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By L. Rhobar. University of Dubuque.

It is as though the mind had decided that a physical pain is preferable to an emotional one buy top avana 80mg fast delivery. THE CASE FOR OXYGEN DEPRIVATION How does one know that oxygen deprivation is responsible for the pain? First top avana 80mg otc, many of the body’s reactions to tension and anxiety are the result of abnormal autonomic reactions purchase top avana 80 mg online. The best known is peptic ulcer (a common operation years ago was to cut the 62 Healing Back Pain autonomic nerves to the stomach as treatment for an ulcer) buy cheap top avana 80 mg, but so are spastic colitis discount top avana 80 mg without a prescription, tension headache, migraine headache and a host of others. Therefore, it was thought logical that the pathological physiology of TMS might also originate in the autonomic system. If the autonomics were to be involved in TMS, the best way that they could produce mischief in muscles and nerves would be through the circulatory system. The small blood vessels bringing blood to these tissues (arterioles) need only be constricted a bit, less blood would reach the area, the tissues would be mildly oxygen deprived and pain would result. One body of evidence that the physiologic alteration in TMS is oxygen deprivation is clinical. It has long been recognized that heat, introduced into muscle by diathermy or ultrasound machines, will relieve back pain temporarily. All three of these physical measures are known to increase blood flow through muscle. Increased blood flow means more oxygen, and if that relieves pain it is logical to assume that oxygen deprivation was responsible for the pain. Wegner, reported finding microscopic changes in the nuclei of biopsied muscles from back pain patients suggesting oxygen deprivation in “Morphologie und Pathogenese des Weichteilrheumatismus,” Z. For additional evidence on the critical role of oxygen in TMS we are indebted to a group of research workers who have demonstrated in their laboratories in recent years that muscle oxygenation is low in patients suffering from a disorder known as primary fibromyalgia. Typical of these reports is one published in the Scandinavian Journal of Rheumatology in 1986 (Vol. What this means for the etiology (cause) of TMS, as I have long maintained, is that fibromyalgia, also known as fibrositis and myofibrositis (and to some as myofasciitis and myofascial pain), is synonymous with TMS. I have treated a large number of patients who came with the diagnosis of fibromyalgia; their medical histories and physical examinations were consistent with severe TMS. Therefore, it is reasonable to maintain that the finding of mild oxygen deprivation in the muscles of patients with fibromyalgia supports the hypothesis that the cause of pain in TMS is the same—oxygen debt. As mentioned earlier, TMS manifests itself in many ways, both qualitatively and quantitatively, and it is clear that what is called fibromyalgia is one of the ways in which TMS occurs. These patients are among those who suffer the most severe conditions, for they tend to have pain in many different muscles and to suffer from insomnia, anxiety and depression as well as generalized fatigue. All these manifestations are interpreted as evidence of a higher level of repressed emotionality, primarily anger and, therefore, more severe symptoms. Most contemporary medical investigators cannot accept such an explanation since it violates their basic presumption that the etiologic explanation for physical abnormalities must be in the body itself. They cannot conceive of the idea that something like back pain might originate in the brain. And therein lies a great tragedy for the patient, for as long as this conceptual recalcitrance persists the patient will continue to be misdiagnosed. It is responsible for the excruciating pain that people experience when they are having an acute attack, as described in the first chapter. In the thousands of patients I have examined through the years I have rarely found the involved muscles to be in spasm. Wolfe in a paper published in 1952 titled “Life Situations, Emotions and Backache,” published in Psychosomatic Medicine (Vol. It is of great interest that both muscle spasm and this chemical buildup can be observed in long-distance runners, whose muscles suffer from oxygen deprivation. The presence of muscle pain, either felt spontaneously or induced by the pressure of an examiner’s hand, means that the muscle is mildly oxygen deprived. The Physiology of TMS 65 Trigger Points The term trigger points, which has been around for many years, refers to the pain elicited when pressure is applied over various muscles in the neck, shoulders, back and buttocks. There is some controversy over what precisely is painful, but most would agree that it is something in the muscle.

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We honor our values most by leaving them permeable to modification in the course of experiences occurring as we attempt to actualize them buy discount top avana 80 mg on line. This capacity to learn while doing exemplifies the virtue of open-mindedness as Dewey describes it purchase top avana 80 mg online. Dewey seems confident that the ongoing modification of values and strategies during action will be enhancement and not vitiation buy 80 mg top avana mastercard, but he does not fully explain how cheap 80 mg top avana. Be that as it may cheap 80 mg top avana with visa, congealed values truncate experience in addition to foreclosing possibilities for their own growth. Our psychic investment in experience is lessened when we make our values sacrosanct and keep them closed. To the degree that we protect our values from the influence of experience, we diminish its power to move us. Tiles draws attention to the dynamic, although not infinitely malleable quality of ends in his book Dewey. In contrast to the final cause of Aristotle, which has to do with completion of an entelechy involving the expression of a pre-determined essence, Dewey denies that the end, the fulfillment, can be so largely read out of the beginning. This is because he has a more plastic idea of the nature of organisms, particularly humans, than did Aristotle. As Tiles notes, the thoroughly reciprocal relation of ends and means for Dewey requires some interdeterminacy of ends. They are not, as current theories too often imply, things lying beyond activity at which the latter is directed. Here the intravascular volume contracts or the osmolarity increases, renin, anti-diuretic hormone and other hormones pour out, and water seeking behavior plus the qualitative subjective state of "thirst" is generated. These aims-in-view or "final causes" exert what might be analogous to a "pull" as opposed to the "push" of hypovolemia and a dry mouth. They act as cues which further reinforce both the subjective state of thirst in its dominance over consciousness, and its production of water seeking behavior. The "push" of the DEWEY’S VIEW OF SITUATIONS, PROBLEMS, MEANS AND ENDS105 drive, habit or trait is reinforced by the "pull" of the cue or aim-in-view which could either be present in the environment or produced in fantasy. The final ends are twofold: one is the correction of a physiological imbalance manifested by thirst and perhaps other sensations like a dry mouth, fatigue, dizziness and overheating; the other is the pleasurable sensations accompanying and following quenching of thirst. We have now seen partially how "ends," at least envisioned fulfillments, can operate as means. Dewey reevaluates, as noted in the last chapter, certain things which have usually been seen as ends in themselves, placing them in context. It turns out that the whole notion of anything "in itself" is suspect when the very nature of any entity has to do with its relations. Also both an end and a means, knowledge is, for the pragmatist, opinion which has been tried out and found effective in handling situations. There is debate, of course, about what constitutes proper "handling" of a situation and whether there is something sufficiently objective about a situation that "proper handling" of it can be justified to everyone’s satisfaction. In the absence of any common basis for understanding the nature of situations, any assertions about the "truth" of knowledge which results in proper handling of them look purely idiosyncratic. Nevertheless, on this view, while knowledge remains an end, and while the attainment and use of it have their own intrinsic delights, the criterion by which it is ultimately validated is its usefulness as a tool, i. Scientific knowledge, which quantifies objects, assorts their characters in definable categories and reduces them to formulae for manipulation, brackets objects for certain uses. These qualities are evanescent and fragile, aesthetic, moral or spiritual qualities which elude compre- hension within the categories of instrumental knowledge. We had to drop the immediacy, the intangible aesthetic and other final qualities of things so that science could render our understanding of them useful in material manipulation. In their immediacy we "can do nothing" with the terminal qualities "save have, suffer and enjoy them. Sensuous immersion in and experience of the immediate qualities of things is something most of us would refer to as a kind of knowledge, but this is not the knowledge of science. Science knows things in order to deal with them, whereas qualitative understanding is final. The quality of my experience of this "home" is related to qualities and values of many other past and present things. Although experience provides the raw material for both "knowledge" and qualitative familiarity, only that replicable part of experience which can be placed under concepts and stored for future instrumental use keeps the name of knowledge for the pragmatist.

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Chapter 9 introduces the notions of healthcare "need effective top avana 80 mg," "want top avana 80 mg low cost," and "utilization" and discusses the factors that influence the demand for health services and the ultimate level of utilization generic 80 mg top avana otc. Part III focuses on the practical aspects of healthcare marketing order top avana 80 mg line, describing marketing strategies and marketing techniques—both traditional and cutting edge—as they relate to healthcare buy 80 mg top avana. Chapter 10 discusses the notion of marketing strategies, describing the strategy-development process xvi Introduction and indicating means of implementing strategies. Chapter 11 distinguishes between public relations, advertising, and other traditional marketing activities. Chapter 12 presents contemporary marketing techniques, often adopted from other industries, and their potential contribution to health- care marketing. Part IV presents a practical guide to managing and supporting the marketing process in healthcare. Just as the concept of marketing is rela- tively new in healthcare, so is the notion of "managing" the process. Chapter 13 provides an overview of the marketing process, tying together various components discussed earlier in the text. It provides an overview of the issues involved in managing and evaluating marketing initiatives. Part IV also describes the various functions that are necessary to support the mar- keting effort, from the initial market research to technology-based approaches to managing the customer base. Chapter 14 presents an overview of the marketing research process, describing the uses of research by marketers and reviewing basic research techniques with application of healthcare. Notwithstanding its late introduction in the book, marketing planning should be an early and constant consideration in the marketing process. Chapter 16 examines the categories of data that are used for marketing research and planning, indicating the manner in which these data are generated and the sources from which they can be obtained. Part V includes a single chapter—Chapter 17—on the future of healthcare marketing. The current status of the field is summarized and prospects for the future are considered. The factors that are likely to influ- ence the future course of marketing are considered, and speculation on the future characteristics of healthcare marketing, and marketers, is offered. PART I HEALTHCARE MARKETING: HISTORY AND CONCEPTS art I describes the overall context necessary for an understanding of the field of marketing and its applications to healthcare. One can- P not understand where the field is going unless one knows where it has been, so the evolution of the field requires review. Ultimately, this sec- tion places healthcare marketing solidly within the frameworks of both the healthcare industry and the marketing profession and provides insights into what had been tried in the past. Chapter 1 presents an overview of the history of marketing, ulti- mately focusing on its more recent history in the healthcare arena. It describes the factors that led to a shift from a production orientation to a service orientation in healthcare, with the concomitant growing awareness of market demands. The stages in the development of healthcare market- ing are outlined, and the changes that occurred in the field are noted at each stage. The factors that have contributed to successive periods of health- care marketing successes and setbacks during the past quarter of a century are reviewed. Chapter 2 addresses marketing within a context that was initially resistant to any type of business principles in general and "formal" mar- keting in particular. The chapter describes the ways in which healthcare is different from other industries and in which healthcare marketing is dif- ferent from other types of marketing. The factors that have contributed to the acceptance of marketing in healthcare are identified, along with the contribution that marketing can make to the industry. Chapter 3 reviews the developments that have occurred in health- care in recent years and describes their implications for marketing. The importance of the transformation experience by healthcare in the 1980s for the emergence of marketing as a function within healthcare organiza- tions is noted. The halting evolution of marketing as a legitimate health- care endeavor is outlined. Key terms and concepts are defined, and the special treatment of these notions in healthcare is reviewed.

The supply of health services is affected by the vagaries of health professional training programs top avana 80mg without prescription, restrictions brought to bear by certificate-of-need processes and other regulations order top avana 80mg, and even fads that affect the healthcare industry order top avana 80mg without prescription. The level of demand cheap top avana 80 mg, arguably the most problematic of the three governing factors purchase top avana 80mg with mastercard, is typically not controlled by the end user. Except for elective procedures for which the consumer pays out of pocket, most of the decisions that affect the demand for health services are made by gatekeepers such as physicians and health plans. Thus, the level of demand is more often a function of such factors as insurance plan provisions, availability of resources, and physician practice patterns than the level of sickness within the population. Healthcare Organizations A number of characteristics set healthcare organizations apart from the sell- ers in other industries. Many healthcare organizations, particularly hospi- tals, still linger in the production stage of their evolution. Many such The Challenge of Healthcare M arketing 27 organizations argue that their goal is the provision of high-quality medi- cine. They feel that by providing state-of-the-art technology and the physi- cians, nurses, and allied health personnel to support it, they will be able to attract customers. As with the early industrialists, many of these healthcare organizations have historically maintained oligopolistic or even monopolistic con- trol over their markets. Because of their dominance in the market or arrangements with competitors, health services providers have often been able to ensure a steady flow of patients without having to solicit them. Virtually all healthcare organizations face some competition, and innovations like telemedicine have broadened the scope of would- be competitors. While some purveyors of healthcare goods or services are single minded in their intent, large healthcare organizations like hospitals are likely to pur- sue a number of goals simultaneously. Indeed, the main goal of an aca- demic medical center may not be the provision of patient care at all; it may be education, research, or community service, with direct patient care being a secondary concern. Even large specialty practices are likely to be involved in teaching and research, and, while they are not likely to neglect their core activity, they often have a more diffuse orientation than organizations in other industries. Not-for-profit organizations have historically played a major role in healthcare; even today, not-for-profits continue to control a large share of the hospital-bed inventory. Although physician groups are usually incor- porated as for-profit professional corporations, large numbers of commu- nity-based clinics, faith-based clinics, and government-supported programs operate on a nonprofit basis. This not-for-profit orientation creates an envi- ronment much different from that characterizing other industries. The fact that many health facilities and programs operate with government support also creates a different dynamic. For some organizations the unpredictability of government subsidy is an unsettling factor. For others the assurance of government support allows them to operate perhaps less efficiently than they would otherwise. Another factor that sets healthcare organizations apart from their counterparts in other industries is the emphasis placed on referral rela- tionships. Hospitals depend on admissions from their medical staffs, and their staff members in turn depend on referrals from other physicians. Indeed, except in emergency situations, patients can only gain hospital admission through a referral. Many specialists will not accept self-referred patients but rely on other physicians to send them patients. The same types 28 arketing Health Services of referral relationships exist with regard to other services (e. This situation has become more complicated in that health plans may exert some level of influence over the referral process. Not only do health plans determine which providers can be seen under a particular coverage plan, they may require patients to be referred to specialists and may even seek to authorize any such referrals. In no other industry do parties who are not the end user exert such an influence on the process (see Box 2. Referral relationships as used here include any Importance of mechanism for the steering of consumers by a third party into the dis- Referral tribution channels of a healthcare organization or any use of an inter- Relationships mediary to promote goods and services to healthcare consumers. The importance of such relationships in healthcare is reflected by the fact that the end users of health services frequently do not make the consumption decision themselves.

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