Qualitative methods are useful for assessing the transcultural experiences of IMG residents and for informing curricular changes in residency training. These methods may help other training programmes to identify the particular needs of their trainees in addressing emotionally laden experiences.
A model has been developed to help physicians negotiate with patients in more explicit and effective ways. This model provides physician teachers and learners with a framework and a common language to describe the dynamic nature of the doctor-patient negotiation. This framework consists of three dimensions: content, relationship levels, and the problem-solving phases. The constructs of disease, illness, sickness and the patient's context are used to describe the content of negotiation: this is what the doctor and patient are talking about. Autonomy, power, control and responsibility are the constructs that define the relationship levels: autonomism, egalitarianism, parentalism, and autocracy. These levels describe how the doctor and patient relate to one another during their negotiation. The problem-solving phases are relationship building, agenda setting, assessment, problem clarification, management and closure. Teachers and learners can use this model to describe how the doctor and the patient affect the negotiation process, and how the process in turn affects the doctor-patient relationship and medical care. With practice using this model, physicians can increase their repertoire of negotiating strategies that will efficiently enhance doctor-patient collaboration, the problem-solving process and the health of the patient and family.
Low social support and expressed emotion have been associated with depression, but no studies examined their relative contributions. A self-report questionnaire was developed to measure family emotional involvement and perceived criticism to assess the main components of family expressed emotion. Eighty-three family practice patients older than 40 years responded to a survey assessing depressive symptoms, social support, life events, and expressed emotion. Perceived criticism, intense emotional involvement, and negative life events were all independently associated with depressive symptoms. After controlling for expressed emotion, the association of low social support with depressive symptoms was no longer statistically significant. The results support the primacy of family interactions (with high perceived criticism and emotional involvement) over low social support in explaining the association between social relationships and depression.The social support literature has shown a Most findings come from large epidemiological strong and consistent relationship between the studies that rely on simple measures of social perception of social support and psychological support that focus solely on the positive aspects well-being (S. Cohen & Syme, 1985). Family of social support. Some studies examined cornmembers, particularly the spouse, appear to be ponents of the concept such as social network the most important source of social support and composition and size and emotional and instruaccount for most of the association between so-mental support (Orth-Gomer & Unden, 1987). cial support and adaptation (House, 1981). Socia i SU pp O rt is seen either as directly (Will-There is some evidence that support from i am s, Ware, & Donald, 1981) promoting health sources outside the family cannot compensate or as buffering the adverse effect of stressors for what is missing from within the family (House, 1981). There is controversy in the social (Brown & Harris, 1978; Coyne & DeLongis, support literature as to whether the direct effect '986).or the buffering effect is more important (S. Co-Despite the strength of the association of sohen & willS
Programme implementation is extremely unlikely given the current organization of health care settings. To maintain the use of such programmes, we need to change the "unit of leverage" in the system: from the clinical encounter--that is, practitioners working with individual patients in a case-finding manner--to an organizational level--that is, the appropriate use of managerial and information systems supporting health care settings to identify at-risk patients systematically as they enter primary care and hospital settings. With appropriate infrastructure support, practitioners will be able to fulfil the potential for as well as maintain the use of comprehensive, secondary prevention programmes to reduce alcohol risk and harm in the population.
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