Under attack: devaluation and the challenge of tolerating the transference.
(41/1327)
Devaluation presents one of the therapist's most difficult challenges: conducting therapy and managing resistance with patients who force the therapist into very aggressive and uncomfortable experiences. When these situations arise, the therapist has a twofold task. He or she must tolerate the transference so as not to engage in a countertransferential enactment. Additionally, from this vulnerable vantage point, he or she must help the patient understand both the meaning of and the consequences of devaluations of the therapist. Two cases are presented that recognize devaluation as an example of projective identification and illustrate the challenge in working with this dynamic. (+info)
A participant observation study using actors at 30 publicly funded HIV counseling and testing sites in Pennsylvania.
(42/1327)
OBJECTIVES: This study was designed to augment an evaluation of Pennsylvania publicly funded HIV counseling and testing sites, particularly of the staff-client interaction. METHODS: Actors were trained as research assistants and sent to 30 randomly chosen sites to be tested and counseled for HIV disease. Instruments based on Centers for Disease Control and Prevention (CDC) guidelines were designed and used to evaluate them. RESULTS: Data were generated that identified the range of compliance with CDC guidelines and state policy. Among the findings were that 10 of 30 sites required signed consents despite a state policy allowing anonymous testing. Only 17% of providers developed a written risk reduction plan, even though 69% of all sites surveyed by mail asserted that such plans were developed. Only 2 of 5 HIV-positive actors were offered partner notification services, even though 100% of sites visited by an interviewer claimed to offer such services. CONCLUSIONS: The findings suggest that although evaluation methods such as mail surveys and site visits are useful for evaluating the existence of appropriate policies and protocols and gathering baseline data, they might not be sufficient for assessing actual staff-client interaction. (+info)
Attitudes to fertility issues among adults with cystic fibrosis in Scotland. The Collaborative Group of Scottish Adult CF Centres.
(43/1327)
BACKGROUND: With increasing life expectancy, issues of fertility and pregnancy are pertinent to patients with cystic fibrosis. For this reason, the four Scottish Cystic Fibrosis centres asked men and women with cystic fibrosis about their attitudes to fertility and to information given to them by health professionals. METHODS: A postal questionnaire was sent to 116 men and 79 women aged 16 years and over attending four Scottish Cystic Fibrosis clinics. RESULTS: There was a 70% response rate (82 men, 54 women). All but two men knew that they were likely to be infertile. 37% of respondents lived with a partner; 14 women (26%) and five men (6%) had children. For 85% of men and 72% of women having children was important now or would be in the next 10 years. 43% of men and 26% of women had never had any discussion on fertility issues with cystic fibrosis health professionals. 56% of men thought that first discussion with a health professional about infertility should be before the age of 16 years; 12% remembered having a first discussion at that age. Learning of their infertility was associated with strong negative emotions for most men. Women were more likely than men to have initiated first discussion (17 (32%) versus eight (10%); p<0.01). Twenty five men (31%) and 32 women (59%) were currently using contraception. Ten men (12%) and 15 women (28%) had discussed contraception at the Cystic Fibrosis clinic (p = 0.01). CONCLUSIONS: Parenting and fertility issues are important for men and women with cystic fibrosis but many patients do not find out what they want to know from discussion with health professionals. Patients want discussion to begin in early adolescence. Men in particular are likely to be reluctant to introduce these issues; health professionals should be aware of the need actively to initiate discussion. (+info)
The information needs and understanding of 5-10-year old children with epilepsy, asthma or diabetes.
(44/1327)
This exploratory study compared the information needs and understanding of 25 5-10-year olds with epilepsy with those of 10 children with asthma and 10 with diabetes (of the same age range). The children were interviewed whilst attending specialist clinics by the first author and were unaware of her professional status. All the children had access to specialist nurses and their families had received literature about their condition. The interview covered five main areas: knowledge of their condition, psychological effects, medication, restrictions on lifestyle, where they obtained their information and if they had unanswered questions. The children with epilepsy had far more unanswered questions and felt excluded from discussions with doctors. They also appeared reluctant to tell their friends their diagnosis and, at such a young age, felt stigmatized by their condition. The results highlight a contrast in the understanding of children with epilepsy when compared with those with asthma or diabetes. It is proposed that if a simple biological model were used to explain epilepsy this could aid children's understanding and reduce their reluctance to disclose their diagnosis. (+info)
Pet insurance--essential option?
(45/1327)
As Hawn (2) says, "insurance is about risk and peace of mind." She reports that the American Humane Society supports pet insurance because companion animals are able to be treated for disease or accidents that are life-threatening where, otherwise, they would have been euthanized. For veterinarians, she suggests that pet insurance allows them to practice veterinary medicine "as if it were free." It is inevitable that pet insurance will grow as a recourse for veterinary fees. This may be a savior to some families whose budget is stretched to the limit at a critical moment in the health care of their cherished pet. We in the veterinary profession have an advantage over other professions. We have seen the good, the bad, and the ugly of insurance, as it applies to human health and dental care. If we work hand-in-hand with our own industries, collectively we may be able to develop a system that wins for everyone, with fees that allow practice to thrive and growth strategies that accommodate new treatment and diagnostic modalities, as well as consistent and exemplary customer service. The path ahead is always fraught with bumps and potholes. We can be a passive passenger and become a victim of the times or an active driver to steer the profession to a clearer route. Pet insurance is but one of the solutions for the profession; the others are a careful assessment of our fees--charging what we are worth, not what we think the client will pay; business management; customer service; leadership of our health care team; lifelong learning; and more efficient delivery systems. Let us stop being a victim, stop shooting ourselves in the professional foot, and seize the day! (+info)
Disclosure of HIV status to medical providers: differences by gender, "race," and immune function.
(46/1327)
OBJECTIVE: The authors used data from a larger study to explore differences by gender, self-reported racial identification, and immune function in disclosure of HIV-positive serostatus to medical providers (dentists, family doctors, and emergency room [ER] and obstetrics-gynecology [ob/gyn] providers). METHOD: The authors analyzed interview responses from a convenience sample of African American and white men and women receiving HIV medical care at urban hospitals and clinics in St. Louis. Missouri. RESULTS: Of 179 respondents using at least one of three types of providers, 124 (69%) disclosed their HIV status to all applicable types of providers, 39 (22%) disclosed to only one or two types of providers, and 16 (9%) did not disclose to any of these types of providers. "Race" and CD4 count, but not gender, were independently associated with disclosure to dentists, family doctors, and ER providers in multivariate logistic regression analyses. CONCLUSIONS: Differences in disclosure rates, especially among patients who may be asymptomatic, suggest a need for public health education of both medical providers and patients with HIV. (+info)
Hospital practices in maternity wards in Lebanon.
(47/1327)
This study was conducted in Lebanon with the main objectives of acquiring baseline data on practices and routines applied in the obstetrics ward for women having normal delivery; estimating the frequency of certain practices; and assessing whether women are given choice in these practices. A national sample of 39 hospitals was selected. The director, head midwife, or head nurse of the obstetrics department was interviewed using a semi-structured questionnaire. The hospitals studied are largely equipped to cope with emergencies and services are available 24 hours a day. On average, the caesarean section rate is 18% and the stillbirth rate is 10 per 1000, but with considerable variability between facilities. The majority of hospitals do not have written policies or standard birth procedures and lack mechanisms for evaluation. Generally, minimal prenatal information is given to women. Companions are allowed during labour but this access is more restricted in delivery. The reported configuration of professional care during labour and delivery is favourable to high quality care. In terms of mobility during labour, most hospitals allow women to move. However, 31 hospitals set an i.v. drip to all women and some use continuous fetal monitoring method. Mobility is restricted in delivery; in 23 hospitals women are tied down. Nearly all hospitals give intra-muscular anaesthesia whereas epidurals are used less frequently. As for postpartum care, most hospitals do not initiate breastfeeding within one hour of birth and few have rooming in. The majority of hospitals do not provide women with family planning methods and a few do not even discuss methods with them. The approach used in this study constitutes a tool for understanding and assessing maternity services that should be applied in other settings. The tool is available from the authors. (+info)
Continuous quality improvement for patients with back pain.
(48/1327)
Recent evidence has changed traditional approaches to low back pain, suggesting minimal bed rest, highly selective imaging, and early return to normal activities. However, there are wide geographical variations in care, and substantial gaps between practice and evidence. This project sought to merge scientific evidence about back pain and knowledge about behavior change to help organizations improve care for back pain. Participating insurance plans, HMOs, and group practices focused on problems they themselves identified. The year-long program included quarterly meetings, coaching for rapid cycles of change, a menu of potential interventions, and recommendations for monitoring outcomes. Participants interacted through meetings, e-mail, and conference calls. Of the 22 participating organizations, 6 (27%) made major progress. Typical changes were reduced imaging, bed rest, and work loss, and increased patient education and satisfaction. Specific examples were a 30% decrease in plain x-rays, a 100% increase in use of patient education materials, and an 81% drop in prescribed bed rest. Despite the complexity of care for back pain, rapid improvements appear feasible. Several organizations had major improvements, and most experienced at least modest improvements. Key elements of successful programs included focus on a small number of clinical goals, frequent measurement of outcomes among small samples of patients, vigilance in maintaining gains; involvement of office staffs as well as physicians, and changes in standard protocols for imaging, physical therapy, and referral. (+info)