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It would lead us too far astray to go over the many classifications of emotion which have been made cheap 400mg viagra plus with amex, and I doubt that any one is entirely complete and satisfactory viagra plus 400 mg overnight delivery. Suffice it to say that certain values relate to physiological needs and their satisfaction: hungering buy viagra plus 400 mg fast delivery, thirsting purchase viagra plus 400 mg overnight delivery, lusting viagra plus 400mg visa, avoiding pain, being tired or cold or frightened. Almost as central are our fundamental emotional conditions: being lonely, belonging, being curious, restless, secure, amused, ashamed or caring for children. Other value expressions begin more with schematic bodily positions, but always with a qualitative aspect. For example, embracing, clinging, being let down, turning away, reaching out, pushing away. Many others could be added to this short list, but the point is that many evaluative stances are understood metaphorically in terms of these basic, literal physical experiences and emotional states. To say that "The behavior of the President in the Oval Office give me dysuria" fails to capture the elements "stimulation by a repulsive object" and "violent physiologic rejection response. The cognitive structure of nakedness (an example of a schema, being uncovered), or that of being approached from outside the visual field (usually from behind) for example, is mapped onto vulnerability. The simple schema of heavy and light, based on our physical encounters with material objects, is the basis for a metaphorical mapping of "heavy" onto serious ("Heavy, Man. As everyone who has experienced distinct types of joy and suffering can attest, there are experiential differences which make qualitative comparisons problematic. While we might be able to rate nausea, dyspnea, arthralgia and depression separately on subjective scales of 1 to 10, and while we might prefer arthralgia of 9 to dyspnea or depression of 9 in the abstract, a great deal is lost by trying to convert these distinct experiences into common units of suffering. Qualitatively different physiological feelings, like different pieces of music, have the effect of distracting from each other. Our choices among different types of suffering depend on the particular suffering which is afflicting us at the time. Furthermore, I contend that there is not a neutral standpoint inside or outside of any particular pleasant or unpleasant experience from which it can be assessed. Actually undergoing an experience and reflecting on it later in the light of other 36 CHAPTER 1 experiences is a continuing process which is never finished. These considerations frustrate the search in utilitarian thinking for any fungible unit of value and make precise talk about "cost effectiveness" incoherent. The category of value is enormously complex, containing present action- determining values, consciously unrecognized values, potential values, anthro- pocentric and non-anthropocentric values, constant values and fluctuating ones as well as plural bases for value such as life-promoting, aesthetic and moral groundings. Some partly literal and partly metaphorical concepts of what constitutes value are durability, weight, complexity, size, scarcity, and labor intensity. Additionally, some values can themselves be evaluated on the basis of other ones, which means that the category has a sort of internal dynamism and capacity to evolve. Based on values we have, we can decide that there are others which we ought to adopt. Finally, even on first glance it appears that certain valuable things, such as our children or our food, are centrally important, whereas others such as pre-Columbian art are less so. So value as a complex category, in addition to all of the above factors, must be partly radial with central cases and peripheral ones. Evaluations of ends and outcomes which are qualitatively so diverse defy quantifi- cation in most instances. No argument has been offered to prove that only the "quantitative" is "shared" and that "qualitative" necessarily means "idiosyncratic. CONCLUSION Moses did not come down from Mount Sinai with a commandment to cognize all of medical care in terms of the efficient pursuit of a fully understood end. We should ask which clinical situations are really illuminated by being thought of in such terms. The habitual use of prefabricated values congenial to the hurried journey scenario has monopolized our understanding of clinical medicine in the United States. Assumptions implicit in this scenario and metaphorical map lend themselves to the elaboration of rigid protocols for diagnosis, treatment, "disease management" and "case management. Such protocols work best as "if/then" hypothetical imperatives which can be plugged in for generic situations.

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However discount 400 mg viagra plus with mastercard, when Mark an- nounced that he was extending his own parental leave by several weeks discount viagra plus 400mg line, without pay buy 400mg viagra plus amex, to share fully in this important family event buy generic viagra plus 400mg on line, Angie became ag- itated and fearful effective 400mg viagra plus. Her own father had never heard of parental leave and left all child raising to her mother. Money, or the lack of it, was always an issue in her home, and the family had to make sacrifices to survive on her father’s modest income. Mark’s decision to take leave without pay and be a hands-on dad aroused fearful memories in Angie of financial hardship and concerns regarding her adequacy as a parent, since she believed Mark now looked to her as the expert in matters of childcare. Their constant bickering and Angie’s anxiety brought them into counseling, lamenting the loss of close- ness at what they had hoped would be the "happiest time of their lives. In Angie’s case, her new responsibilities aroused old memories and fears of financial instability. She was also burdened by the unfounded belief that Mark expected her to be the expert. When the expectations of each partner were explored in therapy, Angie shared her assumption that Mark was looking to her for childcare exper- tise. She also shared her discomfort with having Mark at home after the ini- tial settling in period, since it would soon become obvious to him how little she really knew about caring for their newborn. Mark, on the other hand, looked forward to his time at home as an opportunity to bond with their child and learn with his wife how to be parents. Initially, neither Angie nor Mark was able to directly verbalize fears and insecurities to each other. They learned basic communication skills, and with the help of their therapist, each was able to express and acknowledge in- securities about their new roles. They recognized that neither was the expert and developed a plan to participate together in infant-care classes immedi- ately, and parenting classes as their child developed. They were encouraged to expand their circle of friends to include other couples with infants and young children. They learned problem-solving skills to help them resolve parenting and relationship issues as they arose. Some additional time in therapy was used to explore Angie’s unresolved fears around the couple’s finances. The couple was instructed to prepare an annual household budget together, giving them a clear picture of their fi- nancial needs and resources, and to make whatever adjustments were nec- essary to live within their means. This exercise concretized their financial picture and made them partners in finding solutions. Having specific knowledge of their family finances and actively participating in developing a budget and brainstorming necessary changes alleviated Angie’s fear of the unknown, a significant factor in her childhood experience of financial hardship. Finally, the couple was instructed to prioritize their relationship by planning a weekly date night. To eliminate the financial burden of such an assignment, they were instructed to be creative beyond the typical movie night or dinner out and spend no more than five dollars. This added an element of fun and creativity and encouraged dates such as walks along the beach and picnics in the park. Marriage partners bring individual skills into the marriage and develop couple skills that impact their ability to parent effectively. On an individual level, one’s ability to be flexible, to adapt to change, assume new responsi- bilities, and defer personal satisfaction to attend to another are all qualities that bode well for the new parent. Couples acquire a style and identity in the early days before children that characterizes their relationship. Those who have bonded too tightly Couples with Young Children 47 may have difficulty expanding to include a child, and those so loosely con- nected may find it challenging to reorganize around a new member. Rigidly structured relationships with clearly defined roles are especially challenged when a new baby arrives, but among the most important skills couples bring to the childbearing years is their ability to problem solve. When a new baby enters the family circle, there is a decided shift in at- tention from the spouse to the newborn. Although having positive feelings toward their child, anger and resentment may simultaneously be directed at their partner. Fatigue from many sleepless nights, insecurity in handling the numerous childcare tasks, unmet expectations, and the loss of the undivided attention from one’s spouse all contribute to the confusion and turmoil young parents experience. The ground rules have changed, and although old patterns of relating are not always accessible, new pat- terns have not yet been clearly established (Wolfson & DeLuca, 1981).

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The eager acolyte coped competently with the presentation itself and with agreeably animated discussion until he was fazed by a particularly difficult challenge buy viagra plus 400 mg. Obviously discount viagra plus 400 mg free shipping, one should try to avoid accepting unwelcome invitations and purchase viagra plus 400mg, if one has to delegate the invitation to a colleague viagra plus 400mg without a prescription, albeit armed with your prepared script generic viagra plus 400mg amex, bear in mind that he might have problems dealing with questions. Moreover, care must be taken not to underestimate the intelligence or knowledge of the 58 HOW TO DEAL WITH QUESTIONS audience; invariably someone will know more about some aspects of the subject than the speaker. You can choose what to say or not to say in the presentation, but you can only speculate about questions, and "being called in question" clearly presents more dangers than the presentation itself. Invited to address French professors of social medicine in the elegant Chateau de Longchamps in Paris about a European Association to which I wanted to recruit them, I was unexpectedly bidden to speak in French. The chairman came to the rescue: "They all speak English, mon ami, so it is only fair now to switch to your language. For example, if addressing "clinical advances in late onset diabetes", one should review the epidemiology, the history of the diagnosis, treatment and management of the disease, together with its effect on the person as a whole, its relationship to other conditions, and its social, occupational, and economic implications. Turning up in a dinner jacket and finding everyone else in casual smart attire, the late Sir John Brotherston – then CMO Scotland – explained, "I have just come from the office". Conversely, failing to wear a dinner jacket to a "black tie dinner" is not so easily explained away. A jacket and tie can always be removed if appropriate; indeed, it may be effective after a formal presentation to slip off one’s jacket before knuckling down to questions. At a typically sparsely attended AGM which I was waiting to address, it was agreed that those attending should constitute the executive committee en bloc. The scrupulous secretary insisted on listing the names, thereby 59 HOW TO PRESENT AT MEETINGS identifying an unknown young person as being from the medical newspaper, PULSE. Practise conciseness and clarity as distinct from brevity and over-simplification. Fluency is admirable but a stammer, which can suddenly afflict anyone in a difficult situation, can be turned to good account. The distinguished and much loved paediatrician, Freddie Miller, who had a particularly engaging stammer, used to relieve his hearers of any embarrassment by claiming that it was an advantage – "it gives one time to think". Guard against giving gratuitous offence by insensitivity about age, gender, religion, or race. A soft answer can turn away wrath and, more importantly, does nothing to diminish one’s authority. Heaven defend one from the high platform, the scattered remote audience, the dim lighting, except, infuriatingly, in front of one’s own eyes. Ignore the spoiler who is muttering disapprovingly and speak directly to the empathetic listener. Be sensitive to the effect of your answer on the audience as a whole; including any reporters. If the question is very wide, lack of time similarly precludes a reply in breadth. The celebrated Scots dramatist, James Bridie, a "chronic" medical student in those halcyon days when universities were relaxed about examinations, when asked the external relations of the knee joint, replied, "I do not know the external relations of the knee joint, but the external relations of the elbow joint are... You may have been forewarned about the bearded chap in a red shirt and green tie, and are therefore prepared. The chairman may come to the rescue but only you can decide whether or not to give way. An effective ploy is to claim that you are coming to that particular point later, whether or not you have any such intention. On being interviewed Keith Joseph was a disconcertingly honest intellectual, best remembered for his reorganisation of the NHS as Secretary of State in the Health Administration in the early 1970s. The story is told of his first television interview in the early days of that revealing medium, when he was a new junior minister. He answered every question unguardedly, and had the insight at the end to observe that the interview had been disastrous. Today’s politicians are trained to deal with interviews, especially on television. Keith Joseph’s experience reminds us of the crucial 61 HOW TO PRESENT AT MEETINGS importance of knowing whether the interview is being recorded or broadcast "live", or whether there may be an opportunity to see or hear it in advance and to make changes.

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