By B. Rhobar. Grand View College.

They identifed four risk factors for a disrupted quences of work-home interference among medical residents purchase 20 mg cialis sublingual amex. In addition generic cialis sublingual 20 mg, • describe some interventions that can improve the personal many doctors are embarrassed to fnd that they need relation- relationships of physicians. They are often “wounded healers” who have already faced stressors that make them vulnerable to mental illness, Case or who have undiagnosed mental health problems (e. Most of the residents in the such problems are likely to be compounded in spousal rela- program have intimate partners, and several have children. Although the One of the residents told the program director that this onset of relationship diffculties can be insidious, physicians resident had not had a chance to spend meaningful time should be alert to the warning signs, such as more frequent with their partner, with the exception of a yearly vacation. Useful strategies that develop and safeguard intimacy in a relationship include: protecting time to communicate with one’s partner; reading Introduction about the dynamics of relationships; attending a marital retreat; Certain traits that seem to go with the territory of medicine attending couples therapy; and taking time to manage one’s can have a detrimental effect on physicians’ personal lives. Refection for educators Warde and colleagues, reported increased marital and parental Get to know the spouses and signifcant others in the lives satisfaction have been closely associated with a decrease in of the residents in your program early on in residency confict between professional and familial roles. Educate residents’ spouses about the physician the confict between the demands training and home-life, and health resources available to their families (e. These individuals are often the frst to in both parental and marital satisfaction. Adequate vacation time, fexible Case resolution work hours and equitable part-time work are conditions of The program director organizes a day-long retreat for the employment that are conducive not only to improved family residents and their signifcant others. The program director life and mental well-being but also to greater job satisfaction brings in a well-known speaker to discuss issues surround- and productivity. Physicians are most satisfed as parents when ing physician health, including work-lifebalance, ways to they have a supportive spouse and when the work–home con- maintain healthy intimate relationships, and recognizing ficts of both partners are minimal. The resident body fnds the expe- medical practice can also affect physicians’ relationships with rience very useful and decide to make this an annual event their children. For instance, Armstrong’s group, found that to help prevent family stress related to residency training physicians who worked for a salary were more fulflled in their and to help recognize the roles that each of their families parental role than physicians who worked on fee-for-service play in their own residency program. Finally, the employment status of one’s spouse seems to play a role in parental satisfaction. It is also im- medical families, and portant to value the work and other pursuits of one’s partner, • explore challenges specifc to those relationships. Case As seductive as the practise of medicine can be, Michael Myers A resident requests a meeting with their supervisor over reminds us to “say yes to the relationship and practise say- coffee. The resident becomes distraught while disclosing ing no to other offers” (Myers 2001). Spend a minimum of that she miscarried her frst pregnancy three weeks ago twenty minutes alone with your spouse each day and plan a and that her partner, a more senior resident, is preoccu- date together every week. The resident acknowledges that her partner has tried Monica Hill and Nancy Love quote the novelist Henry James to be supportive, but feels that “he just doesn’t get it. Unbalanced criticism, defensiveness, Successful marriages and similar partnerships are built on ridicule, a posture of superiority, and “shutting off ” are poi- knowledge, friendship, fondness and admiration (Gottman sonous to this process (Hill and Love 2008). For physicians as for anyone else, this means having population, domestic violence and abuse occurs in medical time together to develop the essential advantage of such rela- families too. It includes affection, expressiveness, sexuality, cohesion, compatibility, autonomy Dual-physician relationships and confict resolution (Myers 2001). Confict between work and familial roles is inevitable at times, whether one or both partners are physicians. Classically, role Work and family life strain has been more frequently noted among female physi- The issue of deferring intimacy in favour of medical work has cians, but in reality male physicians experience it as well. Half been described in the literature on medical marriages (Myers of married women physicians are married to other physicians 2001 and Gabbard 1989). Dual-physician relationships bring sional advancement over the nurturing of intimate relation- certain challenges, such as complicated schedules and career ships, working long hours at the expense of their home lives. Careers postpone their investment in the “emotional bank account” of can be shaped, reshaped and salvaged more easily than rela- their families or in some cases, avoid admitting that they in fact tionships and families. Paradoxically, however, “the marital interests can be satisfying, which can lead to greater mutual relationship is the main source of coping with the stress of understanding, support and shared parenting (Schrager et al medical practice” (Gabbard 1989). It would seem, however, whether by preference, mutual decision or default, that women physicians continue to take Physicians who enjoy successful intimate partnerships learn more responsibility on the home front than their male counter- early that certain attributes that serve them well at work are parts. For example, while physicians of female physicians being the primary or sole income earner are accustomed to their role as experts and expect to be in in their households. In contrast to Protecting and nurturing our intimate relationships may require most physicians’ experience of medical education, marriage is a re-examination of our professional responsibilities and work non-competitive. As you develop your resident group or consider Relationships, however, do require work in realtime, a sense of your eventual practice setting, keep these questions in mind: humour, and a degree of luck. John Gottman, a respected re- • Does your group discuss shock-absorber systems for searcher in marriage and relationships, stresses the importance parental leaves and urgent family issues? She had speculated that a child would keep geographical triangle: home, school and workplace. Keeping her relationship together, given her partner’s attraction to logistics as simple as possible will beneft your marriage and “more medicine” and achievement. He expresses fear of giving in Raising children together to his feelings lest they derail his career focus. With the For many women physicians, the question of when to plan counsellor’s help, they review their priorities with regard childbearing is especially challenging when training demands to career plans and the timing of child-bearing. Supportive sessions lead to a better understanding of their mutual colleagues and training programs are nearly as important as a objectives, and of the supports available to them to help supportive partner. Furthermore, resi- dency training directors never accompany graduated residents impact on your family, whose sleep is being disturbed by the to the infertility clinic. The concept that it takes a village to raise a child applies to medical families, too. Women physicians are particularly aware Vacations are one of the non-urgent but important elements that the more they work, and the greater number of children of time management.

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Consider cerns purchase cialis sublingual 20mg on line, it can sometimes impair decision-making about personal these as you interact with your family physician generic 20 mg cialis sublingual otc, and as you health issues. In family medicine, much of our ability to diagnose and ad- Rules for patients to get along with their doctor: vise is based on a trusting relationship with our patients that • Rule 1: Your doctor can’t do it alone. As in all relationships, there must be doctor does not mean you should not ask support and resolve to permit the relationship to grow. As one commentator has written, for there to be a justifed trust between patient and doctor, “the consultation must be distractible. Case resolution • Rule 5: They want to know what is going to be The resident used the services available through her local done and when. I am a good patient, that the patient must always agree with the physician’s recom- believe it or not. Because one shoe doesn’t patient fnd concordance on an approach to care in illness and ft all: a repertoire of doctor–patient relationships. Objectives that only 14 per cent of the participants consumed the recom- This chapter will mended six to eight glasses of water per day, and the majority • describe some of the barriers to adequate nutrition in the (60 per cent) snacked less than once a day (Winston 2008). A workplace, qualitative study in which physicians were interviewed about • discuss how inadequate nutrition can affect physicians their workplace nutrition habits reported that 19 of the 20 par- personally and professionally, and ticipants expressed that they sometimes have diffculty eating • suggest ways in which individual physicians can infuence and drinking during work hours (Lemaire et al 2008). In particular the usual attention to healthy What is the impact of inadequate nutrition on physi- nutrition has been gradually eroded by long sessions in cians? Poor nutrition for physicians during the work day has the operating room and lengthy work days. The resident signifcant consequences, both for the individual physician and regards the nutrition choices at the hospital as unaccept- for the workplace. Physicians have previously described how able and fnds they are missing meals, losing weight and their inability to eat and drink properly during work hours is generally feeling awful on most days. When considering physicians’ nutrition in the For physicians: workplace, the solution should be simple—just make time to • Eat breakfast. However, the issue is not so straightforward, and • Carry healthy and convenient snacks with you. Nutrition in the health care workplace To improve nutrition in the workplace, physicians and health For health care organizations: care organizations must enhance their awareness and under- • Improve the quality and variety of foods available standing of the impact of inadequate nutrition and the barriers in the workplace. Without this knowledge, there will be little • Improve access to nutritious food (e. For example, one study provided a description of some eat, drink and store food from home. They also Case resolution felt that inadequate nutrition had a negative impact on both The resident is facing an issue common to most physi- their ability to complete their work and on their interactions cians—diffculty obtaining adequate nutrition during the with patients, colleagues and other health care professionals. The resident consumed adequate nutrition during a work day had better becomes more aware of the link between nutrition and cognitive function than those who neglected their nutritional well-being. Physicians have identifed several baked rice or whole grain crackers, juice boxes, yogurt practical barriers to healthy eating in the work environment. The resident identifes clean and secure These include lack of time to stop and eat, mostly as a result storage areas on the units where they work and also keeps of staff shortages and workload issues, lack of scheduled a few snacks in their lab coat pocket and locker. The breaks, lack of convenient access to food, poor food choices resident makes time for a healthy balanced breakfast daily. In addition to these practical barriers, physicians have room and ward work schedule. The resident encourages also described how certain attributes of medical professional- the other members of the team to do the same. The ism may in fact hinder their workday nutrition (Lemaire et al resident lobbies the health care organization to improve 2008). For example, doctors have expressed how their strong access to and quality of available nutrition, and to provide work ethic and sense of professionalism discourages them designated, convenient spaces for nutrition breaks. Changing the status quo Many physicians are aware of healthy nutritional choices and Winston J, Johnson C, Wilson S. To overcome these barriers, there needs to be advocacy for ad- equate nutrition in the workplace. Education and dialogue will guide physicians and health care organizations to an increased awareness of the doctors’ nutrition patterns, a facilitation of positive change, and an appreciation of the link between physician nutrition and work performance. As physicians and health care organizations promote the benefts of improved nutrition and workplace wellness, everyone will beneft, given the important link between physician wellness and quality of patient care. Summary Various personal and workplace factors can make it diffcult for physicians to ensure adequate nutrition during their work day. Physicians and health care organizations share a responsibility to improve workplace nutrition by raising awareness, changing nutrition practises and improving access to nutritious food in the workplace. It begins for The medical student most people with deciding sometime during the undergraduate Admission to medical school is a tremendous accomplish- years of university to pursue studies in medicine. There is the delight of achievement, the pride of family is the frst step toward a professional career that is rich in per- and friends, and the promise of a rewarding future. The memory of this joy will serve taken lightly, as the years of training are demanding and require successful candidates in good stead during their transition to self-discipline and dedication. This transition is not meant to be easy, but it preparation, followed by many years of practice, along with brings great potential for personal and academic growth. Medical school admission Medical school can present challenges to one’s personal life.

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Gibson (1993) did not observe reduced micronutrient intakes when total sugars intake exceeded 25 percent of energy generic cialis sublingual 20mg visa. A linear reduction in several micronutrients was observed with increasing total sugars intake (Farris et al cheap cialis sublingual 20mg visa. High Fat, Low Carbohydrate Diets of Children Risk of Obesity In the United States and Canada, there is evidence that children are becoming progressively overweight (Flegal, 1999; Gortmaker et al. Furthermore, Serdula and coworkers (1993) reviewed a number of longitudinal studies with vary- ing cut-off levels for obesity and concluded that 26 to 41 percent of obese preschool children and 42 to 63 percent of obese school-age children became obese adults. Clinical evidence of disease associated with excess body weight, reduced physical activity, or high dietary fat intakes, however, are generally absent. The evidence for a role of dietary fat intakes in pro- moting higher energy intakes and thus promoting obesity in young chil- dren is conflicting. A positive trend in energy intake was associated with an increased percent of energy from fat for children up to 8 years of age (Boulton and Magarey, 1995). A positive correlation between fat intake and fat mass has been reported for boys 4 to 7 years of age (Nguyen et al. However, several studies showed a positive correlation between dietary fat intake and body fatness in children 8 to 12 years of age (Maffeis et al. The average fat intake of nonobese children was measured to be 31 to 34 percent for children 9 to 11 years old, whereas the average fat intake of obese children was 39 percent of energy (Gazzaniga and Burns, 1993). A positive association between fat intake and several adiposity indices were observed, but only for up to 35 percent of energy (Maillard et al. Furthermore, a significant positive association between fat intake and total cholesterol con- centration was observed in only two of five countries (Knuiman et al. The prevalence of aortic fatty streaks differs only slightly among children and adolescents of all populations studied, regardless of the fre- quency of atherosclerosis and coronary artery disease in adults of the respective population (Holman et al. The absence of a relation between aortic fatty streaks and the clinically relevant lesions of atherosclerosis in epidemiological and histological studies has thus raised questions on the clinical significance of fatty streaks in the aorta of young children (Newman et al. The Pathobiological Deter- minants of Atherosclerosis in Youth Study, however, has provided evidence that an unfavorable lipoprotein pattern (i. These findings are consistent with the hypothesis of the progression of fatty streaks to fibrous plaques under the influence of the prevailing risk factors for coronary artery disease (McGill et al. In addition, there are still pivotal issues that must be examined further, including the relationship between fatty streaks found in the arteries of young children and the later appearance of raised lesions associated with coronary vascular disease, the effects of dietary total fat modification on predictive risk factors in children, the safety of the diet with respect to total energy and micronutrients for the general population, and the long- term health benefit of establishing healthy dietary patterns early in childhood. It can been seen from these tables that as the level of carbohydrate intake decreases, and therefore the level of fat increases, certain nutrients such as folate and vitamin C markedly decrease. Furthermore, with increasing levels of fat intake, the intake of saturated fat relative to linoleic acid intake markedly increases. Dietary fat provides energy, which may be important for younger children with reduced food intakes, particularly during the transition from a diet high in milk to a mixed diet. The ranges of fat intake include intakes of saturated fat that should be consumed at levels as low as possible while consuming a nutritionally adequate diet. Maximal Intake Level for Added Sugars As for adults, no more than 25 percent of energy from added sugars should be consumed by children to ensure adequate micronutrient intakes. For those children whose intake is above this level, added sugars intake can be reduced by consuming sugars that are primarily naturally occurring and present in foods such as milk, dairy products, and fruits, which also contain essential micronutrients. Monounsaturated fatty acids are not essential fatty acids, but they may have some benefit in the prevention of chronic disease. Other reports indicate that mono- unsaturated fatty acids have a neutral or beneficial effect on risk (Hu et al. Much work has been conducted and is ongoing to identify the ideal substitute for saturated fat in a blood cholesterol- lowering diet. The effects of a high monounsaturated fatty acid versus a low fat, high carbohydrate diet on serum lipid and lipoprotein concentrations have been a focus of considerable scientific inquiry. Eighteen well- controlled clinical studies that compared the effects of substituting mono- unsaturated fatty acids versus carbohydrate for saturated fat in a blood cholesterol-lowering diet have recently been reviewed (Kris-Etherton et al. In these studies, when on both high monounsaturated fat and low fat, high carbohydrate diets, saturated fatty acids contributed to 4 to 12 percent of energy and dietary cholesterol varied from less than 100 up to 410 mg/d. Diets high in monounsaturated fatty acids provided 17 to 33 percent of energy from monounsaturated fatty acids and contained more total fat (33 to 50 percent energy) than the low fat, high carbohy- drate diets (18 to 30 percent energy). The low fat, high carbohydrate diets provided 55 to 67 percent of energy from carbohydrate. Compared to baseline values, serum total cholesterol concentrations changed from –17 to +3 percent on the low fat, high carbohydrate diet, whereas it changed from –20 to –3 percent on the high monounsaturated fatty acid diet. The change in serum triacylglycerol concentrations ranged from –23 to +37 percent for individuals consuming the low fat, high carbo- hydrate diets and from –43 to +12 percent for diets high in monounsaturated fatty acids. Similarly, some intervention studies showed no effect of monounsaturated fatty acid intake on indicators for risk of diabetes (Fasching et al. Uusitupa and coworkers (1994), however, reported a significantly lower area under the curve for plasma glucose concentration and a greater glucose disappearance rate when healthy women consumed a diet rich in monounsaturated fatty acids (19 to 20 percent) compared with a diet rich in saturated fatty acids. Risk of Cancer Bartsch and colleagues (1999) reported a protective effect of oleic acid on cancer of the breast, colon, and possibly the prostate. A few epide- miological studies have reported an inverse relationship between mono- unsaturated fatty acid intake and risk of breast cancer (Willett et al. Increased consumption of olive oil was associated with significantly reduced breast cancer risk (La Vecchia et al. A diet high in monounsaturated fatty acid-rich vegetable oils, includ- ing olive, canola, or peanut oils, has been associated with a protective effect or no risk of prostate cancer (Norrish et al. Some speculate that the apparent protective effects of olive oil (and other vegetable oils) reflect constituents other than monounsaturated fatty acids including squalene (Newmark, 1999), phenolic compounds, antioxidants, and other com- pounds (Owen et al. No significant association has been reported for monounsaturated fatty acid intake and risk of colorectal cancer (Giovannucci et al. Risk of Nutrient Inadequacy In the United States, monounsaturated fatty acids provide 12 to 13 per- cent of energy intake.

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