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By Q. Mortis. Howard Payne University.

Medicine takes up a large part of my life but I always manage to find time to do other things order doxycycline 200 mg with mastercard prophylactic antibiotics for uti guidelines. We also learn about statistics during that time and how to carry out statistical procedures using the computer order doxycycline 100mg fast delivery antibiotic 1000mg. I didn’t do statistics at school but it’s not a disadvantage since we are taken through things step by step. It’s the same with computing so that even if you’ve never even switched one on before, it soon becomes possible to produce spreadsheets and data analyses. Depending on the case, I sometimes find myself spending longer in the lab to make sure 65 LEARNING MEDICINE I’ve seen everything that I’m supposed to see down the microscope. We eventually found the ophthalmology department and introduced ourselves to the nurses and met the consultant as arranged. We were able to see five patients during the three hours we were there, and it really opened my eyes to the treatments possible. This is the time when we learn how to carry out certain examinations or procedures, everything from blood pressure measurement to drug dilutions. This week we learnt how to examine the eye with an ophthalmoscope and carry out an eye test like you have done at the opticians. It was more complicated than it seemed, and it took me and my partner Toby the entire two hours to get through everything. Lucy and I gave an account about what we’d seen on the ward, and Farid gave a presentation on how laser treatments work to improve eyesight. We discussed the case but realised there were still some aspects to it we didn’t understand. We do this about twice each semester so we have some time to socialise together as a group. At 3 pm we had another theatre event, this one was about eye surgery and the techniques they use—it was quite gruesome. Each semester we’re asked to give our opinions on how the course is going and any improvements that we think should be made. We fill in lots of questionnaires about everything, from the books we use in the library to what we think of our tutors. The staff are really good and although PBL is now well established in its third year, they are still willing to make changes and genuinely listen to our problems. We finished at 4 pm but I went to the computer lab to use one of the computer assisted learning (CAL) programmes. I like using them because they’re more interactive than textbooks; they usually have quizzes so I can test myself at the end. It was quite a good session since we managed to tie up nearly all our loose ends and still had time to talk about the social issues that the case raised. Our clinical tutor gave us a clinical perspective on the case and told us a few of his experiences too. The good thing about working in groups is that it helps us to develop our communication skills. We are always having to explain our theories and listen to each other, which means we get very good at talking about medicine. It is good preparation for us as future doctors as we’ll have to do this constantly with patients. I’ve become very good at working in a team too—an invaluable skill to have as a doctor. One of the best things about PBL is that you really get to know the people in your group very well because you work together as a team. You go through a lot together, and the groups are small enough to allow you to work closely with everyone during the semester. It teaches you important and essential skills for being a doctor as well as being brilliant fun. C-MB Communication skills The teaching of communication skills to medical students has improved greatly across the board in recent years, largely in response to public demand.

Luke states that he loves Shannon very much but he’s concerned about her angry outbursts that occur without warn- ing buy doxycycline 100 mg mastercard hpv. Luke says he doesn’t understand it and Shannon says she doesn’t under- stand it either and she feels terrible about the outbursts generic doxycycline 200 mg otc antibiotic induced yeast infection. She’s a nurse and 282 SPECIAL ISSUES FACED BY COUPLES people tell her that she does things that she denies doing. For example, an- other nurse found a used syringe on the lunch tray of one of Shannon’s pa- tients. Not surprisingly, she presents with clear features of posttraumatic stress disorder (PTSD). Her angry outbursts, which further exploration suggests may be based on flashbacks, are consistent with PTSD. There is the possi- bility of some type of dissociative disorder given the response of Shannon’s coworkers who notice her forgetfulness at work and Shannon’s inability to remember these incidents. Her individual therapist is already attending to the safety issues of Shannon’s patients. In relation to the dissociative be- haviors, what concerns the couples therapist, however, is how these may impact the relationship. We assess this by using a number of psychological inventories including the Impact of Events Scale (Horowitz, Wilner, & Alvarez, 1979), the Trauma Symptom Checklist (Briere, 1996), and the PTSD subscale from the MMPI (Keane, Malloy, & Fairbank, 1984). Luke may also require individual treatment related to his own trauma and this may retard the onset of the couples therapy. Shannon and Luke represent a dual-trauma couple and their dynamic appears to be a cycle of angry outbursts (Shannon) and retreat (Luke), leav- ing the couple feeling confused. The therapist will need to be alert to a pos- sible additional diagnosis of substance abuse in either or both persons. Throughout the couples therapy, Shannon and Luke need to develop con- scious awareness of those moments when Shannon experiences angry out- bursts or dissociation. Shannon tells us in therapy that she finds Luke "insensitive and uncaring" as he continues to become more withdrawn from her and "leaves the house for hours" after her outbursts. Luke states that Shannon’s angry outbursts "scare me" and he leaves because, "I don’t know what to do when she’s like that. Shannon’s outbursts may be triggered by environmental cues (the smell of alcohol and tobacco during sex with Luke). This likely stimulates thoughts and feelings from the past that intrude on her present reality, causing Shannon to believe that she is in danger. As Siegel (1999) describes it, the brain is an anticipation machine and Shannon’s sense of anticipation is heightened due to her traumatic experience of the past. Shannon’s dissociative behavior at work suggests that she may also be dis- sociating when she is with Luke. Luke’s withdrawal from Shannon may rekindle feelings of abandonment related to her earlier abuse. Knowing that Shannon’s mother was aware of but did not stop the sexual abuse, Treating Couples with Sexual Abuse Issues 283 helps the therapist understand Shannon’s feelings of abandonment and her vulnerability to her stepfather’s victimization. The therapist can help her separate memories of these early attachment failures from the interper- sonal workings of the relationship with Luke. This in turn will reduce the personalization and reactivity that is taking place within the context of the current relationship. Educating the couple about the etiology of dissocia- tion, helping them understand that it is a protective measure, is a first step to mitigating this issue. The couples therapist can reframe each of Shannon and Luke’s behaviors as providing protection in moments of fear and can help them find alternative methods to communicate their fears to each other. Shannon’s rage can also be explained as a normal response to her abuse and its expression as a part of her healing process. The therapist must help Shannon become aware of the triggers that cause her outbursts and help her develop the conscious awareness of her fear, so as to better com- municate her fear with Luke and ease her distress. Somatic cues that pre- cede problematic behaviors (for example, muscle tension and stomach upset) can serve as early warning signals of these reactive behaviors. For example, Shannon’s reactions to the smells of alcohol and tobacco may now be associated with traumatic memories of her abuse and these surface when she is having sexual contact with Luke.

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