This document summarizes a gastroenterologist's perspective on the field of gastroenterology. It discusses how gastroenterology combines both the science and art of medicine. The science involves understanding the microscopic functions of the gut and how stress can affect gastrointestinal symptoms. However, diagnosing and treating gastrointestinal illnesses also requires understanding the patient's life context and experiences. This blending of the objective biological factors with the individual patient is what makes gastroenterology both challenging and rewarding. The document emphasizes the importance of effective communication and developing a trusting relationship with patients, especially those suffering from chronic or complex conditions.
tHESE SLIDES ARE PREPAREED TO UNDERSTAND about HEALTH ASSESSMENT IN EASY WAY Important links- NOTES- https://mynursingstudents.blogspot.com/ youtube channel https://www.youtube.com/c/MYSTUDENTSU... CHANEL PLAYLIST- ANATOMY AND PHYSIOLOGY-https://www.youtube.com/playlist?list=PL93S13oM2gAPM3VTGVUXIeswKJ3XGaD2p COMMUNITY HEALTH NURSING- https://www.youtube.com/playlist?list=PL93S13oM2gAPyslPNdIJoVjiXEDTVEDzs CHILD HEALTH NURSING- https://www.youtube.com/playlist?list=PL93S13oM2gANcslmv0DXg6BWmWN359Gvg FIRST AID- https://www.youtube.com/playlist?list=PL93S13oM2gAMvGqeqH2ZTklzFAZhOrvgP HCM- https://www.youtube.com/playlist?list=PL93S13oM2gAM7mZ1vZhQBHWbdLnLb-cH9 FUNDAMENTALS OF NURSING- https://www.youtube.com/playlist?list=PL93S13oM2gAPFxu78NDLpGPaxEmK1fTao COMMUNICABLE DISEASES- https://www.youtube.com/playlist?list=PL93S13oM2gAOWo4IwNjLU_LCuhRN0ZLeb ENVIRONMENTAL HEALTH- https://www.youtube.com/playlist?list=PL93S13oM2gAPkI6LvfS8Zu1nm6mZi9FK6 MSN- https://www.youtube.com/playlist?list=PL93S13oM2gAOdyoHnDLAoR_o8M6ccqYBm HINDI ONLY- https://www.youtube.com/playlist?list=PL93S13oM2gAN4L-FJ3s_IEXgZCijGUA1A ENGLISH ONLY- https://www.youtube.com/playlist?list=PL93S13oM2gAMYv2a1hFcq4W1nBjTnRkHP facebook profile- https://www.facebook.com/suresh.kr.lrhs/ FACEBOOK PAGE- https://www.facebook.com/My-Student-S... facebook group NURSING NOTES- https://www.facebook.com/groups/24139... FOR MAKING EASY NOTES YOU CAN ALSO VISIT MY BLOG – BLOGGER- https://mynursingstudents.blogspot.com/ Instagram- https://www.instagram.com/mystudentsu... Twitter- https://twitter.com/student_system?s=08 #PEM, #ASHA,#DIPHTHERIA,#ICDS,#nurses,#ASSESSMENT, #APPEARENCE,#PULSE,#GRIMACE,#REFLEX,#RESPIRATION,#RESUSCITATION,#NEWBORN,#BABY,#VIRGINIA, #CHILD, #OXYGEN,#CYANOSIS,#OPTICNERVE, #SARACHNA,#MYSTUDENTSUPPORTSYSTEM, #rashes,#nursingclasses, #communityhealthnursing,#ANM, #GNM, #BSCNURING,#NURSINGSTUDENTS, #WHO,#NURSINGINSTITUTION,#COLLEGEOFNURSING,#nursingofficer,#COMMUNITYHEALTHOFFICE
1. Define and identify the purposes of a nursing diagnosis.
2. Know what NANDA means and where to find more information.
3. Differentiate between the types of nursing diagnosis and be able to provide an example of each.
4. Differentiate a nursing diagnosis from a medical diagnosis.
5. Identify the three segments of a diagnostic statement and give examples of a comprehensive diagnostic statement.
- What is the nursing diagnosis?
- What is NANDA?
- Types of nursing diagnosis and examples of each.
- Criteria of nursing diagnosis.
- What is the difference(s) between a medical diagnosis and nursing diagnosis?
- Example: Pneumonia
- Possible nursing diagnosis:
o Altered gas exchange,
o Ineffective airway clearance,
o Activity intolerance,
o Risk for imbalanced nutrition,
o Risk for infection transmission,
o Discomfort.
- Refer to Maslow’s needs again
- Exercise
o Nursing diagnosis for Bronchitis
o Nursing diagnosis for Hypertension
This Nursing care plan is based on the format of Indian nursing council according in which assessment points aren't included. The hepatitis B is a most dangerous diseases condition and it's Incubation period, 2 to 3 months.Prodronal symptoms (insidious onset): fatigue, anorexia,
transient fever, abdominal discomfort, nausea, vomiting,
headache.May also have myalgias, photophobia, arthritis, angioedema,
urticaria, maculopapular rash, vasculitis. Icteric phase occurs 1 week to 2 months after onset of
symptoms.
tHESE SLIDES ARE PREPAREED TO UNDERSTAND about HEALTH ASSESSMENT IN EASY WAY Important links- NOTES- https://mynursingstudents.blogspot.com/ youtube channel https://www.youtube.com/c/MYSTUDENTSU... CHANEL PLAYLIST- ANATOMY AND PHYSIOLOGY-https://www.youtube.com/playlist?list=PL93S13oM2gAPM3VTGVUXIeswKJ3XGaD2p COMMUNITY HEALTH NURSING- https://www.youtube.com/playlist?list=PL93S13oM2gAPyslPNdIJoVjiXEDTVEDzs CHILD HEALTH NURSING- https://www.youtube.com/playlist?list=PL93S13oM2gANcslmv0DXg6BWmWN359Gvg FIRST AID- https://www.youtube.com/playlist?list=PL93S13oM2gAMvGqeqH2ZTklzFAZhOrvgP HCM- https://www.youtube.com/playlist?list=PL93S13oM2gAM7mZ1vZhQBHWbdLnLb-cH9 FUNDAMENTALS OF NURSING- https://www.youtube.com/playlist?list=PL93S13oM2gAPFxu78NDLpGPaxEmK1fTao COMMUNICABLE DISEASES- https://www.youtube.com/playlist?list=PL93S13oM2gAOWo4IwNjLU_LCuhRN0ZLeb ENVIRONMENTAL HEALTH- https://www.youtube.com/playlist?list=PL93S13oM2gAPkI6LvfS8Zu1nm6mZi9FK6 MSN- https://www.youtube.com/playlist?list=PL93S13oM2gAOdyoHnDLAoR_o8M6ccqYBm HINDI ONLY- https://www.youtube.com/playlist?list=PL93S13oM2gAN4L-FJ3s_IEXgZCijGUA1A ENGLISH ONLY- https://www.youtube.com/playlist?list=PL93S13oM2gAMYv2a1hFcq4W1nBjTnRkHP facebook profile- https://www.facebook.com/suresh.kr.lrhs/ FACEBOOK PAGE- https://www.facebook.com/My-Student-S... facebook group NURSING NOTES- https://www.facebook.com/groups/24139... FOR MAKING EASY NOTES YOU CAN ALSO VISIT MY BLOG – BLOGGER- https://mynursingstudents.blogspot.com/ Instagram- https://www.instagram.com/mystudentsu... Twitter- https://twitter.com/student_system?s=08 #PEM, #ASHA,#DIPHTHERIA,#ICDS,#nurses,#ASSESSMENT, #APPEARENCE,#PULSE,#GRIMACE,#REFLEX,#RESPIRATION,#RESUSCITATION,#NEWBORN,#BABY,#VIRGINIA, #CHILD, #OXYGEN,#CYANOSIS,#OPTICNERVE, #SARACHNA,#MYSTUDENTSUPPORTSYSTEM, #rashes,#nursingclasses, #communityhealthnursing,#ANM, #GNM, #BSCNURING,#NURSINGSTUDENTS, #WHO,#NURSINGINSTITUTION,#COLLEGEOFNURSING,#nursingofficer,#COMMUNITYHEALTHOFFICE
1. Define and identify the purposes of a nursing diagnosis.
2. Know what NANDA means and where to find more information.
3. Differentiate between the types of nursing diagnosis and be able to provide an example of each.
4. Differentiate a nursing diagnosis from a medical diagnosis.
5. Identify the three segments of a diagnostic statement and give examples of a comprehensive diagnostic statement.
- What is the nursing diagnosis?
- What is NANDA?
- Types of nursing diagnosis and examples of each.
- Criteria of nursing diagnosis.
- What is the difference(s) between a medical diagnosis and nursing diagnosis?
- Example: Pneumonia
- Possible nursing diagnosis:
o Altered gas exchange,
o Ineffective airway clearance,
o Activity intolerance,
o Risk for imbalanced nutrition,
o Risk for infection transmission,
o Discomfort.
- Refer to Maslow’s needs again
- Exercise
o Nursing diagnosis for Bronchitis
o Nursing diagnosis for Hypertension
This Nursing care plan is based on the format of Indian nursing council according in which assessment points aren't included. The hepatitis B is a most dangerous diseases condition and it's Incubation period, 2 to 3 months.Prodronal symptoms (insidious onset): fatigue, anorexia,
transient fever, abdominal discomfort, nausea, vomiting,
headache.May also have myalgias, photophobia, arthritis, angioedema,
urticaria, maculopapular rash, vasculitis. Icteric phase occurs 1 week to 2 months after onset of
symptoms.
SHARE Presentation: Palliative Care for Womenbkling
Dr. Michael Pearl discusses supportive palliative care for women with cancer, how it differs from hospice care, and the New York Palliative Care Information Act. Dr. Michael Pearl is Professor and Director of the Division of Gynecologic Oncology in the Department of Obstetrics, Gynecology and Reproductive Medicine at Stony Brook University Hospital.
The purpose of this survey for PA's & NP's was to identify perceived needs regarding education for managing patients with type 2 diabetes. 145 PA/NP's participated in the survey.
SHARE Presentation: Palliative Care for Womenbkling
Dr. Michael Pearl discusses supportive palliative care for women with cancer, how it differs from hospice care, and the New York Palliative Care Information Act. Dr. Michael Pearl is Professor and Director of the Division of Gynecologic Oncology in the Department of Obstetrics, Gynecology and Reproductive Medicine at Stony Brook University Hospital.
The purpose of this survey for PA's & NP's was to identify perceived needs regarding education for managing patients with type 2 diabetes. 145 PA/NP's participated in the survey.
C H I R O E CO . CO M F e B r u a r y 2 4 , 2 0 1 7 • C H I R .docxclairbycraft
C H I R O E CO . CO M F e B r u a r y 2 4 , 2 0 1 7 • C H I R O P R A C T I C E CO N O M I C S 41
WELLNESSAPPROACH
THE NUMBER OF INDIVIDUALS WHOSUFFER FROM COMPLEX CHRONICdiseases such as heart disease,
diabetes, cancer, and autoimmune
disorders is on the rise. The conven-
tional care provided by allopathic
medicine is oriented toward acute care
and the diagnosis of trauma or disease
of limited duration, such as a broken
limb or heart attack.
Medical physicians practicing in this
model typically prescribe drugs or
surgery with the goal of ameliorating
the immediate conditionand symptoms.
If, as a DC, you are frustrated by
watching your patients suffer from
chronic disease and be cycled through
the system of diagnosis and drugs
without improvement, Functional
Medicine (FM) can provide you with
powerful tools and strategies to help
your patients regain their health.
Why Functional Medicine?
The acute-care approach is ill-equipped
to handle the multifaceted issues that
accompany most chronic diseases. It’s
also a model that fails to address the
unique genetic background of each
individual. It also does not take into
account the impact of modern lifestyles
and environmental factors that can
lead to an increase in chronic diseases.
These factors include diet, exercise,
exposure to toxins, and stress. For
these reasons, most doctors are
unequipped to assess the underlying
causes of disease. They do not know
how to utilize diet, exercise, and
nutrition as preventive factors in
combating chronic disease.
From an allopathic perspective, FM
offers a novel approach and method-
ology to treating andpreventing chronic
diseases. From a chiropractic perspec-
tive, seeking to discover the underlying
cause of disease by examining how
structure impacts function is a foun-
dational principal for the profession.
By joining forces, either through
collaboration or in a more formal
integrative or multidisciplinary practice
setting, allopathic physicians and
chiropractors can help their patients
derive the greatest benefit from both
perspectives. Practitioners of FM
develop individualized treatment
programs that address the interaction
between the external environment and
the internal environment of the body,
The heart of the matter
What you need to know about Functional Medicine.
BY MARK SANNA, DC
A
D
O
BE
ST
O
C
K
http://www.chiroeco.com
42 C H I R O P R A C T I C E CO N O M I C S • F e B r u a r y 2 4 , 2 0 1 7 C H I R O E C O . CO M
WELLNESSAPPROACH
including the immune, endocrine, and
gastrointestinal systems.
How is Functional Medicine
different?
From an FM perspective, the primary
factors considered during a patient
assessment include foundational
lifestyle factors: nutrition, exercise,
sleep, stress level, interpersonal
relationships, andgenetics. These
primary factors are, in turn, influenced
by certain predisposing factors,
ongoing physiological processes, and
discrete events that result in an
imbalance in the body’s ability to
maintain .
2Reducing Stroke Readmissions in the Acute.docxlorainedeserre
2
Reducing Stroke Readmissions in the Acute Care Setting
Michelle L Wallace
NUR 430
Professor Roberts
Introduction:
Cardiovascular diseases, obesity, cancer, and stroke are some of the leading diseases in the world, and they are the most frequent causes of death in recent past years. Stroke is the condition when there is a blockage of blood supply, and oxygen to any part of the brain. Unfortunately, his will cause the death of brain cells. This capstone project is about stroke readmissions that are increasing with passing time. There are efforts being made to reduce stroke readmissions to hospitals, and there are a lot of factors involved. Patients should be given proper awareness, and nurses should be educated so they may treat the patients with the appropriate care necessary. According to the American Heart Association, 389 deaths occur each day due to a stroke in 2016 (Sunil, 2013). This proposal will discuss the different ways to reduce the stroke causes and readmissions in the hospital.
Purpose:
The purpose of the project is to discuss the different causes of stroke and other cardiovascular diseases and further, it will discuss the ways of prevention and treatment as well. It is a common observation that stroke readmissions are increasing day by day, and patients are not getting enough care and treatment in hospitals. It is observed that may stroke patients are admitted to the hospital, go home after treatment; and unfortunately, have to re visit hospitals again and again. The awareness level has to be increased and the education level has to be enhanced as well. The community should be engaged in the different training sessions and proper guidance should be given to them (Stephanie Rennke, 2015). There are different strategies for reducing stroke readmissions in the hospitals. First, it should be noticed that the immune system and nervous system of the patients are weak, and they have to build immunity and the concept of self-care should be introduced. The families and peer groups should be supportive enough and diet recommendations should be given to them. Subsequently, it would be the duty of the nurses to provide education to patients hopefully resulting in the reduction of stroke readmissions.
Personal Reflections:
There are different significant issues regarding ailments and medical experts are presenting their strategies to control these issues; however, I have selected stroke for the proposal. Stroke and its incidence are increasing day by day, and the western countries are most at risk. Sedentary lifestyles are increasing, and the junk food prevalence is enhanced in western countries as well. We as a people are so busy with jobs and business, there is very little time to incorporate a healthy lifestyle. Unfortunately, there is a lack of routine exercise as a nation. On the other hand, the ratio of smokers is also increasing, in which is ...
2Reducing Stroke Readmissions in the Acute.docxBHANU281672
2
Reducing Stroke Readmissions in the Acute Care Setting
Michelle L Wallace
NUR 430
Professor Roberts
Introduction:
Cardiovascular diseases, obesity, cancer, and stroke are some of the leading diseases in the world, and they are the most frequent causes of death in recent past years. Stroke is the condition when there is a blockage of blood supply, and oxygen to any part of the brain. Unfortunately, his will cause the death of brain cells. This capstone project is about stroke readmissions that are increasing with passing time. There are efforts being made to reduce stroke readmissions to hospitals, and there are a lot of factors involved. Patients should be given proper awareness, and nurses should be educated so they may treat the patients with the appropriate care necessary. According to the American Heart Association, 389 deaths occur each day due to a stroke in 2016 (Sunil, 2013). This proposal will discuss the different ways to reduce the stroke causes and readmissions in the hospital.
Purpose:
The purpose of the project is to discuss the different causes of stroke and other cardiovascular diseases and further, it will discuss the ways of prevention and treatment as well. It is a common observation that stroke readmissions are increasing day by day, and patients are not getting enough care and treatment in hospitals. It is observed that may stroke patients are admitted to the hospital, go home after treatment; and unfortunately, have to re visit hospitals again and again. The awareness level has to be increased and the education level has to be enhanced as well. The community should be engaged in the different training sessions and proper guidance should be given to them (Stephanie Rennke, 2015). There are different strategies for reducing stroke readmissions in the hospitals. First, it should be noticed that the immune system and nervous system of the patients are weak, and they have to build immunity and the concept of self-care should be introduced. The families and peer groups should be supportive enough and diet recommendations should be given to them. Subsequently, it would be the duty of the nurses to provide education to patients hopefully resulting in the reduction of stroke readmissions.
Personal Reflections:
There are different significant issues regarding ailments and medical experts are presenting their strategies to control these issues; however, I have selected stroke for the proposal. Stroke and its incidence are increasing day by day, and the western countries are most at risk. Sedentary lifestyles are increasing, and the junk food prevalence is enhanced in western countries as well. We as a people are so busy with jobs and business, there is very little time to incorporate a healthy lifestyle. Unfortunately, there is a lack of routine exercise as a nation. On the other hand, the ratio of smokers is also increasing, in which is .
Reply 1Explain the role of health education in health promotion..docxcarlt4
Reply 1
Explain the role of health education in health promotion. How is the nursing process used in developing health education? Describe a contemporary issue, local or global, that a family may experience today. What steps would the nurse take to address these as part of a health education plan?
The role of health education in health promotion is vital. Health promotion by definition is “educating people about healthy lifestyles, reduction of risk, developmental needs, activities of daily living (ADL’s) and preventive self-care.” (Whitney et al., 2018). In order to live a healthy lifestyle an individual must know what a “healthy lifestyle” consists of. The same goes for reducing risks, ADL’s, preventative self-care and developmental needs. It is important for the healthcare professional or in our case, the nurse, to educate an individual continuously for the duration of the patient's care with the nurse. They should be educated on what the medications are that they are being given, as well as why it is being administered, dosage, route etc. For example, patients always want to know why they are getting Lovenox or Protonix when they have not taken it before. They should also be educated on diet choices, at the hospital that I work at, sometimes the patients will be placed on certain diets like nothing by mouth (NPO), American Diabetes Association (ADA), renal, heart healthy, low potassium etc., and they state that they do not have diet restrictions at home, so they have to be educated on why they were placed on the diet and they should consider this type of diet once discharged.
The nursing process is used in developing health education because the nurse must assess the patient. This assessment is not only a head to toe assessment, but the nurse must also determine the patients needs, readiness to learn and the patient's ability and desire to actively engage in their plan of care and meeting goals. Then the nurse makes their nursing diagnoses, for example is their non-compliance evident, immobility, learning deficit etc. The nurse then develops a plan of care and action that can be made with the patient and begins to implement the plan of care. The nurse and patient evaluate how well they are meeting their care goals and continue to develop a plan that changes to the patients needs and better assists with meeting goals. Throughout the whole process the nurse is educating the patient on what the problem is preventing the patient from getting better and then the nurse educates the patient on how they can work towards solving that problem.
A contemporary issue that a family may experience today is the issue of vaccination. There is a lot of information out there that is telling parents to not vaccinate their children. However, recently there was an issue with a measles outbreak in New York where I live, as well as some other states. In the media there became this discussion about the importance of vaccinating your children, not only for the.
Write down the clinical importance of occupational history in medical practice.
Identification of potential health risks: Obtaining an occupational history can help healthcare providers identify potential health risks associated with a patient's occupation. For instance, a patient working in a factory that uses toxic chemicals may be at risk of developing respiratory problems or cancer.
Diagnosis and management of work-related illnesses and injuries: Understanding a patient's work history can help healthcare providers diagnose and manage work-related illnesses and injuries. For example, a patient with carpal tunnel syndrome may be diagnosed with a work-related injury if their job involves repetitive hand motions.
Appropriate preventive measures: Knowledge of a patient's occupation can help healthcare providers provide appropriate preventive measures to reduce the risk of developing work-related illnesses or injuries. For instance, a healthcare worker may be advised to use personal protective equipment (PPE) to prevent exposure to infectious diseases.
Legal and insurance purposes: Occupational history can also be important for legal and insurance purposes. For example, a worker's compensation claim may require documentation of the patient's occupation and the circumstances surrounding the injury.
Social and environmental factors: Occupational history can provide information about a patient's social and environmental factors that may contribute to their health status. For example, a patient with a stressful job may be at higher risk of developing mental health conditions.
In summary, obtaining a patient's occupational history is crucial for healthcare providers to understand potential health risks, diagnose and manage work-related illnesses and injuries, provide appropriate preventive measures, and consider social and environmental factors.
Question: Mention the importance of past history in medical practice.
Past medical history is an important aspect of medical practice as it provides valuable information about a patient's health status and can help healthcare providers make informed decisions about their diagnosis, treatment, and management. Here are some points and examples elaborating the importance of past medical history in medical practice:
Understanding the patient's medical background: A patient's past medical history can provide information about their medical conditions, surgeries, hospitalizations, and medications. This information can help healthcare providers understand the patient's medical background, which is essential for accurate diagnosis and treatment. For example, a patient with a history of heart disease may be at higher risk of developing complications from a respiratory illness.
Identifying risk factors and potential health problems: Past medical history can help identify risk factors and potential health problems that may be relevant to a patient's current condition. For instance, a patient with a his
Running Head PICOT STATEMENT1PICOT STATEMENT4.docxglendar3
Running Head: PICOT STATEMENT 1
PICOT STATEMENT 4
PICOT statement
Name of the student:
Good start on your PICO question this week. However, I am not clear on what the PICOT question is. What is the specific intervention, comparison, and outcomes you are evaluating? I noted a few corrections and comments in your paper. Be sure to make corrections before including this in the final capstone paper in week 9. Thanks. – Mrs. Guzman
PICOT Sstatement
Patient/Ppopulation
The population that is mostly affected with hypertension are male adults between the ages of 40 and 70 with hypertension, and with different diseases, that shows alteration in lifestyle (attracting routinely in practice and taking in more advantageous and sufficient dinners), appeared differently in relation to patients who use solution to treat/manage their high blood pressure, assist to manage their heartbeat and lessen the threat of making cardiovascular sicknesses in their recovery time inside a half year. The period will be adequately long to make a sick be able not to encounter the evil impacts of high blood pressure and to in like manner diminish the threats that the general population will customarily experience (Dua, et.al, 2014). Comment by Melanie Guzman: Meaning is not clear Comment by Melanie Guzman: This is vague Comment by Melanie Guzman: 5 authors: Put all last names inn first citation, then et al. in subsequent citations
Intervention Comment by Melanie Guzman: Headings bolded
The essential strategy for mediation for sick with high blood pressure it is with no vulnerability to place them under medicine so that they can be restored. That is the most secure way as it will impact the patient to have the ability to manage themselves to the extent how they to think, what they eat and even the activities that they endeavor to take an interest in. The age of the patients will in like manner suggest that the sick are given arrangement that can oversee them in the most useful means and which they can recognize with everything taken into account. The medicine that can be provided for this circumstance is one that can diminish the brutality of a prescription. The nursing intercession for sick with high blood pressure is evaluating the migraine torments that sick is encountering and checking the obscured vision in like clockwork until the point when it leaves. Another nursing mediation is for an attendant to teach a sick on how they counsel with their specialist before the medicine is ceased (Dua, et.al, 2014). Comment by Melanie Guzman: This is not clear. What is the identified problem? PICOT statement? What evidenced-based interventions related to that problem are you proposing? Comment by Melanie Guzman: What interventions are being doing to prevent high blood pressure? Is evaluation of migraine a major issue with HTN? Comment by Melanie Guzman:
Comparison Comment by Melanie Guzman: What are you specifically comparing in your PICOT statement?
The first c.
Running Head PICOT STATEMENT1PICOT STATEMENT4.docxtodd581
Running Head: PICOT STATEMENT 1
PICOT STATEMENT 4
PICOT statement
Name of the student:
Good start on your PICO question this week. However, I am not clear on what the PICOT question is. What is the specific intervention, comparison, and outcomes you are evaluating? I noted a few corrections and comments in your paper. Be sure to make corrections before including this in the final capstone paper in week 9. Thanks. – Mrs. Guzman
PICOT Sstatement
Patient/Ppopulation
The population that is mostly affected with hypertension are male adults between the ages of 40 and 70 with hypertension, and with different diseases, that shows alteration in lifestyle (attracting routinely in practice and taking in more advantageous and sufficient dinners), appeared differently in relation to patients who use solution to treat/manage their high blood pressure, assist to manage their heartbeat and lessen the threat of making cardiovascular sicknesses in their recovery time inside a half year. The period will be adequately long to make a sick be able not to encounter the evil impacts of high blood pressure and to in like manner diminish the threats that the general population will customarily experience (Dua, et.al, 2014). Comment by Melanie Guzman: Meaning is not clear Comment by Melanie Guzman: This is vague Comment by Melanie Guzman: 5 authors: Put all last names inn first citation, then et al. in subsequent citations
Intervention Comment by Melanie Guzman: Headings bolded
The essential strategy for mediation for sick with high blood pressure it is with no vulnerability to place them under medicine so that they can be restored. That is the most secure way as it will impact the patient to have the ability to manage themselves to the extent how they to think, what they eat and even the activities that they endeavor to take an interest in. The age of the patients will in like manner suggest that the sick are given arrangement that can oversee them in the most useful means and which they can recognize with everything taken into account. The medicine that can be provided for this circumstance is one that can diminish the brutality of a prescription. The nursing intercession for sick with high blood pressure is evaluating the migraine torments that sick is encountering and checking the obscured vision in like clockwork until the point when it leaves. Another nursing mediation is for an attendant to teach a sick on how they counsel with their specialist before the medicine is ceased (Dua, et.al, 2014). Comment by Melanie Guzman: This is not clear. What is the identified problem? PICOT statement? What evidenced-based interventions related to that problem are you proposing? Comment by Melanie Guzman: What interventions are being doing to prevent high blood pressure? Is evaluation of migraine a major issue with HTN? Comment by Melanie Guzman:
Comparison Comment by Melanie Guzman: What are you specifically comparing in your PICOT statement?
The first c.
Running head PROJECT MILESTONE TWO 1.PROJECT MILESTONE.docxtodd581
Running head: PROJECT MILESTONE TWO
1.
PROJECT MILESTONE TWO
6.
Running head: FINAL PROJECT MILESTONE
3.
Southern New Hampshire University
January 6th, 2019
Research question: “Does self-disclosure of the therapist improve eating disorder treatment.”
Hypothesis: Self-disclosure of the therapist improves eating disorder treatment.
Information On Research
The key variables for this research are self-disclosure of the therapist and eating disorder treatment. This research will focus on online research whereby participants will be recruited from an eating disorder charity database. The participants will be asked about the status of their condition and how they feel about having the disorder. The neutral condition will be that the therapists will disclose their sexuality and their feelings towards the patients’ conditions and personality (Marziliano, Pessin, Rosenfeld, & Breitbart, 2018).
Process of Study
The study will continue for two months with the therapists making contact with the participants once every week. These conditions will form the independent variables. The dependent variable would be participants continued to receive positive self-disclosures from the therapist leading to a greater level of patient self-disclosure, which lowered their shame, and encouraged the participants to continue with the treatment process. The participants will also be asked if they have been involved in any treatment before, and how they could describe their therapeutic alliance (Fuertes, Moore, & Ganley, 2018).
A longitudinal study and the rate of drop-out will be used to gather more information about the participants. The collected data will then be analyzed in relation to the independent variables by the end of the study. One of the ethical issues, which will be looked into while conducting the study, is informed consent. Participants will be informed about the purpose of the research and will have the right to participate or not participate in it. Secondly, the research will ensure the privacy and confidentiality of every participant.
Annotated Bibliography:
Secrecy and concealment are typical behaviors in individuals with eating problems. In the article titled “ Self-Disclosure in eating disorders,” researchers examined women with greater related eating issues and determined whether or not, these women would be willing to disclose information. In this study, different types of disclosure were calculated considering the body appearance of the individual and to restrained eating. This article would benefit my research because it provides great information that will confirm my theory and test my hypothesis.
Abstract 1.
Those who suffer from eating disorders are very emotional beings. Often times, some may not feel a need to express their need to not eat foods. Many women become self-conscious about their weight and find it hard to share th.
Hospice care and palliative care: Is there a difference between the two, and if so, what?
Many people still think that palliative care means hospice care. But today, hospice is only a small part of palliative care.
The goal of palliative care is to prevent or treat the symptoms and side effects of a disease; and it should be part of the picture from the first day a serious illness is diagnosed.
Dr. Jim Meadows, Director of Hospice and Palliative Care at Tennessee Oncology, will discuss this important topic. How does a family and a health care team best work together to guide a patient through a terminal illness? How does everyone continue to support quality, patient-centered, end-of-life care?
I didn't know this option of Palliative care existed prior to my mother's passing earlier this year of colorectal cancer. However, I do now know about it and want to share it with all of you
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Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
1. I n s i d e t h e M i n d s™
The Art and Science of
Gastroenterology
Top Doctors on Diagnosing
Gastroenterological Conditions, Educating
Patients, and Conducting Clinical Research
Nelson Bonheim, M.D., FACP, FACG, Center for GI Medicine, Fairfield and Westchester
Paul Martin, M.D., Mount Sinai School of Medicine
Douglas A. Drossman, M.D., UNC Center for Functional GI and Motility Disorders
David J. Bjorkman, M.D., MSPH, University of Utah School of Medicine
Charles D. Gerson, M.D., Mount Sinai School of Medicine
Bennett E. Roth, M.D., David Geffen School of Medicine, UCLA
2.
3. Gastroenterology:
The Focus on Mind and Body
Douglas A. Drossman, M.D.
Professor of Medicine and Psychiatry;
Co-Director, Division of Gastroenterology and Hepatology
UNC Center for Functional GI and Motility
Disorders
4. INSIDE THE MINDS
Gastroenterology: A Blending of Science and Art
The field of gastroenterology meets my needs of combining the technical
aspects of medicine with a strong focus on the patient; it truly is a blending
of science and art. In that regard, gastroenterology is different from
other medical sub-specialties. For example, with cardiology, pulmonary
disease, and nephrology, clinicians can rely on cardiac catheterization
lung physiology or kidney function tests to understand how well a specific
organ is functioning, and this closely relates to how ill the patient is. But
understanding gastroenterological illnesses is more complex; there are
no numbers or calculations of organ function to explain why the patient
has abdominal pain or nausea. Thus conventional physician and patient
expectations to test, diagnose, and treat are not always met. Gastroenterology
looks at the person and his or her symptoms (e.g., pain, nausea, or diarrhea)
in the context of daily functioning, life stress, quality of life, and coping
style. It is all of these in combination that determines the challenge and
excitement of working with gastrointestinal disorders.
The science of gastroenterology starts at the microscopic or submicroscopic
level, understanding how neurotransmitters and hormones in the bowel
such as serotonin or cholecystokinin (CCK) affect gastrointestinal function.
Furthermore, stress can produce these and other neurotransmitters in the
brain and they can then work “downstream” to affect intestinal motility,
inflammation of the bowel or the secretion of these organs. All GI
symptoms are intimately connected to and regulated by the brain; that is
why understanding psychosocial issues are so paramount.
The gastroenterologist must understand the science in relation to possible
disease and dysfunction of organ systems that produce symptoms and often
consider how it may be modified by the individual’s life context. Thus, nausea
may occur from a disease in the liver, or from gallstones, a stomach ulcer,
poorly functioning intestinal movements (motility), medication side effects,
a recent infection, an early pregnancy, a recollection of early traumatic
experience or even having an argument with one’s spouse. Similarly, a
patient with inflammatory bowel disease (IBD) may be doing well and then
5. GASTROENTEROLOGY: THE FOCUS ON MIND AND BODY
suddenly experience pain and diarrhea; the disease itself may or may not
have worsened, but other factors—such as a super-imposed infection, stress,
or dietary change or any combination—may also be the cause.
Then these historical data need to be refined with a physical examination
and diagnostic studies: when to do the blood tests, or an endoscopy, whether
to order the CT scan or MRI or even do no testing at all. Once all this
information is obtained the gastroenterologist must put it all together, and
come up with a reasonable diagnostic approach and plan of care. So the
science involves integrating the evident data on gastrointestinal pathology
and physiology within the context of the person. This brings us to the art: the
interaction with the patient.
The art of gastroenterology is not what you do but how you do it. It involves
understanding and participating in the patient’s inner world as related to his
or her illness: to use good interview skills to validate the previous medical
information and obtain new meaningful data directly from the patient, and
to put the more personal psychosocial influences into proper context. It also
involves understanding the patient’s “illness schema” or perception of what
is wrong, and what his or her concerns or expectations are from the doctor.
Then the information is integrated into an effective diagnostic and treatment
plan. Finally, the physician must convey this information in a manner that
is acceptable to the patient, and work toward reaching mutual agreement as
to how to move forward. In effect, all of this involves establishing a trusting
relationship with good communication and shared decision making.
When the diagnostic issues are clear, such as with a gallbladder attack,
hemorrhaging from a duodenal ulcer or a bowel obstruction, the expectation
for diagnosis and treatment is almost always shared; the doctor must take
control and the patient agrees to this. But the way in which the diagnostic
and treatment plan is conveyed remains important, and good communication
improves patient understanding and reduces anxiety. Importantly, when the
gastrointestinal illnesses are chronic, different expectations for diagnosis
and treatment between patient and physician may arise and more work is
needed to be sure that both are “on the same page.”
6. INSIDE THE MINDS
These skills are not learned through technology or textbooks. Rather it
requires that gastroenterologists be mentored from knowledgeable teachers,
learn from their own experience with patients, and also possess a genuine
desire to help the patient. Typically, doctors like patients who get better and
thank them for the effort. But the most prevalent GI disorders are chronic
(e.g., chronic liver disease, inflammatory bowel disease, functional GI and
motility disorders, chronic pancreatitis, and intestinal malabsorption) and
require ongoing management. With these patients, physicians need to value
the process of their care. This means building the relationship to help patients
help themselves, expecting only occasionally to make a rare diagnosis or
to cure. What patients with chronic illness truly want is a sense of hope,
and to have a doctor who cares and won’t abandon them. The studies show
that an effective physician patient relationship not only improves patient
satisfaction and adherence to treatment and avoids litigation, but it also leads
to better clinical results (1-3).
Communication Strategies
A trusting patient-doctor relationship characterized by good communication
and shared decisions can be enhanced by using a few simple strategies. I tell
students, residents, and GI fellows (i.e., internists taking additional training in
the sub-specialty of gastroenterology) that to obtain meaningful information
one must “sit where the patient is”: to see their personal understanding
and expectations from the illness (their “illness schema”). The following
questions can help:
1) What do you think is going on?
2) What are your concerns or worries?
3) What brings you here at this time?
4) What are your expectations from me?
Asking these questions lets the patient know of their physician’s interests in
their personal views. Likewise, the patient’s responses help their physician
understand any misconceptions that need to be addressed. For example,
patients often believe that their abdominal pain is due to cancer, or that
7. GASTROENTEROLOGY: THE FOCUS ON MIND AND BODY
their chest pain is due to heart disease or a hiatal hernia. However, chronic
abdominal pain is uncommonly related to cancer, heart disease can be easily
excluded, and a hiatal hernia rarely produces symptoms. So the physician
who elicits these beliefs can appropriately address them thus reducing their
patient’s unneeded worry or concern.
Communication skills are also important for handling patients’ responses
to test results and diagnoses. Paradoxically, some patients with chronic
or unexplained symptoms may be disappointed when a specific structural
diagnosis is not found (`Is it in my head then?”, “Is this doctor competent?”).
This may lead the patient to request more studies at a time when the
physician sees their symptoms as part of a chronic illness that does not
require further diagnostic studies. Consequently, the patient may view the
physician’s lack of interest to do diagnostic studies as a failing, while the
physician may perceive the patient’s insistence to do more studies as defiant
of his or her plan. This dilemma is avoided if the physician is able from
the outset to elicit the patient’s perspective and respond appropriately. For
instance, the greatest concern to most patients is cancer. If the doctor quickly
reassures by saying “Nothing is wrong,” the patient may perceive this as a
false reassurance without proper attention to the issue and lose confidence.
However, if the doctor says, “We can never fully exclude cancer but I feel
reassured from what you’ve told me and the study results that you have
(name diagnosis) and we should focus on management. However, I’ll stay
vigilant to any changes in your clinical condition that could require further
studies, for example, if you have bleeding or weight loss.” This approach
takes the patient’s concerns seriously and emphasizes continuation of care
while presenting boundaries to ordering unnecessary studies.
Understanding the Life Context in Developing a Diagnosis and
Treatment Plan
Sometimes the process of developing a diagnosis and treatment plan is
straightforward. If, for instance, a patient reports blood in the stool or has
heartburn or becomes jaundiced, it does not take more than ten or fifteen
minutes to get the history and decide on a plan: endoscopy for bleeding or
8. INSIDE THE MINDS
heartburn, or blood studies and diagnostic imaging to evaluate the liver. The
rest follows without difficulty.
On the other hand, seeing patients with chronic unexplained conditions often
require a more comprehensive biopsychosocial perspective (4). Diagnosis
first involves reviewing extensive records, often in advance of the patient’s
visit, to see what studies have and have not been done. Once the background
information is obtained rather than asking the same questions or redoing the
tests, the physician tries to go where others have not: to consider diagnoses
that may have been overlooked, and importantly to find out about the illness
within the life context of the patient. For example, did the symptoms be in at
Christmas dinner on the first anniversary of the parent’s death? Or has there
been a history of emotional trauma or physical or sexual abuse (5)? At tertiary
care medical centers half of the women seen in the gastroenterology clinics
report a history of abuse, and those individuals have more severe symptoms
and poorer quality of life (6). We are now learning that this observation may
be due to malfunctions in certain areas of the brain that can amplify the pain
(7,8). It is this biopsychosocial understanding of illness and disease that puts
the patient’s symptoms into a clearer perspective and opens the door to more
effective treatments.
Physicians who use a biopsychosocial perspective can often uncover critical
information. For instance, some patients have become conditioned to respond
to stress with gastrointestinal symptoms, yet are not aware of this association.
This may be confusing, or in the least, challenging for gastroenterologists
where an association with stress seems evident. For example, if a child goes
to school for the first time at age five, he or she might experience a psychophysiological response to the fear of leaving home: abdominal cramps and
diarrhea. If the parent singles out these symptoms as a reason to keep the child
home, and in fact “rewards” the child by providing toys and allowing him to
watch TV, the child’s relief in avoiding the feared situation could reinforce the
recurrence of such symptoms in future distressing circumstances, even into
adult life. If, on the other hand, the parent says, “You have a stomachache.
Maybe you are feeling nervous about going to school; let’s talk about it,”
then the child learns to understand his anxiety about going to school and
9. GASTROENTEROLOGY: THE FOCUS ON MIND AND BODY
verbalize it rather than expressing it through the conditioned symptoms. Our
research has shown that patients who make the link between stress and GI
symptoms seem less distressed with their symptoms and don’t go to doctors
as often as patients who do not make this link (9).
I once had a patient with a history of many years of abdominal pain and
many evaluations say to me on the first visit: “I am not leaving this table
until you agree to operate.” These are challenging situations for both patient
and doctor. Indeed, the patient who says that they know their pain is “real”
and there is no stress in their lives requires a physician with experience,
patience, and skill to provide a different level of understanding and support.
These patients may have also been mishandled by the health care system,
and they are fearful of being rejected yet choose to see many doctors trying
to find an answer.
Rather than take a biopsychosocial perspective, it is often much easier in our
litigious and cost-focused health care system to perform expensive tests and
prescribe symptomatic treatments without making the effort to understand the
patient’s perspective. Patients with complex long-standing conditions don’t
benefit from this approach. In the 1970s, researchers studied a concept called
“furor medicus” (10). They evaluated patients who came to the emergency
room and divided them into two groups: those with acute problems and
those with chronic conditions. Researchers found that patients with chronic
conditions had more procedures done, more medications prescribed, and
more exploratory laparotomies performed even when the doctors believed
they probably weren’t indicated. Why should they go against their better
judgment? Furor medicus depends on two factors: the level of uncertainty
within the doctor and the level of insistence by the patient to do something.
Residents in training are likely to perform extra procedures and unneeded
treatments because they don’t have the experience to deal with the uncertainty
of medicine; on the other hand, even experienced physicians may go against
their better judgment and order studies and treatments when the patient
insists that something be done now in order to achieve a quick solution. The
most respected gastroenterologists are those who can step back and look at
the big picture rather than simply react. In situations like this it is best to
“don’t just do something, stand there.”
10. INSIDE THE MINDS
Instead of rushing to do something, in these types of situations, the physician
needs to acknowledge the patient’s frustration, make it clear that the pain is
real, and then focus on developing a supportive relationship that helps the
patient find ways to accept the illness and learn to self manage. These are
patients who have been to many doctors and what they need is someone
to work with them regardless of the diagnosis or outcome. It may take a
little longer on the first visit to obtain and integrate the needed information
and establish an effective relationship. However, the results pay off for the
patient, far more than paying for another endoscopy that turns out negative.
This is the type of practice I choose to do, and working with someone who
has suffered for many years without understanding why, and helping them to
find the answers and improve their quality of life is immensely rewarding.
But aren’t we talking about gastroenterology? As it turns out, I have not
reflected on the technical aspects of the discipline. Technical skill and
adequate knowledge of the science is a requirement for training. The
learning is standardized and reinforced in practice and it is challenging and
exciting: stopping a bleeding artery in the stomach, taking out a gallstone
during sphincterotomy or managing a complex liver transplant patient.
However, a deeper satisfaction can occur through training and application
of the more cognitive aspects of gastroenterology, clinical reasoning and
decision making, communication skills, and building of the physicianpatient relationship. The use of these skills pays off in the long-term care of
patients with chronic GI disorders through physician and patient satisfaction,
improved clinical outcomes, and reduced costs.
Helping Patients with Functional GI Disorders to Help Themselves
I’ve been fortunate to have trained both in gastroenterology and
psychosomatic or biopsychosocial medicine, and so my focus tends to be on
the interaction of the brain and gut (4); my practice often involves working
with the most complex functional GI disorders. These disorders must be
understood from a biopsychosocial approach in order to integrate the role of
biological, psychological, and social factors in understanding the illness for
clinical care and research.
10
11. GASTROENTEROLOGY: THE FOCUS ON MIND AND BODY
About fifteen years ago, I was fortunate to recruit William Whitehead Ph.D.
from Johns Hopkins to the University of North Carolina and together we
founded the UNC Center for Functional GI and Motility Disorders at the
University of North Carolina (www.med.unc.edu/ibs). Our collaboration
has led to an internationally recognized program in clinical care, research,
and teaching of the functional GI and motility disorders.
Patients with functional GI and motility disorders who have been to many
high-quality practices are referred to us because they continue to have
disabling symptoms and poor quality of life. On occasion we come up
with new diagnoses and treatments; however, most often we attend to the
educational and management aspects of conditions that have already been
diagnosed. Yet patients may say, “No one has told me what I have,” which
I interpret as a failure in communication. They say “Nothing has worked
for me” and here it is important to understand what was prescribed, for
how long, whether it was taken, and how much the patient was given the
opportunity to become involved in the care.
Because functional GI disorders do not have specific findings with laboratory
studies, X-ray or endoscopy, the patients often feel that something else
is being missed, or that without any of these findings their symptoms are
psychosomatic or “in my head.” They feel “out of control” and unable to
manage their symptoms. A vicious cycle then ensues: without feeling able
to understand or control a condition that has great impact on their life, the
patient becomes anxious and distressed, and that in turn leads to more
symptoms. And so it continues. At UNC we employ gastroenterologists,
physician assistants, psychologists, and motility experts who work together
to get to know the illness, the patient, and their psychosocial and coping
resources to find the ways to break the vicious cycle. In addition to using
state-of-the-art diagnostic and treatment methods when needed, we also
help patients regain their sense of control over their illness and their life.
We make the effort to provide a clear physiological explanation as to why
they are having the symptoms, and offer rationale for treatment based on
this understanding. A major effort is to focus on helping patients become
“empowered” so they can feel in control enough to manage their symptoms.
11
12. INSIDE THE MINDS
Since these are chronic GI disorders, we explain that while “cure” may not
occur, they can still regain their daily function and improve their quality
of life. It’s not unusual for a patient with years of disability to come back
feeling much better saying: “The symptoms are still there, but they don’t
bother me as much.”
Helping to Advance the Field of Functional GI and Motility Disorders
Scientific knowledge in the area of functional GI and motility disorders
has grown quite rapidly over the last two to three decades with research
relating to visceral hypersensitivity, neurotransmitters and receptors in the
GI system, alterations of bacterial flora, post-infectious IBS, brain imaging,
and the brain-gut axis. Our ability to integrate these diverse areas into a clear
understanding is based on the shift from the more traditional biomedical
model to the Biopsychosocial Model (4) first promoted by George Engel
in 1977 (11). (Figure 1) demonstrates the multi-component nature of this
model for the functional GI disorders.
Figure 1
Patients with functional GI and motility disorders comprise the largest
component of gastroenterology practice, about 40 percent (12). While research
is giving us the scientific knowledge to understand when, how, and why
these disorders develop, the work has not yet become common knowledge.
Advancement in this field has grown so fast that it is only beginning to
12
13. GASTROENTEROLOGY: THE FOCUS ON MIND AND BODY
become a standard component of educational curricula. Therefore work is
needed to introduce this new knowledge in medical schools to clinicians
and scientists as well as to the general public. There are several national and
international initiatives to help disseminate this information.
The Rome Foundation (www.romecriteria.org) is an organization of over
one hundred world experts in functional GI and motility disorders who are
committed to helping the lives of patients with these disorders. The group
has helped educate clinicians and scientists, other health care workers, the
pharmaceutical industry, and regulatory agencies by publishing diagnostic
criteria and a compilation of the evidence-based clinical and research
findings. The primary products of Rome III was published in the journal
Gastroenterology in April, 2006 (13) and as the Rome III book later that year
(14). These publications help advance the field by providing comprehensive
information on the pathophysiology, diagnosis, and treatment of over two
dozen adult and pediatric functional GI disorders. Other projects underway
include CD slide sets, lectureships, and other educational materials.
The International Foundation for Functional Gastrointestinal Disorders,
headed by Nancy and William Norton, is the largest lobbying and patient
advocacy group of its kind (www.iffgd.org). Based in Milwaukee WI, this
group provides educational information to patients, responds to patient
questions, provides a national resource list of physicians for patients,
advocates for research funds from Congress to go to NIH, and raises funds
independently to support research. It also hosts international educational
conferences for physicians.
Other scientific groups that have been organized to focus on these
disorders include the Functional Brain-Gut Research Group (www.
fbgweb.org), the American Motility Society, and the European Society for
Neurogastroenterology and Motility. Together these groups have worked to
help advance our scientific knowledge of these disorders ultimately to the
benefit of patients.
Figure 2 shows the number of citations (publications) in the area of irritable
13
14. INSIDE THE MINDS
bowel syndrome, only one of the many functional GI and motility disorders.
It clearly demonstrates the increased scientific interest in this condition. I
believe that in ten to twenty years this will be one of the most important
clinical and research areas in gastroenterology.
Figure 2
The Success of a Gastroenterology Practice
To be successful, gastroenterologists must acquire a variety of skills.
Within clinical practice, gastroenterologists diagnose and treat patients in
their offices and also see them as consultants when they are inpatients in
the hospital. They must be good at listening, synthesizing information, and
relating well to patients. A certain amount of these skills are innate, though
physicians can also learn to enhance them. Perhaps the area least developed
in training programs relates to communication skills and the physicianpatient interaction. I learned these skills through my training with George
Engel (15), as well as through later study with the American Academy on
Physician and Patient which follows the work of Karl Rogers. I now try to
teach these skills in presentations and workshops at home and when traveling.
However, these components that are intrinsic to good practice are not
rewarded financially since third party payers favor reimbursing procedures
over such “cognitive skills.” Nevertheless the rewards occur through clinical
improvement associated with physician and patient gratification.
14
15. GASTROENTEROLOGY: THE FOCUS ON MIND AND BODY
Success in clinical gastroenterology requires an open mind to new ideas,
ongoing study, and a great deal of experience seeing a wide variety of
patients. I believe it is also helpful to keep the practice “alive” by engaging
in some form of teaching, either as a volunteer at a medical center or by
having fellows and residents rotate through the practice under supervision.
Clinical gastroenterologists must also be skilled in endoscopic procedures,
primarily colonoscopy, and upper endoscopy. A large part of gastroenterology
practice involves screening colonoscopy, but with the emergence of virtual
colonoscopy, an X-ray procedure, gastroenterologists will spend less time
in the future doing screening colonoscopies. However, other procedures
like therapeutic colonoscopy, diagnostic upper endoscopy, and, of course,
emergency endoscopy for gastrointestinal bleeding and other urgent
problems will continue.
It also helps to bring on younger physicians to the practice as it grows since
the older clinicians are exposed to the newer knowledge from their younger
colleagues. Finally, the success of a gastroenterology practice also depends
on the quality of the office staff, the nurses, technicians, receptionists, and
accounting personnel. The needs of patients are met by staff that possesses
technical efficiency and good interpersonal skills. There is no excuse for a
patient calling in distress and not being able within a reasonable period of
time to reach someone who can help. These days it’s difficult to have the
physician return calls immediately so many practices have a pool of nurse
practitioners who are available to return phone calls or relay laboratory
results or other clinical information.
Academic gastroenterologists primarily perform research and their
success is gauged by the federal grants they receive, the publications they
produce, and the presentations they are invited to. They also often carry
on small practices in the hospital and have teaching responsibilities. Once
their publications become familiar to peers, they are often invited to give
presentations nationally and even internationally. These activities often
lead to appointments to regional, national and international committees and
organizations, including their leadership in these organizations. The standards
for success are reasonably clear and are often set by federal agencies (e.g.,
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16. INSIDE THE MINDS
NIH), the American Board of Internal Medicine, academic organizations
like the American Gastroenterology Association or the American College of
Gastroenterology, or the home academic institution.
The standards for success within academic gastroenterology are reached by
the small few who are committed to work hard to excel in their particular
research area. My research interests relate to treatments for functional GI
disorders, the role of stress (including abuse history) on clinical outcomes,
research in health related quality of life, brain imaging, and the proper design
of treatments studies for these conditions.
Sub-Specialties Within Gastroenterology
Gastroenterology is a complex field encompassing a variety of organs and
systems. Research is constantly changing the way we view GI diseases and
conditions. As a result, a variety of sub-specialties within the broad area
of gastroenterology have emerged, as it now has become difficult to keep
on top of everything in this field. When I was in training in the 1970s we
worked in all areas of gastroenterology and liver disease. Over time, “sub
sub-specialties” emerged where individuals worked solely with particular
organ systems, such as the esophagus, pancreas, and the liver, and each had
their own sets of diseases and dysfunctions. In fact, over the past twenty to
thirty years, liver disease has developed into the clearly defined sub-specialty
of hepatology. Nowadays gastroenterologists often distinguish themselves
as either “solid” (i.e., liver and pancreas) or hollow organ (i.e., esophagus
stomach, and intestines) specialists.
Specialists in other organ system areas include esophagologists,
pancreatobiliary physicians, and nutritionists. There are also experts
who work with one set of diseases, such as inflammatory bowel disease
(ulcerative colitis and Crohn’s disease) or GI cancer. Physicians who work
in these areas usually do some general gastroenterology, but emphasize their
particular discipline in practice or research.
In addition to organ system specialists, there are procedural specialists
working under the broad field of endoscopy. While all gastroenterologists
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17. GASTROENTEROLOGY: THE FOCUS ON MIND AND BODY
learn endoscopy, some focus primarily on the technically precise disciplines of
endoscopic ultrasound or interventional endoscopy, doing sphincterotomies
for gallstones in the common bile duct and stent placements for benign and
malignant strictures. In recent years there is growing interest in endoscopic
surgery.
Finally, there is a small and emerging group of sub-specialists who focus on
functional GI and motility disorders, and treat the largest group of patients
(about 40 percent) seen in gastroenterology practice. Diagnosis is based on
symptoms and at times physiology testing since there are no findings on Xray or endoscopy. The symptoms are understood to be caused by dysfunction
of the nerves and muscles of the gastrointestinal system. This leads to altered
motility, increased nerve sensitivity called visceral hypersensitivity, and
other physiological dysfunctions that are amplified by stress and emotions.
Many who have an interest in this field are skilled in gastrointestinal motility
of the esophagus, stomach, intestines, and anorectum while others focus
primarily on diagnosis and management based on the symptoms that define
these disorders. The disorders include irritable bowel syndrome, which is the
most common one, as well as esophageal chest pain, functional dyspepsia,
bloating, functional constipation, vomiting disorders, biliary dysfunction,
diarrhea, incontinence, and rectal pain.
Challenges in Gastroenterology
The biggest challenge in gastroenterology is to address and hopefully reverse
the shift over the last two decades from a focus on the provision of quality
care to that of bringing in more money (16). Physicians are performing more
and more procedures and are seeing patients in briefer periods of time since
more income can be generated by doing a procedure than by performing a
clinic visit, talking, and thinking. For example, it is not unusual for a patient
coming for abdominal pain to immediately get an endoscopy and if it’s
negative, be prescribed a narcotic painkiller without the physician thinking
through the diagnosis, the reason for the visit or the long-term management
plan. Managed care has changed the way we look at patients these days:
diagnostic tests have replaced clinical decision making and a quick fix is
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18. INSIDE THE MINDS
preferred, and if it brings in more money, all the better.
A second challenge is to reverse the continued reduction of federal funding
for clinical gastroenterological research. Many gastroenterologists who do
clinical research are being forced to move out of academic medicine into
the pharmaceutical industry or clinical practice, because it is becoming
more difficult to find the needed support to do clinical research. Although
the National Institutes of Health (NIH) are looking to provide more
“translational” and clinical research support, their history is to prioritize
basic over clinical research, and the lowest priority is directed toward the
functional GI and motility disorders. Furthermore, any effort to reverse this
pattern is hampered by continual budget cuts to NIH due to other priorities.
The general perception that basic research is a funding priority relates to the
premise that finding the molecular basis for diseases will lead to cures. No
doubt this has potential for many diseases. However, the health problems in
Western society have shifted from immediately treatable acute diseases to
multi-determined chronic disorders that impact the patient and the family.
With chronic illnesses, treatment now needs to be directed toward symptom
management and improved quality of life, and cure may not be likely for
quite some time. Thus, it is important to find ways to allocate clinical funds
for research to help patients manage chronic gastrointestinal disorders.
A third challenge, because of their profound health care impact, is to find
ways to legitimize the chronic gastroenterological disorders. For example,
irritable bowel syndrome is considered second to the common cold in work
absenteeism and about $2 billion is spent treating patients with IBS; when
factoring in indirect costs such as loss in work productivity, the cost to
society in the U.S. is close to $20 billion (17). Yet these disorders are not
considered as important compared to cancer or heart disease. They can be
overlooked, ignored, or considered insignificant by the media, general public,
and funding agencies, despite their morbidity, impaired quality of life, and
health care costs. It’s not completely clear why this is the case, though it may
relate to societal values that minimize or bring humorous attention to bodily
functions like gaseousness, vomiting, and defecation—difficulties produced
by gastrointestinal disturbances. Furthermore, because these disorders do
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19. GASTROENTEROLOGY: THE FOCUS ON MIND AND BODY
not show abnormalities by X-ray or endoscopy, they are often relegated to
second-class status when compared to disorders with obvious biological
markers like ulcer disease, colon cancer or inflammatory bowel disease
(18). People often believe that if the doctor can’t find a physical cause for
the symptoms then it is “in the head.” Thus, there needs to be a way to
communicate to patients, physicians, and society an understanding of the
biopsychosocial model for understanding GI disorders.
The fourth challenge, as discussed, is to find the ways to teach physicians
how to build their clinical decision making and relationship skills. I believe
that the advances in technology within the field have been and will continue
to take care of themselves. The risk is that the field will move almost
completely toward technology, since it is exciting and it pays well. Yet the
paradox is that most of GI patient care involves outpatient management
of chronic disorders. After thirty years in practice, my experience has
shown that the attention to aspects of good data gathering, clinical
reasoning, communication and relationship building contributes the most to
physician and patient satisfaction and to improved clinical outcomes for all
gastrointestinal disorders. It is therefore critical that the personal elements of
the doctor-patient relationships do not become lost along the way.
Learning to Stay on Top
The field of gastroenterology changes constantly. To keep up and stay ahead,
gastroenterologists need to attend meetings—regionally, nationally, and
sometimes internationally—and academicians need to speak and collaborate
with other investigators at these meetings. Listening to and participating in
presentations and discussions among peers is far more illuminating than
simply reading journal articles. Nevertheless there are key journals that
help one stay knowledgeable in the field: Gastroenterology, Gut, American
Journal of Gastroenterology, Clinical Gastroenterology and Hepatology, and
the Journal of Clinical Gastroenterology. It is also helpful to write articles,
because it hones one’s clinical and research skills. One must review the
literature on the chosen topic, and then synthesize that knowledge along
with the research findings or clinical experience into a “story” that others
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20. INSIDE THE MINDS
can learn from. Learning works best by having a focused question that can
be communicated to others.
Looking to the Future of Gastroenterology
In the 1960s, gastroenterologists moved away from being internists with
special interests in the gastrointestinal tract to becoming “proceduralists,”
performing endoscopies and later interventional endoscopies and ultrasound.
Now gastroenterologists can reduce the need for surgery by endoscopically
removing polyps before they turn into cancer, or draining abscesses that
otherwise would require an operation, or taking out gallstones. Over the next
five years, we are likely to see more emphasis on technical procedures such
as surgical endoscopies and newer diagnostic imaging methods. It is likely
that interventional endoscopy will begin to move away from “mainstream”
gastroenterology.” The technical demands in the future will require
additional training to maintain competence than can be provided by a regular
GI fellowship. Similarly, other areas of gastroenterology will also separate
out because of their own unique features. Hepatology has already done
that; possibly inflammatory bowel disease specialists and GI oncologists
will need to affiliate more with multidisciplinary teams at medical centers
because of the need to collaborate with surgeons and radiologists.
What will be left? Routine gastroenterological care and endoscopy will
always be needed by patients in the community, and I believe that is where
most gastroenterologists will be. The gastroenterologist in practice will
function much like the internist—serving as a “gatekeeper” and managing
the routine problems like GERD, functional GI disorders, milder forms of
liver, and other GI disorders on an ongoing basis and performing routine
endoscopies as needed. The practicing gastroenterologist will refer the
patients to specialists when expertise is needed in a more specialized area of
gastroenterology. This is already happening.
I am hopeful that most gastroenterologists, particularly those primarily
involved with functional GI and motility disorders, will have found ways
to learn the communication and cognitive skills to effectively diagnose and
care for these patients. This may require a shift in our health care economics
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21. GASTROENTEROLOGY: THE FOCUS ON MIND AND BODY
to a more nationalized system where proper compensation can be applied
to such cognitive skills. It is also likely that nurse practitioners or physician
assistants, as well as nutritionists and psychologists, will be part of this health
care team. In the end, the hope is that all patients with GI disorders will be
better served.
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22. INSIDE THE MINDS
Reference List
(1) Drossman DA. The Physician-Patient Relationship. In: Corazziari E,
ed. Approach to the Patient with Chronic Gastrointestinal Disorders.
Milan: Messaggi; 1999: 133-39.
(2) Stewart MA. Effective physician-patient communication and health
outcomes: a review. CMAJ. 1995; 152:1423-33.
(3) Kaplan SH, Greenfield S, Ware JE, Jr. Assessing the effects of
physician-patient interactions on the outcomes of chronic disease.
Med Care. 1989; 27:S110-S127.
(4) Drossman DA. Presidential Address: Gastrointestinal Illness and
Biopsychosocial Model. Psychosom Med. 1998; 60:258-67.
(5) Drossman DA, Talley NJ, Olden KW, Leserman J, Barreiro MA.
Sexual and physical abuse and gastrointestinal illness: Review and
recommendations. Ann Intern Med. 1995; 123:782-94.
(6) Drossman DA, Li Z, Leserman J, Toomey TC, Hu Y. Health status
by gastrointestinal diagnosis and abuse history. Gastroenterol. 1996;
110:999-1007.
(7) Drossman DA, Ringel Y, Vogt B, Leserman J, Lin W, Smith JK et al.
Alterations of brain activity associated with resolution of emotional
distress and pain in a case of severe IBS. Gastroenterol. 2003;
124:754-61.
(8) Drossman DA. Brain Imaging and its Implications for Studying
CentrallyTargetedTreatments in IBS:APrimer for Gastroenterologists.
Gut. 2005; 54: 569-73.
(9) Lowman BC, Drossman DA, Cramer EM, McKee DC. Recollection
of childhood events in adults with irritable bowel syndrome. J Clin
Gastroenterol. 1987; 9:324-30.
(10) DeVaul RA, Faillace LA. Persistent pain and illness insistence
- A medical profile of proneness to surgery. Am J Surg. 1978;
135:82833.
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23. GASTROENTEROLOGY: THE FOCUS ON MIND AND BODY
(11) Engel GL. The need for a new medical model: A challenge for
biomedicine. Science. 1977; 196:129-36.
(12) Mitchell CM, Drossman DA. Survey of the AGA membership relating
to patients with functional gastrointestinal disorders. Gastroenterol.
1987; 92:1282-84.
(13) Drossman, D. A. The Functional Gastrointestinal Disorders and the
Rome III Process. Gastroenterology 130(5), 1377-1390. 2006. Ref
Type: Journal (Full)
(14) Drossman DA. The Functional Gastrointestinal Disorders and
the Rome III Process. In: Drossman DA, Corazziari E, Delvaux
M, Spiller R, Talley N, Thompson WG et al., eds. Rome III: The
Functional Gastrointestinal Disorders. 3rd Edition ed. McLean, VA:
Degnon Associates, Inc.; 2006.
(15) Drossman DA. Can the primary care physician be better trained in
the psychosocial dimensions of patient care? Int J Psychiatry Med.
1977; 8:169-84.
(16) Drossman DA. Medicine has become a business. But what is the
cost? Gastroenterol. 2004; 126:952-53.
(17) Sandler RS, Everhart JE, Donowitz M, Adams E, Cronin K,
Goodman C et al. The burden of selected digestive diseases in the
United States. Gastroenterol. 2002; 122:1500-1511.
(18) Drossman DA. Functional GI Disorders: What’s in a Name?
Gastroenterol. 2005; 128:1771-72.
Douglas A. Drossman received his M.D. degree at Albert Einstein
College of Medicine and obtained his medical residency at the
University of North Carolina School of Medicine and NYU — Bellevue
Medical Center. He sub-specialized in psychosocial (psychosomatic)
medicine at the University of Rochester School of Medicine and in
Gastroenterology at the University of North Carolina.
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24. INSIDE THE MINDS
Dr. Drossman is professor of medicine and pychiaty at the University of
North Carolina School of Medicine, and co-director of the UNC Center
for Functional Gastrointestinal and Motility Disorders (since 1993).
He is founder, past chair (19891993), and newsletter editor of the
Functional Brain-Gut Research Group of the AGA, chair (since 1989)
of the Rome Committees (Rome I II and III), and president of the Board
of the Rome .Foundation (since 2004), past chair of the Functional GI
campaign of the American Digestive Health .Foundation’s Digestive
Health Initiative (19992001) and of the Motility and Nerve-Gut
Interactions Section of the AGA Council (2003-2005). He is pastpresident of the American Psychosomatic Society (1997), a fellow of
the American College of Physicians, a master of the American College
of Gastroenterology, and is on the board of directors and chair of the
Scientific Adviso,y Board of the International Foundation for Functional
GI Disorders (IFFGD). He is on the Institute of Medicine Committee of
Gulf lFar Veterans and Stress, has been an ad hoc member of the NIHNCCAM advisory board, and is a member of NIH-National Commission
on Digestive Diseases.
Dr. Drossman has written over 400 articles and book chapters,
has published two books, a GI procedure manual, and textbook of
functional GI disorders (Rome I, II, III), and serves on six editorial
and advisory boards in gastroenterology, psychosomatic medicine,
behavioral medicine, and patient health. He just completed his fiveyear
term as associate editor of the journal Gastroenterology and has been
the gastroenterology section editor of the Merck Manual.
Dr. Drossman ‘c research relates to the clinical, epidemiological,
psychosocial, and treatment aspects of gastrointestinal disorders.
He has developed and validated several assessment measures (e.g.,
illness severity and quality of life questionnaires for IBD and IBS,
and an abuse severity scale) for clinical research, is involved in
psychosocial outcomes research, and has a research program on brain
imaging in IBS. .He has been prinepal investigator on several NIH
sponsored research grants including a multi-center grant for treatment
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25. GASTROENTEROLOGY: THE FOCUS ON MIND AND BODY
(antidepressant and cognitive-behavioral treatment) of the functional
bowel disorders. He also consults with regulato y and pharmaceutical
agencies regarding the design and evaluation of treatment trials. He
is a recipient of the Janssen Award for Clinical Research (1999), the
American Pychosomatic Society President’s Award (2003), the AGA
Joseph B. Kirsner-Fiterman Award in clinical research (2005), and the
AGA Mentors Research ScholarAward (2007).
His educational and clinical interests relate to the psychosocial and
behavioral aspects of patient care. He has produced numerous articles
and videotapes on the biopychosocial aspects of medical care, medical
interviewing, and the patient-doctor relationship, and received second
price at the 1997 AMA International Film Festival. As a charter fellow
of the American Academy of Physician and Patient, he facilitates
workshops to develop clinical skills in physician patient communication.
He received the AGA Distinguished EducatorAward (2004).
Dedication: To my mentors: George Engel, M.D., Don Powell M.D.,
and Debbie Drossman
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28. I n s i d e t h e M i n d s™
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