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Also the numbers of available places vary from school to school and year to year buy ceftin 500 mg low cost, as do their selection criteria and the precise design of their curriculum order ceftin 250mg amex. For example buy ceftin 250mg low cost, at Cambridge buy discount ceftin 500 mg line, arts graduates are particularly encouraged in the expectation that they may bring a different perspective and that through the college system they will receive the necessary academic and pastoral support discount 250mg ceftin with amex. Three Cambridge colleges are sharing the responsibility for these students: Hughes Hall, Lucy Cavendish (women only), and Wolfson. Arts graduates are expected to have acquired basic science knowledge, whether through A levels or an approved foundation course. St George’s requires satisfactory performance in a professionally designed written entrance exam testing basic knowledge, reasoning skills, and communication. This variety is increasing choices for prospective medical students, and means you will need to shop around to find what suits you best. Interview or no interview If you have a fear of interviews or an objection to being selected on the basis of an interview then there are schools which still do not interview (Table 4. The most important advice is to visit as many schools as possible, take in the general feel of the place, look at the accommodation and facilities, explore the local area, and especially take time to talk to the current students, most of whom will, of course, be biased in favour of their school but who will at least be able to enthuse about the good points and answer your questions. Open days and sixth form conferences provide a more formal opportunity to do this. A little careful groundwork can not only improve your chances of obtaining a place at a medical school but also help you to ensure that that place is at the right school in which to spend some of the best years of your life. Application and selection The whole emphasis of this book is to aid and encourage potential medical students to examine properly the career they are considering. This chapter deals in more detail with some of the practical "nuts and bolts" of the process of applying to and being selected by a medical school. All too often careers advice concentrates too much on these practicalities,implying the only criteria for choosing future doctors are whether they can fill out an impressive application form and get themselves selected. This detracts from the more important process of your addressing medicine’s suitability as a career for you,and your suitability to be a doctor. Only after giving this serious consideration should you consider the details of application and selection set out in this chapter. Unfortunately, the qualities which count for most in medicine are not precisely measurable. The measurable—examination performance at school—neither necessarily relates to these qualities nor guarantees intellectual or practical potential. Stewart Wolfe, an American physician, was right to ask: Are the clearly specified and hence readily defensible criteria those most likely to yield a wise and cultivated doctor—a person capable of dealing with uncertainty, of compassionate understanding and wise judgment? Can an ideal physician be expected from an intellectual forme fuste who has spent his college years only learning the "right answers"? Furthermore, there is no acceptable objective measure of the quality of the doctor against which to test the validity of selection decisions. In this sea of uncertainty it is not surprising that selection processes are open to criticism. None the less, few patients would choose a doctor without meeting him or her first and a strong argument can be made for discovering the people behind their UCAS forms, if only briefly. Also, many applicants think that they should have a opportunity to put their own case for becoming a doctor. Selection for interview (and at some schools for offer without interview) is made on the strength of an application submitted through UCAS. An application completed partly by the applicant and partly by a referee, 44 APPLICATION AND SELECTION usually the head or a member of the school staff, who submits a confidential reference. Altogether, about 12 000 home and European Union applicants compete for over 6000 (soon to be 7000) places to read medicine at United Kingdom universities, together with about 1500 overseas students who compete for about 330 places. Deans and admission tutors who have to scan a thousand or two application forms (which they receive reduced in size from the original application) simply do not have time to spend deciphering illegible handwriting. Personal details The first section of the UCAS form presents the personal details of the applicant, including age on 30 September of the coming academic year. Many applicants give instead their current age and at a glance seem to fall below the minimum age for entry at some medical schools or to be so young that older applicants might reasonably be given priority over them. True, the date of birth is also requested, but the quickly scanning eye may not pick up the discrepancy. The list of schools attended by an applicant is often a useful guide to the educational opportunity received. More ability and determination are needed to emerge as a serious candidate for medicine from an unselective school with 45 LEARNING MEDICINE 2000 pupils, of whom only 10–15 normally enter university each year, than from a selective school for which university entry is the norm.

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Because one can think of this boundary as being composed of two oppositely charged sheaths 250mg ceftin fast delivery, it is commonly referred to as the double layer discount ceftin 500mg on-line. In the ideal case buy 250 mg ceftin with mastercard, if two electrodes made of the same metal were in contact with a solution of their salts (e buy discount ceftin 500mg online. If the metals were different buy generic ceftin 500 mg on-line, such as copper and zinc electrodes, there would be a galvanic potential between the two (Figure 4. In the context of measuring EMG potentials, the electrodes must be identical, because you want the measured voltage difference to be attributable to half-cell changes due only to ionic flow within the electrolyte — not to galvanic potentials. Zn Cu ZnSO4 CuSO 4 47 DYNAMICS OF HUMAN GAIT The concepts of half-cell potential and the double layer are extremely im- portant for anyone working in the field of electromyography, because arti- facts in the measured voltages can result when the double layer is disturbed by movement of the electrode. Warner (1972) describes a motion artifact as a percentage disturbance of the double layer. Electrode motion is unavoidable during walking, and especially during running; but if the artifact can be re- duced somehow, the final EMG data will contain fewer errors. The easiest way to achieve minimal motion artifacts is by choosing suitable electrodes. Pure silver is a poor electrode for EMG studies, because silver ions do not exist in the body nor in commonly used electrolytes. Large artifacts can also be caused by the migration of chloride ions from the body to the electrode surface. On the other hand, if the silver is coated with silver chloride, it is usual to obtain a stable half-cell po- tential of only 0. This, together with the fact that a stable equilibrium can be achieved between the chloride ions in the electrolyte and those in the body, allows EMG signals of moving subjects to be measured relatively accu- rately. Warner (1972) describes a second possible source of artifact when measur- ing EMG signals from an exercising subject: the changes in the composition of the electrolyte resulting from the addition of sweat. A similar problem occurs in long- term studies in which the electrolyte is not completely sealed from the air and progressive drying occurs. In the latter case, crystals form and there are fewer free ions available to make up the half-cell (Warner, 1972). To conclude this discussion of characteristics that make up a good elec- trode, it must be emphasized that the physical attachment of the electrode should be firm enough to restrict lateral motion and electrolyte drying, yet not so firm that it hinders the movement of the subject. The electrodes should be as similar as possible, with a low half-cell potential, such as found with the MUSCLE ACTIONS REVEALED THROUGH ELECTROMYOGRAPHY 48 Ag/AgCl combination. If these are used, they should be cleaned gently, after each application, to keep the silver chloride coating intact. Electrophysiology Until now, we have tacitly assumed that there is some activity under the skin that is worth measuring. At this stage it is worthwhile to consider the under- lying physiological processes that cause an electrical voltage to appear on a person’s skin. Of necessity the discussion will be brief, but you are encour- aged to refer to other excellent books on this topic (Loeb & Gans, 1986; Webster, 1976). At the risk of oversimplifying the physiological processes that result in a nerve impulse being transmitted down a nerve axon, Figure 4. In this diagram a dipole (a small object with a positive and negative charge at each end) is moving along a volume conductor. A differential amplifier records the difference between the potentials at Points A and B on the conductor. Initially there is no difference between these points, so the output from the amplifier is zero. However, as the dipole approaches Point A, this point becomes negative with respect to B, and there will be some negative output. Not only does Point B start to register the approaching negative charge, but Point A begins to feel the effect of the positive charge at the other end of the dipole. Finally, when Point B registers the positive end of the dipole, and Point A has returned to zero potential, the quantity A-B is slightly negative. Refer to the text for an explanation of the way that the triphasic signal (b) is generated. It should be noted that a single axon leading to a muscle is responsible for the innervation of as few as 3 or as many as 2,000 individual muscle fibres (Win- ter, Rau, Kadefors, Broman, & DeLuca, 1980). A neuron and the muscle fibres that it innervates are referred to as a motor unit.

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Although he had not ventured into clay work before generic ceftin 500mg on line, he showed minimal anxiety with the medium ceftin 250mg with mastercard. Initially cheap 500 mg ceftin, he wanted to use clay molds rather than creating the characters spontaneously; to assuage his apprehension ceftin 500mg fast delivery, I provided one mold (of faces) cheap ceftin 500 mg on line. Prior to the narrative, Randy was instructed to create clay characters for his story. Once these were completed he created the environment (an is- land) where the characters lived. I purposefully selected an island, rather than other settings, for Randy to symbolically associate the feelings of child- hood survival and abandonment with the harshness of solitary endurance that an island conjures. Additionally, when it was time to re- 231 The Practice of Art Therapy cite his story (although this was almost 4 weeks later), Randy retained all of the characters’ names and biographical information as initially presented. After completing the art work, Randy told this story: Therapist: Welcome to "Master Theater," where we have Randy who is going to tell us a story today. The main charac- ters are Ug and Thug, and an elephant, bear, monkey, turtle, and dragon [see Figure 5. So he started fighting with Ug and he got onto Ug’s boat and learned that there was no gold on the entire island, and there has never been any gold. Randy: Thug had hurt the elephant badly because he tried to get the bear to kill the elephant. It’s got all these little people that maintain it, and the dragon keeps the little people in order. Randy: This monkey was with his family and they had a whole bunch of brothers and sisters. Randy: The bear’s parents are brown bears, but he was a polar bear, and so the Paradise Island climate is just right for everybody and he is 5. Randy: The turtle is just a big, huge turtle that Ug found and brought him to the island on his boat. You get caught in the sand spit and the sand spit will ask you three questions about your life, and if you’re not honest about it, it will eat you up. If you get sucked down there you just stay there forever and ever with the bad people. They can just think about the island and all the people who are having fun there and have a place to go in their head. There is somebody who will help them, but they need to get up and work and try to find it. Therapist: You also told a story within a story about Thug and the gold, what is the moral in that story? Randy: You need to talk and trust people sometimes even when you know they might be lying to you because it could get you killed, or hurt, physically or mentally, if you don’t. Each character on Paradise Island can be said to symbolize Randy at different stages of his life. Ug is Randy in the present ("all Ug wanted to do was live by himself") as well as the idealized personality ("Ug found him [monkey] and brought him to Paradise Island" [Ug as a competent rescuer]). His relationships parallel the aggressive characteristics of Randy’s interactions, as well as the abusive familial relations. The monkey seems to represent Randy in his hurt, infantile state as the smaller entity in the family unit who is cast aside. The bear, another cast-aside entity, appears to correlate to Randy’s removal from his home ("The bear’s parents are brown bears, but he was a polar bear, and so the Paradise Island climate is just right for everybody. Interestingly, magical components in his story are either out of reach (boat), evil (hole to the center of the world), or based upon strictly superego manifestations (the spirit faces and the sand spit). Overall, Paradise Island has been populated with those who have been cast aside from the mainland, a group of misfits where Ug has found a mea- sure of self-esteem and regard. Unfortunately, the "guidance" that is avail- able is not being utilized and instead sits idle awaiting counsel. Instead, the group is content to "just kick back and relax and do what they want to" on an island based upon inner desires and primitive impulses. In response to Randy’s story the following narrative was related: Therapist: Once upon a time there was a young man named Ug who came to the island because he wanted to escape the mainland. He de- cided he had enough of that, and he built his own ship and sailed the magical ship far away into the sea beyond all signs of land. Ug was living happily and built a hut and lived alone with the animals who treated him nicely, until one day this guy named Thug came on the island who said he was there to get him.

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Promotion involves a range of tactics involving publicity purchase ceftin 500 mg mastercard, adver- tising buy ceftin 500 mg low price, and personal selling (Berkowitz 1996) buy ceftin 250mg mastercard. The promotional mix refers to the various communication techniques such as advertising ceftin 250mg low cost, personal sell- ing buy cheap ceftin 250 mg on line, sales promotion, and PR or product publicity available to the marketer to achieve specific goals. Because promotion covers all forms of marketing communication, it includes communications that deliver value in addition to those that entice transactions. For example, health plans can devise communications that enable new members to better understand their coverage and rules for accessing care, enabling them to avoid frustration and get better use of their coverage in addition to promoting member satisfaction and reten- tion. Providers can advise new patients on how to avoid place frustrations and costs and address symptoms and concerns online prior to appointments to improve quality and patient satisfaction. The application of the traditional four Ps of the marketing mix to healthcare is considered problematic by many observers. Some consider these dimensions of marketing inappropriate for a service-oriented insti- tution like healthcare. The uncomfortable fit between the four Ps of mar- keting and healthcare has even led some to pronounce the death of the four Ps and suggest their replacement with some other, more appropriate model in healthcare (see Box 4. Some have announced the death of marketing’s traditional in Healthcare four Ps, often calling for some other conceptualization of the market- ing mix to replace them. Citing these pillars of the marketing mix as anachronisms in healthcare, English (2000) has argued for their replacement with a more contemporary set of letters—the four Rs: • Relevance—getting to know consumers, acting and speaking in their interests, lis- tening to and understanding them, creating and using databases about them • Response—creating and fulfilling brand expectations, orchestrating service experi- ences that profitably meet the needs and wants of consumers • Relationships—forging formal links between the organization and targeted con- sumers • Results—gaining market share and share of customers There is no need to argue over the usefulness of the four Rs championed by English. Who could argue against getting to know consumers better, responding to the needs identified for the market, building relationships with customers, and focusing on the results produced through the organization’s programs? They remain distinct factors still appropriate for application to healthcare marketing. Relevance and response are valid emphases for marketing, with both relationships and results essential outcomes for them. Nevertheless, the four Ps are still the attributes we work with to achieve marketing outcomes, with the four Rs involving a somewhat different perspective on these attributes. Product The first P, the product of healthcare, still represents what healthcare providers are mar- keting—the benefits to consumers of using particular services in specific contexts. One of the Rs, relationships, does significantly alter marketing, although not in the ways described by English. If a lasting, loyal relationship is the aim of healthcare marketing, it makes sense for the product to be the lasting benefit to consumers that the relationship offers and delivers. Price The flip side of product benefits is product costs to the purchaser, which may well be reduced through more efficient and responsive staff and systems but are rarely eliminated altogether. The benefits of health promotion and risk reduction typically require significant lifestyle changes and additional efforts by consumers and often their families as well in supporting or enabling such changes. Gym workouts, changes in diet, and even change of jobs to reduce stress may impose financial burdens, although quitting smoking or obtaining treatment for alcohol or drug abuse should improve finances. Considering the often lasting and sig- nificant benefits available through healthcare and the coverage that makes it feasible, com- pared to the typical one-time costs thereof, the value of long-term relationships is likely to be perceived more positively than the typical encounter. Place The third P relates to all factors of the transaction or relationship experience that make it easy to obtain their benefits. In some cases place factors may enhance perceptions of the quality of the product. Enabling communications with providers between visits online, for example, can add value of its own and eliminate the need for some face-to-face visits and their place costs. Knowing that one’s personal physician, or at least an on-call sur- rogate, is always available can add a lasting sense of security for parents with a new baby or those with life-threatening conditions. Having one’s medical record available online for emergency or for out-of-area physicians to use can improve both quality and con- venience for patients and give them confidence when traveling. All forms of mar- keting communications in healthcare seem to be increasing, particularly direct-to-con- sumer advertising by pharmaceutical firms. Advertising alone is estimated as a $1 billion annual expenditure for healthcare providers and a $2 billion annual expenditure for phar- Other Marketing Processes A variety of other marketing concepts could be introduced at this point. The following sections present selected concepts that are likely to be use- ful to reader in later chapters. Marketing Planning Marketing planning may be defined as the development of a systematic process for promoting an organization, service, or product. This straight- forward definition masks the wide variety of activities and potential com- plexity that characterize marketing planning. Marketing planning can be limited to a short-term promotional project or comprise a component of Basic M arketing Concepts maceutical companies.

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