Health policy Proposal
Current research reveals that the health of the American population continues to deteriorate greatly. This is fuelled by factors, such as obesity, sexually transmitted diseases and the use of alcohol. In a paper written for the 2002 Annual Report of the Chief Medical Officer (England), the causes and effects of obesity are directly tied to age, education level and the social class of an individual. The paper stated that two of the major causes of obesity are poor eating habits, such as overconsumption of junk food and the total lack of regular exercises (Laverty & Pugh, 79).
In another survey, it was found that there is rapid increase in the levels of new infections of sexually transmitted diseases due to limited sex education, especially among teenagers. This also led to increased teenage pregnancies among the teenage girls between 16 and 18 years of age; increased number of abortions as well as growing use of over-the-counter pregnancy prevention pills. Research has also shown how consumption of alcohol is rapidly increasing among the working class of the nation, which leads to serious ramifications for both the individual and the nation’s health. Some of the effects of alcohol were found to include reduced family support by the alcoholics, increased alcohol related road accidents and poor spending culture.
In order to handle the above mentioned health related problems, the following are some of the issues that must be put into effect with immediate action. First, in order to deal with obesity, the health care department in conjunction with the government must actively campaign for social awareness on the danger of junk food to an individual’s health. The individuals must be taught on dangers of obesity to a person’s health as well as how to cultivate good eating and exercise habits.
Secondly, in order to reduce the spread of STIs, the proposed policy must allocate drugs and trained medical personnel to all health facilities across the region. Laverty and Pugh (40) write that there has been a decrease in the use of protection among unmarried couples due to the fact that AIDS is no longer a death sentence, but rather a disease that can be sustained. In response to this, the sexually active population must be taught on the dangers of unprotected and premarital sex, as well as the need for regular medical checkups on one’s health status.
The problem of alcohol has been one of the hardest problems to handle, following the controversy that exists in increasing alcohol price as a possible solution. In order to help settle this menace, several actions can be used together, rather than isolating a particular possible solution. This can be achieved by controlling access to alcohol, reducing economic access as well as addressing social access of the same. For example, Institute of Alcohol Studies (IAS) proposed that there be a reduced travellers allowance together with an increase in alcohol cost and prevention of alcohol purchase during working hours.
Several challenges have arisen in regard to the above mentioned solutions including the rate at which an individual is expected to retain responsibility for their irresponsible behaviors. For example, Zimmern and Hope (51) argue that people legally deemed maybe irresponsible ought not to be made to pay for health care. Another problem is the question: what can be done to an individual who consciously refuses treatment that is known to be lifesaving? Moreover, there has been heated debate regarding the moral reasoning behind raising alcohol levy, with critics arguing that the majority of alcohol consumers are responsible drinkers with a few problem drinkers in between (Zimmerman, 46). In relation to the STI prevention and treatment, the health sector has limited resources including capital and human labor, which makes it a big challenge to send enough drugs and clinicians to all the health facilities around the country.
Academy of Medical Sciences.Calling Time: The Nation’s drinking as a major health issue, Academy of Medical Sciences. 2004. Web.
Institute of Alcohol Studies. Alcohol Harm Reduction Strategy for England, Institute of Alcohol Studies, London. Print. 2004
Laverty, S, Pugh, R.N. Sexually transmitted infections.In Key Topics in Public Health – Essential Briefings on Prevention and Health Promotion, ed. L Ewles, pp. 157-16. London: Elsevier.2005. Print.
Zimmerman C. The Health Risks and Consequences of Trafficking in Women and Adolescents, London School of Hygiene and Tropical Medicine, London.2003. Print.
Zimmern, R.L, Hope, T. Ethical Context. In Policy Futures for UK Health, ed. P Garside, pp. 51-60: Radcliffe Publishing Ltd.2005.
Online Legal Sources
The internet has several legal resources on the topic of medical malpractice. These sources include:
Lewinbuk, K (2013). First do no harm: The consequences of advising clients about litigation alternatives in medical malpractice cases. Journal on Legal Malpractice and Ethics. The article offers an analysis of the effects of various litigation alternatives in medical malpractice cases.
Xu, X. (2008). Malpractice liability burden in midwifery: A survey of Michigan certified nurse-midwives. Journal of Midwifery & Women’s Health. This article gives specific attention to the issue of medical malpractice in midwifery. It draws its conclusions from a survey conducted in the State of Michigan.
Kersh, S. (2008). Medical Malpractice and the U. S Health Care System. New York: Cambridge University Press. This eBook is a thorough analysis of the legal aspects of medical malpractices using various case studies.
Nell, M. (2014). Girl gets $32M settlement in medical case over quadruple limb amputations. ABA Journal. This website uses a real life case to communicate the legal consequences of medical malpractice.
Medical malpractice cases and hospital negligence. (2012). Clifford law Offices. This website by Clifford law offers an overview of what medical malpractice is. It then offers readers information regarding how to access help when in need of legal assistance.
In order to find these sources, I typed the key words legal issues concerning medical malpractice into the Google search engine in my browser. This led me to a pop up window with links to various websites with relevant information as per my key words. I chose a few of these links depending on the authority of the author. Thus, I avoided websites such as Wikipedia and other opinion papers and instead chose those from scholarly websites. I then chose the websites with the most relevant information after going through the information in the various websites.
The first pages of the legal sources submitted herein can be printed from these links:
Girl gets $32m settlement in medical case over quadruple amputations by Nell- http://www.abajournal.com/mobile/article/32m_settlement
Medical Malpractice liability burden by Xu- www.ncbi.nlm.nih.gov/m/pubmed/18164430/
ONLINE LEGAL SOURCES 2
Running Head: ONLINE LEGAL SOURCES 1
Brand Equity Strategic Vision: Case Study of Gatorade
Robert Cade, Harry James Free, Dana Shires, and Alejandro de Quesada formed a team of researchers at the University of Florida College of Medicine. Their motivation was from an increased need for a product that replaces the body fluid lost by athletes during physical exercise. The researchers founded the Gatorade brand in 1965 as a single product line consisting of Gatorade thirst quencher. The product was in powder and liquid form under orange and lemon lime flavor variants. Gatorade is available in nutritional foods and beverages in the form of protein drinks, nutrition bars, and sports drink (Xu 1).
The parent company of Gatorade is Quaker Oats Company in the United States. PepsiCo acquired the ownership of Gatorade in 2001 at a cost of $13 billion (Dreier 3). PepsiCo is a multinational company known for producing the strongest convenient food and beverage in the world after Coca Cola Company. The strong brand equity of Gatorade attracted the potential investor. The main target markets for Gatorade are the United States, United Kingdom, and Canada. The brand is available in approximately 80 countries (HighBeam Research 5).
Brand Equity Strategic Vision
Brand equity describes the value of a brand name in creating competence and profits for a product. Brand equity also known as brand value is essential for changing profit margins, market share, and consumer logo recognition and quality perception (Zmuda 8).
Origin of Brand Equity
Gatorade achieves brand equity through advertising, production, sales force, promotion, and distribution. The brand focuses on developing packaging data and markets to reflect its company’s culture and emotional benefits to consumers. Brand equity arises from the investment of Gatorade in research and development and creation of benefits to consumers. PepsiCo as the current owner of the brand has to focus on value generation. It is necessary to create management competences to build customer relationships. Brand equity is essential for promoting market share and sales of Gatorade. It influences personal choice because consumers have different personal desires. Gatorade developed the strategy of developing and rebuilding new communication to restore the value of the brand. The communication messages would reconnect the brand with customers to rebuild beneficial relationships, loyalty, and success of the brand in the target markets essential for future stability of the business (Zmuda 12).
Brand equity designs to reflect the real value of a product or service brand name. Brand equity is critical because brands create strong influence on critical business outcomes, especially market share and sales. Brand equity makes the price of Gatorade remain high and attractive. It has several benefits to PepsiCo that include providing support brand extensions and receive greater trade support and cooperation. Gatorade enjoys a competitive advantage and immense loyalty. Consumers perceive the brand differently and produce effective interpretations of product performance.
Brand equity increases the effectiveness of marketing communication and enables high yields in licensing opportunities. Measuring Gatorade brand equity requires an understanding from the view of financial assets. Aaker brand equity model associates with five issues that include brand loyalty, perceived quality, brand awareness, channel relationships, and brand associations (Aaker 9). Brand equity represents the financial value of brand assets. The brand targets team players at the age of 18 to 34. Gatorade targets this segment because it makes the larger market share in the market for sport drinks (Berendsen 6).
Gatorade is a brand of noncarbonated beverages in the United States and has continued to dominate the market despite the high competition in the market. Consumers have different tastes and preferences making it essential for Gatorade to have a variety of flavors. The founders introduced this brand in the market as a sporting beverage attracting the interest of the market in which there was high-demand for such a product. Customers switched from competitors increasing the financial performance and market share of the company. The success of the brand led to new entrances into the market with a similar product features. This created high competition in the market. PepsiCo has to apply unique strategies to attract customers during their decision-making processes (Business Wire 13).
Consumers tend to purchase products that have a superior value and reputation. Gatorade had to improve its value through vivid promotions and improvement in quality and variety of its products to survive and maximize profits. Moreover, Gatorade is a sporting product and changes in the economic conditions reduce the purchasing patterns of consumers leading to higher competition for market share in the market. PepsiCo has to regulate its prices to cater for changes in buying patterns of consumers (Zmuda 13).
Gatorade creates unforgettable experience for its customers to offer distinct privileges and services to retain them. The brand maintains competitive edge through implementing core competencies with distinctive capabilities. These capabilities include customers linking, market sensing, and channel bonding. Gatorade products combat heat-related performance within a period of 1 hour. They replenish carbohydrates and electrolytes while exercising and allow muscles recovery and rehydration after exercise. The marketers offer these products to accommodate customer needs in the sports sector. The products improve the performance of its customer in sports. The ability to form strong connection with customers is the strategy vision of Gatorade and the key success in the future (Zmuda 14).
Gatorade connects the high price of its products with quality and customer satisfaction to ensure company profitability. The employer engages employees in training and career development to deliver quality products and services to customers. Marketers fulfill the promises they make to shareholders and employees ensuring their support and commitment. Brand equity helps motivate employees to build clear direction and sense of purpose for the brand. Gatorade sets high prices for its product to reflect on their high quality and performance. Perceived quality relates with customer retention and loyalty to satisfy perceived value of customers in proving nutrients and energy during exercises. Quality is the key to success of Gatorade in the target markets across the world (Zmuda 1).
Gatorade targets sport players across the world. Gatorade is a widely known brand helping it conquer increased production costs and competition in the market. Marketers continuously evaluate the value network of the business to ensure high profits and sales. They ensure proper selection of segments, capture of potential markets, selection of appropriate promotional tools, and quality planning of marketing strategies to guarantee maximum returns in the long run. Gatorade is available in retail stores to ensure availability to customers. The sales force ensures effective distribution of the brand across stores in the target markets (Wilner 1).
The success of Gatorade brand is the most valuable resource of PepsiCo. The brand is an external indication to prestige, taste, value, and quality of the products. Consumers compare the perceived values of the brand with performance. Gatorade must be of high quality and social position to satisfy its target market. The brand has a variety of preferences and experience to satisfy customer needs. This involves different flavors that include orange, fruit punch, and lemon-lime. Gatorade captures the true essence of sporting food and beverages. This ensures a close association of the customer with the brand (Stanford 84).
The brand owner establishes new product lines and label designs. The ability to offer a line of quality and unique flavors improves the brand’s value and differentiates the brand from the competitors in the target markets. The brand owner concentrates on innovating new and developing the existing products toward a strong brand value. There is high-demand for healthy products in the market and the creation of healthy drinks interests and attracts the attention of the market to the product. This helps attract and maintain large market shares in the target markets. The brand owner uses the natural energy boosting ingredients to create products that compete efficiently in the target markets. The Gatorade product line should be able to compete with energy drinks in the market through providing healthier alternatives to fats paced lifestyle customers in the target markets (Berendsen 8).
According to Business Wire (2), Gatorade builds a powerful brand in the minds of its customers by defining the compelling purpose of the product line. It creates enormous ideas that stand out among competitors and reflect in the needs and satisfaction of customers. This helps the brand build a strong reputation and prestige of customers at a personal level. Gatorade builds customer loyalty to retain and attract potential customers through encouraging advocacy and new products and services. Engaging in consistent advertising and other promotional activities helps build preference, attract target customers, sustain price premium, and drive buying behavior (Zmuda 14).
Gatorade uses a logo “G” that is a well known trademark creating identity of its products. Its strong brand ensures effective marketing programs and quality experience of customers with the products. Consumers want to identify with the Gatorade because of the desire of knowledge of brand structure and create exposure to new and existing products for Gatorade. The brand communication messages stimulate value creation in the products to influence customers to purchase them. The promotional activities achieve a strong brand value in the target markets. This will make it easy for the business to create high recognition and perception of quality and satisfaction to customers (Zmuda 18).
The research process will cover the procedures of data collection, analysis, and presentation to create value to the user. The methodology elaborates the sampling techniques to ensure the collected data is free from bias, and the user can depend on it. Questionnaires will be the best method of data collection. This is in (Appendix 1). The questionnaire methodology will contain the pertinent issues on Gatorade products and how they satisfy customers in the target markets (Zmuda 17).
Brand equity creates opportunities to help achieve organizational objectives. Gatorade entry in the market was successful because there was low competition on sport drinks in the market. The success of the brand attracted the interests of new entrances and development of existing ones in the industry leading to high competition for market share. Consumers have a buying behavior that involves recognition of the need, search for the product that satisfies the need and available alternatives to the product, make the purchase, and evaluate the post purchase (Zmuda 20). The decision-making process of the consumer can involve influence from family, friends, and outside resources, such as media. Gatorade focuses on the teenagers or young adults engaging in sports. Therefore, Gatorade has to acquire high acceptance in the target market, and this means high investment in media and team players because they are the main influencers on this target segment (Xu 3).
Stanford (86) identified that PepsiCo has to ensure high quality products, product features, designs, prices, and costs of production to improve brand equity for Gatorade to be in the consumer purchasing decisions. The increase in competitor products and demand for health conscious beverages in the market has led to price sensitivity because consumers can easily switch from one brand to another with less differentiation on the products (Berendsen 9). Team players have high levels of income increasing the market potential of the target market. PepsiCo has to enlarge its target market segment to the professionals to increase return on investment. The company also invests in meeting the market demands by developing customer focus on experience and satisfaction to improve profits, sales, and market share (Leisure Management Magazine 28).
Verification of Collected Data
Gatorade achieves success because of brand equity. The activities of business support promotion activities and product development to make high profits and attract a large market share. Gatorade has elements that make the brand unique and different from those of competitors. This creates a positive association of the brand in the minds of customers. The elements arise from the financial performance of the brand. PepsiCo is second after Coca Cola in producing strongest beverages in the world. PepsiCo purchased Gatorade because the brand performed well in the market. Gatorade dominates 75% of the market share of United States in the sport drinks. The main competitors of this brand are Vitaminwater, Lucozade Sport, and Powerade.
Brand equity creates competitive advantage and helps Gatorade differ from the competitors in meeting the demands of the target market. Success of the brand in creating competitive advantage arises from its ability to offer a variety of flavors. The brand can also build a strong heritage of natural healthy ingredients, and to create a well-established brand. These factors guarantee success and sustainability of the brand name in the future. PepsiCo manages the brand portfolio to ensure that the communication messages differentiate the products from those of competitors and that the messages create influence on potential consumers. PepsiCo had to overcome the gap created after the discontinuation of the Gatorade brand name leading to more losses on brand loyalty and decline in the financial performance of the brand. PepsiCo improves communication to distributors and consumers to influence them improve their purchasing power. The company ensures a consistent brand transformation in image, reputation, and perception to survive in the competitive market of beverages. PepsiCo also strives to understand the nature of the market and implement marketing tactics, such as brand equity creating competitive pricing for the success of the business.
PepsiCo takes time to understand the target market, its market segments, and customer demands to make effective strategies. The company ensures brand equity to acquire the understanding and knowledge of essential elements of improving the brand equity. It ensures effective communication and building of strong customer and supplier relationships for sustainability of the business. PepsiCo relies on a wide range of flavors, health promotion beverages, and quality customer services to succeed in creating competitive advantage. Gatorade has an excellent chance of influencing consumer buying behavior to sell its products. It targets the teenagers and professionals in the sports sector. Gatorade has to take advantage of this market segments to maximize profits.
Aaker, David. Managing brand equity. Simon and Schuster, New York. 1991.
Berendsen, Patricia. “Gatorade for the soul.” Child & Family 14.1 (2011): 6-10.
Business Wire. “Gatorade Case Study: using consumer segmentation and social media to drive market growth.” Gatorade case study: using consumer segmentation & social media to drive market growth (2011): 1-18.
Dreier, Fred. “Gatorade gets a dose of hope in new deal.” Street & Smith’s Sportsbusiness Journal 14.15 (2011): 3.
HighBeam Research. “Pepsi campaign to mark the start of global business strategy.” Marketing Week (01419285) 35.7 (2012): 5.
Leisure Management Magazine. “Gatorade gives back.” Leisure Management 30.3 (2010): 28.
Stanford, Duane. “Gatorade goes back to the lab.” Bloomberg Businessweek 4256 (2011): 84-88.
Wilner, Barry. “Who needs Gatorade?.” Sportbusiness International 167 (2011): 1.
Xu, Xinwen. Brand audit: Gatorade. GRIN Verlag, New York. 2012.
Zmuda, Natalie. “Gatorade grapples with getting its complete lineup on grocery shelves.” Advertising Age 82.30 (2011): 2-25.
Zmuda, Natalie. “Gatorade loses its competitive edge.” Crain’s Chicago Business 31.17 (2008): 14-15.
Zmuda, Natalie. “Gatorade: we’re necessary performance gear.” Advertising Age 83.1 (2012): 2-21.
Appendix 1: Questionnaires
Which is the sports drink of your choice and why?
Physician assistants are medical practitioners who interact directly with patients under a surgeon’s supervision. The physician assistants are charged with the responsibility of providing diagnoses to patients. They also provide prescriptions to patients and assessing the medical history of a patient. The services provided by the specialists extend to care giving in nursing homes. Healthcare systems for rural areas have physician assistants who offer medical services.
Physician assistants’ work schedules are extremely strained requiring them to work full time and sometimes even during weekends and holidays. Most physician assistants work in health practitioners’ offices as well as hospitals, both state and privately owned. A smaller percentage of them work in outpatient health centers and government educational services especially when conducting outreach programs.
There are distinct educational requirements for interested applicants. Physician assistants hold master’s degrees with a background in health related disciplines in their undergraduate studies. Nursing is an example of a relevant discipline. Government policies require standards such as the Physician Assistant National Certifying Examination (PANCE) for licenses to be provided).
The role of physician assistant involves direct interaction with patients therefore the practitioners have to posses various skills associated with their line of work such as excellent communication skills. Effective decision making capabilities are required in an effort to ensure the medical practitioners provide the necessary care in spite of demanding environments. The medium wage indicator for a physician assistant is $90,930. The figure is calculated according to the logistics provided by the U.S. Bureau of Labor Statistics (Bureau of Labor Statistics, Occupational Outlook Handbook, 2014).
Factors such as an aging population and emergence of chronic diseases have created demand for employment of more physician assistants (Bureau of Labor Statistics, Occupational Outlook Handbook, 2014). Their roles are expected to grow in the future as more states allow their involvement in primary health care. Government agencies should therefore continue to support and acknowledge the role played by these important health practitioners.
Bureau of Labor Statistics, U.S. Department of Labor. (n.d). Occupational Outlook Handbook, Physician Assistants, Retrieved January 16, 2014, from http://www.bls.gov/ooh/healthcare/physician-assistants.htm
Medical science has been practiced for decades, with advances being made to try diagnose, treat and prevent different illnesses and diseases in humans. This field aims at establishing the cause on unknown ailments that affect different organs in human. One such disease is multiple sclerosis, which is caused when myelin sheath, the cover that protects the surrounding nerve cells is damaged.
Multiple sclerosis is a disease characterized by symptoms of neurologic dysfunction which results to different separate scars called lesions within the central nervous system, due to exposure to unknown environmental factors (Zivadinov & Bakshi, 2003).
These lesions affect the entire tract. One such important organ affected by multiple sclerosis is the brain (Lezzoni, 2010). Which is diagnosed through clinical procedures that show the presence of white lesions within the brain. The disease is also known to be of autoimmune origin (Burks & Johnson, 2000), in which the immune system cause inflammations in the brain and may result to permanent disability due to axonal destruction within the brain.
Different parts may be affected, examples of such being the hypothalamus, brain stem, cerebellum and the thalamus. The hypothalamus, the main gland of the brain (Chambers, 2011) is normally affected with lesions attacking this region, and in other cases spreading to the floor of the anterior hypothalamus (Melmed, 2011), to form ependymal cysts on the third ventricle. In the brain stem, lesions attack this region with small patches that range between few millimeters that may grow to larger lesions (Miller et al. 1997). The brain stem may cause the brain stem syndrome in other instances. In the cerebellum region of the brain, small irregular or rounded lesions occur while in thalamus region, excessive deposits of iron in this area is known to be as a result of multiple sclerosis.
The disease also affects other regions within the brain, these include cerebral and the cortex brain nuclei which are severely affected at the onset of multiple sclerosis.
The pathological process of multiple sclerosis is much vivid. This disease occurs when there is demyelination of nerve fibers found within the system. Certain nerves and veins such as the cerebrospinal veins become abnormal, and results to endothelial junctions that are broad which allow immune cells to come into the brain from the circulatory system. Multiple sclerosis is much characterized by plaques that form when white blood cells behave in an abnormal way, resulting to changes in the blood composition. Due to this, the white blood cells penetrate the tissues and secret lymphokines which results to inflammation and production of myelin, which produce astrocytes which in turn produce sclerosis (Matthews & Oakley, 2001). On the other hand, inflammation in the brain stem is brought about by changes of hypothalamic activities (Birnbaum, 2009), and in other cases altering the physiologic processes in the auditory and sensory regions. In the cerebral regions, multiple sclerosis results to an increase in cerebral lactate levels (Waxman, 2007) from the changes of mitochondrion activities.
Multiple sclerosis affects human beings of all ages, with the main cause still unknown. However, there are modification agents (Kauffman, Jackson et al. 1999) and other certain heredity factors resulting to the disease. People with multiple sclerosis are always rehabilitated due to lack of known cure of the disease, though different stages are controllable, it has a long term effect that leads to permanent disability.
Burks, J. S., & Johnson, K. P. (2000). Multiple sclerosis: Diagnosis, medical management, and rehabilitation. New York: Demos.
Birnbaum, G. (2009). Multiple sclerosis: Clinician’s guide to diagnosis and treatment. Oxford: Oxford University Press.
Chambers, C. (2011). Destined for disease. S.l.: Balboa Pr.
Kauffman, T. L., & Jackson, O. (1999). Geriatric rehabilitation manual. New York: Churchill Livingstone.
Iezzoni, L. I. (2010). Multiple sclerosis. Santa Barbara, Calif: Greenwood.
Melmed, S. (2011). The pituitary. Amsterdam: Elsevier/Academic Press.
Miller, D. H. (1997). Magnetic resonance in multiple sclerosis. Cambridge: Cambridge University Press.
Matthews, W. B., & Rice-Oxley, M. (2001). Multiple sclerosis: The facts. Oxford: Oxford University
Waxman, S. G. (2007). Molecular neurology. Burlington, MA: Elsevier Academic Press.
Zivadinov, R., & Bakshi, R. (2004). Brain and spinal cord atrophy in multiple sclerosis. Hauppauge, N.Y: Nova Biomedical Books.
Applicability of Principlism
With the expansion of the field of medical science, coupled with increasing research activities, there is a need to take a critical is an evaluation of to evaluate whether ethical considerations go along with these changes. Beauchamp and Childress (2009) define the term ethics as the generic considerations applied to a variety of ways in evaluating and understanding the moral basis of life. Bioethics in turn means the application of ethical practice to the field of medical research and science.
Principlism is an approach to bioethics that evaluate the role of principles in determining moral codes on one hand, and the uniqueness of each individual moral condition on the other hand. It is an evaluation of the standards versus the situation. In essence, this theory contradicts that postulated by the narrativists, who believe that communication is at the core of ethical considerations.
Principlism and narrativism both share the same objective; an explanation of the nature of bioethics. The focus of this article is not to delve in to the differences in strengths of these two theories. Nevertheless, this research evaluates the application of the principle of principlism in medical ethical case considerations, its relative ease of approach and its weaknesses. This paper postulates that the application of principlism is an effective way to handle and tackle the issues of bioethics. It evaluates the principles postulated by this approach, considering cases of its application and presenting conflicts emanating from the application. Finally, the paper presents an opinion piece on the effectiveness of using this approach to deal with bioethics
To begin with, we are going to evaluate each of the generalization of the application of principlism aspects separately. The first postulation by Beauchamp and Childress is that basic principles coupled with specific actions are the guiding rules of ethical decisions. That presented with an ethical case, the medical practitioner need to evaluate the set of rules and regulations presented by the demands of the profession. At the same time, it is required that situational contexts, in terms of the uniqueness of the case be considered. In addition, possible dilemmas and the possibility of violating the principles as an aspect of promoting the general good of the patient need to be observed.
The second guiding principle involves taking actions that are morally justifiable while at the same time being hinged upon the tenets of the relevant principles. This principle provides room for personal judgment, background study, and patient special condition. The judgment has to be consistent with the requirements of the profession under such a situation, like to save a life. The success of taking such a personal judgment should be measured by evaluating the degree of cohesion in the constructs of the decision making process. These principles are considered basing on the values of fairness, human rights, equity, and social determinants influencing health
Because of evaluating the considerations in the medical field, the authors arrived at a set of ethical principles that need to be observed. According to the principlism approach, there are four tenets to build a bioethical code from. These five aspects are Beneficence, Justice, Non-maleficence, and Respect for the patient’s autonomy. In order to gain clear insight, the researcher evaluated each of them separately and how they are applicable.
Respect for the Patient’s Autonomy
The patient is a human being that deserves a level of respect. Any consideration of moral decision-making should be based on the assumption that the patient is a rational agent and is therefore capable of making voluntary and informed decisions. In bioethics, the respect the patient’s autonomy implies that the patient is capable of acting intentionally and is capable of making decisions that are for their own good. This principle is what defines the patient-physician relationship in the form of informed consent. Autonomy calls for the respect of the right of the patient to privacy, humane treatment, and choice. The medical provider is required to share any information with the patient, list the benefits, and give the patient the right to choice, after considering the alternatives.
This principle requires medical practitioners to act in a manner that does not intentionally create harm or injure the patient, whether through acts of commission or omission. It is considered as a negligent act that can result in prosecution if the care provider intentionally or carelessly exposes the patient to harm or injury. This can be through leaving the patient unattended to, failure to provide the right care in time or creating a situation that exposes the patient to a risk. This principle requires that the medical provider to be competent. As a result, it assures that the patient will be provided with the best care away for harm.
This principle ensures that the provider has a duty to protect the benefit of the patient. The ordinary meaning of this principle is that health care providers have a duty to be of a benefit to the patient, as well as to take positive steps to prevent and to remove harm from the patient. These duties are based on the belief that the provider has to act with rational and self-evident approach in implementing the goals of medicine. Apart from guiding healthcare provision, they also form the basis of medical research to further the benefits of the patients. The principle can be applied to both the patient and society as a whole. The society stands to benefit from beneficence through actions meant to prevent disease through research and the use of vaccines
Beneficence is believed to outweigh autonomy when dealing with emergencies (Jonsen 2005, 245). When a person is in a situation where he or she requires emergency treatment, then the doctor acts in his or her best interests by providing healthcare. This can happen in total disregard of the opinion of the patient. Under these circumstances, it is believed that the doctor knows what is to the patient under those circumstances.
Justice is the approach based on fairness. The patient has a right to fair treatment, getting what is rightfully entitled to them as a patient. Therefore, the healthcare provider strives to ensure that the individual and society gets what they are entitled to (Beauchamp & Childress 2009, 226). The principle of fairness requires that each person be accorded an equal share, according to the needs that they have. In addition, the patient deserves to be accorded merit to their contribution. Finally, the patient has a right to be charged according to the prevailing market rates for the service.
The principle of justice implies that there exists some level of entitlement. Since some resources are not enough, that is, they are in short supply. There is the need to create a method of fair distribution to ensure every person has a piece of it. As a matter of ethical evaluation, the situation has to be considered to evaluate whether the option of the patient making a choice can be waived at the expense of beneficence.
This evaluation of the four principles of bioethics presents a question of cultural applications. When Beauchamp and Childress formulated these principles, they argued that these principles have formed the normative culture of the medical field from time immemorial (Beauchamp & Childress 2009, 3). They stated that none of these principles is bigger than the other. This equal weight has resulted in confusion when two or more principles are in conflict with each other. As a result, these approaches have been challenged to be confusing, resulting in more conflict than solution (Bruera 2009, 86). As such, medical practitioners have considered other approaches to evaluate bioethics.
The immediate way to evaluate the application of ethics is by considering all the principles simultaneously. Take an example of a physician who meet a patient who is in dire need of health and does not want to be treated, as she or he cannot pay for the treatment. Under such circumstances, the provider considers the four principles simultaneously to come up with a decision. However, each of these decisions should always be based upon the common good of the patient.
The other part of the theory is the fact that it admits the uniqueness of situations. That under normal life circumstance, there will arise situations that do not conform exactly to the descriptions of the principles. In some circumstance, there healthcare provider may be required to ignore the requirements of the principles. In such circumstances, the healthcare provider can cite the actions that were done to promote a general good.
In my opinion, this dynamic nature application of the principlist approach to bioethics covers effectively the variety of ethical dilemmas that the practitioners in this field encounter. However, it complicates the application of ethics in the manner it provides contrasting approaches to the application of ethics, such as the case if autonomy and beneficence. The leaves too much room to the application of judgment while we know that this judgment can vary from individual to individual. By failing to set clear guidelines to approach conflicts of principles, it leaves too much room for debate.
The basis of this approach is the fact that it is based upon the cultural expectations of the medical practitioners. In short, moral justification plays a critical role in determining the choice of the ethical choice. It is within the terms of the principlism approach that doctors justify decisions made outside the client’s consent. Under such circumstances, the belief is that the patient is not capable of determining the required action. On the other hand, there exist situations when the doctor is obliged to obtain the client’s permission before undertaking the treatment plan suitable to the situation. This is the principle of truth telling, when the patient is entitled to the right to information. The justification for research is also provided within this approach. Finally, this author noted that there exists shortcomings with this approach, especially when there are conflicts between two or more principles.
Azatsop, J. 2013. Access to nutritious food, socioeconomic individualism, and public health ethics in the USA: a common good approach. Philosophy, Ethics, and Humanities in Medicine, 8(6), 234-256.
Beauchamp, T. and Childress, J. 2009 Principles of Biomedical Ethics 6th Edition New York: Oxford University Press.
Bruera, E. 2009. Textbook of palliative medicine (Pbk. ed.). London: Hodder Arnold.
Jonsen, A. R. 2005. Bioethics beyond the headlines: who lives? who dies? who decides? . Lanham, Md.: Rowman & Littlefield.
International Medical School
Becoming a doctor is a long and demanding process that may prove to be particularly challenging for international students wishing to practice at their home country. Thousands of American and Canadian students leave their country each year to study medicine abroad, but not as many manage to return to work at home after completing their studies. There is an increasing concern that many Canadians and Americans studying medicine abroad might never be successful at their attempts to pursue postgraduate medical training and residency in their home countries.1 In order to understand the challenges international medical students face in their attempt to find work at their home country after completing their studies, it is necessary to first look at what it takes to become a doctor in both the United States and Canada.
Medical School Process in Canada and the United States
The road to becoming a physician in Canada consists of three major steps: acquisition of a university degree, attending medical school, and finishing residency. To start with, the individual must obtain a university degree from a recognized institution.2 Most medical schools require students to have undertaken a science major in college though this is not the rule of the thumb for all medical schools. However, medical schools require students to have taken science courses as part of undergraduate studies since it is a prerequisite for understanding and applying medical theory. Once the individual has earned a university degree, the next step would be to pursue medical education, which of course begins with being accepted in a medical school. Medical education in Canada takes four years. The first two years are spent studying medical theory including human anatomy, medical terminology, and pharmacology. The final two years are devoted to on-the-job training to gain practical knowledge. Students are given the opportunity to attend to real patients under different circumstances. After completing medical training, the student is required to pass medical licensing exams. The Medical Council of Canada is in charge of medical licensing. Once the doctor obtains a license, he or she can begin practicing anywhere in the country. Before a doctor can commence independent practice, he or she must complete residency training. This involves learning from mentors, adapting to working schedules of a real hospital, and training senior medical students. The length of residency varies from two years to as many as six years depending on the area of specialization.
The medical process in the United States is almost similar to the process in Canada with common steps such as earning a bachelor’s degree in natural sciences, attending medical school, obtaining licensure, and completing a residency program. Students in the United States are required to pass the Medical college admissions test (MCAT) before gaining admission to most medical schools. Medical doctors are required to pass the U.S. Medical Examination (USMLE) in order to obtain a medical practitioner’s license. In addition to residency training, doctors in the United States who wish to specialize in endocrinology, cardiology, pediatric surgery, and other highly specialized fields require highly specialized training called fellowship. On average fellowships take between one and three years depending on the area of study. Although certification is not mandatory, the American Board of Medical Specialties (ABMS) is charged with the responsibility of certifying medical specialists.
Going to School Abroad
The number of Canadian medical students studying abroad has been growing rapidly in the past five years. The Canadian Resident Matching Service (CaRMS) estimated the number of Canadian students attending medical school abroad at 3500.3 CaRMS is the only organization in Canada that assists medical graduates to obtain residency positions in the country. According to a CaRMS survey conducted in 2010, there are nearly 80 medical schools in about 30 countries offering Canadian students medical training. Most Canadian students prefer to study in the Caribbean and Ireland. However, the number of Canadian students studying medicine in Australia, Poland, and the Middle East is growing steadily.4 Each year, these schools produce nearly 700 doctors, about a third of the number of Canadian students graduating from medical schools at home each year.
The number of Americans medical students studying overseas has also been growing significantly since the 1980s. In the early 1980s, only 6 percent of United States medical students went to medical schools abroad. By 2000, the number had risen to 20 percent and reached approximately 39 percent in 2003.5 However, Americans wishing to study medicine abroad end up in many of the over 90 countries offering medical studies in English.6 The exact number of American medical students studying in foreign countries is not clear. However, it is estimated that about 1000 students leave the States to pursue a medical degree oversees.7 The main reason why Canadian and United States students choose to study medicine abroad is lack of sufficient opportunities for placemen in Canadian and United States medical schools respectively. In Canada, only 25 percents of applicants seeking a position in Canadian medical schools are accepted.8 In the United States, the percentage is higher with 43 percent getting into medical school.
Coming Back To Canada
Process of coming back to Canada
After graduating from medical schools abroad, Canadians intending to return to Canada for postgraduate training must follow several steps. First, the returnee should submit an application to the physician Credentials Registry of Canada (PCRC).9 The PCRC examines the individual’s credentials for validity by performing a source verification request. This service is offered at a fee. The next step is to sit the Medical Council of Canada Evaluation Examination (MCCEE). Students required to undertake MCCEE are those from medical schools in the International Medical Education Directory list but not Canadian or US-accredited. Students write the MCCEE during their final year of medical school. The final step involves applying to the Canadian Residency Match Service (CaRMS). CaRMS assists Canadian international students to obtain residency positions in Canada. Matching is a competitive process that also involves immigrant medical graduates. In order to qualify for CaRMS, individuals must be graduates of a medical school recognized by the Foundation of the Advancement of International Medical Education and Research (FAIMER), obtain Canadian citizenship, and pass the MCCEE exam.
How many come back, how many stay
According to CaRMS survey, slightly over 90 percent of Canadian medical student’s studying abroad were interested in returning to their home country for their postgraduate medical study. Those who wished to stay abroad were less than 10 percent. Out of the 90 percent who wish to return to Canada to pursue further medical training, 87 percent would like to practice medicine in Canada. The rest cited several reasons for not staying in Canada after postgraduate studies: insufficient positions that meet their preferences, better pay and economic conditions abroad, and family issues. CaRMS noted that Canadian students in medical schools abroad who are nearing graduation are less likely to express intentions of returning to Canada for postgraduate study compared with students who are still in their initial stages of study. The main reason for this observation is that as Canadian students studying abroad near graduation, they become more aware of the limitations surrounding their return to Canada for further training and thus become more open to alternatives.
A significant change in the number of Canadian international medical students wishing to return home for postgraduate training has been observed over the years. In 2006 for example, only 67 percent of Canadian students studying medicine abroad intended to go back home for further training. This percentage increased by more than 20 percent in the following five years to stand at 90 percent in 2010. Another observation in 2006 was that Canadian students studying in European schools were more interested to go back home for further training compared to those attending medical schools in the Caribbean. However, no significant regional difference was observed in the 2010 study.
Canadians who do not wish to return to Canada to pursue their postgraduate medical training cite several reasons for their decision. The main barrier is the requirement to do return of service work, in which more than 60 percent of Canadian international medical students are not interested.10 The second major barrier is the lack of opportunities to do the preferred residency in a preferred location in Canada. This mostly affects Canadians studying medicine in Ireland. The other major barrier affecting Canadian medical students in the Caribbean is that a significant number of students feel they cannot match successfully. The other minor barriers include personal attachment to the foreign country, high cost of examinations at the home country, absence of preferred residency in Canada and fear of failure to pass licensure examination. In addition to these barriers, a significant number of students do not wish to return to train and work in Canada for other reasons including availability of better opportunities in the United States, complexity of the process of returning home, better pay and working conditions elsewhere.
Although Canadians continue to face barriers in their attempt to return home to pursue their postgraduate medical education, there have been improvements over time, though not significant. For example, in 2006, medical degrees obtained outside Canada were perceived as inferior to those obtained in Canadian medical schools.11 As a result, graduates from medical schools abroad were poorly treated in Canada. However, CaRMS changed this perception by allowing international medical graduates to participate in matching.12
Process of coming back to the United States
United States foreign medical graduates have five main ways in which they can return to the United States to study or practice medicine. First, the student many transfer to a medical school in the United States and repeat one or more years depending on the school’s transfer policy.13 Second, the student can return by achieving certification from the Educational Commission for Foreign Medical Graduates (ECFMG), which ascertains that the student has met all the educational requirements. Third, the graduate can obtain a full medical license from a recognized state body. Fourth, the graduate may receive residency by completing and passing a licensure examination offered by a licensing body or state. Finally, some foreign medical students have the option of Fifth Pathway. This is available to students who have completed their training in a foreign school but have not done internship. These students can undertake one year of clinical training in place of foreign internship after which they can proceed with residency training without carrying out return of service work in the foreign country. These students are required to pass the ECFMG and USMLE examinations.
The main challenge American international medical graduates face in their attempt to return to the United States to practice medicine is acquisition of a medical license. Physicians trained abroad are required to pass the U.S. Medical Licensing Exam (USMLE) as well as undertake their residency training in the United States.14 The Educational Commission for Foreign Medical Graduates certifies foreign-trained physicians. The certification process involves passing the USMLE offered in two phases. After certification, the aspirant must join a United States medical institution to do residency training. Physicians intending to specialize are required to undertake specialty training called fellowship, which is quite tough for new graduates.
Chances are limited for United States citizens who graduate with medical degrees from foreign countries in their attempt to obtain residency positions. In 2011, only slightly above 50 percent of United States foreign medical graduates participated in the National Resident Matching Program (NRMP) compared with 94 percent of medical graduates in the United States.15 In the same year, only about 40 percent of foreign medical students of non-United states origin had a chance to Match. An additional limitation is that foreign graduates are rarely considered for highly rewarding specialties such as orthopedic surgery. Other challenges facing United States foreign medical graduates in their attempt to return to practice in the United States is the additional conditions for obtaining licensure including the longer time of application process, requirement to undertake additional training, and higher pass mark in USMLE examinations.
The rigorous process of coming back has limited the number of medical graduates intending to practice medicine in the United States. About 4000 physicians attempt to return to the United States to pursue postgraduate medical training and residency. However, only less than 1 percent manages to enter residency. The rest pursue other alternatives such as physician assistants, registered nurses, and respiratory therapists. Generally, students wishing to leave the United States to study medicine abroad must consider their chances of being accepted if they wish to seek postgraduate training and residency in the United States. They should bear in mind that less than half of United States foreign medical graduates become practitioners in the United States each year and this number is only a few hundreds.
International students in Canada
Many Canadian medical schools do not admit foreign medical students. Those that do so provide very limited opportunities. International medical students in Canada cannot apply for residency training in Canada.16 Instead, they are required to go back to their home countries to work as doctors. In other words, all international medical students pursuing medicine in Canada go back to their home countries after leaving medical school.
International students in the United States
Although the United States admits international students intending to study medicine in the country, only a limited number of students succeed. This because medical schools in the United States are not even enough to accommodate more than half of the qualified resident citizens who apply for medical training.17 The law requires United States public medical schools to admit state residents only. In addition, foreign students can only be admitted id they have a bachelor’s degree from a college in the United States or have spent at least two years of their undergraduate training in the United States. Even so, foreign medical students wishing to study in the United States make up less than 0.1 percent of successful applicants.
Sources of Funding
The main types of funding available for medical students in the United States include family saving and government loans.18 In addition, students may receive funding from individual campuses to finance their study abroad program. Academic awards in form of scholarships may be available for some students as well as grants and fellowships.19 Other possible sources of funding include scholarships offered by the preferred foreign country where the student prefers to study medicine and loans from non-united states governments.
Canadians studying medicine abroad fund their education through several sources. Family savings and bank loans are the main sources funds for most Canadians. About 70 percent of Canadians studying medicine abroad utilize a combination of these two funding types.20 Personal savings and Canadian government grants account for about a third of Canadian students medical education bills. Other minor types of funding include bank loan in a foreign country and study abroad grants. Canadian students in the Middle East and Europe rely mostly on family savings to finance their education while most Canadians in the Caribbean and Australia use bank loans in Canada to pay for their education. Other funding options include Ontario Student Assistance Program (OSAP). OSAP provides financial aid to Canadian citizens, permanent residents, and protected persons.21 Canadian medical students can use OSAP money to finance their education abroad. However, they are required to be non-beneficiaries of Canadian government loans.
Both the United States and Canadian education systems present tough challenges to citizens of the two countries who have studied medicine abroad when attempting to return home for further training or practice. In Canada, the main barrier for Canadian foreign medical students intending to pursue postgraduate studies in Canada is the difficulty in obtaining preferred residency positions in preferred locations. The requirement to do return work is also a major hindrance affecting mainly students graduating from the Caribbean medical schools. Residency positions are limited in Canada, numbering about 400. Over 700 Canadian foreign graduates and more than twice as many non-Canadian foreign medical graduates compete for these positions. The main difficulty the United States foreign medical graduates face when returning for postgraduate medical study in the United States is the long process of licensure and acceptance. This process involves sitting for USMLE exams several times and extended periods of additional training. Although thousands of American foreign medical students seek residency in America each year, less than 1 percent succeed. The rest either stay in foreign countries or take up positions inferior to their intended residency positions.
“Steps involved in returning to Canada for postgraduate training.” Health employment Manitoba, http://www.healthemployment.ca/pra_step.html (accessed January 9, 2013).
CanadaFAQ. How to become a doctor in Canada. CanadaFAQ, http://www.canadafaq.ca/how+to+become+a+doctor+in+canada/ (accessed January 8, 2013).
CaRMS. Canadian students studying medicine abroad. CaRMS Report, 2010. http://www.carms.ca/pdfs/2010_CSA_Report/CaRMS_2010_CSA_Report.pdf (accessed January 8, 2013)
Croasdale Myrle, “More U.S. medical students are studying abroad,” Amednews. http://www.ama-assn.org/amednews/2003/10/06/prsf1006.htm (accessed January 9, 2013).
Dehaas,Josh, “Slim Chance of Residency upon return.” MACLEAN.CA On Campus, http://oncampus.macleans.ca/education/2012/06/19/medical-school-dean-warns-against-overseas-schools/ (accessed January 9, 2013).
Irfan Dhalla & Karen Born, “Why are so many Canadians going abroad to study medicine?” Healthy Debate, http://healthydebate.ca/2011/03/topic/politics-of-health-care/why-are-so-many-canadians-going-abroad-to-study-medicine (accessed January 9, 2013).
Krupa Carolyne, “Foreign-trained health professionals put on path to practice in U.S.” Amednews, July 25, 2011, http://www.ama-assn.org/amednews/2011/07/25/prl20725.htm (accessed January 9, 2013).
Lev G. Fedyniak, Medical study Abroad, Transitionsabroad.com, http://www.transitionsabroad.com/publications/magazine/0305/medicalstudyabroad.shtml (accessed January 8, 2013)
MacLeod, Andrew. “What’s a fair deal for Canadians Trained Abroad to be doctors?” The Tyee, http://thetyee.ca/News/2012/04/10/Canadian-Doctors-Trained-Abroad/ (accessed January 9, 2013).
Miller Edward J. and Joni Huff, International Students and Medical Education: options and Obstacles, http://premed.owu.edu/pdfs/millerHuffArticle.pdf (accessed January 9, 2013).
Net Industries, Foreign Medical Study – Admission, Transfer to U.S. Schools, Internship and Residency, Fifth Pathway Opportunities,” Net Industries and its Licensors, http://careers.stateuniversity.com/pages/100000650/Foreign-Medical-Study.html (accessed January 9, 2013).
Settlement.org, “Who is eligible for the Ontario Student Assistance Program (OSAP)?” Settlement.org, http://www.settlement.org/sys/faqs_detail.asp?k=POSTSEC_FIN&faq_id=4001161 (accessed January 9, 2013).
Sheppard, Mary C. “Too many Canadians studying medicine overseas.”CBC News, Feb. 23, 2011, Health section http://www.cbc.ca/news/health/story/2011/02/22/canadian-students-medicine-overseas.html (accessed January 8, 2013).
The study of medicine in the united states,” The student room, http://www.thestudentroom.co.uk/showthread.php?t=253003 (accessed January 9, 2013)
Veritas Prep, “Transferring from foreing medical schools,” US News Education, September 12, 2011, http://www.usnews.com/education/blogs/medical-school-admissions-doctor/2011/09/12/transferring-from-foreign-medical-schools (accessed January 9, 2013).
CanadaFAQ, “How to become a doctor in Canada,” http://www.canadafaq.ca/how+to+become+a+doctor+in+canada/ (accessed January 8, 2013)
CaRMS, Canadian students studying medicine abroad, CaRMS Report, 2010. http://www.carms.ca/pdfs/2010_CSA_Report/CaRMS_2010_CSA_Report.pdf (accessed January 8, 2013)
Mary C. Sheppard, “Too many Canadians studying medicine overseas,”CBC News, Feb. 23, 2011, Health section http://www.cbc.ca/news/health/story/2011/02/22/canadian-students-medicine-overseas.html (accessed January 8, 2013).
Myrle Croasdale, “More U.S. medical students are studying abroad,” Amednews. http://www.ama-assn.org/amednews/2003/10/06/prsf1006.htm (accessed January 9, 2013)
Lev G. Fedyniak, Medical study Abroad, Transitionsabroad.com, http://www.transitionsabroad.com/publications/magazine/0305/medicalstudyabroad.shtml (accessed January 8, 2013)
Net Industries, “Foreign Medical Study – Admission, Transfer to U.S. Schools, Internship and Residency, Fifth Pathway Opportunities,” Net Industries and its Licensors, http://careers.stateuniversity.com/pages/100000650/Foreign-Medical-Study.html
Irfan Dhalla & Karen Born, “Why are so many Canadians going abroad to study medicine?” Healthy Debate, http://healthydebate.ca/2011/03/topic/politics-of-health-care/why-are-so-many-canadians-going-abroad-to-study-medicine
“Steps involved in returning to Canada for postgraduate training,” Health employment Manitoba, http://www.healthemployment.ca/pra_step.html (accessed January 9, 2013)
CaRMS, Canadian students studying medicine abroad, CaRMS Report, 2010. http://www.carms.ca/pdfs/2010_CSA_Report/CaRMS_2010_CSA_Report.pdf (accessed January 8, 2013) 29.
Andrew MacLeod, “What’s a fair deal for Canadians Trained Abroad to be doctors?” The Tyee, http://thetyee.ca/News/2012/04/10/Canadian-Doctors-Trained-Abroad/ (accessed January 9, 2013).
CaRMS, Canadian students studying medicine abroad, CaRMS Report, 2010. http://www.carms.ca/pdfs/2010_CSA_Report/CaRMS_2010_CSA_Report.pdf (accessed January 8, 2013) 29.
Net Industries, “Foreign Medical Study – admission, transfer to U.S. Schools, Internship and Residency, Fifth Pathway Opportunities,” Careers State University, http://careers.stateuniversity.com/pages/100000650/Foreign-Medical-Study.html (accessed January 9, 2013).
Carolyne Krupa, “Foreign-trained health professionals put on path to practice in U.S.,” Amednews, July 25, 2011, http://www.ama-assn.org/amednews/2011/07/25/prl20725.htm (accessed January 9, 2013).
Veritas Prep, “Transferring from foreing medical schools,” US News Education, September 12, 2011, http://www.usnews.com/education/blogs/medical-school-admissions-doctor/2011/09/12/transferring-from-foreign-medical-schools (accessed January 9, 2013).
The Association of Faculties of Medicine of Canada, “Admission Requirements of Canadian Faculties of Medicine,” AFMC Canada, http://www.afmc.ca/pdf/2012_ad_bk.pdf (accessed January 9, 2013) 4.
“The study of medicine in the united states,” The student room, http://www.thestudentroom.co.uk/showthread.php?t=253003 (accessed January 9, 2013)
Edward J. Miller & Joni Huff, International Students and Medical Education: options and Obstacles, http://premed.owu.edu/pdfs/millerHuffArticle.pdf (accessed January 9, 2013)
The Center for Global Education, “Financing Study Abroad,” Students Abroad, http://www.studentsabroad.com/handbook/financing-study-abroad-program.php?country=Kenya (accessed January 9, 2013).
CaRMS, Canadian students studying medicine abroad, CaRMS Report, 2010. http://www.carms.ca/pdfs/2010_CSA_Report/CaRMS_2010_CSA_Report.pdf (accessed January 8, 2013) 22. The Association of Faculties of Medicine of Canada. “Admission Requirements of Canadian Faculties of Medicine.” AFMC Canada, http://www.afmc.ca/pdf/2012_ad_bk.pdf (accessed January 9, 2013).
Settlement.org, “Who is eligible for the Ontario Student Assistance Program (OSAP)?” Settlement.org, http://www.settlement.org/sys/faqs_detail.asp?k=POSTSEC_FIN&faq_id=4001161 (accessed January 9, 2013).
Josh Dehaas, “Slim Chance of Residency upon return,” MACLEAN.CA On Campus, http://oncampus.macleans.ca/education/2012/06/19/medical-school-dean-warns-against-overseas-schools/ (accessed January 9, 2013).
An arrhythmia is defined as a change in the pulse or normal rate of the heart, usually between 60 and 100 beats per minute (Hopkinsmedicine.org 2012, para.1). In most instances, Arrhythmias are categorised by their position in the heart as well as by their pace or rhythm. Atrial arrhythmia is an anomaly that transpires in the chambers of the heart, the left or right atrium. There are two upper chambers in the heart. Atrial arrhythmias develop in one of the two chambers of the heart (Hopkinsmedicine.org 2012, para.3). Arrhythmias are highly connected with aging and normally ensue more regularly during middle age. At any rate, 10 to 15 percent of the population who have 70 years and above, experience arrhythmias.
Arrhythmia is regarded as the heart’s normal response to varying conditions, which can be brought about by: increased stress levels, high emotional levels, irregular sleeping patterns and exertion. An arrhythmia may necessitate medical treatment once it occurs repetitively over an extended period. In addition, one should visit a medical practitioner when they suffer the following symptoms; fainting, which in medical terms is known as syncope, pains in the chest, and shortness of breath, as well as headaches and palpitations (Hopkinsmedicine.org 2012, para.6).
Types of Atrial Arrhythmias
There are many types of atrial arrhythmias. They have been discussed below as follows:-
This is the electrical indicator that goes around irregularly through the muscles of the atria causing them to palpitate (occasionally, in excess of 400 times per minute), devoid of contracting. In this context, the atria denote the upper chambers of the heart. The ventricles, which are the lower chambers of the heart, do not take delivery of habitual impulses leading to out of rhythm contraction (Freeman 2003, p. 90). This makes the heart beat irregularly and uncontrolled. Atrial fibrillation is the most universal atrial arrhythmia, whereby 85 percent of persons who experience it are 65 years and above. Occasionally, atrial fibrillation causes blood clot, which enters the bloodstream and trigger stroke. Stroke mostly attacks the aged. Hypertension or underlying heart disease enhances the possibility of stroke from atrial fibrillation just like age does even in the absence of the heart disease or hypertension.
Premature Atrial Contraction (PAC) or Premature Atrial Impulses
PAC is a common and gentle arrhythmia. This is defined as a heartbeat that starts off outside the sinus node. This heart beat sends electrical impulses through the upper chamber. Mostly, it occurs after a heartbeat has been initiated by the sinus node and before the subsequent normal sinus discharge. One may feel a heartbeat skip. Continuous consumption of tobacco, caffeine, alcohol and increased stress levels can cause a PAC or amplify their rate of recurrence.
The Sinus Tachycardia is portrayed when the sinus node releases electrical signals abnormally fast (Baltazar 2009, p.180). This serves to increase the heart rate to a low of 100 beats per minute. At rest, the heart rate is 140 per minute, but during exercises it increases to 200 beats per minute (Baltazar 2009, p.182). Usually, a normal response to stress or even exercise can also be caused by the adrenaline levels, heart conditions, as well as consumption of alcohol, nicotine and caffeine.
Supra ventricular Tachycardia (SVT)
This category of atrial arrhythmia is characterized by a brisk heart rate which ranges between a 100 and 240 beats per minute. In most instances, Supraventricular Tachycardia commences and stops unexpectedly (Baltazar 2009, p.184). SVT takes place when an electrical impulse enters the atrial muscles for a second time. This may be a disorder which an individual may acquire at birth. Mostly, SVT is caused by a disparity in the electrical coordination of the heart. Often, SVT sets in motion during infancy or teenage years. It can also be triggered by caffeine exercise or consumption of alcohol (Baltazar 2009, p.184). SVT is hardly ever perilous, but can result to a drop in blood pressure of a patient, causing near-fainting incidents and remotely, fainting episodes.
Atrial flutter is characterised by the regular and coordinated beating of the atria. This is the factor that differentiates the atrial flutter from atrial fibrillation (Freeman 2003, p. 90). In most circumstances, the old persons (60 years and above) together with those having some heart disorders, suffer from atrial flutter. These heart disorders comprise of thickening of the muscles of the heart and problems with the heart valve. Atrial flutter is categorised into two categories, depending on the pathways responsible for this disorder. Atrial flutter Type I is noted by a rise in the heart rate which remains at 150 beats per minute. On the odd occasion, this rate may get to 300 beats per minute. At other times, it dwindles to 75 beats per minute. Atrial flutter Type II is symbolised by the sharp increase in the atrial rate. In this case, the ventricular rate may range between 160 to 170 beats per minute. In both the atrial fibrillation and atrial flutter there is increased risk of stroke as these rates increase.
Sick Sinus Syndrome (SSS)
This syndrome is common among the elderly. The syndrome is described as the improper firing of electrical impulses, which are caused by scars in the Sinoatrial node (SA node) or disease. SSS usually causes the rate of the heart to slow. At times, it varies between abnormally slow rates and fast rates. SSS is a progressive condition which is made up of episodes escalating in frequency and duration. Sick sinus syndrome is caused by either the presence of the diseases in the trial muscles or degeneration of the electrical system of the heart.
Sinus bradycardia is associated with generation of impaired impulse in the Sinoatrial node. This category of arrhythmia causes a decrease in the heart rate less than 60 beats per minute. It is commonly caused by SSS, in addition, to drugs like calcium-channel blockers and beta-blockers. Seldom is sinus bradycardia caused by conduction of impaired impulses to the muscles of the atria.
Wolff-Parkinson-White Syndrome (WPW)
This syndrome is brought about by the failing electrical signals which pause in the atrioventricular node as a consequence of an extra pathway, allowing the impulse to circumvent the normal pathway (Lippincott & Wilkins 2009, p. 173). In some instances, the syndrome is also referred to as bypass tract as a result of bypass of the normal pathway by the electrical impulses. WPW syndrome creates heart rates, which approach 240 beats per minute. Patients with WPW syndrome may occasionally develop atrial fibrillation, which puts them at a risk for contracting a perilous ventricular arrhythmia (Lippincott & Wilkins 2009, p. 173).
Cause of Atrial Arrhythmias
Increased malfunctions with the heart’s electrical coordination or the response of the muscles to the signal can lead to arrhythmias. Medical practitioners have succeeded in categorizing arrhythmias according to their causes which are as follows;
Disorders of Impulse Generation
This is a signal that produces a fraction of the heart’s electrical system excluding the Sinoatrial node. When this is interrupted, one may get heart diseases or arrhythmia.
Disorders of Impulse Conduction
This Impulse Conduction disorder blocks the electrical impulses of the heart thus, preventing it from flowing in its normal pathway. This creates an abnormal procedure which in turn creates an atrial arrhythmia.
Heart attacks scar the heart, which interferes with the smooth functioning of the electrical impulses. Persons devoid of heart diseases can suffer from an arrhythmia for anonymous causes. Heart attacks increase the probability of an individual to contracting arrhythmia.
The risk factors include emotional stress. Stress increases the aging rate and interferes with the frequency of the heartbeats. In addition, regular consumption of alcohol, diet pills, caffeine and tobacco increases the chances of a person to developing arrhythmia. Lastly, some prescribed medications for colds, allergy, coughs and heart drugs as well as anti-depressants amplify the chances of an individual to contact the atrial arrhythmia.
The inception and length of the symptoms of arrhythmia varies depending on its frequency, type, duration besides the presence of structural heart diseases. There are many symptoms of the arrhythmia, but the most common indicators are as highlighted below; the first symptom is palpitations, which are commonly referred to as the sensational skipping of the heartbeats (Tisdale & Miller 2010, p.462). When one suffers from palpitations, they should seek the services of the medical personnel with immediate effect. Shortness of breath creates an unfavourable environment in the heart of a person as it slows the pace of the heartbeat. Fatigue is associated with tiredness. Continuous or repeated fatigue causes arrhythmia. Chest pains are quite dangerous as they should be reported to the physicians as soon as they occur.
Another symptom, which may lead to arrhythmia, is fainting. Regular cases of fainting or seizures should be investigated for the presence of atrial arrhythmia (Tisdale & Miller 2010, p.462). The urge to keep on urinating may send a signal that one has either diabetes or arrhythmia. However, certain arrhythmias may perhaps cause fainting and in occasional circumstances cause stroke, whereas others (considered to be silent arrhythmia) have no symptoms. Once a person experiences different patterns of heartbeat, they should consult a doctor with the view to treating the arrhythmia on time. The earlier the symptoms are realised, the faster the treatment. These symptoms may vary from one person to the other. People who exercise are not at risk of getting arrhythmia as compared to those who do not exercise.
It is a herculean task to diagnose arrhythmias as a consequence of their unpredictability and succinctness. A physician will normally take into consideration a patient’s medical record, and carry out a comprehensive physical examination. During the examination, the physician may discover an arrhythmia by means of a stethoscope. Infrequently occurring arrhythmia lasts for a short period as they do not cause visible symptoms. These types of arrhythmia require supplementary and detailed analysis, such as the use of electrocardiogram (ECG); an ambulatory electrocardiogram (holter monitor), as well as a loop electrocardiogram.
How Exercise may help with Arrhythmias
Exercise is quite significant for any human being. Arrhythmia is caused by exercise when they are taken with intensity. When one is doing exercises, the body works hard, and this raises the blood pressure (Thow 2009, p.97). The increased blood pressure has the effect of releasing hormones, which trigger arrhythmia. In addition, the consumption of caffeine or even nicotine prior to or subsequent to exercising leads to instances of episodes. When one has other types of heart diseases, they can suffer from arrhythmia during or subsequent to the exercise.
In order to improve the conditions of the heart, it is advisable that people undertake exercises on an occasional basis (Thow 2009, p.98). Most people are consuming foods which have high calories. These calories convert into fats when they enter the body of the human being. Exercises aid in burning out all the fatty acids (calories) in the body while expanding the lung capacity besides improving the heart rate. However, exercises have to be taken as per the advice of the instructors. One should take enough breaks between exercises.
One should relax by gradually diminishing their activities after a rigorous training session to ensure that their heart rates slowly return to a normal pace (Thow 2009, p.98). One should not overexert himself during the exercises. One is advised to discontinue any exercise that makes them experience arrhythmia. Regular aerobic exercises aids in increasing the heart rate. Besides, this exercise engages all parts of the body. Aerobic Exercises improves the respiratory and heart muscles. The heart muscles are particularly crucial as they improve the pumping of blood to other parts of the body.
In some instances, arrhythmia may not necessitate treatment. In other cases, arrhythmias can only be controlled and suppressed by treating the underlying causes. Symptomatic arrhythmia may oblige one or more of the subsequent treatments to shrink the integer or extent of arrhythmic events. The common medications, which help in suppressing arrhythmia, are Calcium channel blockers, beta-blockers, anti-arrhythmic agents and digitalis. It must be noted that digitalis should not be prescribed for certain types of arrhythmias, for instance, Wolff-Parkinson-White syndrome. Persons suffering from atrial fibrillation are normally prescribed to use an anticoagulant with the view to minimizing the risk of blood clotting and stroke. Other treatments are discussed below;
The procedure of cardioversion serves to restore normal heartbeats by sending out a succinct electric shock via the chest to the heart. This procedure is commonly administered to outpatients in a hospital. This is performed when the patient is under intense anaesthesia or sedation. Cardioversion is commonly used to treat the ventricular arrhythmias, atrial flutter, and atrial fibrillation.
Radiofrequency Catheter Ablation
While using the Radiofrequency Catheter Ablation, a catheter, which has an electrode tip, is carefully placed on the affected spot. Here, the catheter distributes energy to tear down the tissue that is prying with the regular transmission of the heart’s electrical impulses (Griffin et al 2007, p.654). This treatment comes in handy, to treat atrial fibrillation, certain types of ventricular arrhythmias, atrial flutter and Supraventricular Tachycardia.
Under this method, a tiny electronic device is surgically and carefully implanted under the skin which is close to the collarbone. The pacemaker maintains a slow heartbeat by conveying electrical charges in a rhythmic pattern to the right Ventricle and right atrium (Griffin et al 2007, p.655). In most instances, pacemakers are utilised in treating the syndrome of Sick Sinus.
When using the maze procedure, a physician creates numerous incisions through the atrium. As a result, the resulting scar tissue transits impulses through the electrical system of the heart in a mode that permits normal conduction, but fails to sustain atrial fibrillation. This procedure is held in reserve for patients who have negative report in the catheter ablation. It is also reserved for persons who are undergoing surgical operations for different conditions. This is because the process is regarded as a form of cardiac surgery.
Baltazar, R. F. 2009. Basic and bedside electrocardiography. Philadelphia, Wolters Kluwer Health / Lippincott Williams & Wilkins.
Freeman, R. K., Garite, T. J., & Nageotte, M. P. 2003. Fatal heart rate monitoring. Philadelphia, Lippincott Williams & Wilkins.
Griffin, B. P., Rimmerman, C. M., & Topol, E. J. 2007. The Cleveland Clinic cardiology board review. Philadelphia, Lippincott Williams & Wilkins.
Hopkinsmedicine.org. 2012.Cardiac Arrhythmias. Retrieved 25, November 2012 from: http://www.hopkinsmedicine.org/heart_vascular_institute/conditions_treatments/conditions/arryhthmias.html
Lippincott Williams & Wilkins. 2009. Cardiovascular care made incredibly easy! Philadelphia, Wolters Kluwer Health / Lippincott Williams & Wilkins.
Thow, M. 2009. Exercise Leadership in Cardiac Rehabilitation for High Risk Groups an Evidence-Based Approach. Chichester, John Wiley & Sons.
Tisdale, J. E., & Miller, D. A. 2010. Drug-induced diseases: prevention, detection, and management. Bethesda, Maryland, American Society of Health-System Pharmacists.
Medical practitioners use the term dementia to refer to a chronic and severe loss of thinking capability, especially memory. Apart from just memory loss, a person suffering from dementia usually has problems carrying out daily routine tasks that he/she was capable of doing before the onset of the condition. For instance, the person may get lost in well known surroundings. He/she may also demonstrate poor judgment when it comes to simple decision making, lose interest in his/her erstwhile enjoyable activities and show strange changes in personality. Dementia most often happens in later years and becomes especially common in persons over the age of eighty five. Some form of memory loss is usual as people get old. On the contrary, dementia is not (Thompson, 2006, p. 3).
Most old people worry that they are becoming senile if they become slightly forgetful or if they have bouts of absent-mindedness. However, these memory lapses most often remain mild and do not significantly interfere with a person’s functioning. In dementia, a patient suffers severe memory loss that is so severe such that it affects his/her functioning. Such a person may need constant attention since he is prone to making extremely wrong choices. Dementia is normally caused by a condition or disease that damages tissues of the brain thereby disturbing the brain’s functioning. It takes several years to fully develop and is most prevalent in old people. However, there are some cases where some persons in their thirty’s develop the condition. This paper discusses the four main forms of dementia along with their causative factors. It will also highlight the diagnosis and treatment of dementia as well as give advice on how to care for people having dementia (Thompson, 2006, p. 4).
Forms of Dementia
There are four main forms of dementia: Alzheimer’s disease (prevalence rate of 62% among dementia patients), vascular dementia (prevalence rate of 27% among dementia patients), dementia with Lewy bodies (prevalence rate of 8% among dementia patients) and frontotemporal dementia (prevalence rate less than 3% among dementia patients). These forms are discussed in detail in the following section (Nazarko, 2011, p. 216).
Alzheimer’s disease (AD) is by far and large the cause of dementia in the elderly. In the United States, it is also the seventh leading cause of human deaths. AD is an irreversible, progressive brain disease that is typified by memory loss which leads to eventual declines in speech and language, visuospatial as well as decision making capabilities. Applying a range of psychometric tests to evaluate the cognitive and behavioral declines associated with the disease usually results in a clinically probable as opposed to a definitive, confirmed diagnosis. However, taking the patient through medical imaging tests (such as functional and structural PET or MR) may show the physiological and structural brain changes that are characteristics of advanced AD. These studies can thus strengthen a clinically probable diagnosis since they are not confirmatory (Shagam, 2009, p. 155).
As of 2009, medical researchers were in the process of developing practical imaging based screening that will facilitate the diagnosis of the disease. In the current practice, brain biopsies and postmortem histological assessments serve as AD confirmatory standards. The pathology of the brain that doctors use to verify AD is the incidence of neuritic (senile) plaques made up of a mesh of dying nerve cells adjacent to an amyloid protein core. The next section discusses possible causes of AD.
Pathological Causes of AD
Amyloid precursor membrane protein is found in many tissues in the human body. These include neuron synapses that act as chemical links between the nerve cells. The enzymatic digestion of the large amyloid molecule produces smaller amyloid beta proteins that form part of the neuritic plaques that are normally found in brains of people suffering from the Alzheimer’s disease. The exact relationship between the disease and the incidence of this insoluble and fibrous beta protein aggregate is not yet known. This has however not prevented some researchers from making some suggestions regarding the relationship. For instance, some posit that the incidence of amyloid protein neuritic plaques is capable of the following:
Disrupting tissue architecture.
Initiating apoptosis or systematic cell death.
Altering cell metabolism so as to produce oxygen-free radicals
(Shagam, 2009, p. 155)
Genetic factors, along with certain ways of life and environmental pressure, play a significant role in increasing the risk of acquiring AD. This is supported by the fact, although it is primarily a disease for the elderly, there are some persons as early as in their thirties that have the disease. There are some chromosomal changes linked to early onset of AD. About 1% of relatively young AD cases are linked to alterations in chromosome 21. Mutation of this chromosome affects the function and structure of amyloid precursor protein. This causes it to crease into cytotoxic fibrillar beta amyloid aggregates. Another genetic cause is the presence of presenilin 1 gene that accounts for nearly half of all early-onset AD cases. Presenilin 1 is situated on chromosome 14 and is a component of the enzyme complex that is responsible for leading to toxic accumulations of beta amyloid protein found in the brain (Shagam, 2009, p. 156).
The usual incidence of AD (that occurs after age 60) may also be as a result of an underlying genetic component. Researchers have observed that changes in APOE (apolipoprotein E) gene, which is located on chromosome 19, has the potential of increasing late onset risk of AD. Intriguingly, changes in APOE can result from various environmental and lifestyle factors such as smoking and diet. This suggests that smoking and some foods may cause late onset AD. The APOE gene encompasses instructions for producing apolipoprotein E, which carries fats and cholesterol to the liver through the bloodstream. There are at least three different (albeit slightly) variants of the gene. Experimental studies have shown that, apart from increasing the possibility of developing atherosclerotic fatty lumps in the blood arteries, the APOE*E4 variant is linked to increased numbers of amyloid plaques in the brain. Although the distinction may be subtle, it has been observed that people having the APOE*E4 gene generally have a higher hereditary risk suffering a heart attack or a stroke with or without having a cardiovascular disease. These people also have an increased risk of developing the Alzheimer’s disease (Shagam, 2009, p. 156).
Vascular dementia accounts for about 27% of all dementia cases. This makes it the second most common old age dementia. While the development of AD is gradual, the onset of vascular dementia is by far and large abrupt, occurring after a patient suffers a stroke or a heart attack which significantly decreases blood flow through or to the brain. In some cases, vascular dementia may develop slowly and progressively especially when a patient suffers a succession of small strokes or, alternatively, small transient ischemic attacks. These strokes and attacks eventually lead to multi-infarct dementia. The behavioral and physical signs and symptoms of this multi-infarct dementia vary according to the portion of the brain that has been affected. However, some notable physical examples of vascular dementia symptoms include walking or shuffling with small quick steps, incontinence and weaknesses in arms or legs. Behavioral symptoms include slurred speech, difficulty in following simple instructions and getting lost in well known surroundings (Deegan, 1987, p. 112).
Many patients of dementia have a condition called mixed dementia. Mixed dementia comes about when a person has both the Alzheimer’s disease and vascular dementia (Dezell, 2009, p. 29-30). However, developments in the body of knowledge have ensured that it is now possible to differentiate AD from vascular dementia. This is done through structural MR studies which highlight defining anomalies in the cerebral white matter and lacunar infarcts. In the same breath, studies have shown that vascular blockages are the main causes of vascular dementia. For this reason, risk factors of vascular dementia are simply those associated with vascular disease. These include the following:
(Shagam, 2009, p. 157)
In the later years of the 19th century, German psychiatrist and neurologist Arnold Pick described a case of an elderly patient who had dementia as well as a progressive loss of speech. After the patient had died, an autopsy examination revealed that he had had brain atrophy. However, unlike the diffuse brain atrophy linked to the Alzheimer’s disease, this type of dementia apparently targeted only the frontal and temporal lobes. This was later referred to as frontotemporal dementia (Shagam, 2009, 157).
Behavioral and physical signs and symptoms of frontotemporal dementia include the following:
Changes in personality.
Progressive aphasia, uncertain speech as well as difficulty in finding a right word to say.
Rigidity and shaking.
Lack of social awareness.
Neglected personal hygiene.
Muscle weakness and atrophy.
Increased or development of n
ew musical or artistic talents, in some cases (Kaufman, 2007, p. 127)
Worsening of language skills, where a patient almost loses the ability to speak fluently or connect words to their usual meaning, is normally the hallmark of most types of frontotemporal dementia. Inappropriate behavior, shaking and rigidity are also key symptoms of some types of this dementia.
Unlike the Alzheimer’s disease, frontotemporal dementia sometimes leaves the memory of patients relatively intact. In addition, it may spare some cognitive capabilities. Nonetheless, it is not definitively clear what causes frontotemporal dementia. However, some studies have suggested that they are caused by genetic alterations. For instance, some scholars have found out that close to 50% of persons in some families have frontotemporal dementias connected to changes in genes that code for ubiquitin or tau proteins. These altered proteins then form impossible-to-solve deposits in brain neurons. These deposits may lead to frontotemporal atrophy (Shagam, 2009, p. 157).
A comprehensive look at the patient’s history, a thorough physical exam and medical imaging examinations play a significant role in not only diagnosing but also differentiating frontotemporal dementia from other forms of dementia. For instance, structural MR scanning can assist in correlating observed behavioral and physical changes to alterations in brain anatomy. Other functional imaging modalities that include SPECT (single photon photoemission computed tomography) and PET can help in detecting areas of decreased perfusion and metabolism (Shagam, 2009, p. 157).
Dementia with Lewy Bodies
This is a spectrum disorder that involves a gradual but significant decline in a patient’s behavior and cognitive ability. Other common features of dementia with Lewy bodies include delusions, hallucinations as well as considerable changes in sleep and autonomic processes such as digestion and heart rate. There are some forms of dementia with Lewy bodies that lead to rigidity, shaking and balance difficulties. Lewy bodies are anomalous aggregates of alpha synuclein, neurofilament and ubiquitin α-B crystalline proteins. They are the key features of dementia with Lewy bodies. As a result, researchers believe that their presence (inside the brain’s cortical cells and the brainstem) is the cause of this form of dementia. One key type of dementia with Lewy bodies is the Parkinson disease dementia, PDD (Lezak et al., 2004, p. 222).
Patients suffering from dementia with Lewy bodies exhibit at least two of the following behavioral signs and symptoms:
Persistent visual hallucinations.
Unpredictable attention and concentration.
Impulsive Parkinson motor signs
The onset of Parkinson disease can lead to the development of dementia. This is exemplified by the fact that about twenty percent of Parkinson patients eventually develop PDD. There are some patients who later develop AD. Parkinson disease is a neurodegenerative condition that results from the death of a particular group of cells in the substantia nigra that produce dopamine. Dopamine is a basically a neurotransmitter that aids in regulating movement, walking and balancing. It also, in one or another, influences creative drive, cognition, sleep, motivation, attention, mood and learning. This simply means that the death of dopamine-producing cells will affect all these processes (Lezak et al., 2004, p. 222).
Just like the other forms of dementia, confirmatory diagnosis of PDD (and dementia with Lewy bodies for that matter) is challenging. However, a prior diagnosis of Parkinson disease and behavioral signs of at least two of the following conditions can help in the diagnosis:
Poor attention span.
Frequent memory lapses.
Poor planning and organization of self.
Apparent deficits in visuospatial capability.
Reduced language and speech capability
(Shagam, 2009, p. 159)
Apart from the above signs, symptoms such as paranoid delusions, hallucinations and disproportionate sleepiness during daytime can point to probable PDD diagnosis. In the same breath, persons who have dementia with Lewy bodies normally have the neuroleptic malignant syndrome, a potentially life threatening condition that is characterized by rigidity, high fever and muscle breakdown. In ordinary cases, non dementia patients who have the syndrome are prescribed antipsychotic drugs such as fluphenazine, thioridazine and haloperidol. Dementia patients have to avoid these drugs (Shagam, 2009, p. 159).
Although it is common knowledge that dementia is primarily a disorder for the elderly, numerous studies have shown that the condition frequently remains unrecognized and unevaluated under primary care settings. This is because dementia patients are incapable of correctly reporting their symptoms. In addition, many physicians are not familiar with dementia signs and symptoms. In some cases, physicians doubt the usefulness of diagnosis and treatment of dementia while many decry the lack of adequate examination time. While correctly diagnosing a dementia disorder is challenging enough, differentiating the different forms of dementia is even more challenging. This is because the physical and behavioral signs and symptoms of the different forms of dementia overlap. Furthermore, there is no definitive biomarker that can determine authoritatively the form of dementia that a patient is suffering from. To this end, diagnosis of dementia may take several steps before a specific disorder is identified (Shagam, 2009, p. 159).
Patients may exhibit occasional memory problems and this may cause concern among their family members or people they live with. When these problems persist, the family members may find it ideal to contact primary care givers and enlighten them about their observations. Since dementia can result from more than forty diverse diseases and conditions ranging from drug interactions and head injuries to dietary deficiencies and Parkinson disease, it is almost impossible to diagnose and treat dementia in the preliminary examination. A physician has to take the patient through a comprehensive blood, urine and physical test to rule out potential causes for the behavioral changes. The patient’s medical history and medical images should also be analyzed. Information from medical imaging and laboratory procedures may also provide timely hindsight concerning treatable causes of the patient’s cognitive impairment. This may also determine whether or not the patient has dementia (Shagam, 2009, p. 160).
When there are credible signs that the patient has dementia, the physician may try to determine its cause. If for instance the condition was caused by changes in brain function, the physician can assess the patient’s cognitive deficits, memory status and day to day living skills. A clinician can use this information to posit the form of dementia and the patient’s dementia status. He/she can then recommend the best assisted living arrangements (Shagam, 2009, p. 160).
A specialist such as a neurologist, neuropsychologist, psychiatrist or gerontologist cam help the patient’s primary care giver assess him/her for dementia. At the moment, there are some tests that can provide vital information about a patient’s cognitive ability and daily living skills. These tests include the Clock Drawing Test, the Mini Mental State Examination (MMSE) and the Blessed Dementia test scale. The MMSE is used to evaluate the patient’s orientation, attention, recall, language and calculation skills. This test usually depends on the patient’s capability to read, write and offer verbal responses. This can be a challenge to persons who generally have low English literacy, those who are visually or hearing impaired and those who have difficulties in communication. These persons may perform poorly in this test even if they do not experience a genuine decline in cognitive ability. In addition, some patients may refuse to take part in the exam in an attempt to conceal their deficits or some may believe that the questions they are asked too trivial to be answered (Prasher, 2005, p. 59).
In this exam, the assessor asks simple questions such as “What is the date today?” and “What is the name of this clinic?” The patient may also be asked to do simple tasks such as counting or spelling backwards, repeating a sequence of three words, copying a drawing or writing down a full sentence. The highest score that a patient can achieve is usually 30. In most cases, examiners use the following grading rubric:
24 -30 – the patient is essentially normal.
20 – 23- the patient may be suffering from early stage AD.
10 – 19 – the patient is at middle stage AD.
0 – 9 – the patient is at late stage AD
Stern, 2010, p. 112
When the patient has no communication problems and when he/she fully participates in the test, the MMSE dependently distinguishes patients who have cognitive deficiencies from those that don’t.
The Clock Drawing Test is also used to examine patients for possible dementia. The ability of a person to draw the face of a clock having properly oriented numbers and clock hands displaying a specific time (say, 15 minutes past 2) tests for a gamut of motor, cognitive, perceptual and executive function skills. Patients who have dementia may commit errors such as counter clockwise numbering, repeated numbers, missing numbers as well as out of the ordinary spatial arrangements of clock features. Since clocks are universal and clock drawing circumvents many cultural and language barriers, this test is a more ideal tool than the MMSE. Many patients are always more than willing to participate in this test. For this reason, some medical practitioners have argued that the Clock Drawing Test be added to the annual physical examinations taken by older adult patients. This will help in detecting early dementia (Prasher, 2005, p. 59).
The Blessed Dementia Scale assesses a patient’s daily living skills as opposed to cognitive skills. In this scale, a care giver, with the help of a family member, ranks the ability of the patient to perform simply household tasks, recall recent events and handle money. It also tests his/her ability to dress and eat unassisted. In some cases, specialists use it to evaluate bowel and bladder continence of the patient. This scale serves as a dementia assessment tool while at the same time indicating the level of care a patient needs to lead a normal life (Shagam, 2009, p. 160).
Functional Medical Imaging
This is a relatively new diagnostic imaging tool that makes it possible to identify the form of dementia a patient may be suffering from. This technology is a significant improvement on Radiography, Computed Tomography and Magnetic Resonance which can show anatomical and structural changes occasioned by a disease. This is because it makes known the physiological changes that precede or accompany current signs and symptoms. Therefore, apart from just being a tool for assessing the different forms of dementia, it may in future become a crucial screening tool to identify individuals at risk of catching diseases such as cancer, schizophrenia and heart disease. However, functional imaging still needs some improvements if it is to achieve this capability (Shagam, 2009, p. 161).
Functional imaging entails computationally intensive processes that combine or overlay functional data onto structural Magnetic Resonance or Computed Tomography images. This fusion normally links the physiological results to fixed anatomical pointers. At the moment, the most used functional imaging technologies to test for dementia are Positron Emission Tomography (PET), Single Photon Emission Computed Tomography (SPECT), Molecular Imaging (MI) and functional Magnetic Resonance (fMR) (Monahan et al. 2010, n.p. )
Dementia Management and Treatment
Up until this moment, there is no known cure for dementia. In a majority of cases, management and treatment of dementia is aimed at ameliorating the signs and symptoms that accompany the condition. To this end, clinicians and other practitioners’ measure of dementia treatment and management success is not dependent on its cure but the extension of the time period until when the patient needs institutionalization, or in most cases, dies. In the United States of America alone, it is believed that people spend in excess of one billion dollars every year on five prescription medications that ameliorate signs and symptoms associated with dementia. However, the exact potential of these medications is not well known. This is because (of all patients that take the medications) more than 80 percent do not experience noticeable or sustained benefits from using them. This suggests that these medications need to be improved (Shagam, 2009, p. 163).
At the moment, dementia treatment is geared towards managing the behavior of a patient so that to ensure his/her safety. This behavior management also ensures that the patient at least maintains a dignified and quality life, even during old age. However, this medication cannot substitute attentive care and assistance by a family member or primary care giver. In many cases, these persons (who take care of dementia patients) may need counseling and medication so as to combat their depression, anxiety and anger that may come with taking care of a dementia patient (Shagam, 2009, p. 164).
The US Food and Drug Administration is the body charged with regulating the use of medical drugs in the country. It is also the body charged with regulating medications to be taken by dementia patients. As the paper had mentioned before, there is simply no cure for AD or dementia (at least at the moment). Drugs prescribed to patients only reduce the severity of symptoms for some weeks or months. Regarding the management of dementia, the US Food and Drug Administration approved pharmaceutical use of cholinesterase inhibitors. In assessing a drug’s efficacy, medical practitioners bring into play factors such as anxiety, improvement in cognition, reduced behavioral problems, memory and self sufficiency. The long term efficacy measure is the length of time until a patient requires institutionalization. Cholinesterase inhibitors are effective in restoring memory and thinking capabilities. This is because they prevent acetylcholine (an extremely crucial neurotransmitter that regulates thinking and memory) from breaking down (Shagam, 2009, p. 164).
Important cholinesterase inhibitors used to manage Alzheimer’s disease are donepezil, rivastigmine and galantamine. Donepezil can be used by all AD patients regardless of the status of the disease. Another inhibitor that can modify AD symptoms is tactin. However, this inhibitor has been found to cause liver damage. As a result, its usage may not be appropriate for such vulnerable individuals. Although these inhibitors are effective in managing AD, all of them come with side effects. These include vomiting, nausea, insomnia and slow heartbeat. In the same breath, their effectiveness is typically temporary and decreases with increase in AD progress. In addition, their effectiveness significantly reduces when the patient’s brain produces less and less acetylcholine (Shagam, 2009, p. 164).
Another type of drug used to alleviate AD symptoms is memantine (medical name N– methyl D –aspartate, NMDA). The exact functioning mechanism of this drug is not understood very well. However, some researchers believe that it controls the quantity of glutamate the brain generates. The onset of AD normally leads to the brain’s overproduction of glutamate thereby leading to an increased rate of brain cells death. By regulating glutamate production, memantine slows the development of AD. For instance, physicians agree that the drug preserves a patient’s day to day life skills including dressing and toileting, even if for some few months. This suggests that their regular intake can slow down the full onset of AD. This drug ensures that a patient leads a quality life for a few more months or years. It also gives family members and primary care givers much needed respite (Shagam, 2009, p. 164).
Vascular dementia is brought about by the cumulative effect of several relatively smaller strokes and blood clots. This simply means that lifestyle and remedial treatments that are used to prevent heart disease, hypertension and diabetes which reduce heart attack risks and short lived ischemic attacks can also prevent vascular dementia. However, once an individual has vascular dementia, the only viable treatment is medication to lessen depression, control aggressive behavior or relieve restlessness. Treatment of vascular dementia is different from treatment of AD. This is because although dopaminergic medications reduce rigidity and shaking in AD patients, they are ineffective in doing the same for vascular dementia patients. This underlines the importance of physicians identifying the exact dementia disease they are treating (Shagam, 2009, p. 164).
The significance of knowing the type of dementia that a patient suffers is apparent during the management and treatment of frontotemporal dementia. Just like in the other cases, medication in this type of dementia is aimed at alleviating the behavioral symptoms of patients. However, researchers have found out that the cholinesterase inhibitors used in the management of AD cannot be used in frontotemporal patients. This is because they only worsen the situation. The use of antidepressants such as escitalopram and sertraline has always been encouraged during the treatment of frontotemporal dementia (Shagam, 2009, p. 164).
There are various drugs that can ameliorate the symptoms of dementia with Lewy Bodies patients. These include the following;
Cholinesterase inhibitors that slow down the cognitive decline process.
A combination of carbidopa and levodopa that may reduce shaking and rigidity.
These drugs have been useful in the management of Parkinson disease.
Antipsychotics to control patient’s frequent hallucinations.
As it can be seen, dementia with Lewy Bodies medication can treat specific symptoms.
This makes it to a bit easier for patients to lead a normal life. However, most of them come with side effects. The effects associated with cholinesterase inhibitors had already been mentioned already. Levocopa and carbidopa have been found to cause hallucinations while some antipsychotics cause patients to shake and tremor (Shagam, 2009, p. 164).
Caring for People with Dementia
Persons suffering from dementia need special attention and care. This is because most of them become incapable of making even the simplest of decisions on their own. As a result, they need regular and (in some cases) around-the-clock delivery of some of the following:
Specialist and mainstream day services
Assistive technology and long distance care
Sheltered or additional care housing
Specialist and mainstream residential care
Rehabilitation and intermediate care
Care in general hospitals
Specialist mental health services such as memory assessment services, inpatient care, psychological therapies
and community mental health services
(TBPS, 2007, p. 18-19)
These types of care call for a carefully planned, coordinated and managed care plan. Therefore, it is vital that health, social and home care providers work hand in hand in coming up with a care program that will ensure that a patient at least leads a normal and quality life. More importantly, the care plans have to be specialized to a patient’s mental and physical needs, life history, family and social circumstances, preferences and current level of cognitive and functioning capacity. In developing this plan, carers should take into account the following:
The plan is agreeable amongst health and social services providers as well as the patient’s family members or primary care givers.
Assignment of tasks should be specific.
The person with dementia should at least approve it.
If this approval is untenable, their close family members should approve it.
The plan is subject to regular reviews and changes, at an agreed upon frequency.
Changes are made according to the development of dementia.
The patient needs regular medical and physical examinations
(TBPS, 2007, p. 16.
Since some dementia conditions and signs are spontaneous, it is advisable that the patient has full access to timely medical services. During the early stages of dementia, a patient can be taken care of at home by family members with the help of specialized personnel. This is because the patient can still make some well thought out decisions. This is facilitated when the patient is receiving proper medications. In addition, family members and loved ones are in a better position carry out tasks such as bathing him, feeding him, toileting him and dressing him. They also know his/her interests and hobbies and offering them such will keep them entertained. However, this does not mean that caring for the patient at home should be left to loved ones only. Specialist care personnel should also be involved on a regular basis (TBPS, 2007, p. 14-16).
When the stage of dementia is advanced, it may not be appropriate to provide care at home. This is because homecare may not be adequate enough to address all the patient’s physical and medical needs. At this stage, housing the patient at specialized institutions that have full time qualified care givers will ensure that he/she gets the best possible care.
Caring for an older person is quite challenging. This challenge is even amplified when that adult cannot do very simple tasks on his own or when he fails to recall information such as his/her name. It can be frustrating when such a person cannot even remember their loved ones or fails to recognize the care giver whom they spend a lot of time together. Therefore, dementia care givers need appropriate training to prepare them for the task ahead. For instance, they need to training to understand what the patient is going through and why he fails to muster supposedly trivial things. In addition, they need to know how to deal with a patient who becomes agitated or aggressive frequently. These people need training so as to monitor the patient’s signs and symptoms for appropriate reporting to the physicians. Lastly, these carers need regular counseling and depression, anxiety that may be brought about during the caring process ((TBPS, 2007, p. 16-17).
The prevalence of dementia has made many people to dread getting old. However, developments in the medical practice have ensured that this condition can be managed such that a patient at least leads a quality life. This writer hopes that further developments in medical research and technology will make the condition treatable. If this will not be achieved, these developments may make the condition preventable.
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Kaufman, D. M. (2007). Clinical neurology for psychiatrists. Philadelphia: Saunders Elsevier.
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Miller, C. A. (2009). Nursing for wellness in older adults. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
Monahan, F. D., Neighbors, M. & Green, C. (2010). Manual of Medical-Surgical Nursing Care: Nursing Interventions and Collaborative Management. Maryland Heights: Elsevier Health Services.
Nazarko, L. (2011). Understanding dementia: diagnosis and development. British Journal of Healthcare Assistants, 5(5):216-220.
Prasher, V. P. (2005). Alzheimer’s disease and dementia in Down syndrome and intellectual disabilities. Oxford ; Seattle: Radcliffe Publishing.
Shagam, J. (2009). The many faces of dementia. Radiologic Technology, 8(12), 153-168.
Stern, T. A. (2010). Massachusetts General Hospital handbook of general hospital psychiatry. Philadelphia: Saunders/Elsevier.
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Thompson, S. B. N. (2006). Dementia and memory: A handbook for students and professionals. Aldershot, England: Ashgate.
Treating traumatic brain injury
Traumatic brain injury
Jane is my sixteen years old lady suffering from traumatic brain injury that resulted from a severe road accident. She did not sustain body injuries, but her head is believed to sustain internal injuries. After the accident, two years ago, she is unable to do many things on her own and she has even drop out of school to nurse the brain injury. Although she has been recovering well, she still needs both medical and supervision attention. Many times she forgets what she is doing and supposed to do; hence, somebody must be with her to help when she loses memory (McCrea & American Academy of Clinical Neuropsychology, 2007, p. 84). The condition of her memory loss is moderate, but she requires attention because the memory loss can last for two hours a day. Therefore, in case she is making a peanut butter sandwich, her mother or sisters should be with her to offer any assistance she requires.
Evidence shows that Jane is slowly recovering given that the number of hours of memory loss is decreasing with time. One year ago, her memory loss lasted between two to three hours a day, but nowadays does not go beyond two hours. This indicates that with both medical and close supervision, Jane is likely to recover completely (Silver, McAllister, & Yudofsky, 2011, p. 23). Therefore, the family members have opted to let her perform some chores on her own as a recovery process, but with close supervision. This case will analyze how Jane makes a peanut butter sandwich for the family every morning. In order to help her recover, the family has taught her a strict method to follow as professional cooks demand.
Furthermore, in order to reduce memory loss, every morning Jane wakes up and prepares herself to go to the supermarket. She buys bread and butter if it is spent with the assistance of her younger sister. After this she leads her sister back home. On reaching home, she cleans her specially made kitchen table and places the three required items; bread, knife and butter on the table. After cleaning her hands, she carefully opens the bread’s plastic bag and places two slices side by side on a clean plate. Afterwards she carefully closes the plastic bag. She opens the peanut butter jar by twisting the lid in a counter-clockwise direction and places the lid on top of the table facing upwards. With the help of a knife, she applies the butter on the two slices of bread. After spreading the butter on each slice, she joins them, places them on a separate plate, and opens the plastic bag until she prepares a sandwich for each member of the family (Draznin, 2004, p. 109). After preparing the sandwich she must clean the table, replace the butter lid and serve. This exercise helps Jane develop memory and recover from it.
Studies indicate that a full recovery for this case is possible. Therefore, in order to help Jane recover fully, the family members should learn a few basic things to do to her. First, the family members should ensure that whenever Jane is travelling, she does not endure impact and travels safely. This reduces the chances of increasing the trauma. Second, they should ensure that Jane does not engage in risky games and if possible Jane should not engage in any sport. This reduces the likelihood of becoming a victim of head injuries. Third, they should ensure that Jane does not engage in any form of cycling to reduce accidents resulting from it. Finally, eating and living healthy is yet another aspect to consider because Jane’s brain is still developing (Ghajar, 2000, p. 926). Therefore, the chances of a full recovery for Jane are high given the family observes this together with taking her for medical checkups.
Draznin, S. (2004). Simple cooking fun. Huntington Beach, CA: Teacher Created Materials, Inc.
Ghajar, J. (2000). Traumatic brain injury. The lancet, vol. 356, 923-929.
McCrea, M., & American Academy of Clinical Neuropsychology. (2007). Scientific advances in mild traumatic brain injury: Implications for rethinking post-concussion syndrome. New York: Oxford University Press.
Silver, J., McAllister, T., & Yudofsky, S. (2011). Textbook of traumatic brain injury. Washington, DC: American Psychiatric Pub.