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An overlay is produced by cutting out the positions of the correct responses order female cialis 20mg amex. This can then be placed over the student’s answer sheet and the correct responses are easily and rapidly counted buy 20 mg female cialis fast delivery. Before doing so ensure that the student has not marked more than one answer correct! In most major medical examinations a computer will be used to score and analyse objective-type examinations quality 20mg female cialis. You must therefore be familiar with the process and be able to interpret the subsequent results purchase female cialis 20 mg fast delivery. The computer programme will generally provide statistical data about the examination including a reliability coefficient for internal consistency generic 20mg female cialis overnight delivery, a mean and standard deviation for the class and analyses of individual items. Should you be 147 the person responsible for the examination you will need to know how to interpret this information in order to process the examination results and to help improve subsequent examinations. If you are not familiar with these aspects we strongly suggest you seek expert advice or consult one of the books on educational measurement listed at the end of the chapter. DIRECT OBSERVATION Direct observation of the student performing a technical or an interpersonal skill in the real, simulated or examination setting would appear to be the most valid way of assessing such skills. Unfortunately, the reliability of these observa- tions is likely to be seriously low. This is particularly so in the complex interpersonal area where no alternative form of assessment is available. Nevertheless, in professional courses it is essential to continue to make assessments of the student’s performance, not least to indicate to the student your commitment to these vital skills. In doing so, you would be well advised to use the information predominantly for feedback rather than for important decision-making. Various ways have been suggested by which these limitations might be minimised. One it to improve the method of scoring and another is to improve the performance of the observer. Evidence suggests that the reliability of a checklist decreases when there are more than four points on the scale. The assessor has to decide whether each component on the list is present/absent; adequate/inadequate; satisfactory/unsatis- factory. Only if each component is very clearly defined and readily observable can a checklist be reliable. The essential feature is that the observer is required to make a judgement along a scale which may be continuous or intermittent. They are widely used to assess behaviour or performance because no other methods are usually available, but the subjectivity of the assessment is an unavoidable problem. Because of this, multiple independent ratings of the same student undertaking the same activity are essential if any sort of justice is to be done. They are derived from published formats used to obtain information about ward performance of trainee doctors. The component skill being assessed is ‘Obtaining the data base’ and only one sub-component (obtaining information from the patient) is illustrated. The first is that there is an attempt to provide descriptive anchor points which may be helpful in clarifying for the observer what standards should be applied. In a study we undertook, it was the format most frequently preferred by experienced clinical raters. Improving the performance of the observer It has often been claimed that training of raters will improve reliability. This seems to make sense but what evidence there is shows that training makes remarkably little difference! A study of our own suggested that a better approach might be to select raters who are inherently more consistent than others. Common sense dictates that observers should be adequately briefed on the ratings form and that they should not be asked to rate aspects of the student’s performance that they have not observed. ORAL The oral or vice-voce examination has for centuries been the predominant method, and sometimes the only method, used for the clinical assessment of medical students.

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Freeman completed his pediatric training at Hopkins where David Clark had served as his mentor and role model buy cheap female cialis 10 mg on line. This was followed by a child neurology fellowship at the Columbia Neurological Institute order female cialis 10mg on-line, Preface xix under the mentorship of Dr order female cialis 10mg with amex. Freeman was initially recruited by McKhann to join him at Stanford generic female cialis 10mg mastercard, but after enjoying sunny California for only 3 years purchase female cialis 20 mg online, he repacked and returned to the East coast. It is notable that three of the four initial neurology residents, Gary Goldstein, William Logan, and Mark Molliver, were all pediatric neurology trainees. Apparently, the Osler medical residents were not informed that they were being supervised by mere pediatricians. The goal from the outset was to train academic neurologists who would advance the field, as well as train others. In starting the child neurology program, Freeman’s initial goal was to reverse the segregation policy that had been in place during his residency. He established an integrated clinic that wall open to all—black, white, rich or poor—and staffed it with residents and medical students under his supervision. Freeman also organized a com- bined service for pediatric neurology and neurosurgery patients. Clearly, the patients received better and more consistent care than if they had been on only a surgical ser- vice. Unfortunately, in later years because of house staff shortages, billing, and other issues, this unique concept had to be abandoned. The goal of the pediatric neurology training program was identical to that of adult neurology, i. During his tenure as Director of Child Neurology from 1969 to 1990, he trained 44 individuals in child neurology. Thirty-one of the 44 entered academic neurology and most went on to run their own training programs—wonderful legacy! His philosophy was to attract the best and the brightest and instill in than the joys of academia. As one of his pupils, I can personally attest to his strong character, teaching and motiva- tional skills, academic achievements, but most importantly to his ability to be a friend and long-term counselor. This book is a testimony to the quality and quantity of an impressive group of residents trained over the years at Johns Hopkins. Haller Professor of Pediatric Neurology Director, Child Neurology Johns Hopkins University School of Medicine Contributors Anthony M. Avellino Division of Pediatric Neurosurgery, Children’s Hospital and Regional Medical Center, University of Washington School of Medicine, Seattle, Washington, U. Bale Division of Neurology, Department of Pediatrics, The University of Utah School of Medicine, Salt Lake City, U. Shannon Barnett Department of Psychiatry, The Johns Hopkins Hospital, Baltimore, Maryland, U. Belman Department of Neurology, School of Medicine, State University of New York (SUNY) at Stony Brook, Stony Brook, New York, U. Bergin Childrens Hospital, Department of Neurology, Boston, Massachusetts, U. Bibat Neurogenetics Unit, Kennedy Krieger Institute, Johns Hopkins Medical Institutions, Baltimore, Maryland, U. Ian Butler The University of Texas Medical School at Houston, Houston, Texas, U. Department of Neurological Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland, U. Cohn Johns Hopkins Hospital, Children’s Center, McKusick-Nathans Institute of Genetic Medicine, Baltimore, Maryland, U. Conry George Washington University School of Medicine, Children’s National Medical Center, Washington, D. Courvoisie Division of Child and Adolescent Psychiatry, Department of Psychiatry and Behavioral Sciences, The Johns Hopkins Medical Institutions, Baltimore, Maryland, U. Martha Bridge Denckla Johns Hopkins University School of Medicine, Kennedy Krieger Institute, Baltimore, Maryland, U. Dure, IV Division of Pediatric Neurology, Department of Pediatrics, The University of Alabama at Birmingham, Birmingham, Alabama, U.

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Not all these symptoms are present at the some one percent of the worldwide use of fungicides generic 10mg female cialis with visa, herbi- same time cheap 20mg female cialis fast delivery. Septic shock produces more drastic See also Bacteriocidal cheap female cialis 20mg fast delivery, bacteriostatic symptoms order female cialis 10 mg amex, including elevated rates of breathing and heartbeat buy 10 mg female cialis, loss of consciousness and failure of organs throughout the body. The onset of septic shock can be rapid, so prompt med- BBacteremicACTEREMIC ical attention is critical. The discovery of bacteria in the blood should be taken Bacteremic is a term that refers to the ability of a bacterium to as grounds to suspect bacteremia, because bacteria do not typ- multiply and cause an infection in the bloodstream. Antibiotic therapy is usually initiated sion of the bloodstream by the particular type of bacteria is immediately, even if other options, such as the transient entry also referred to as bacteremia. In addition, If the invading bacteria also release toxins into the antibiotic therapy is prudent because many bacteremic infec- bloodstream, the malady can also be called blood poisoning or tions arise because of an ongoing infection elsewhere in the septicemia. Along with the prompt start of treatment, the antibiotic associated with septicemia. Use of an ineffective antibi- 44 WORLD OF MICROBIOLOGY AND IMMUNOLOGY Bacteria and bacterial infection otic can provide the bacteria with enough time to undergo lacking fimbrae, showing that these structures can indeed pro- explosive increases in number, whereas the use of an antibiotic mote the capacity of bacteria to cause infection. At the As with many other infections, bacteremic infections point of entry, usually at small breaks or lesions in the skin or can be prevented by observance of proper hygienic procedures mucosal surfaces, growth is often established in the submu- including hand washing, cleaning of wounds, and cleaning cosa. Growth can also be established on intact mucosal sur- sites of injections to temporarily free the surface of living bac- faces, especially if the normal flora is altered or eliminated. The rate of bacteremic infections due to surgery is much Pathogen growth may also be established at sites distant from less now than in the past, due to the advent of sterile surgical the original point of entry. Access to distant, usually interior, procedures, but is still a serious concern. If a pathogen gains access to tissues by adhesion and See also Bacteria and bacterial infection; Infection and invasion, it must then multiply, a process called colonization. The initial inoculum is rarely sufficient to cause BACTERIA AND BACTERIAL INFECTION damage. A pathogen must grow within host tissues in order to Bacteria and bacterial infection produce disease. If a pathogen is to grow, it must find appro- Infectious diseases depend on the interplay between the abil- priate nutrients and environmental conditions in the host. If the ability of factors that affect pathogen growth, but the availability of a microorganism to invade, proliferate, and cause damage in microbial nutrients in host tissues is most important. Not all the body exceeds the body’s protective capacities, a disease nutrients may be plentiful in different regions. Infection refers to the growth of microorganisms ents such as sugars, amino acids and organic acids may often in the body of a host. Infection is not synonymous with disease be in short supply and organisms able to utilize complex nutri- because infection does not always lead to injury, even if the ent sources such as glycogen may be favored. Trace elements pathogen is potentially virulent (able to cause disease). In a may also be in short supply and can influence the establish- disease state, the host is harmed in some way, whereas infec- ment of a pathogen. For example, iron is thought to have a tion refers to any situation in which a microorganism is estab- strong influence on microbial growth. Specific iron binding lished and growing in a host, whether or not the host is proteins called transferrin and lactoferrin exist in human cells harmed. Such is the affinity of these The steps of pathogenesis, the progression of a disease proteins for iron, that microbial iron deficiency may be com- state, include entry, colonization, and growth. Pathogens like mon and administration of a soluble iron salt may greatly bacteria use several strategies to establish virulence. Many bacteria pro- teria must usually gain access to host tissues and multiply duce iron-chelating compounds known as siderophores, which before damage can be done. In most cases this requires the help them to obtain iron from the environment. Some iron penetration of the skin, mucous membranes, or intestinal chelators isolated from pathogenic bacteria are so efficient that epithelium, surfaces that normally act as microbial barriers. Passage through the skin into subcutaneous layers almost For example, a siderophore called aerobactin, produced by always occurs through wounds and in rare instances pathogens certain strains of E. Most infections begin with the adherence of bacteria to After initial entry, the organism often remains localized specific cells on the mucous membranes of the respiratory, ali- and multiplies, producing a small focus of infection such as a mentary, or genitourinary tract.

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Neurologists diagnose and treat many conditions that impair gait generic 20mg female cialis with mastercard, like Parkinson’s disease order 10 mg female cialis free shipping, MS generic 10mg female cialis with amex, and ALS—an expertise generally beyond the knowledge of primary care physicians buy cheap female cialis 10 mg line. Nonetheless buy female cialis 10mg with visa, many neurologists are not trained explicitly in mobility aids or improving walking per se (as op- posed to addressing the underlying illness), so they refer patients to phys- ical or occupational therapists. In fact, until recently, few neurologic dis- eases had effective treatments; neurologists learned primarily to diagnose disease, leaving day-to-day (often palliative) care to other physicians. She likes being the primary physi- cian caring for her patients over time and explicitly addressing mobility needs. My old professor used to say he could teach anybody to diagnose neurologic diseases, but managing patients sep- arates the men from the boys. Unlike orthopedics and neurology, geriatrics and rheumatology are sub- specialties of internal medicine. Many primary care physicians learn as- 158 / Physicians Talking to Their Patients pects of these disciplines during their training, sometimes complicating de- cisions about when to refer patients. Rheumatologists, also internal medicine subspecialists, care for people with arthritis and other rheumatic diseases—disorders of connective tis- sues and joints marked by inflammation, degeneration, and metabolic de- rangements. Primary care physicians commonly see patients with arthritis, and they know the prevailing medical treatments, so the question becomes when to refer to rheumatologists. Josh Landau trained as both a pri- mary care physician and rheumatologist. I was taught a mnemonic—ADEPT, that is ambulation, dressing, eating, personal hygiene, and transfers. If the X rays are worse but all the other things are better—function, pain, quality of life overall—then we put X rays as a lower priority. Its treatment is reason- ably safe, which is not true for other rheumatic diseases, by and large. That includes function, activities of daily life, pain, not hurting them with my medicines. I usu- Physicians Talking to Their Patients / 159 ally give a speech about podiatrists and occupational therapists, splinting, things that are terrifically safe. They may or may not help, but they’re very safe—more than I can say about my medicines. But I have a harder time getting many patients to accept these kinds of maneuvers than medicines. Landau worries that primary care physicians “refer patients way too late or not at all, either to a rheumatologist or an orthopedic surgeon. They aren’t really aware of the indications for joint replacement surgery or how that can help people. They underutilize rehabilitation services, view it as voodoo, an unproven remedy, which to be honest it is. We don’t have ran- domized control trials of physical therapy with sham physical therapy. On the other hand, rheumatology fellowship taught me a sense of what these different modalities offer in terms of function and quality of life. Landau’s comments highlight the complexities of referrals, espe- cially when physicians have some knowledge in a field. The role of the specialist is one of ad- vising the patient and the primary care physician” (Holman 1996, 42). Pri- mary care physicians must coordinate care and bear ultimate responsibility when specialists have no solutions. Patrick O’Reilley again described his patient with peripheral neuropathy and cataracts. I referred her to a neurologist who confirmed my suspi- cions that she has peripheral neuropathy, but he didn’t come up with any specific reasons for it. I got physical therapists out to see her in her house, and they say, “We’ve done as much as we can. According to Cassell, “specialists tend to think in terms of their spe- cialty, have less knowledge of contextual or personal factors in the illness, and use technology earlier and more extensively in the diagnostic process than generalists do” (1997, 170). Certainly, referrals generally aim to benefit from specialized knowledge. But in evaluating walking difficulties, some specialists inquire more about people’s daily lives and activities than do their primary care physicians. Landau (a rheumatologist) is enhancing overall quality of life through un- 160 / Physicians Talking to Their Patients derstanding and improving function.

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