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My brothers and sisters It was in Rhyl discount geriforte 100 mg harbs cake nyc, on the sea-coast of North Wales geriforte 100 mg with visa herbals india chennai, were never made to fetch and carry for me, and I that two fundamental principles of the nursing joined in their play. The Royal Alexandra Hospital was pledom and the great education of pain”; she was perhaps the first hospital for cripples ever to advo- destined to limp her way through life with stick cate fresh air as an integral part of treatment; and or crutch; but already she had learned a first prin- it was the teaching of Miss Graham, one of the ciple—the joy of life despite disability—and this founders, that “no nurse is worth her salt if she was to be her great contribution to medicine. She was awarded the Agnes knew that “you might as well try to stop queen’s badge and brassard, and spent a year in Niagara as stop my mother when once she had Northamptonshire nursing a typhoid epidemic. Hunt decided to return as a district nurse in treating 500 victims of a to England, Agnes Hunt decided to stay in smallpox epidemic. She was In 1900, “mother broke it to me that she was influenced in this decision by an accident sus- becoming old and deaf and intended to live with tained by a young man who was felling trees. He no more travel and there could be no more respon- was found dead 2 months later and from the sibility as a district nurse. But, on reflection, this marks on his wrist he had tried to gnaw his hand indomitable girl realized that it might still be pos- off. Training as a nurse began as lady- preventive treatment, and resettlement of the dis- pupil at the Royal Alexandra Hospital in Rhyl, abled. Now, in 1948, the vast resources of the 148 Who’s Who in Orthopedics Ministry of Health and the Ministry of Labour are cars had recently been introduced; the roads of engaged in the treatment and resettlement of Shropshire were narrow; and the Baschurch nearly one million disabled persons. Bobby met hospitals and after-care clinics have been estab- Jonathan Hustler’s new car with its rush and hoot lished throughout the country. The beginning was: “mother intended with his precious load, and off he set in the middle of to live with me. The road was narrow, the road was long; country house with an estate of no more than Jonathan’s language grew very strong. The neighbours laughed to see the sight; Bobby drainage was primitive; the garden was so run-riot looked neither to left nor to right; till the dray and the that it was a jungle and became known as the whole of its cripple crew, safely back to the home he lion’s den; there were a few cowsheds with drew. When Jonathan started out that day, he swore that broken walls and leaking roofs—this was the nothing should bar his way, though police traps in every Baschurch Convalescent Home. The sheds were more damp and Three years later, recurrence of infection in the draughty within than without, so that open-air hip joint made it necessary for Sister Hunt to treatment was quickly enforced. An editorial, signed by Brother Aaron, One day, soon after I had returned from the Royal reads: Southern Hospital and was still on a frame, I drove the black cob in the dray to Shrewsbury to do my What causes the most excitement is the picnics. I had several cripples with me, the cripples on drays with springs and the others on one of whom was disabled only in the arm and could wagonettes. When we have reached the spot planned, climb on and off the vehicle to ask the shopkeepers to the horses are taken out and fastened to the trees and come out. As luck would have it the cob was restive all the cripples who can’t get about are put on rugs. Those on crutches play as well but ment that adds to one’s dignity and the bobby’s only they are far more artful for when they are about a yard answer was that he considered it unsafe and must take off the base they suddenly drop; of course the crutches my name and address. I told him, and thinking to reach it if they don’t and they are let stand up as if they impress him added that I used to live at Boreatton Park. All sing until they have hardly Unfortunately he knew this place only as a private any breath left to sing the National Anthem. The people lunatic asylum; my brother had let the house for that in the cottages all come out and by the look on their purpose some time after my father’s death. The police- faces we could almost believe they wished to be ill just man remarked acidly that it was just the sort of place for the sake of the picnics. There were picnics to the country and picnics This association with Robert Jones was a mile- to the seaside. The famous pony, Bobby, “the stone by which the Baschurch Convalescent dearest and wickedest of ponies,” made history Home became an orthopedic hospital. McCrae for himself when he was so often left in sole Aitken was at that time house surgeon at the charge of a cargo of cripples. Sir Frederick Royal Southern Hospital, Liverpool, and he Kenyon recorded an incident in verse.

The topic itself is more focused as the researcher has mentioned buy cheap geriforte 100 mg on-line zordan herbals, specifically discount geriforte 100 mg online herbals on deck review, the areas he wishes to consider – nurses’ attitudes, carers’ experiences and available support. His topic is immediately more manageable be- cause he is only considering nurses or carers who come into contact with sufferers of Alzheimer’s disease. How- ever, he needs to think about whether he is going to consider hospitals, residential homes, or both, and in what areas. Also, is he going to contact people who look after their relatives at home? HOW TO DEFINE YOUR PROJECT / 11 Although, on the surface, this project appears more manageable, this researcher has a major point to con- sider. In the UK all social research which is carried out on health care premises comes under the jurisdic- tion of Research Ethics Committees. These committees were set up to ensure that research does not harm pa- tients in any way and that it is done in their best inter- ests. In the USA a similar function is carried out by Institutional Review Boards. This means that the re- searcher would have to get his project approved by the appropriate committee before he could go ahead with the research, and it is not guaranteed that his pro- ject would be given approval. As he would have to sub- mit a full and detailed proposal to the committee, he could be conducting a lot of preliminary work, only to be turned down. Researchers need to think carefully whether this is a route they wish to take, and if so, ob- tain the appropriate advice before committing them- selves. Statement 3: We want to find out how many of the local residents are interested in a play scheme for children dur- ing the summer holiday. This project put forward by a tenants’ association ap- pears to be straightforward and manageable, although there are still several issues which need addressing. My first question for this topic would be: do you really want to find out how many of the local residents are inter- 12 / PRACTICAL RESEARCH METHODS ested, or do you want to find out the interests of resi- dents with children of the appropriate age who would ac- tually use the scheme? If the latter is the case, this narrows down the research population and makes it more manageable. Finding out whether someone is interested in something is not actually the same as finding out whether someone would use the service. For example, I might think a play scheme is a good idea for other children as it might keep them off the streets, but not for my little darlings who are too occupied with their computer. If I said ‘yes, I am interested’, this could be misleading as I have no in- tention of using the service. However, if the purpose of the research is to obtain funding for the scheme, then the more people who express an interest, the better, although the tenants’ association would have to be careful not to produce misleading information. I would also find out whether the tenants’ association was interested only in the issue of how many people were interested in it and would use the play scheme. If they were doing this research anyway, would it be a va- luable addition to find out what sort of scheme resi- dents would like, and what activities their children would like? HOW TO DEFINE YOUR PROJECT / 13 SUMMARY X You must take time to think about your research as this will save you problems later. X When you’re thinking about your research, ask your- self the five ‘Ws’: – What is my research? X Discuss your sentence with your tutor or boss and re- vise if there is any confusion. The first thing you need to do is to think about your research methodology. This is the philosophy or the general princi- ple which will guide your research. It is the overall ap- proach to studying your topic and includes issues you need to think about such as the constraints, dilemmas and ethical choices within your research. Now that you have read Chapter 1, some of these issues will be fresh in your mind. Your research methodology is different to your research methods – these are the tools you use to gather data, such as questionnaires or interviews, and these will be discussed in Chapter 3. UNDERSTANDING THE DIFFERENCE BETWEEN QUALITATIVE AND QUANTITATIVE RESEARCH When you start to think about your research methodol- ogy, you need to think about the differences between qua- litative and quantitative research. Qualitative research explores attitudes, behaviour and ex- periences through such methods as interviews or focus groups. As it is attitudes, behaviour and experiences 14 HOW TO DECIDE UPON A METHODOLOGY / 15 which are important, fewer people take part in the re- search, but the contact with these people tends to last a lot longer.

Some doctors resist referring patients to other physicians be- cause of the implied challenge to their capabilities and authority quality geriforte 100mg herbals medicine. But most primary care interviewees openly admit their limitations in addressing mo- bility and welcome expert advice generic 100 mg geriforte with visa herbs good for hair, typically from specialists in neurology, rheumatology, geriatrics, and orthopedics. I describe their roles briefly below; extensively describing each specialty is beyond my scope here. Physician Specialists Orthopedists generally perform surgery, aiming to ease pain and improve function. Primary care physicians typically refer patients to orthopedists to evaluate whether surgery is warranted, although some patients inde- pendently seek orthopedic input. Some orthopedists specialize in replacing hip or knee joints, while others mainly do back operations (in some insti- tutions, neurosurgeons also perform back surgery). A few often avoid op- erating, recognizing that surgery carries risks and benefits are sometimes uncertain. Neurologists diagnose and treat many conditions that impair gait, like Parkinson’s disease, MS, and ALS—an expertise generally beyond the knowledge of primary care physicians. Nonetheless, many neurologists are not trained explicitly in mobility aids or improving walking per se (as op- posed to addressing the underlying illness), so they refer patients to phys- ical or occupational therapists. In fact, until recently, few neurologic dis- eases had effective treatments; neurologists learned primarily to diagnose disease, leaving day-to-day (often palliative) care to other physicians. She likes being the primary physi- cian caring for her patients over time and explicitly addressing mobility needs. My old professor used to say he could teach anybody to diagnose neurologic diseases, but managing patients sep- arates the men from the boys. Unlike orthopedics and neurology, geriatrics and rheumatology are sub- specialties of internal medicine. Many primary care physicians learn as- 158 / Physicians Talking to Their Patients pects of these disciplines during their training, sometimes complicating de- cisions about when to refer patients. Rheumatologists, also internal medicine subspecialists, care for people with arthritis and other rheumatic diseases—disorders of connective tis- sues and joints marked by inflammation, degeneration, and metabolic de- rangements. Primary care physicians commonly see patients with arthritis, and they know the prevailing medical treatments, so the question becomes when to refer to rheumatologists. Josh Landau trained as both a pri- mary care physician and rheumatologist. I was taught a mnemonic—ADEPT, that is ambulation, dressing, eating, personal hygiene, and transfers. If the X rays are worse but all the other things are better—function, pain, quality of life overall—then we put X rays as a lower priority. Its treatment is reason- ably safe, which is not true for other rheumatic diseases, by and large. That includes function, activities of daily life, pain, not hurting them with my medicines. I usu- Physicians Talking to Their Patients / 159 ally give a speech about podiatrists and occupational therapists, splinting, things that are terrifically safe. They may or may not help, but they’re very safe—more than I can say about my medicines. But I have a harder time getting many patients to accept these kinds of maneuvers than medicines. Landau worries that primary care physicians “refer patients way too late or not at all, either to a rheumatologist or an orthopedic surgeon. They aren’t really aware of the indications for joint replacement surgery or how that can help people. They underutilize rehabilitation services, view it as voodoo, an unproven remedy, which to be honest it is. We don’t have ran- domized control trials of physical therapy with sham physical therapy. On the other hand, rheumatology fellowship taught me a sense of what these different modalities offer in terms of function and quality of life. Landau’s comments highlight the complexities of referrals, espe- cially when physicians have some knowledge in a field.