C-1 Final Exam Study Guide
Transcript of C-1 Final Exam Study Guide
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C1FinalExamStudyGuide,5/12/11
HumanDevelopmentandLearningTheory
1.Foreachofthefollowingdevelopmentaltheories,knowthestages,associated
characteristics,
and
ages:
a.Cognitive(Piaget)
b.Social(Erikson)
c.Moral(Kohlberg)
d.Psychosexual(Freud)
REMEMBER:
Pee 3letterssochildrenshouldgainbladdercontrolshortlyafterage3
Poop 4letterssotheyshouldgainbowelfunctionshortlybeforeage4
Groomingbyage4
COGNITIVE Piaget
(1)Sensorimotor
(Birth
2years)
babylearnsfromsensoryobservation,controlmotorfunctionsmore,andexplore
environment
ObjectPermanence babyunderstandsthatanobjectisstillthere,eveniftheycan'tseeit
Symbolization theycancreatevisualimage
**Theattainmentofobjectpermanencemarksthetransitionfromsensorimotorstagetothe
preoperationalstageofdevelopment**
(2)PreoperationalThought(36yearsold)
childrenusesymbolsandlanguagemore
unable
to
think
logically,
or
understand
consequences
of
actions
Immanentjustice punishmentforbaddeedsisinevitable
Egocentric viewofthemselvesascenterofuniverse
PhenomenalisticCausality onethingcausesanother(thundercauseslightning)
AnimalisticThinking endowphysicaleventsandobjectswithhumancharacteristics
SemioticFunction canuseasymboltostandforsomethingelse
(3)ConcreteOperations(710yearsold)
childrencanoperateandactontheconcrete,real,andperceivableworldofobjectsand
events
developmorals
Operationalthought childrencannowseethingsfromsomeoneelse'sperspective(replaces
egocentricthought)
SyllogisticReasoning logicalconclusionisformedfromtwopremises(ieifyouknowthat
horses
aremammals,andthatallmammalsarewarmblooded,thenhorsesarewarmblooded)
Conservation althoughshapeofobjectmaychange,itisstillthatobject(ieballofclayis
smooshedout,youstillknowitisclay)
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Reversibility understandrelationshipbetweenthings(iewatercanbecomeice,andthen
becomewateragain)
**Youknowyouarestillinpreoperationalstageiftheyhavenotcompletedconservationor
reversibility**
(4)Formal
Operations
(11
years
old
to
end
of
adolescence)
thinkingisabstract(politics,religion,ethics),abilitytoreasondeductively,defineconceptsand
skillsfordealingwithpermutationsandcombinations
HypotheticodeductiveThinking enablespersontomakehypothesisandtestit
DeductiveReasoning generaltospecificreasoning
InductiveReasoning specifictogeneralreasoning
StagesinSocialDevelopment(EricErickson'sStagesofSocialDevelopment)
stressedimportanceofchildhoodeventsandexperienceduringadulthood
Youhavetoworkthougheachofthe8stagesofepigeneticprincipals.Youcaneitherhavea
healthy
ornothealthyoutcome;ifyouhaveanunhealthyoutcomeyoucan'tmoveontothenextphase
oryou
canhaveregression
EpigeneticPrincipal developmentoccursinsequential,definedstages,andthateachstage
mustberesolvedinordertomovetothenextstage
PsychosocialStages
Phase1:Trustvs.Mistrust(Birth 1yearold)
Toget babyreceiveswhatisoffered,andelicitswhatisdesired
infantistakingintheworldthroughitsmouth,earandeyes
development
of
trust
is
from
mother
and
mother
anticipating
its
needs
Phase2:Autonomyvs.ShameandDoubt(13yearsold)
dependentonamountandtypeofcontrolthatparentexertsoverchild(Can'tbetoomuchor
toolittle)
canhaveproblemssuchasOCD,inflexibility,etc
Phase3:Initiativevs.Guilt(35yearsold)
OedipusComplex:competingwithparentofsamesexforaffectionsofoppositegenderparent
childisactive,developingmotorskills,etc
starttohaveadultherorolemodels
canhaveproblemswithconversion,inhibitionorphobias
**Phase
4:
Industry
vs.
Inferiority
(5
11
years
old)**
takingprideinlearningnewskills
sociallyisthemostimportantstage
Phase5:Identityvs.RoleConfusion(1121yearsold)
adolescentispreoccupiedwithquestionofidentity
problemswiththisstagecanresultinrunningaway,criminalbehavior,andsexualrole
confusions
Fidelity faithfulnesstoideologythatprovidesaversionofselfinworld
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Phase6:Intimacyvs.Isolation(2140yearsold)
abilitytohonorcommitmentstoconcreteaffiliationsandpartnerships,evenwhenthat
requires
sacrificeandcompromise
Distantiation readinesstorepudiate,isolateandifnecessarydestroythoseforcesandpersons
whoseessence
seems
dangerous
to
one's
own
Phase7:Generativelyvs.Stagnation(4060yearsold)
concernforestablishingandguidingthenextgeneration
Phase8:Integrityvs.Despair(60death)
acceptingresponsibilityforaperson'sownlife
"Healthychildrenwillnotfearlifeiftheireldershaveenoughintegritytonotfeardeath"
StagesinMoralDomains(Kohlberg)
Kohlbergstudiedchildrenviaaskingtheirreasoningandjudgementinaseriesofstorieswhere
charactersfacemoraldilemmas
youcan'tskipstages
Level1.PreconventionalReasoning(ages410)
goodandbadareinterpretedintermsofexternalrewardsandpunishment
Stage1HeteronomousMorality
Rulesarefixedandabsolute.Moraldecisionsarebasedonfearandavoidanceofpunishment
Example,Idonottakemysistersbikebecausemydadwillbemadatme.
Stage2Individualism,Purpose,andExchange
childrenpursuetheirowninterestsbutletothersdothesame.
Theyreasonthatiftheyarenicetoothers,otherswillbenicetotheminreturn.
Example,Foracookie,Iwillpickupmytoys.
Level2.ConventionalReasoning(ages1013)
Individuals
apply
external
standards
(i.e.,
standards
set
by
parents,
government,
etc).
Stage3MutualInterpersonalExpectations,
RelationshipsandInterpersonalConformity
Childrenandadolescentsoftenadopttheirparentsmoralstandardsandattempttoliveupto
social
expectationsandrolesbybeingniceandconforming.
"goodboygoodgirl."
Example,Ikeepmydeskcleanbecausemyteacherlikesit.
Stage4SocialSystemsMorality
focusonmaintaininglawandorderbyfollowingtherules,doingonesduty,andrespecting
authority.
Example,IraisemyhandwhenIhaveaquestionbecausethatisoneoftheclassrules.
Level3.PostconventionalReasoning(adolescencetoadulthood)
thehighestlevelofmoraldevelopment.Individualsrecognizealternativemoralcourses,
exploreoptionsandthendecideonapersonalmoralcode.
Stage5 SocialContractorUtilityandIndividualRights
Rulesoflawareimportantformaintainingasociety,butvalues,rightsandprinciples
transcendthelaw
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Example,Ipaytaxesbecauseitisthelaw.
Stage6UniversalEthicalPrinciples
peoplefollowtheseinternalizedprinciplesofjustice,eveniftheyconflictwithlawsandrules
Example,Ipaytaxesnotbecauseitisthelawbutbecauseitistherightthingtodo.
Stages in Psycho Sexual Development (Freud's Stages of CognitiveDevelopment)- Person is constantly trying to get pleasure from different areas (depending onwhat phase they are in). If they are to move on to the next phase they must haveconflic t resolution or else they can't move onto the next phaseFreud's Phases of Psychosexual Development- id, ego, superego, drives, instinctOral (Birth - 1 year)- child focusing libidinal and aggressive energy toward oral pleasure zones (likessuckling, but trying to control aggressive urges to bite)
Anal (1-3 years old)- need to develop autonomy from caregiver and more bodily control
Phallic (3-5 years old)- focus on play and genitalia- Oedipal complexLatency (5-11 years old)- diminished sexual drive, and focused on social relationsGenital (11 and above)- physiological changes associated with puberty- renewed interest in sex and in the other gender
Developmental Snapshots
Infancy (Birth - 18 months)Birth- Normal baby = 7-7.5 lbs and 19-21 inches long- grows more than any other time in life- completely dependent on caregiversGoals: (1) Secure attachment (2) Regulation of sleep wake cycle (3) Creation offeedingpattern2 Months +- baby smiles and parents respond, which promotes bondingErickson's: Trust vs. Mistrust Stage - inconsistent parents can lead to mistrust in
baby6+ Months- child resolving oral gratification (suckling), but learning to not bite- a child to adequately resolves these conflicts can give and receive from others,trustothers, and experience self reliance. Person who doesn't resolve these stagesmay bedependent, low self esteem, envy and jealousy
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Piaget's Sensorimotor Stage - baby uses motor skills to explore, make sense of theworld,and develop schema
Toddler(18months36months)
motor
skills
develop:
run
and
climb
stairs
abilitytosolveproblemsontheirown
symbolicandmagicalthinkingdevelops
Erikson'sAutonomyvs.Shame&Doubt
exploreenvironmentanddevelopbetteranalsphinctercontrol
Mahler'sRapprochementstage
separationindividuationoccurs
Freud'sAnalPhase
needtoseparateanddevelopautonomyfromparent;greatercontrolofbodymovements
TransitionalObject helpschildrenmaketransitionfromdependenceoncaregiverto
independence;normal
PreoperationalStage
childrenfunctionatprelogicalstate
Prelogical can'tuselogictomakeconclusions
ConservationofMass(Piaget)
childisaskedwhatcupofwaterhasmorewaterinit,eventhoughbothglasses
hasthesameamountofwater.Thechildwillchoosetheglassthatislarger
ImportantBladder&FecalControlMarkers
Preschooler(3years 5years)
growthisslowed
bladdercontrolisgainedby30months(almost3yearsold)
develop
cooperative
play,
and
learn
to
work
with
others
magicalthinking
childdevelopssexualurgestowardsparentofoppositesexandcompeteswithsamesex
parent
moralsenseofrightandwronghasdeveloped
learnaggressiveimpulsescanbeconstructivelyexpressed
Piaget'sPreoperationalStage continues
EricksonsInitiativevs.Guilt
candevelopinitiateandcompetenceifallowedtoexploreenvironmentandinitiate
meaningful
motorandintellectualactivities
Freud'sPhallicPhase curiosityaboutbody(genitalia)functions
OedipalComplex seeksrelationshipwithparentsofsamesex.Eventuallygetsresolved
CastrationAnxiety fearoffathercastratingson(bychild)
Egocentrism everyeventisperceivedtooccurinrelationtothechild
SchoolAge(5years 12years)
growthratesareequaluntilage9,whengirlsgrowfaster
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magicalthinkingfades
canfocusfor45minforschool
seekpraisefromotheradults(teachers,coaches,etc)
moreimportanttogetvalidationfrompeers
seekrolemodelssuchassuperheros
EricksonsIndustry
vs.
Inferiority
childseeksvalidationfromsucceedinginschool,socialinteractionstodevelopconfidenceand
industry.Otherwise,thechildfeelsinferior
Piaget'sConcreteOperations
developlogicthatisusedtosolveproblems
Freud'sLatencyPhase
diminishedsexualdrive
However,childrenstillmasturbateanddohavesexualurges
Conservation
quantityremainsthesamedespitechangesinappearance
Adolescence(1218yearsold)
developmentofsenseofidentityandselfrelianceandlessdependenceonparentsthatwill
allowtransitiontoadultrolesandresponsibilities
failureofsuccessfullycompletingthesestagesleadstorolediffusion(identityconfusion)
wheretheadolescencedoesn'tknowhisorherroleintheworld
Puberty periodofadolescencethatresultsinsexualmaturation
Adolescence periodfromonsetofpubertytobeginningofadulthood
Telearche breastdevelopmentinfemales
Pubarche pubichairdevelopment
Menarche onsetofmenses
Adrenarche adrenalcortexsecretesandrogens
Piaget'sFormal
Operations
useabstractconcepts,problemsolving
Freud'sGenitalPhase
renewedinterestinpleasurefromexcretoryactivity
Erikson'sIdentityvs.RoleDiffusion(1220years)
developsenseofidentitywithrespecttoselfandsocietywithaclearrole
******************************************************************************
*******
Learning
2.Beabletodeterminewhetherornotadevelopmentaldelayispresent,andwhenthereisa
need
for
intervention.
3.Knowclassicalandoperantconditioningtheories,includingwhicharemosteffectiveforchild
discipline/parenting. Inparticular,befamiliarwiththefollowing:
a.PositivereinforcementbehaviorincreasedbyrewardChildincreaseshisbehavior
towardhisyoungerbrothertogetpraisefromhismother
b.Negativereinforcement behaviorisincreasedbyavoidanceorescape,Child
increaseshisbehaviortowardhisyoungerbrothertoavoidbeingscolded
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c.Punishment behaviordecreasedbysuppression,Childdecreaseshishittingbehavior
afterhisotherscoldshim
d.Extinction behavioreliminatedbynonreinforcement,moreeffectivethan
punishment,behaviormaybeincreasedbeforeitdisappears,Childstopshittingbehavior
whenthebehaviorisignoredbyhismother
e.Unconditioned
stimulus
automatic
response
without
having
to
be
learned
produces
response,odoroffood,injection
Conditionedstimulusproducesresponsefollowinglearning,soundoflunchbell,siteof
thenursethefollowingmonth
f.Unconditionedresponse naturalreflexivebehaviorthatdoesnothavetobelearned
/conditionedresponse,cryinginresponsetoinjection,cryingwhenseeingthenursethe
followingmonth
g.Stimulusgeneralizationnewstimulusthatresemblesconditionedstimulusresultsin
conditionedresponse,firebellmakeyoudrool
h.Discriminationreferstotherecognitionandresponsetodifferencesbetweensimilar
stimuli(tellingthedifferencebetweencowanddog allarefourlegged)
i.Primary/secondaryreinforcers
Reinforcer is anything that maintains a response or increases its strengthPrimary reinforcers are independent of previous learning (e.g., the need for food)Secondary reinforcers are based on previous learning (e.g., getting money for mowingthe lawn).- Interestingly, continuous reinforcement, or reinforcement of every response, leadsto rapid acquisition, but not maintenance, ofbehavior. On the other hand, partialreinforcement, or reinforcing a behavior intermittently, is most effective inmaintaining a behavior (thisresearch comes from gambling - and doesn't refer to punishment)
4.Knowthedefinition,dimensions,andcategoriesoftemperament(e.g.,easy,difficult,and
slowtowarmup).
Types of Children TemperamentsEasy children tend to adapt quickly to change, have predictable eating and sleepingpatterns, and are usually positive.Difficult children have trouble adapting to change, have unpredictable or irregulareating and sleeping patterns, and tend to be more negative
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Slow-to-warm-up children are initially similar to difficult children, but they are able toadapt and improve as they become more comfortable in the social environment- As adolescents, easy children are at lowest risk for psychological problems,diff icult children are at highest risk, and slow-to-warm-up children have amoderately increased risk.
5.Knowthedefinitionandtypesofattachment(e.g.,secure,insecure/avoidant,
insecure/ambivalent),whatinfluencesattachment,andgoodnessoffit.
AttachmentAttachment - relationship an infant develops with caregiversTypes of At tachment- there are several types of attachment: (1) Secure attachment, (2)Insecure./Avoidant Attachment,and (3) Insecure/Ambivalent AttachmentSecure attachment - determined by maternal sensitivity and responsivenessInsecure Attachments- the type of insecure attachments is determined by the infants
temperamentGoodness of fit - interaction between parent and child in terms of motivation and styles
of behavior
Death,Dying,andGivingBadNews
1.KnowthestagesofgriefasdescribedbyKublerRoss,aswellascommonmanifestationsof
griefinadultsandchildren.
Stages of Dying (Kubler Ross) ~ all of these are normalDeath arrives bringing grave adjustemnts
1. Denial- People repress conversation, deny physician's verdict- Only when denial becomes dysfunctional that the doctor should confront2. Anger- Health care professionals get little training in dealing with anger- Important to LET IT BE- Anger of patient and loved ones is valid- Do not get defensive, and seek to find out what you can do to meet the needs ofthepatient3. Bargaining
- Gives illusion of control in a situation in which one is powerless- Physicians can accept bargains that do not compromise the patient care4. Depression/grieving- Normal to have depression, but important to make sure it is not clinicaldepression5. 5. Acceptance of Death- few patients reach this point- Usually exhaustion and advancing organic brain dysfunction
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CHILDREN
Longergrief
Abilitytoexperienceintenseemotionlimited
Thinkaboutlossimmediately
Lossofspeech,diffusedistress(youngerthan2)
Dysfunctionin
eating,
sleeping,
bowel,
bladder
(5
yo)
Phobic,hypochondrial,withdrawn(schoolage)
Behaviorproblems(adolescents griefaslongasadults))
2.Knowhowculturalattitudesinfluenceindividualgriefreactionsandhowtoapproach
individualsfromdifferentcultureswhoaredealingwithdeathanddying.
Have to be sensitive to culture; some cultures want doctor to deliver bad news, whileothers want family members to deliver bad news
- Important to use interpreter (if not fluent in native language), even though familymembers maybe bilingual- Most important: Communication skills must be practices, implemented, andobserved with feedback- Important for doctor to respect patient's wishes (autonomy), even if it clashes withdoctor's own beliefs about disclosure- Important to respect patient's right to choose- Nondisclosure occurs most frequently w ith cancer; especially when there is abad outcome expected- Cases illustrate where physician wants to tell patient, but patient family tells doctor to
NOT tell patient because of cultural practices and beliefsFor the case regarding the Chinese male:- Important to allow patient to die in his home country, children to do their duty andprotect elder from bad news, and for resident to be relieved from burden of lying or notdisclosing information about patient to the patient; normal to not tell patient he or sheis dyingFor the case regarding the Georgian male:- Patient may be more likely to commit suicide because of disgrace of not being able totake care of family; normal to not tell patient he or she is dying
3.Identifycharacteristicsofnormalandcomplicated/pathologicalbereavementforadultsand
children.
Normal vs. Complicated BereavementNormal Bereavement- when person can accept the death of a person and let go of memories andexpectations of deceasedpersonComplicated Bereavement- person is unable to fully comprehend or work through the loss
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Problems that Can Arise with Complicated Bereavement(1) Introjection - wholesale enactment of traits of a lost loved one(2) Identification - bereaved persons wear clothing or adopt mannerismsbelonging to theDeceased
4.Knowhowtodeliverbadnewsappropriately,includinghowtodeliverbadnewsto
individualsfromdifferentculturalbackgrounds.MakesureyouknowtheSPIKESprotocol.
Six Stages of SPIKE(1) Setting up the InterviewRehearse what you will say and how you will respond to questionsHelpful guidelines
Arrange for pr ivacyInvolve significant others
Arrange for pr ivacy
Involve significant othersSit down - relaxes patientMake connection with patient - eye contact, touch patient armManage time Constraints - let patient know if you have to be somewhere or that youexpect your pager to beep(2) Assessing the Patients Perception
Ask opened ended questions to see what the patients perception is of the medicalsituation"What have you been told about your medical situation?""What is your understanding of the reasons we did MRI?"You can correct misconceptions
(3) Obtaining the Patients InvitationYou need to ask patient if they want all information about diagnosis or don't wantitIf patient doesn't want to know, offer to answer questions that they may have in future itheychange their mind
Ask the patient, "How would you like me to give you the information about the testresults"(4) Give Knowledge and Information to PatientTell patient in layman's termsDon't be too blunt
Give information in small chunks and assess how they are understanding itDon't say, "There is nothing else we can do for you"(5) Address the Patient's Emotions with Empathetic ResponsesIf necessary ask patient what their emotions are (may not always be clear)MethodObserve for any emotion from patientIdentify emotion from patientIdentify the reason for emotion (usually from bad news)
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After letting patient express feelings, express empathy by making a connectingstatement(6) Strategy and SummaryPatients who have plan for future are less anxious
Ask patient if they are ready to talk about future plans for dying
Ask pat ient to express thei r fears: worried about family, loss of job, pain andsuffering,hardship on othersUnderstand what the goal of the patient is : symptom control, making sure get bestpossibletreatment
CopingStyles,DefenseMechanisms,andPersonality
1.Knowthedefinitionsofthevariousdefensemechanisms,beabletoidentifythemostmature
defensemechanisms,andbeabletorecognizethemanifestationsofdefensemechanisms. We
recommendyou
try
to
come
up
with
examples
of
each
to
help
you
remember
them
better.
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2.Knowthedefinitionofcopinganddifferenttypesofcopingskills. Beabletoprovide
examplesofeach:
a.Conscious/unconscious
b.Healthy/unhealthy
c.Cognitive/behavioral
Coping responses to stress
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- one particular coping st rategy may be effective in one situation, but it doesn'tmeanit's effective in all situations
A coping response to stress can be:(1) Cognitive and or Behavioral in nature
Cognitive- change the way that you think about the situationExamples of Cognitive Coping Strategies:- Changing the way you think- Humor
Cognitive reframing - looking at the positive side Perspective taking - understanding someone else's perspective Generating a plan of action to solve a problemBehavioral - techniques you can physically do to mediate the effects of stressExamples of Behavioral Coping Strategies:- Mediate- Progressive muscle relaxation
- Going or walk- "Blowing off steam taking one's anger outslamming a door hard, but this canactually increase anger and aggression- Listening to soothing musicDefense Mechanisms - largely unconscious reactions that protect a person fromunpleasant emotions such as anxiety, guilt, threats to self-esteem, aggression, dejection(depression)- You can have some conscious awareness about using defense mechanisms- defense mechanisms are not necessarily considered abnormal or pathologic, itdepends on how they are used and can be thought of in terms ofthe degree of maturityExamples of Defense Mechanisms Strategies:- Humor- Altruism- Denial(2) Conscious or Unconscious level(3) Healthy/adaptive or unhealthy/maladaptive- Examples of healthy/adaptive responses include: physical exercise, seekingsupport (benefiting), meditation
Examples of unhealthy/maladaptive responses inc lude: self-indulgence(overeating, drugs, alcohol, excessive spending), aggression, striking out at others,giving up, and blaming yourself; but these are not absolute(overeating, drugs, alcohol, excessive spending), aggression, striking out at others,giving up, and blaming yourself; but these are not absoluteThere are some situations in which giving up is a good thing: such as giving up in anonconstructive relationship
3.Knowthecharacteristicsofdifferentpersonalitytraits,andrecognizehowthesetraitsare
manifestedinthephysicianpatientrelationship.
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PatientEducation,Compliance,andChange
1.Knowthetenetsofthetranstheoreticalmodel,including:
a.the
stages
of
change
b.basicprinciplesofmotivationalinterviewing
c.techniquesforhelpingpatientsineachstageofbehaviorchange
2.Usingtheprinciplesofthetranstheoreticalmodelandmotivationalinterviewing,determine
appropriatephysicianresponsestopatientsinvariousstagesofchange. Thismeansthatyou
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willneedtoanalyzethephysicianresponsesbasedontheunderlyingconceptrepresentedby
eachresponse,NOTonthewaytheresponsesounds.
MOTIVATIONALINTEVIEWING
Expressingempathy
Developingdiscrepancy
Rollwithresistance
Supportselfefficacy
3.Knowthefactorsassociatedwithtreatmentcompliance,aswellasthefactorsassociated
withtreatmentnoncompliance.
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4.Knowwhatinformationshouldbesharedwheneducatingpatients,aswellashowto
effectivelyprovidepatienteducation.
Givept
multiple
forms
of
info
Usesimplelanguage
Startwiththemostimportantinfo,likediagnosis
Talkaboutmedications
Followup
HumanSexuality
1.Knowthephasesofthenormalsexualresponsecycle,includingtheappropriateorderof
events
and
the
mechanism
of
action
for
each
phase.
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2.Knowthevarioussexualdisorders,including:
a.Hypoactivesexualdesire
b.Sexualaversiondisorder
c.Femalesexualarousaldisorder
d.Male
erectile
disorder
e.Orgasmicdisorder
f.Prematureejaculation
g.Vaginismus
h.Dyspareunia
Sexual Dysfunct ion in Men**most common causes are combo: somatic and psychological elements, withpossible primary andsecondary etiologies**- **Most common erectile dysfunction psychological causes: anxiety, guilt, anger
towards sexual partner **Premature Ejaculation - ejaculation that occurs before it is desire, without reasonablecontrol over timingof ejaculation- **plauteau phase** of sexual response cycle is short or absent- might be related to diminished serotonergic neurotransmission and 5-HT2C or 5-HT1AreceptordisturbancesSpectatoring - male is performing, and not being emotionally involved, so can'tejaculateInhibited ejaculation - can be: psychological, biological (spinal cord injury, MS, severe
diabetes, drugsthat inhibit adrenergic innervation, etc)Sexual Dysfunction in Women- **men are more likely to seek help for sexual dysfunction than women**Orgasmic disorder: occurs in both men and women; can't have an orgasm, and can belifelong oracquired; Lifelong: has never had an orgasm; Acquired: is currently unable to achieveorgasm despiteadequate stimulationFemale Sexual arousal disorder: inability to maintain vaginal lubrication until sex act iscompleted
despite adequate physical stimulationDyspareunia - pain during sexual intercourse; can be due to psychological orphysiological reasonssuch as: PID, insufficient lubrication, thinning of vagina during menopause, scarringfromepisiotomies,etcVaginismus - involuntary contraction of pubococcygeus muscles surround outer 1/3 ofvagina; easily
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treated with education, counseling, behavioral exercises that involve insertion of largerdilators intovagina; many patients have a history of dyspareunia**the majority of unconsummated marriages results from vaginismus**Sexual Aversion: aversion to sexual activities which can result from many things such
panic disorders,sexual phobias, sexual victimization, rape, etc; treatment with anxiolytic (anti anxiety)medication &brief psychotherapyHypoactive Sexual Desire Disorders- can effect both male and female- can stem from OCD, and anhedonia (symptom of depression - can't experiencepleasure fromactivities that you previously found pleasurable), diabetes, no longer attracted topartner, powerstruggles, etc
**Anxiety d isorders, mood, and substance abuse must be treated before orconcomitant withtreatment for hypoactive sexual desire**
3.Knowthevariousparaphilias,including:
a.Exhibitionism
b.Fetishism
c.Frotteurism
d.Pedophilia
e.Sexualmasochism
f.Sexualsadism
g.Voyeurism
h.Paraphiliasnototherwisespecified
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4.Recognizetherangeofnormalsexualfunctioningintermsofsexualorientationandbehavior
throughoutthelifecycle.
Normal Variations in Sexual behavior- It is normal for both males and females to have nocturnal arousals, but it is morenoticeablein men- It is normal for sexual function to diminish with age:- Male sexual function peak in 20's; refractory period increases in 30's (Teens: 20-30min; 3 hours-3
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days in 70 year old men)- women sexual function peak in 30's or 40's, and decline in 50's (menopause)- Masturbation in both males and females is normal, and includes the use of sexual toysas beingnormal
- Having sexual fantasies (which usually begins in teens), is normal, but decreases withmiddle age
5.Identifytheriskfactorsassociatedwithsexualorientationandbehavior(forexample,
sexuallytransmittedinfections,tobaccouse,etc),includingrecommendationsforscreeningand
preventativepractices.
Male Homosexuals- Men who have sex with men are at high risk for:
- HIV, particularly black and Hispanic men, and younger gay men- STDs indicates high risk for sexual practices and can help spread HIV- Gonorrhea & gonococcal urethritis - with chlamydial infection- Syphilis - large increase in infections, particularly in homosexual men- HSV-2 (Herpes)- infection with HSV might facilitate spread of HIV- HPV - might increase anal cancer risk; homosexual men have higher rates of analcancer- Higher rate of anal cancer- Hepatitis A & Hepatitis B - most homosexual men are not immunized for these- Psychosocial Disorders - homosexual men have higher rates of depression, anxiety,mood disorders,
suicide, eating disorders, alcohol, substance abuse and smokingScreening GuidelinesThere are not an official set that is universally accepted, so this just includes all of them- physicians should ask patients about their sexual history in a nonjudgmental way, andchanges in sexualpractices- homosexual men should be assessed for risk for HIV infection- CDC recommends more frequent STD screening for high risk homosexual men(multiple partners, useillicit drugs)- Vaccinations for Hepatitis A & B
- Rectal screening- Serological tests for Herpes-2 (HSV-2)- PAP smears- screen for psychosocial problemsFemale Lesbians**Never assume that lesbians have never been actively sexual with men**- lesbians are less likely to get STD testing than heterosexual women- lesbians should stil l be screened for violence in relationships
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- women who had same sex attraction were significantly more likely to have suicidaltendency, engage inself harm vs. heterosexual women- risk for ovarian cancer is higher in lesbians because they are likely to have lowparity, low
exogenous hormone use, smoking, higher BMI (factors that increase risk for ovariancancer), but nostudies have been performed to determine ACTUAL risk of ovarian cancer in lesbiansvs. heterosexualwomen- smoking is higher in lesbian populations- Lesbians are more likely to have high BMI, waist to hip ratio- Lesbians are more likely to engage in regular exercise**No proven increase in risk of cardiovascular disease among lesbians andbisexual women**- risk of breast cancer is debated and unknown
- alcohol use being higher in lesbians vs. heterosexuals is debated- Rates of drug use in lesbians vs. heterosexuals is debatedSTDs transmitted between women: Herpes, HPV, TrichomoniasisTheoretically t ransmitted between women: Chlamydia, Gonorrhea, syphilis, HepatitisB, HIV, bacterialvaginosis
AlcoholUseandMisuse
1. Knowthediagnosticcriteriaforalcoholabuseanddependence. Youshouldknowthe
symptomsforeachdisorderandthenumberofsymptomsrequiredtoestablisha
diagnosis. Youshouldalsobeabletodistinguishbetweenthetwodisorders.
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2.Knowthedefinitionofatrisk,moderate,andbingedrinking. Toclarifythequestionin
classregardingbingedrinking,usethefollowingdefinition: drinkingenoughalcoholtobring
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thebloodalcoholto>0.08gram%,whichusuallycorrespondsto>5drinks(formen)or>4
drinks(forwomen)in~2hours.
ALCOHOL
Use Abuse Dependence Binge drinking At risk
Moderatedrinking
Decreased
CHD,reduction in
all cause
mortality,MI
Maladaptivepattern of use
with on e or
more criteriaover a one-
year period
Leads tosignificant
impairment or
distress
Progressive chronicdisease
Genetic disease and
other factors
Consumingenough
alcohol to
get 0.08over 2h
5 for M 4 for W
W: no more
than 1 a day M: no more
than 2 a day 3-4 drinks
per week
1 +
OSLDRepeated
alcohol,inability to fill
obligations
Repeatedalcohol with
dangerous
activityDrinking
despite legal
problemsDrinking
despite social
or
interpersonalproblems
3/7 in last 12 months
TWIP CDo Toleranceo Withdrawal, dry
drunko Impaired control
over drinking,larger amounts
o Preoccupationo Continued use
despite adverse
consequences
o Can't cut downo Activities given up
o Distortion in
thinking, denial
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3.KnowtheFRAMESmodelforbriefintervention,includinghowtoapplytheconceptstoa
clinicalscenario.
Brief interventionrestricted to 4 or less sessions, each session lasting from a fewminutes1 hour, and is designed to be conducted by health professionals who do not
specialize in addictions treatment**brief intervention for alcohol problems is more effective than no intervention,and as often as effective as more extensive intervention**- brief intervention can help non-alcohol dependent patients reduced theirdrinkingFRAMES: Feedback, Responsibility, Advise, Many of Strategies, Empathy, and SelfEfficacyFeedback- tell patient the impact of drinking on their life i.e. hypertension, etc.- share medical consequences of their drink ingResponsibility of the Patient
- emphasize patient responsibility and choice for reducing drinking, no one can makeyou change or make you decide to change. What you do about your drinking it up toyou
Advice to Change- professionals could give patient explicit advice to reduce or stop drinkingMenu of Ways to Reduce Drinking- giving patients a variety of strategies to choose from: pacing, avoiding drinkingsituations, learning to cope with problems that may lead to excessive drinkingEmpathetic Counseling Style- using empathy instead of confrontational approach helped reduce patient drinkingmore
Self-Efficacy or Optimism the Patient- encourage patient to rely on their own resources to bring about change, motivationenhancing techniques
Establishing A Drinking Goal- patient more likely to change thinking behavior when they are involved in the goalsettingFollow-Up- follow-up on patient progress and can be in the form of telephone calls, repeated officevisits, or repeat
physical examinations, lab testsTiming- actual behavior changes based on studies of smoking cessation
**patients are more likely to make behavioral changes when they perceive thatthey have a problemand when they feel that they can change it**
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4.Befamiliarwiththevariousscreeningtoolsrelatedtoalcoholuse,includingtheappropriate
scoring,interpretation,andrecommendedpopulationforeachinstrument(CAGE,AUDIT,
MAST,TACE). Youshouldalsoknowthepurposeofascreeningtool,includingthedefinitions
ofsensitivityandspecificity. YouareNOTexpectedtomemorizethesensitivitiesand
specificitiesofeachscreeninginstrument,butyouSHOULDknowwhichpopulationsaremost
appropriatefor
their
use.
Screening- if LIKELY have a disorder
Screening tools Results
Primary care with limited time On any single occasion during the past 3 months,
have you had more than 5 drinks containingalcohol?
Identifies pt at risk
Annually
CAGE One yes- suggested alcohol problem
More than one yes- strong indicationthat problem exists
AUDIT- alcohol use disorders identification test Use when + CAGE or suspicion
10 questions
8+ harmful, hazardous drinking Useful
o NOT dependent ppl with
problemo Women,minorities,
adolescence,youngadultso NOTgoodforelderly
MAST- Michigan Alcoholism Screening Test
25 questions
6+ problem drinker
Usefulfor
alcohol
dependence
T-ACE 4 questions
Pregnant womenPre-pregnancy risk drinking- more
than 2 drinks per drinking day
5.Recognizethesigns/symptomsofanimpairedphysician,andidentifystepstotakeifyou
suspectaphysicianisimpaired. Youshouldalsoknowtheprevalenceof,therisksofsuicide
associatedwith,
and
the
prognosis
for
impaired
physicians.
CulturalIssuesinHealthcare
1.KnowhowtocommunicatewithindividualswhohavelimitedEnglishproficiency(e.g.,who
shouldserveasaninterpreter,howtocommunicatewithaninterpreter,etc.)
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2.Beabletoanswerquestionsaboutthemainteachingpointsofthefilm,HoldYourBreath.
Theseinclude: properuseofinterpreterservices,understandinghowanindividualsbelief
systemimpactshis/hermedicalcare,effectivelyintegratingmedicaltreatmentwithan
individualsspiritualpractices,managingfamilyrequeststohideinformationfromapatient,
etc.
Abuse,Neglect,andPartnerViolence
1.Forchildabuse/neglect,knowthefollowing:
a.Signs/symptoms
b.Riskfactors(forvictimsandperpetrators)
c.Epidemiology(e.g.,prevalence,mostcommontype,ageatgreatestriskforfatal
injuries,leadingcauseofchildabusefatalities,etc.)
d.Reportingrequirements
e.Assessment/interventionstrategies
Risk factors Epidemiology Signs Management Reporting
Maternal
smoking More than 2
sibling Low infant wt Low income
Unmarried
Unrelatedadults at home Child disability
Whenalso
spouseabuse
aswell
Maternal
depression
Child
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e.Assessment/interventionstrategies
Risk factors Epidemiology Signs Management Reporting
GENERAL
Increased by ptaggression
Low caregiver
self-esteem Living with
caregivers Caregiver older
Caregiver is a
spouse CAREGIVER
Abuse NOT
increased withstress and anger
Financial and
emotional
dependence ofthe caregiver on
the pt Family violence Abuser
characteristics
are better
predictors ofviolence than
victim attributes Most common:
person they live
with Physical abuse:
male caregiver
VICTIM Lack of person
they can confide
Financial- livingalone, no one to
turn to No sex-
differences Physical, mental
ans functional
ability (ADL)
Underreported
Pt refuse intervention
Prehospital care
personnel- unique to
identify abuse Barriers: fear of
offending pts, victimsblame themselves, fear
of losing caregivers Institutional- same
o Residents mustreceive a written
description oflegal rights andmust be able to
file complaints
with theirombudsmen
Falls
Dehydration
Common
sense...
Interview
together andseparately
Avoid
confrontation
Empathy,understandin
g
Physical
exam
Preservation
offamily
Assure
safetyofpts
Homevisits
Not
requiredStates
must have
a centralagency to
coordinate abuse
complaint
s
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Physical- olderwho cannot do
ADL Neglect- no one
to turn for help,
poor health,living alone
Verbal,physical- living
with someone
3.Forintimatepartnerviolence,knowthefollowing:
a.Signs/symptoms
b.Riskfactors(forvictimsandperpetrators)
c.Epidemiology(e.g.,prevalence,timeofgreatestrisktothevictim,etc.)
d.Screeningrecommendations
e.Assessment/interventionstrategies
Risk factors Epidemiology Sings Management Reporting
All races,SES, religion
Victim:
female,young,
unmarried,
low income,
uninsured,childhood
maltreatant,
pregnancy
1/4 Americanwomen will be
physically
assaulted/aped bypartner
Increased
gynecologic, GI,
CNS,musculoskeletal,
cardiac
complaints
Morelikelyto
accessoutpatient
primarycare,specialtycare,ED,
mentalhealth,
substanceabuse
services
$4bln/year
Headache,dizziness, chest
pain, palpitations,
back pain, nausea,indigestion,
stomach pain,
diarrhea,
constipation,pelvic pain,
dysreupenia,
insomnia,depression,
anxiety, PTSD,
suicidalidealization
Routinescreening
New pt
AnnuallyStart with
general
statement,
then directly
Validate her
experience
Assess safetyOffer
resources
Moststates do
not
requireunless
injury
with knife
or gun
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DifficultPatients,Transference,Countertransference,andProfessionalBoundaries
1. Knowthedefinitionsoftransferenceandcountertransference. Beabletorecognizeexamplesofeach.
Transference ptisremindedofsomeonefromthepastwhenadoctorwalksinthe
room
Countertransference doctorexperiencesit
2.Knowthedefinitionofempathy,andbeabletorecognizeappropriateexpressionsof
empathyinthedoctorpatientrelationship.
3.Know
the
common
manifestations
of
difficult
patients
and
describe
appropriate
interventionsandstrategiesforworkingwiththeseindividuals,includingpatientswhoare:
a.Angry
b.Seductive
c.Noncompliant
d.Complainingaboutotherphysicians
e.Inpain
f.Mentallyill
g.Hospitalized
See
the
attachment
4.Recognizeappropriateboundariesforthedoctorpatientrelationship,anddescribe
appropriateresponsestopotentialboundarycrossings/violations. Payspecialattentiontothe
following:
a.Sexualboundaries
b.Dualrelationships
c.Giftsandservices
d.Selfdisclosure(includingreligion/prayingwithpatients)
e.Physicalexamination
f.Physicalcontact
Maintaining Professional & Ethical Boundaries- It is important to define and maintain professional boundaries- Definit ion of if a violation of a boundary has occurred is if **harm to a patienthas occurred****Clear communication is the most important way to maintain boundaries**Sexual Relationships- Sexual relationships between physicians & patients is always a boundary violation
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- Usually preceded by nonsexual boundary violations, so it is important to be attentive tononsexual boundaryissues so that it doesn't develop into sexual ones- Do not engage in a sexual relationship with a patient- If a patient is a FORMER patient, it is more difficult to assess whether or not it is okay.
For example, ifthe one time patient was in the ER, and you saved his/her life, then it is unethical toengage in sexualrelations because the patient may idealize, and be dependent on the physicianDual Relationships- Avoid treating friends and family members because it can undermine the physiciansability to focusobjectively on t reating the patient-**Prior ity of doctors is to do what's best for the patient**Gifts & Services- In the past, it was normal to barter with physicians for services; it is not as common
now- Be careful if a patient offers to barter with services such as babysitting, doingpaperwork, etc for aphysician. Kindly decline the patients offer.- Gift giving may be an unconscious bribe by the patient, and often there is a secret orexplicit expectation ofsome reward or acknowledgement involved in performing services are bestowing aguest; the same can applyto doctorsSelf Disclosure- The physician should not talk about his or her personal life, as it may make thephysician seem needy to the patient or it can use the patient to satisfy the doctorsown needs for comfort or sympathyThe Physical Examination- Always have a chaperone in the room with the physician & patient, especially if thedoctor is conductinga pelvic exam, or if the patient has a history of sexual abuse, anxiety or psychiatricdisorder, litigious patient,or any new patientPhysical Contact- Shaking hands of patients is generally accepted as appropriate- Hugging and kissing is not as accepted, and should not be engaged in becausethe patient may have a prior sexual abuse history or may misconstrue the doctor'sintention- Physicians from other countries who may have different local customs about touchingpatients are notabsolved of the physician responsibility of not violating the patient (ie kissing on cheek,etc)