By D. Thorus. Providence College.

In anchoring this chapter on current issues purchase accutane 5mg otc za skincare, information from a Saqamaw (chief) of a Canadian aboriginal reserve is noted in a number of places (the reserve is the Conne River Reserve [the Miawpukek First Nation] in Newfoundland accutane 30 mg on-line skin care while pregnant, Canada); however, it reflects the efforts among many aboriginal peoples to revitalise traditions and values, while situating them in the development of modern communities. Today’s rediscovery of many traditions and values only minimally rebalances a long history of aboriginal acculturation driven by North American governments, church policies and broad social changes. Although the thrust of the chapter is directed at practitioners of conventional healthcare – in a doctor’s surgery, hospital ward, pharmacy, etc. As a result of this, conventional practitioners are known to side- step discussion with patients on any ‘unproven’, ‘alternative’ or ‘unscien- tific’ practice by peremptorily dismissing it as being outside the scope of their practice. By using general approaches to patients’ questions and practices (covering herbal medicines and magico-religious or spiritual approaches), this also focuses on the importance of reflecting on conventional medical thinking and attitudes. Although accounts of aborig- inal (and other traditional) practices directed at conventional healthcare providers invariably concentrate on belief systems, the premise of this chapter is that effective communication in our increasingly complex multicul- tural communities also demands an awareness of how conventional thinking shapes professional attitudes to ‘unproven’ therapies. Gathering and processing information and responding non-judgementally to patients’ questions about aboriginal use is not easy for a number of reasons. One could even be a practitioner’s recognition that he or she is being compared with a traditional healer whom the patient is visiting for the same problem. To be able to respond to aboriginal practices, conventional healthcare providers need not only to understand belief systems, social circumstances and attitudes (perhaps including uncertain trust in conventional practitioners), but also, as indi- cated, to appreciate the factors that can shape professional attitudes toward non-conventional treatments. As the latter is more for formal education (undergraduate, continuing professional, etc. Moreover, having the relevant knowledge is important when negoti- ating different viewpoints between practitioner and patient. No health tradition is entirely static, and it is clear that infor- mation was often consciously shared so that it is difficult to say whether or not an aboriginal practice is ‘indigenous’. Modern compilations of tradi- tional practices commonly straddle aboriginal and Euro-North American self-care traditions. It is easy to speculate that, as an increasingly common medical term, high blood pressure was seen to fit with the long history of popular medicine (aboriginal and other) of blood purifi- cation, and so was added to lists of uses for ‘blood purifiers’ (alder, consid- ered below, is an example). Blood purification continues to be a popular notion; it extends into the complementary/alternative medicine literature, and merits the attention of conventional practitioners. As William Osler reminded physicians: ‘The greater the ignorance, the greater the dogma. Quick assessments are difficult and demand some evaluation of the record of published and other information from practitioners and of the popularity of usage over time. If, for example, a weak tradition is indicated by a database (and confirmed by a comprehensive literature search), there is no ‘scientific’ justi- fication for encouraging, say, the use of a compress of alder leaves as a generally effective treatment for a headache (see below). On the other hand, given the safety and absence of known allergic reactions of alder leaves as a traditional external application to relieve or ‘cool’ insect bites and inflam- mation, a practitioner may well support a patient wanting to try the treatment. Maybe the query comes from an aboriginal person who is comfortable following a traditional aboriginal regimen that includes a spiritual component, e. Other aspects of a regimen may be important such as changing the leaves frequently to maintain a ‘cooling’ action, which may well provide comfort and a feeling ofrelief;anactiverolebypatients in any therapy is often recognised as helpful. Occasions arise when differences of opinion between patient and practitioner need to be brokered so as to develop or maintain an effective relationship. This is facilitated, partly through background knowledge (step 1), both by uncovering and understanding a patient’s own circumstances and beliefs towards non- conventional approaches, and by critically evaluating published information. A three-step strategy implies one step after the other; however, this may change in practice depending on a particular situation (e. Moreover, the understanding of a specific concept (step 1’s preparation) may need to be revisited or learned for the first time after a case history has been taken (step 2). In this situation, admitting lack of knowledge to a patient is often appro- priate. Although this is problematic for many practitioners, they can be reas- sured that patients accept practitioners’ frank statement that they need to research a topic outside their customary practice before giving advice. The three-step strategy is therefore intended primarily to ensure that all relevant information is considered when responding to issues of efficacy and safety in the context of cultural sensitivity. The strategy for evaluating remedies used empirically Practitioners (and nowadays many patients) want ‘scientific’ evidence to support effectiveness and safety.

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The doctor’s dress and demeanor should be appro- priate to the occasion purchase accutane 5mg fast delivery skin care 50s, and he or she should speak clearly and audibly buy accutane 5mg mastercard acne 30s. As with an oral examination for medical finals or the defense of a writ- ten thesis, listen carefully to the questions posed. Think carefully about the reply before opening your mouth and allowing words to pour forth. Answer the question asked (not the one you would like it to have been) concisely and carefully, and then wait for the next question. There is no need to fill all silences with words; the judge and others will be making notes, and it is wise to keep an eye on the judge’s pen and adjust the speed of your words accordingly. Pauses between questions allow the judge to finish writing or counsel to think up his or her next question. If anything you have said is unclear or more is wanted from you, be assured that you will be asked more questions. Be calm and patient, and never show a loss of temper or control regard- less of how provoking counsel may be. An angry or flustered witness is a gift to any competent and experienced counsel, as is a garrulous or evasive wit- ness. Stay well within your area of skill and expertise, and do not be slow to admit that you do not know the answer. Your frankness will be appreciated, whereas an attempt to bluff or obfuscate or overreach yourself will almost certainly be detrimental to your position. Doctors usually seek consensus and try to avoid confrontation (at least in a clinical setting). They should remember that lawyers thrive on the adversarial process and are out to win their case, not to engage on a search for truth. Thus, lawyers will wish to extract from witnesses answers that best sup- port the case of the party by whom they are retained. However, the medical witness is not in court to “take sides” but rather to assist the court, to the best of the expert witness’ ability, to do justice in the case. Therefore, the witness should adhere to his or her evidence where it is right to do so but must be prepared to be flexible and to make concessions if appropriate, for example, because further evidence has emerged since the original statement was pre- pared, making it appropriate to cede points. The doctor should also recall the terms of the oath or affirmation—to tell the truth, the whole truth, and nothing but the truth—and give evidence accordingly. The essential requirements for experts are as follows: • Expert evidence presented to the court should be seen as the independent product of the expert, uninfluenced regarding form or content by the exigencies of litiga- tion (30). If the expert cannot assert that the report contains the truth, the whole truth, and nothing but the truth, that qualification should be stated on the report (32). In England and Wales, new Civil Procedure Rules for all courts came into force on April 16, 1999 (34), and Part 35 establishes rules governing experts. The expert has an overriding duty to the court, overriding any obliga- tion to the person who calls or pays him or her. An expert report in a civil case must end with a statement that the expert understands and has complied with the expert’s duty to the court. The expert must answer questions of clarifica- tion at the request of the other party and now has a right to ask the court for Fundamental Principals 57 directions to assist him in conducting the function as an expert. The new rules make radical changes to the previous use of expert opinion in civil actions. Most pit- falls may be avoided by an understanding of the legal principles and forensic processes—a topic of postgraduate rather than undergraduate education now. The normal “doctor–patient” relationship does not apply; the forensic physi- cian–detained person relationship requires that the latter understands the role of the former and that the former takes time to explain it to the latter. Meticulous attention to detail and a careful documentation of facts are required at all times. You will never know when a major trial will turn on a small detail that you once recorded (or, regrettably, failed to record). Your work will have a real and immediate effect on the liberty of the individual and may be highly influential in assisting the prosecuting authorities to decide whether to charge the detained person with a criminal offense. You may be the only person who can retrieve a medical emergency in the cells—picking up a subdural hematoma, diabetic ketoacidosis, or coro- nary thrombosis that the detaining authority has misinterpreted as drunken- ness, indigestion, or simply “obstructive behavior. Get it wrong, and you may not only fail to prevent an avoidable death but also may lay yourself open to criminal, civil, and disciplinary proceedings.

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Sufferers should not allow themselves Question 1 to sleep during the day (easier said than done! However buy accutane 20mg cheap skin care videos, short-acting benzodiazepines may be Answer 1 effective if taken before going to bed for two or three nights cheap accutane 5mg with amex acne 8 year old child. Although the benzodiazepine might help in the short Melatonin is of uncertain usefulness but may help sleep term, it does not provide the patient with a long-term solu- patterns, and improves daytime well-being if taken in the tion, and does not tackle the root cause of his insomnia. A better strategy is to allow the subject to have a short, non-drug-induced sleep during the night shift. Pathological This improves efficiency towards the end of the night shift and anxiety is fear that is sufficiently severe as to be disabling. Episodes of paroxys- The use of hypnotics in children is not recommended, except mal severe anxiety associated with severe autonomic symptoms in unusual situations (e. Hypnotics are sometimes attacks and often accompany a generalized anxiety disorder. Children are, however, prone to experi- ence paradoxical excitement with these drugs. Hypnotics relaxation techniques and simple psychotherapy and increase the risk of falls and nocturnal confusion. In the treatment of insomnia, when short-term treatment • In severely anxious patients who are given anxiolytic drugs, with drugs is considered necessary, short-acting hypnotics these are only administered for a short period (up to two should be used in preference to long-acting drugs but with to four weeks) because of the risk of dependence. Early short-lived high peak blood levels are • Benzodiazepines are the anxiolytics normally used where accompanied by anterograde amnesia. Buspirone is as effective as and less hypnotic than the benzodiazepines, Cautions but has slower onset. Adverse effects • Monoamine oxidase inhibitors (used only by specialists) • drowsiness; can be useful for treating anxiety with depression, phobic • confusion; anxiety, recurrent panic attacks and obsessive-compulsive • paradoxical disinhibition and aggression. Compounds with a short half-life tend to be used as hyp- arisen even after limited drug exposure. Pharmacological evi- notics, because they cause less ‘hangover’ effects; longer half-life dence of tolerance may develop within three to 14 days. The drugs tend to be used as anxiolytics, since a longer duration of full withdrawal picture can manifest within hours of the last action is generally desirable in this setting. Benzodiazepines dose for the shorter-acting drugs, or may develop over up to are used for the short-term alleviation of anxiety, but should three weeks with the longer-duration benzodiazepines. The syndrome believed to be more anticonvulsant than other members of the may persist for weeks. Benzodiazepines bind to specific patients who have become dependent should be gradual. Examples • Diazepam – used as an anxiolytic, because of its long Drug interactions half-life. Pharmacodynamic interactions with other centrally acting drugs • Temazepam – used as a hypnotic, because of its short are common, whereas pharmacokinetic interactions are not. Pharmacodynamic interactions include potentiation of the seda- • Lorazepam – potent short half-life benzodiazepine. Since the advent of the newer non-benzodiazepine hypnotics • Benzodiazepines are indicated for the short-term relief (zopiclone, zolpidem and zaleplon), there has been much dis- (2–4 weeks only) of anxiety that is severe, disabling or cussion and a considerable amount of confusion, as to which subjecting the individual to unacceptable levels of distress. In essence, • Benzodiazepines should be used to treat insomnia only when it is severe, disabling or subjecting the individual 1. It is reasonable to prescribe the drug whose cost is lowest, other things being equal. Patients who have not benefited from one of these Flumazenil is a benzodiazepine antagonist. It can cause nausea, flushing, anxiety and fits, so Case history is not routinely used in benzodiazepine overdose which sel- dom causes severe adverse outcome. A 67-year-old widow attended the Accident and Emergency Department complaining of left-sided chest pain, palpita- tions, breathlessness and dizziness. She had been pre- scribed lorazepam, but had stopped it three weeks previously • Clomethiazole – causes conjunctival, nasal and gastric because she had read in a magazine that it was addictive. It can also be used as a sedative during Question 1 surgery under local anaesthesia. Assuming a panic attack is the diagnosis, what is a poten- • Zopiclone, zolpidem and zaleplon – are non- tial precipitant? Buspirone (note that buspirone, although anxiolytic, is not helpful in benzodiazepine withdrawal and may benzodiazepines.

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