By G. Hauke. East Carolina University.
Many rheuma- tologists say it is important to have good listening ability and com- passion 400 mg viagra plus for sale, as many of the diseases they treat 400mg viagra plus otc, such as rheumatoid arthritis, are very painful. Rheumatologists are, to a higher degree than some other subspecialties in internal medicine, involved in the management of pain. Rheumatologists can have more regular hours than many of their colleagues because there is little critical care involved. In 2002 there were 307 active residents in 106 accredited pro- grams in rheumatology. Women made up 52 percent of rheuma- Internal Medicine Subspecialties 51 tology residents. Three years of residency in general internal med- icine are required, along with an additional two years of training in rheumatology. Other Subspecialties Other areas of internal medicine include newer subspecialties. Three of these new subspecialties are critical care medicine, geri- atric medicine, and clinical and laboratory immunology. Critical Care Medicine Critical care medicine involves management of life-threatening, acute disorders—mostly in intensive care units. Critical care spe- cialists take care of patients with shock, coma, heart failure, respi- ratory arrest, drug overdose, massive bleeding, diabetic acidosis, and kidney shutdown. Critical care is a subspecialty of these specialty boards: internal medicine, anesthesiology, neurological surgery, obstetrics and gynecology, and general surgery. Geriatric Medicine Although most subspecialties treat the elderly, geriatric medicine offers physicians the opportunity to intimately understand the needs of the elderly. As the baby boom generation ages, the per- centage of Americans 65 and older will double, reaching 70 mil- lion by the year 2030.
A person’s quality of life and well- being may impact on his or her response to pain 400mg viagra plus otc, and vice versa (Skeving- ton order viagra plus 400mg on-line, 1998; Skevington, Carse, & Williams, 2001). In addition, beliefs about quality of life may be mediated by these concepts that are heavily culturally determined (WHOQOL Group, 1995), and all the processes identified in the model impact on decision making regarding quality of life. Before summing up, two additional sections have been added to satisfy different purposes. In the first, we outline an example of a pertinent socio- cultural issue that reflects and is reflected by individual differences, and seek to show how key issues may be addressed in different ways, cutting across all levels of the model. Although no claim is made for the compre- hensiveness of the model’s components, such examples illustrate that there is some semblance of gestalt, with the whole being more than the sum of the parts. Gender was chosen as the example because it represents an important issue that has widespread influence on individual differences in terms of pain experience and report. The second section provides some limited observations on methods in this area. GENDER: AN EXAMPLE OF FEATURES THAT MAY BE ADDRESSED AT ALL LEVELS OF THE MODEL Central to the debate around gender and pain is epidemiological evidence of more frequent symptom reporting and/or help seeking by women than men (Berkley, 1997; Unruh, 1996), and the greater prevalence of certain con- ditions, like fibromyalgia, in women (Yunus, 2002). Individual differences ex- plained by gender are conceptually important at all levels of the proposed model, although there has been a tendency to focus on a limited number of gender differences at the expense of what are seen as less interesting but more frequently occurring similarities. SOCIAL INFLUENCES ON PAIN RESPONSE 199 importance of socialized gender patterns and sociocultural expectations of pain reporting and help seeking, which shape the behavior of men and women. At Levels 2 and 3, women are seen as highly social in the ways they seek out social information for decision making and actions relating to pain. In interaction with health professionals, women communicate in different styles and receive different treatments for the same conditions (Verbrugge, 1989; Verbrugge & Steiner, 1984, 1985). Differential perceptions of various aspects of quality of life (WHOQOL Group, 1995), and gendered ideologies, histories, and cultures connected with health and health care, as well as lower income, are indicated as relevant factors at Level 4. Factors addressing features from all these levels seem to be evident in Bendelow’s (1993) in-depth qualitative study, which explored women and men’s experience of and beliefs about causes of pain.
Punitive spouse behaviors were also associated with patient physical and psycho- social impairment cheap viagra plus 400 mg with amex. Conflict in the family and lack of social support in the workplace also contribute to increases in pain severity (Feuerstein et al generic viagra plus 400 mg with visa. Lane and Hobfoll (1992) and Schwartz, Slater, Birchler, and Atkinson (1991) found that anger in patients with chronic pain adversely affects the mood of their spouse. Anger and hostility may affect the amount of spousal support given, which influences the adjustment to chronic pain (Burns, Johnson, Mahoney, Devine, & Pawl, 1996; Fernandez & Turk, 1995). For example, Paulsen and Altmaier (1995) found that pa- tients who reported higher levels of enacted spouse social support dis- 4. SOCIAL INFLUENCES AND COMMUNICATION OF PAIN 105 played a greater number of pain behaviors, regardless of whether the spouse was present, as compared to chronic pain patients who reported lower levels of enacted spousal support. When a measure of perceived sup- port was utilized, the pain behavior displayed differed depending on spouse presence/absence and on the level of support. Physician–patient communication is important for proper pain assessment and management (Feldt, Warne, & Ryden, 1998; McDonald & Sterling, 1998; Zalon, 1997). An es- timated 42% of cancer patients do not get sufficient relief from pain, partly because of patient–physician communication barriers (Oliver, Kravitz, Kap- lan, & Meyers, 2001). These barriers may include the patients not knowing their options and fear of addiction to drugs (Oliver et al. Older adults represent a further challenge to physician–patient communication regard- ing pain. For example, nearly half of a sample of older adults who were in- terviewed preoperatively indicated that they would not ask for analgesics, and only 13. Improving patient communication can help eliminate some of these barriers. Older adults who participated in a com- munication training program reported less postoperative pain over the course of their hospital stay than older adults who were not trained in com- munication (McDonald, Freeland, Thomas, & Moore, 2001). Communication between patient and physician can be challenging when there are cultural and linguistic diversities (Johnson, Noble, Matthews, & Aguilar, 1999). A large number of per- sons are affected by conditions that limit their ability to communicate pain (Hadjistavropoulos et al.
However discount viagra plus 400mg otc, the standard error is not a descriptive statistic and must not be used as such buy discount viagra plus 400mg online. Because the standard error is smaller than the standard deviation and approximately half the size of the 95% confidence interval, it suggests that there is much less variability and much more precision than actually exists. In tables, put P = 0·043 not P < 0·05, and use P = 0·13 not “NS” for indicating a lack of statistical significance. This gives your readers the opportunity to evaluate the magnitude of the P value in relation to the size of your study and the difference between groups that you found. Describing the P value as “NS” or “P > 0·05” can be misleading if the actual value is marginal, say 0·07, but the difference between groups is clinically important. Giving the exact value allows readers to make their own judgements about whether it is possible that a type I or type II error has occurred. It is certainly a good idea to reserve P values and significance testing for only what you absolutely need to test. This will exclude the significance testing of baseline characteristics in randomised controlled trials. It will also exclude testing for differences between groups when the 95% confidence intervals tell the whole story. The question of whether you should test hypotheses that were not formed prior to undertaking the study is contentious. One golden rule is never to test a hypothesis that does not have biological plausibility. However, new ideas emerge all the time, and the use of existing data sets to explore new hypotheses makes lots of sense if the study design is appropriate for the question being asked. In clinical trials in particular, the need to reduce type I errors has to be balanced with the much more serious problem of avoiding type II errors. Multivariate analyses Just as word processing does not ensure better writing, multivariate analyses do not ensure better analyses. Kenneth Rothman (www2) It is wonderful that, with the burst in new technology and in “click and point” software, multivariate analyses are now accessible to all researchers. Multivariate analyses should never be undertaken until all the univariate and bivariate analyses are evaluated, understood, and tabulated.