Mark Corson

By H. Vasco. Circleville Bible College.

Ideas which are inconsistent with the system are rejected purchase cordarone 200mg with amex, "not believed generic cordarone 200 mg free shipping," and not acted upon buy cordarone 100mg visa. Lecky was a school teacher and had an opportunity to test his theory upon thousands of students. If the student could be induced to change his self-defini- tion, his learning ability should also change. One student who misspelled 55 words out of a hundred and flunked so many subjects that he lost credit for a year, made a general average of 91 the next year and became one of the best spellers in school. A boy who was dropped from one college because of poor grades, entered Columbia and became a straight "A" stu- dent. A girl who had flunked Latin four times, after three talks with the school counselor, finished with a grade of 84. A boy who was told by a testing bureau that he had no aptitude for English, won honorable mention the next year for a literary prize. The trouble with these students was not that they were dumb, or lacking in basic aptitudes. Instead of saying "I failed that test" (factual and descriptive) they con- cluded "I am a failure. Lecky also used the same method to cure students of such habits as nail biting and stuttering. My own files contain case histories just as convincing: the man who was so afraid of strangers that he seldom ventured out of the house, and who now makes his living as a public speaker. How a Plastic Surgeon Became Interested in Self-Image Psychology Offhand, there would seem to be little or no connection between surgery and psychology. Yet, it was the work of the plastic surgeon which first hinted at the existence of the "self image" and raised certain questions which led to important psychologic knowledge. When I first began the practice of plastic surgery many years ago, I was amazed by the dramatic and sudden changes in character and personality which often resulted when a facial defect was corrected. Changing the physical image in many instances appeared to create an entirely new person. A "moronic," "stupid" boy changed into an alert, bright youngster who went on to become an executive with a prominent firm. A salesman who had lost his touch and his faith in himself became a model of self confidence. And perhaps the most startling of all was the habitual "hardened" criminal who changed almost overnight from an incorrigible who had never showed any desire to change, into a model prisoner who won a parole and went on to assume a responsible role in society. Some twenty years ago I reported many such case his- tories in my book New Faces—New Futures. Following its publication, and similar articles in leading magazines, I was besieged with questions by criminologists, sociol- ogists and psychiatrists. Strangely enough, I learned as much if not more from my failures as from my suc- cesses. The boy with the too-big ears, who had been told that he looked like a taxi-cab with both doors open. Terribly afraid to express himself in any way it was no wonder he became known as a moron. When his ears were corrected, it would seem only natural that the cause of his embarrassment and humiliation had been removed and that he should assume a normal role in life—which he did. Or consider the salesman who suffered a facial dis- figurement as the result of an automobile accident. Each morning when he shaved he could see the horrible dis- figuring scar on Ms cheek and the grotesque twist to his mouth. He was ashamed of himself and felt that his appearance must be repulsive to others. Soon almost all his attention was directed toward himself—and his primary goal became the protection of his ego and the avoidance of situations which might bring humiliation. The Duchess who all her life had been terribly shy and self- conscious because of a tremendous hump in her nose? Although surgery gave her a classic nose and a face that was truly beautiful, she still continued to act the part of the ugly duckling, the unwanted sister who could never bring herself to look another human being in the eye. Or what about all the others who acquired new faces but went right on wearing the same old personality? Or how explain the reaction of those people who insist that the surgery has made no difference whatsoever in their appearance? Every plastic surgeon has had this experi- ence and has probably been as baffled by it as I was. Comparison of "before" and "after" photographs does little good, except possibly to arouse hostility. When I was a young medical student in Germany, I saw many another student proudly wearing his "saber scar" much as an American might wear the Medal of Honor. The duelists were the elite of college society and a facial scar was the badge that proved you a member in good standing. To these boys, the acquisition of a horrible scar on the cheek had the same psychologic effect as the eradication of the scar from the cheek of my salesman patient. The Mystery of Imaginary Ugliness To a person handicapped by a genuine congenital de- fect, or suffering from an actual facial disfigurement as a result of an accident, plastic surgery can indeed seemingly perform magic. From such cases it would be easy to theorize that the cure-all for all neuroses, unhappiness, failure, fear, anxiety and lack of self-confidence would be wholesale plastic surgery to remove all bodily defects. However, according to this theory, persons with normal or acceptable faces should be singularly free from all psychological handicaps. Nor can such a theory explain the people who visit the office of a plastic surgeon and demand a "face lift" to cure a purely imaginary ugliness. There are the 35- or 45- year-old women who are convinced that they look "old" even though their appearance is perfectly "normal" and in many cases unusually attractive.

The chapter commences by addressing the basic principles of the medical examination for both complainants and suspects of sexual assault discount cordarone 100 mg with mastercard. Although the first concern of the forensic practitioner is always the medical care of the patient order 100mg cordarone with visa, thereafter the retrieval and preservation of forensic evidence is para- mount because this material may be critical for the elimination of a suspect cordarone 200mg line, identification of the assailant, and the prosecution of the case. Thus, it is imper- ative that all forensic practitioners understand the basic principles of the foren- sic analysis. Thereafter, the text is divided into sections covering the relevant body areas and fluids. Each body cavity section commences with information regard- From: Clinical Forensic Medicine: A Physician’s Guide, 2nd Edition Edited by: M. This specialist knowledge is manda- tory for the reliable documentation and interpretation of any medical findings. The practical aspects—which samples to obtain, how to obtain them, and the clinical details required by the forensic scientist—are then addressed, because this takes priority over the clinical forensic assessment. The medical findings in cases of sexual assault should always be addressed in the context of the injuries and other medical problems associated with con- sensual sexual practices. Therefore, each section summarizes the information that is available in the literature regarding the noninfectious medical compli- cations of consensual sexual practices and possible nonsexual explanations for the findings. The type, site, and frequency of the injuries described in asso- ciation with sexual assaults that relate to each body area are then discussed. Unfortunately, space does not allow for a critical appraisal of all the chronic medical findings purported to be associated with child sexual abuse, and the reader should refer to more substantive texts and review papers for this infor- mation (1–3). Throughout all the stages of the clinical forensic assessment, the forensic practitioner must avoid partisanship while remaining sensitive to the immense psychological and physical trauma that a complainant may have incurred. Although presented at the end of the chapter, the continuing care of the com- plainant is essentially an ongoing process throughout and beyond the primary clinical forensic assessment. Immediate Care The first health care professional to encounter the patient must give urgent attention to any immediate medical needs that are apparent, e. Nonetheless, it may be possible to have a health care worker retain any clothing or sanitary wear that is removed from a complainant until this can be handed to someone with specialist knowledge of forensic packag- ing. Timing of the Examination Although in general terms the clinical forensic assessment should occur as soon as possible, reference to the persistence data given under the relevant sections will help the forensic practitioner determine whether the examination of a complainant should be conducted during out-of-office hours or deferred Sexual Assualt Examination 63 until the next day. Even when the nature of the assault suggests there is unlikely to be any forensic evidence, the timing of the examination should be influenced by the speed with which clinical signs, such as reddening, will fade. Place of the Examination Specially designed facilities used exclusively for the examination of com- plainants of sexual offenses are available in many countries. The complainant may wish to have a friend or relative present for all or part of the examination, and this wish should be accommodated. Suspects are usually examined in the medical room of the police station and may wish to have a legal representative present. During the examinations of both complainants and suspects, the local ethical guidance regarding the conduct of intimate examinations should be followed (4). Consent Informed consent must be sought for each stage of the clinical forensic assessment, including the use of any specialist techniques or equipment (e. When obtaining this consent, the patient and/or parent should be advised that the practitioner is unable to guarantee confidentiality of the material gleaned during the medical examination because a judge or other presiding court officer can rule that the practitioner should breach medical confidentiality. If photo documentation is to form part of the medical examination, the patient should be advised in ad- vance of the means of storage and its potential uses (see Subheading 2. Details of the Allegation If the complainant has already provided the details of the allegation to another professional, for example, a police officer, it is not necessary for him or her to repeat the details to the forensic practitioner. Indeed, Hicks (5) notes that attempts to obtain too detailed a history of the incident from the complainant may jeopardize the case at trial because at the time of the medical examination the patient may be disturbed and, consequently, the details of the incident may be confused and conflict subsequent statements. The details of the allegation can be provided to the forensic practitioner by the third party and then clarified, if necessary, with the complainant. It may be difficult for the complainant to describe oral and anal penetrative sexual assaults, and the forensic practitioner may need to ask direct questions regarding these acts sensitively (6). Medical and Sexual History The purpose of obtaining the medical and sexual history is essentially twofold: first, to identify any behavior or medical conditions that may cause the doctor to misinterpret the clinical findings, for example, menstrual bleed- ing; and second, to identify any medical problems that may be attributable to the sexual assault, for example, bleeding, pain, or discharge. Other specific details may be required if emergency contraception is being considered. When children are examined, the parent or caregiver should provide comprehensive details of the past medical history. When adults are exam- ined, only relevant medical and sexual history should be sought because confidentiality cannot be guaranteed. What constitutes relevant medical his- tory must be determined on a case-by-case basis by considering the differ- ential causes for any medical findings and the persistence data for the different sexual acts. Forensic practitioners should not ask suspects about the alleged incident or their sexual history. General Examination In all cases, a complete general medical examination should be conducted to document injuries and to note any disease that may affect the interpretation of the medical findings. Anogenital Examination Whenever there is a clear account of the alleged incident, the anogenital examination should be tailored to the individual case (e. However, in some cases, the complainant may not be aware of the nature of the sexual assault. Further- more, children and some adults may not have the language skills or may feel unable to provide a detailed account of the sexual acts at the initial interview. In such cases, a comprehensive anogenital examination should be undertaken if the patient or the person with legal authority to consent on behalf of the patient gives his or her consent.

It is the basis of the relationship between medicine and society cheap 200mg cordarone overnight delivery, which most observers call a social contract purchase 200mg cordarone with visa. The social contract serves as the basis for society’s expectations of medicine and medicine’s expectations of society buy cheap cordarone 100 mg line. It therefore directly inÀuences pro- fessionalism, considering that we live in the era of commercialism, consumerism, bu- reaucratisation and industrialisation [6]. When we think of profes- sionalism, it should be related to different cultures and their social contracts, respecting local customs and values [7]. A decreased public trust in all professions has brought increased attention to medical professionalism; it relates to those skills, attitudes and behaviours that people have come to expect from individuals during the practice of a profession and includes several concepts, such as maintenance of competence, ethical behaviour, integrity, honesty, relationships, responsibility, reliability, altruism, caring and compassion, service to others, adherence to professional codes, justice, respect for others, self-regulation, scienti¿c knowledge, excel- lence, scholarship and leadership. There are no codes in the physician charter of medical professionalism [7] concerning pay-for-performance service. Health care systems are regulated to support the health care needs to a target popula- tion. In some countries, health care system planning is delivered among market participants, whereas in others, planning is made more centrally among governments, trade unions, charities, religious or other coordinated bodies to delivery planned health care services targeted to the populations they serve. It seems a very dif¿cult task comparing different organisations of health care systems, resource allocation and the modality to assure a horizontal and extra salary to improve the quality of care and outcome while reducing costs at the same 30 Professionalism, Quality of Care and Pay-for-Performance Services 351 time. However, health care planning has often been evolutionary rather than revolution- ary. The goals set by health care systems, according to the World Health Organization [8], are good health responsiveness to the expectations of the population and fair ¿nancial contribution. Duckett proposed a two-dimensional approach to evaluation of health care systems: quality, effectiveness and acceptability on one dimension, and equity on the other [9]. Health care providers are trained professionals, working as self-employed individuals or as employees within an organisation – either a for-pro¿t corporation, a nonpro¿t company, a government entity or a charitable organisation. Examples of health care providers are doctors and nurses, paramedics, dentists, medical laboratory personnel, specialist thera- pists, psychologists, pharmacists, chiropractors and optometrists. There are generally ¿ve primary methods of funding health care systems [10–12]: 1. Advances towards improving the standard of care represent a real challenge in health care system management. Escalating costs and the growing imbalance between primary and specialty care have increased the urgency of calls for a fundamental reform of the health care payment system. This is a very critical point of controversy, and strong dispari- ties persist in different area such as continental, national, regional and local environments [13]. At the core of the problem is the fact that the dominant fee-for-service models reward volume and intensity rather than value. However, although faults in the way we pay for health care are obvious, it is much less clear what feasible approach would yield better results. Avoiding disparity of care delivery and the capacity of high-quality care while low- ering costs [14] and protecting patient safety are the cardinal points in a period of recession caused by a broken economy. Poor quality of care is not only costly but also produces errors and increased human suffering; in other words, poor quality of care results in an increase in morbidity and mortality. Patient safety is a new health care discipline that emphasises the reporting, analysis and prevention of medical errors that often lead to adverse health care events. The frequency and magnitude of avoidable ad- verse patient events was not well known until the 1990s, when several countries reported staggering numbers of patients harmed and killed by medical errors. Presenting accounts of anaesthesia-related accidents, the producer stated that every year, 6,000 Americans die or suffer brain damage related 352 A. Media attention, however, mainly focused on staggering statis- tics: from 44,000 to 98,000 preventable in-hospital deaths annually, and 7,000 preventable deaths related to medication errors. According to Hendrickson [28], the concept of using ¿nancial incentives to support and improve quality of care within the context of a professional endeavour such as medicine is not without moral and practical risks: damag- ing professionalism, increasing patient dissatisfaction with the low quality of care deliv- ered, threatening the ongoing physician–patient relationship and, last but not least, the negative trend for access to care for all patients are the main negative elements empow- ering medicine as a mission. Anaesthesiologists, intensivists, critical care physicians and nurses have a broad exper- tise in hospital organisation and the expanding area of quality and safety management by increased adherence to evidence-based guidelines, monitoring processes and improving quality of care [27]. The doctor’s expertise includes both diagnostic skills and consid- eration of each patient’s rights and preferences in making decisions about patient care. Clinicians use relevant clinical research based on the accuracy of diagnostic tests and the ef¿cacy and safety of therapy, rehabilitation and prevention to develop an individual treatment plan [29]. The development of evidence-based recommendations for speci¿c medical conditions, termed clinical practice guidelines, or “best practices”, has improved in the last decade. The process of measuring performance often requires the use of statistical evi- dence to determine progress towards speci¿c organisational objectives. Performance may 30 Professionalism, Quality of Care and Pay-for-Performance Services 353 Table 30. Psychosocial and ethical outcome - Long-term functioning and quality of life - Patient satisfaction - Family satisfaction - Concordance on desired end-of-life decisions - Appropriateness of medical interventions provided 4. There are three ways of evaluat- ing performance: structure, process and outcome (Table 30. Structural measures are used to track and pay for resources that help improve care delivery (e. Process measuring evaluates clinical services demonstrated to be necessary to facilitate positive health outcome, such as testing haemoglobin A1c levels in patients with diabetes or prescribing aspirin to heart attack patients upon hospitalisa- tion. Measures that are not directly connected to improving performance (such as those directed to improving communication with the public to build trust) are measures that are means to achieving the ultimate purpose. As de¿ned by Radwin, what is needed to reduce the clash between “medicine, money and morals” are policies that hold doctors accountable to patients for ful¿lling the profession’s ideals [35]. To evaluate how well a public agency is performing: formulate a clear, coherent mission, strategy and objectives; then based on this information, choose how those activities will be measured; 2.