospital, over 60% of patients
were routinely treated with breast conservation. In
addition, before the RCOP, all breast cancer patients
were not routinely offered adjuvant treatment, be-
cause many could not see an oncologist due to dis-
tance or cost. In other studies, the referral of patients
to a medical oncologist — rather than treatment by
a surgeon alone — was significantly correlated with
the likelihood of receiving adjuvant chemotherapy [7].
Clinical trial accrual to Cancer and Leukemia Group
B (CALGB), National Surgical Adjuvant Breast and
Bowel Program (NSABP) and other trials increased
from essential zero to 9% of eligible patients. This
compares favorably with the 2% national average in
the US.
3.2. Impact of the program on health care professional
recruitment and retention
The RCOP has been successful in helping to recruit
and retain good physicians to rural areas. Physicians
commonly mention the increased academic linkage
and ease of referral to the academic center. These
rural doctors have noted that the concentration of
complex cancer care in the hands of a few local doc-
tors rather than many has allowed them to increase
their expertise. There has also been continued central-
9. ization of some complex procedures such as radiation
and leukemia treatment that are not feasible to per-
form at a rural center.
4. Economic analysis
Pre- and post-RCOP financial data were collected
on 1745 cancer patients treated at the participating
centers, two rural community hospitals, and MCC.
The main outcome measures were costs (estimated re-
imbursement from all sources), revenues, contribution
margins, and profit (or loss) of the program.
Key results are shown in Table 3, modified from
the full report in the Journal of Rural Health [8].
The RCOP had a positive financial impact on the
rural and academic medical center hospitals. The
RCOP was associated with an increased number of
referrals of 330% more cancer patients and 9% more
other medical/surgical patients. The MCC had in-
creased receipts of 6.2%. The rural hospitals each had
over a million dollars in new charges and over
$500 000 US new profit each year. In total, the re-
ceipts for both centers increased by 137%. Most of
this additional income was from ‘ancillary’ services
such as increased use of the computerized axial to-
mography (CAT) or magnetic resonance imaging
(MRI) scan, laboratory, and pharmacy. All patients
were treated regardless of ability to pay, and the pro-
gram generated sufficient profit to allow increased in-
digent care.
The net annual cost per patient fell from $10 233 to
$3862 ( − 62%) associated with more use of outpa-
tient services, more efficient use of resources, and the
10. shift to a less expensive locus of care. The cost for
each rural patient admitted to MCV fell by 40%,
compared to only an 2% decrease for all other cancer
patients consistent with other programs that have in-
creased coordination among providers [9].
L.J. Lyckholm et al. / Critical Re�iews in
Oncology/Hematology 40 (2001) 131 – 138134
5. Other programs
Similar results of improved clinical care process,
equal or better patient outcomes and cost savings
have been reported from the Manitoba Cancer Out-
reach Program, but final results have not yet been
published. The Manitoba Cancer Research and Treat-
ment Program was started in 1984 with similar goals
[10]. It works on a similar model of consultation with
the academic center, then all the care is delivered in
one of six regional centers. Insurance is not an issue
in Manitoba since there is a single universal payer.
However, there are limited funds for cancer and dol-
lars that can be saved by off loading to a regional
center preserve dollars for research. Distance is even
more problematic, with some centers 8 h by train,
impassible by cars, and air transport too costly. Key
rural primary care doctors and surgeons are iden-
tified, and given an initial training program followed
by yearly updates. All protocols are specified in a
central care plan, and the central hub audits dicta-
tions from the rural centers. Similar clinical results
have been obtained, with excellent clinical care and
less overall cost to the province [11]. (personal com-
munication, Harvey Schipper 1999)
11. 6. Applicability to other settings
We have not identified other similar programs that
have published their clinical and economic results.
The closest is the Centre Bernard Lyon that has
shown good adoption of clinical practice guidelines
and better clinical practice [12,13]. This program
should be applicable to other centers that serve rural,
dispersed populations. The main problems have been
sustaining the medical innovation part of the pro-
gram, and not ‘burning out’ the doctors and nurses
who must travel the distance. The continued travel
can be a major problem for health professionals.
7. Ethical issues in rural health care
The challenge is to provide high quality, affordable,
accessible care for all. In the US, the absence of a
single payer system allows exclusion of whole seg-
ments of the population. Combined with the dis-
persed poor population in rural areas, these issues
represent significant obstacles to delivery of care. In
Virginia, one third of the population is rural and
most of these people are medically underserved for
both primary and specialty care. The rural population
has more federal Medicare and state Medicaid health
insurance coverage with a low rate of reimbursement
compared to most insurance, so rural hospitals and
providers have less income than urban centers. ‘Nega-
tive marketing’ or locating services in affluent areas
so that the poor do not have access is widespread.
The ethical issues most prominent in rural health
care include justice issues, especially those involving
access to and delivery of health care, related issues of
12. medical competency, confidentiality and privacy is-
sues, and conflicts of interest related to blurring of
personal and professional boundaries. Finally, institu-
tional ethics committees at rural hospitals are evolv-
ing, but may not have the necessary elements of
expertise that are more accessible in urban centers.
7.1. Justice issues: access to and deli�ery of health care
The principle of justice calls for equitable distribu-
tion of health care resources, meaning that health
care is distributed according to need rather than to
the ability of a person to obtain it. Challenges to this
principle in the rural health care setting include geo-
graphical and financial barriers. In some rural com-
munities health care may be hours away. Nonmetro
and frontier areas possess far less physician coverage
than more urbanized areas even after controlling for
population size. For example, in 1988, the ratio of
primary care physicians per 100 000 persons for re-
Table 3
Impact of RCOP on rural and academic programs
Change (%)Post-RCOPbPre-RCOPa
330%Cancer patients from RCOP areas seen at MCC 173 743
9%75726958All patients from RCOP areas seen at MCC
Estimated receipts, MCC 6.2%$1 770 256 1 879 542
NAEstimated receipts, RCOP $2 314 516 –
137%Total estimated receipts $1 770 256 $4 194 058
−62%$3862$10 233Net annual cost per patient in the system
Inpatient admission, MCC −40%$7370$12 268
13. a Represents average values of 1988 and 1989 financial data.
b Represents average values of 1992 and 1993 financial data.
L.J. Lyckholm et al. / Critical Re�iews in
Oncology/Hematology 40 (2001) 131 – 138 135
mote rural areas was 38.2; for the more inclusive
nonmetro areas it was 51.3. In comparison, metro
areas had a ratio of 95.9 [14,15].
This problem will be compounded as more inde-
pendent community hospitals close their doors due to
the lack of funding. The poor and elderly without
access to transportation may receive little to no
health care. The traffic and complexity of urban cen-
ters may intimidate those who have always lived in
rural areas.
Financial barriers are similar to those experienced
by the poor urban population. The community, how-
ever, may actually be a positive factor in overcoming
these barriers. In a review of these issues, Purtilo and
Sorrell remarked that in times of hardship, rural com-
munity members often help those of their community
who are most financially strapped [16]. Among those
community members are the physicians, who are also
‘expected’ to contribute their services and advocacy
for the patient. Physicians are part of the community,
and ‘‘the high probability that the physician will see a
rejected patient at the drug store, Lions Club dinner,
or next PTA meeting makes saying ‘no’ practically
impossible’’ [17]. This situation may create a tremen-
dous conflict of interest between the physicians’ alle-
14. giance to their community and their hospital, which
may not have the financial resources to provide care
for indigent members of the community.
Improved access to oncology care is at the heart of
our rural cancer outreach program. Oncology care in
the rural setting is equivalent, or sometimes better, in
terms of convenience, than that in the academic medi-
cal center. The most important aspect of the program
is improving financial and geographic access to sub-
specialty care and consultation. Transportation is pro-
vided for patients who have daily radiation
treatments. Although we cannot impact direct costs
of the patients’ oncology care, reducing out-of-pocket
spending, which is significant, appears to be of great
assistance to many of the patients. Finally, by provid-
ing care close to home, we hope to offer comfort and
a greater sense of security to patients who are fright-
ened or feel threatened by the diagnosis of cancer
and the therapy they must endure.
7.2. Competency of medical care
Several issues surrounding competency of medical
care exist in the rural setting, and some are particular
to our rural outreach oncology setting. The first con-
cerns competency to provide specialty care. Many
rural areas have few primary care providers, and no
specialists. There is increasing evidence that high vol-
ume produces high quality and many rural hospitals
will always have low volume [3]. Physicians may feel
forced to provide care, including procedures which
they perform infrequently or are beyond their level of
expertise, especially if the closest large medical center
is 3 – 4 h away. Physician assistants, nurse practi-
15. tioners and other nursing personnel may also provide
care beyond their level of expertise, with minimal su-
pervision, to meet the health care needs of the rural
population.
One of our primary goals was to surmount this
problem by traveling 1 – 2 h to several rural areas to
provide oncology expertise in the form of clinics in
which we see new and returning patients on a bi-
weekly basis. During the clinic appointment, the med-
ical and radiation oncologists and nurse practitioners
perform ongoing management of established patients,
plan diagnostic and therapeutic interventions for new
patients, and counsel patients regarding palliative care
and end of life issues. We also educate the hospital
oncology nursing staff, many of whom have become
certified in oncology nursing. These specialized nurses
see patients every day and administer chemotherapy
and other treatments such as transfusions and intra-
venous fluids, and perform limited patent assessments
thus trouble shooting problems experienced by the
oncology patients.
Problems that can occur in this setting include are
lack of direct supervision on a daily basis, lack of
continuity of care, and problems related to handling
and communicating medical information between the
outreach sites and the cancer center.
Direct supervision by a specialist is obviously im-
possible 2 h away. We work closely with the primary
care physicians in the community and the patients
continue to see them regularly after diagnosis. The
community physicians are most often the first to see
and evaluate patients having problems, and will then
often call one of the oncology physicians to discuss
16. the case. If a patient is having a specific problem that
must be handled by a specialist, such as a compli-
cated neutropenic fever, or spinal cord compression,
the patient usually must be transported to our medi-
cal center. However, the patient may often be stabi-
lized and kept at the rural hospital if the primary
care physician has the support of the oncologists and
other members of the medical center faculty.
Continuity of care is an important concept in the
patient – clinician relationship. Unfortunately, we are
not always able to provide direct continuity of care
to our oncology patients because of time and sched-
ule constraints. We do the best we can by maintain-
ing a constant pool of physicians and nurses
designated for each site, detailed patient summaries
and clinic visits, so that the next physician will know
what the treatment plan and previous problems are,
and frequent use of phone calls to patients we know
are having problems.
Handling and communication of patient informa-
tion involves confidentiality issues described below,
L.J. Lyckholm et al. / Critical Re�iews in
Oncology/Hematology 40 (2001) 131 – 138136
and also involves management of large volumes of
information from multiple sites, which is extremely
challenging. Some information is critical, and elabo-
rate systems are in place to assure that the informa-
tion is noted and recorded by the site nurses and the
cancer center nurse practitioners, and that the oncol-
ogy physicians are made aware of any critical values,
17. such as abnormal CT scans or blood tests. Ongoing
quality assessment is in place to assure impeccable
data management, to avoid missing critical informa-
tion.
7.3. Confidentiality and pri�acy
The proximity in which patients and health care
workers live and work in rural communities makes it
much more likely that physicians and other health
care workers will know their patients personally and
socially, which creates significant challenges to main-
taining respect for confidentiality and patient privacy.
A 1993 survey of 510 general and family physicians
in Kansas revealed that 46% of respondents practic-
ing in a community of less than 5000 were likely to
have more than 5% of patients who were family
members or friends of the physician or staff, signifi-
cantly more than the 13% of respondents from com-
munities of more than 20 000. fourteen percent of the
physicians in the communities of less than 5000 also
reported that in more than 5% of cases medical infor-
mation is passed through the physician or staff to an
outside party who knows the patient in question [18].
Purtillo and Sorrell describe a patient who is found
to have genital herpes during a routine prenatal visit.
The patient pleads with the physician not to enter the
information in her chart: her sister-in-law is the
physician’s receptionist, the county public health clerk
to which this transmissible disease should be reported
is her cousin; other relatives work at the hospital
where she will deliver; ‘‘virtually everybody in the sit-
uation is either a relative, friend or foe’’ [16].
In an instance reported by Roberts et al., a patient
18. drove 6 h to an urban center for help with his sub-
stance abuse problems. He told the attending physi-
cian that he couldn’t go to his community clinic
because his sister worked there, and he was afraid she
would tell the whole family. The patient’s subsequent
non-compliance with the program was at least par-
tially blamed on the burdensome long distance drive
to the urban facility [17].
We have had several patients in our rural oncology
clinics that have expressed unwillingness to be treated
at the facility, because their privacy might be jeopar-
dized. The waiting rooms of these clinics are often
crowded with people who are friends, neighbors and
relatives. Because it is a specialty clinic only for pa-
tients with hematologic or oncologic problems, it is
not difficult for one to know another’s general diag-
nosis. Diagnostic tests are performed, interpreted and
transcribed by patients’ relatives and acquaintances.
The patients are given chemotherapy in one large
room and on any given day, they may find them-
selves sitting next to a neighbor, the local florist, or a
distant cousin. Several of the nurses have found
themselves treating old friends, teachers, neighbors
and relatives. This may sometimes be a comfort to
the patient. but may also be embarrassing or uncom-
fortable for both the patient and nurse.
In our rural outreach practice, we must exchange
information about patients frequently by phone and
often by fax and by email over the Internet. None of
these communication devices are entirely secure, espe-
cially the email system, but they are necessary in
communicating important patient information in a
timely and efficient manner.
19. Safeguarding confidentiality in such circumstances
is important; the Kansas physicians reported several
measures they took to do so, some of which could
potentially compromise patient care, the physician’s
integrity or even legally endanger the physician, such
as in the case of misrepresenting or omitting certain
details on insurance forms, and omitting required not-
ification of local public health officials. Other mea-
sures taken included speaking with office personnel
regarding the importance of confidentiality of a spe-
cific patient, omitting or misrepresenting certain de-
tails for the official medical record and recording the
importance of confidentiality in the chart [15].
Our outreach site staff are aware of the sensitive
nature of our patients’ conditions and maintain a
high level of awareness regarding privacy and confi-
dentiality. Simple measures such as keeping telephone
conversations and reports out of hearing distance
from the waiting room and patient rooms as well as
ongoing discussions regarding confidentiality between
nursing staff and outreach staff are highly effective.
The nursing and secretarial staff maintains a high
level of professionalism and respect for patients, and
in particular, confidentiality, which sets the tone for
the rest of the staff.
7.4. Institutional ethics committees
In response to the mounting complexity and num-
ber of clinical ethical issues encountered in healthcare,
institutional ethics committees are developing in rural
and urban hospitals. Some have the specific goals of
developing and overseeing hospital policies, to re-
spond to the requirements of the JCAHO and similar
20. organizations, and others have multiple goals, includ-
ing the former as well as addressing day-to-day
dilemmas that arise in the course of patient care.
They are as heterogeneous in their compositions as in
L.J. Lyckholm et al. / Critical Re�iews in
Oncology/Hematology 40 (2001) 131 – 138 137
their goals and missions, some composed of physi-
cians and administrators, others representatives from
multiple divisions of the hospital, such as nursing,
pastoral care, and even from the community. Their
members have various levels of ethics knowledge and
expertise. Some have support from local institutions
that have established ethics committees and consider-
able expertise. Others have members who have taken
additional training in bioethics at community or uni-
versity programs.
The hospital ethics committee can be a tremendous
source of knowledge and support for physicians and
other health care providers confronted by the dilem-
mas listed above. It is critical that these committees
have the expertise and influence to support and up-
hold behavior and policy based on ethical principles.
The development of such committees has been de-
scribed as occurring in three stages: emergence of a
local expert, educating the ethics committee and de-
veloping a body of knowledge, and expansion of the
ethics activity into policy development and consulta-
tion [19].
In our rural cancer outreach programs, we have
21. offered the expertise of our established and experi-
enced hospital ethics committee and its members, as
well as persuaded them to identify interested individu-
als for further training by the Richmond Community
Bioethics Consortium. We have also given several lec-
tures and held discussions related to ethical issues in
the care of oncology patients to the nursing and med-
ical staff. We will continue to support them in any
way possible to guarantee ethical treatment of their
patients and employees.
8. Conclusions
There are distinct and novel ethical issues in
providing rural health care. Two groups have shown
that rural cancer outreach (a structured alliance of a
cancer center and rural hospitals and providers)
works well clinically and economically. In addition,
rural cancer outreach is ethical because it is distribu-
tive and just.
Reviewers
Dr Dieter K. Hossfeld, Universitäts-Krankenhaus
Eppendorf, Medizinische Klinik, Abteilung Onkologie
und Hämatologie, Martinistrasse 52, D-20246 Ham-
burg, Germany.
Dr Leslie R. Laufman, Hematology/Oncology Consul-
tants, Inc., 8100 Ravines Edge Ct., Columbus, OH,
43235-5436, USA.
Acknowledgements
We gratefully acknowledge grant support from the
Jessie Ball duPont Fund, 225 Water Street, Jack-
22. sonville, Florida, USA
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Biographies
Laurie Lycholm, M.D., is director of the ethics pro-
gram for the medical school. She also has active roles
as a traveling physician with the Cancer Out- reach
programand as a member of the Brain Tumor Multi-
disciplinary Clinic.
25. Mary Helen Hackney, M.D., is the director of Rural
Cancer Outreach Program and travels regularly to
rural clinics. She is also part of the Breast Health
Center and is involved in patient and physician edu-
cation about breast cancer.
Tom Smith, M.D., is recognized nationally and inter-
nationally for his papers on health services research.
He is currently the director of the ASCO curriculum
on palliative care and has focused his research on
palliative care topics. He is a Project on Death in
America Scholar.
.