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Michigan Native to Throw First best place to buy kamagra uk Pitch at Aug. 30 Great Lakes Loons GameMillie McGinnis, a Michigan native, was chasing her dreams in California when diagnosed with anaplastic astrocytoma glioma. Millie McGinnis, a best place to buy kamagra uk Michigan native, was chasing her dreams in California when she began having intense headaches.

In the fall of 2020, she was diagnosed with anaplastic astrocytoma glioma – a tumor in the frontal lobe of her brain. She was 22 best place to buy kamagra uk years old. After a long road and with the help of medical teams at MyMichigan Health and their partners at Michigan Medicine, McGinnis is planning to travel back to Los Angeles soon to pick up where she left off.Upon receiving her diagnosis, McGinnis’s mother immediately flew to the west coast to help her pack and bring her back to Michigan where she could receive care close to family in Sanford.

McGinnis’s type of best place to buy kamagra uk cancer was determined as grade three, a coordinated treatment plan was necessary involving surgical, oncological and radiation teams at Michigan Medicine and MyMichigan Medical Center Midland.Anaplastic astrocytoma is a rare malignant brain tumor, its exact cause unknown. In addition to having to navigate this unnerving territory, McGinnis’s diagnosis and initial treatments occurred in the midst of the erectile dysfunction treatment kamagra when visitor restrictions were in place. Being separated best place to buy kamagra uk added extra strain and stress onto McGinnis and her family, but medical staff did their best to keep them as connected as they could.

During pre-op in Ann Arbor, doctors and nurses communicated with McGinnis’s mom using FaceTime. McGinnis’s sister, a physician assistant, kept family and friends best place to buy kamagra uk updated on social media.Neurosurgeon Jason Heth, M.D., performed her surgery. It took 15 hours to complete, but the tumor was removed entirely.

McGinnis was able to go home in less than a week to recover with family. €œI don’t really remember much of the time after best place to buy kamagra uk surgery,” said McGinnis. €œI was just incredibly grateful for the expertise of Dr.

Heth and best place to buy kamagra uk his team.”At her follow-up with Dr. Heth, he explained the radiation and chemotherapy were needed. He referred McGinnis to Neuro Oncologist Yoshie Umemura, M.D., in Ann Arbor and Radiation Oncologist best place to buy kamagra uk Rajesh Kotecha, M.D., in Midland.McGinnis was prescribed oral chemotherapy and radiation for six weeks.

Weekly blood draws checked her platelets and white blood counts. €œI was best place to buy kamagra uk exhausted and struggled with eating,” McGinnis said. €œBecause I didn’t have infusions, I didn’t lose my hair.

A person on best place to buy kamagra uk the street probably would never know I had cancer. It reinforced my belief that being kind to every person you come in contact with is so important – you truly never know what they might be going through.”McGinnis received radiation from Dr. Kotecha in Midland while maintaining best place to buy kamagra uk video appointments with her oncologist Dr.

Unamera in Ann Arbor. €œDr. Kotecha’s office has the most amazing group of best place to buy kamagra uk people,” said McGinnis.

€œI highly, highly recommend the staff there. Everyone was best place to buy kamagra uk so kind and welcoming. Their friendliness put me at ease.” Three months after surgery, an additional spot that was noted on the right temporal lobe showed growth.

Dr. Umamera prescribed cyclic chemotherapy with follow-up MRIs. It was an ongoing battle to achieve the proper blood counts so that the chemo could be administered safely, and there were many lapses.

€œWhen I came back in October of 2020, I never imaged it would be a two-year ordeal,” she said. €œVarious things kept popping up that slowed my chemo down, and I’m still here. It has been frustrating.

I will also say that many have it much worse than I do. I don’t spend time asking why. It is what it is.”As McGinnis was unable to work during treatment, she applied for and qualified for grants from the Pardee Cancer Treatment Fund to assist with medication costs and expenses related to treatment.

MyMichigan has begun construction on a comprehensive cancer center for the Midland campus. The James T. And Elsa U.

Pardee Cancer Center (Pardee Cancer Center) groundbreaking was in April of this year.“The Pardee family has done so much to help cancer patients like McGinnis in our region,” said Denise O’Keefe, executive director, MyMichigan Health Foundation. €œTheir commitment to bring a center such as this to our area will have a long-lasting impact on cancer patients in our communities.”In May of 2022, family and friends surprised McGinnis with a “no more chemo” party. As of July, McGinnis is feeling well, exercising at the gym and excited about getting back to California to pursue her career goals.

She will continue being monitored and work with her medical teams to keep her type of cancer under control.When asked what she would say to others having to face something like this, she said “I followed doctors’ order and did my best to keep a positive outlook. I still do – positivity is key. I have also learned not to take anything for granted,” said McGinnis, who will throw out the first pitch at the Great Lakes Loons on Tuesday, Aug.

30. €œI feel truly grateful and blessed to have gotten this far, and I am going to move forward and live my life the way I want to live it.”Those interested in more information on MyMichigan’s comprehensive cancer program may visit www.mymichigan.org/cancer..

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NSW Health has revised the erectile dysfunction treatment re period from 12 weeks down to four weeks effective from today.People who have previously had erectile dysfunction treatment should test for erectile dysfunction treatment after 28 days since their isolation ended if experiencing symptoms and follow the relevant health advice if they test positive is kamagra as good as viagra. People who is kamagra as good as viagra test positive again will be reported and managed as new cases. NSW Chief Health Officer Dr Kerry Chant is kamagra as good as viagra said the reduced re period, which follows the advice from the Australian Health Protection Principal Committee, is due to the latest subvariants of Omicron circulating in the community.“The Omicron BA.4 and BA.5 subvariants are circulating widely in NSW. They are is kamagra as good as viagra more able to evade immunity gained from previous and vaccination re is more likely and possible just weeks after a prior ,” Dr Chant said.“We’re urging people who have recently had erectile dysfunction treatment, even if they left isolation in the past four weeks, not to be complacent. If you develop symptoms again, make sure to test and isolate.”Dr Chant is also urging members of the is kamagra as good as viagra community who are now eligible for a erectile dysfunction treatment booster dose to access it as soon as possible ahead of an expected peak in cases in the coming weeks.

The expansion of the winter booster program means those aged 50 to 64 years are now recommended to receive a second or winter booster is kamagra as good as viagra dose, which is available to all those aged 30 and over.“With the rising number of erectile dysfunction treatment cases in the community driven by a wave of wave of BA.4 and BA.5 s, it is vital people are up to date with their erectile dysfunction treatment vaccinations, as this will provide the best protection against severe illness from erectile dysfunction treatment,” Dr Chant said. Dr Chant said while most cases of erectile dysfunction treatment are mild, some members of the community are at a risk of severe and may be able to access antiviral medications to treat their .“Antivirals work best when taken at the beginning of a erectile dysfunction treatment , so it is really important that if you are at high risk, you plan ahead, speak with a doctor so you understand the treatment options which are available to you if you test positive for erectile dysfunction treatment,” Dr Chant said.All members of the community are being asked to do little things that reduce the risk for more vulnerable members of the community and make a big difference, including by:staying up to date with our vaccinations – for both flu and erectile dysfunction treatmentstaying home if unwell, taking a erectile dysfunction treatment test and self-isolating wearing a mask in public indoor spacesgetting together outdoors or in large, well-ventilated spaces with open doors and windowspractising good hygiene by washing or sanitising our hands taking a rapid antigen test for erectile dysfunction treatment before visiting vulnerable loved ones or going to large gatherings and events..

NSW Health has revised the erectile dysfunction treatment re period from 12 weeks down to four weeks effective from today.People who have previously had erectile dysfunction treatment should test for erectile dysfunction treatment after 28 days since their isolation ended if experiencing symptoms and best place to buy kamagra uk follow the relevant health advice if they test positive. People who test positive again will be reported and managed as new best place to buy kamagra uk cases. NSW Chief Health Officer Dr Kerry Chant said the reduced re period, which follows the advice from best place to buy kamagra uk the Australian Health Protection Principal Committee, is due to the latest subvariants of Omicron circulating in the community.“The Omicron BA.4 and BA.5 subvariants are circulating widely in NSW. They are more able to evade immunity gained from previous and vaccination re is more likely and possible just weeks after a prior ,” Dr Chant said.“We’re best place to buy kamagra uk urging people who have recently had erectile dysfunction treatment, even if they left isolation in the past four weeks, not to be complacent.

If you best place to buy kamagra uk develop symptoms again, make sure to test and isolate.”Dr Chant is also urging members of the community who are now eligible for a erectile dysfunction treatment booster dose to access it as soon as possible ahead of an expected peak in cases in the coming weeks. The expansion of the winter booster program means those aged 50 to 64 years are now recommended to receive a second or winter booster dose, which is available to all those aged 30 and over.“With the best place to buy kamagra uk rising number of erectile dysfunction treatment cases in the community driven by a wave of wave of BA.4 and BA.5 s, it is vital people are up to date with their erectile dysfunction treatment vaccinations, as this will provide the best protection against severe illness from erectile dysfunction treatment,” Dr Chant said. Dr Chant said while most cases of erectile dysfunction treatment are mild, some members of the community are at a risk of severe and may be able to access antiviral medications to treat their .“Antivirals work best when taken at the beginning of a erectile dysfunction treatment , so it is really important that if you are at high risk, you plan ahead, speak with a doctor so you understand the treatment options which are available to you if you test positive for erectile dysfunction treatment,” Dr Chant said.All members of the community are being asked to do little things that reduce the risk for more vulnerable members of the community and make a big difference, including by:staying up to date with our vaccinations – for both flu and erectile dysfunction treatmentstaying home if unwell, taking a erectile dysfunction treatment test and self-isolating wearing a mask in public indoor spacesgetting together outdoors or in large, well-ventilated spaces with open doors and windowspractising good hygiene by washing or sanitising our hands taking a rapid antigen test for erectile dysfunction treatment before visiting vulnerable loved ones or going to large gatherings and events..

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The article kamagra oral jelly perth by Sorra and colleagues in this issue of BMJ Quality and Safety1 reflects a subtle but important shift in national efforts to enhance quality in explanation healthcare. Since 2000 and the publication of To Err is Human,2 there has been widespread recognition of the need to address patient safety issues at kamagra oral jelly perth a systems level. This and subsequent discourse directed attention to organisational culture as a key lever for ensuring safety and quality.

The follow-on Crossing the Quality Chasm report acknowledged the multidimensionality of the cultural challenge by recommending redesign of the American healthcare system including six aims for improvement—safety, effectiveness, patient-centeredness, timeliness, efficiency and equity.3 However, safety has received the lion kamagra oral jelly perth share of attention over the last two decades, perhaps due to Hippocrates’ admonition to ‘first, do no harm’. Efficiency has been particularly neglected. Despite painfully high, and relentlessly increasing, healthcare spending as a percent of US gross domestic product4 and embarrassing comparisons of outcomes for our spending,5 efforts in the USA to address escalating kamagra oral jelly perth costs of healthcare have been relatively recent6 7 and have not sought to address organisational culture.

Even in countries that achieve higher value, that is, patient experience and outcomes over cost, greater efficiency must be an enduring goal.In this context, the article by Sorra and colleagues is remarkable. In a project supported by the US Agency for Healthcare Research and Quality, they offer a set of new survey items to assess the culture of value and efficiency in hospitals and medical offices.1 More importantly, they offer a vision, derived with extensive input from academic experts and clinical professionals, for understanding the role of value and efficiency kamagra oral jelly perth in promoting quality that policymakers, health system leaders and frontline healthcare workers can embrace. Since the authors did not do so explicitly, below I offer a conceptual model implied in this research (figure 1).

The model suggests that value and efficiency culture interacts with kamagra oral jelly perth quality and safety culture and is thus a key contributor and enabler of healthcare quality. In other words, cost and quality go hand in hand in a 1+1=3 type relationship. Streamlining workflows and doing things right the first time enhances quality by improving efficiency kamagra oral jelly perth.

Quality/safety culture and value/efficiency culture have potential for synergy such that their combined impact on outcomes is more than the two independent effects. The more staff gain experiences with activities to improve efficiency, the kamagra oral jelly perth higher and stronger, that is, more widely shared, the culture of value and efficiency. Value/efficiency culture also increases the likelihood that organisations and managers will ensure staff have further experiences with activities to improve efficiency.

This conceptual model is consistent with theoretical frameworks that describe cultural evolution as a process of enabling, enacting and kamagra oral jelly perth elaborating the desired culture.8 9Conceptual model. Role of value/ efficiency culture in promoting healthcare quality." data-icon-position data-hide-link-title="0">Figure 1 Conceptual model. Role of value/ efficiency culture in promoting healthcare quality.How kamagra oral jelly perth health systems administer and use the new value/efficiency item set is critical.

As the conceptual model makes clear, value/efficiency culture should be considered jointly with safety culture, not as a replacement, to understand the outcomes it will produce in kamagra oral jelly perth patient care. Surveys are teaching and expectation setting tools as much as evaluation tools. Thus, including both dimensions of quality signals kamagra oral jelly perth their equal importance and synergistic potential to the organisation.

Additionally, differences in the pattern of results would suggest different approaches for addressing them. For example, where a site exhibits low efficiency culture but kamagra oral jelly perth high safety culture, an organisation might benefit from training, incentives,or programmes that highlight models where value and efficiency enhance safety and quality. In contrast, where efficiency and safety culture are both low, the site may need more basic infrastructure—like personnel and capacity for data collection and analysis—to enable any sort of improvement.

Likewise, efforts to use value/efficiency culture kamagra oral jelly perth results to spur ‘lean thinking’ and other approaches to improve value culture must emphasise the utility of efficiency for improving quality to prevent a ‘cost-cutting as an end in itself’ mentality to pervade.Findings from the pilot test of this culture of value and efficiency survey suggest additional, actionable strategies for using survey data from the new items. In this context, it is worth restating the authors’ conclusion that ‘It is clear from these results that much more needs to be done within healthcare organisations to ensure that activities focused on value and efficiency are supported and conducted’. The first actionable strategy is related kamagra oral jelly perth to the item receiving the lowest score for both hospitals and medical offices.

€˜We invite patients to serve on advisory panels or committees to help us improve the patient care experience.’ While recommended for patient-centred medical homes10 and required as part of research endeavours supported by the Patient-Centred Outcomes Research Institute (PCORI),11 healthcare organisations often baulk at involving patients in efforts to improve patient care12 despite examples of the benefits of patient engagement.13 A second strategy is that particular attention should be given to management support for improving efficiency and reducing waste in hospitals and in medical offices, the dimensions with the lowest scores. The low scores for hospitals and medical groups kamagra oral jelly perth on measures of experience with activities to improve efficiency suggest opportunities for managers to show support for improving efficiency and reducing waste through encouraging more exposure to these activities.The second actionable strategy—encouraging management support and efforts to increase experiences with efficiency and waste reduction activities—requires alignment of incentives for managers and staff. Payers must continue building on value-based payment reforms, including the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), and primary-care focused initiatives like Comprehensive Primary Care Plus (CPC+),14 the Global and Professional Direct Contracting Model15 and the Primary Care First Model16 to ensure that healthcare organisations have more reasons to improve value than to increase services.

Beyond financial incentives, kamagra oral jelly perth acknowledgement and recognition for managers and staff that support value-enhancing initiatives and for healthcare organisations that achieve higher value would motivate attention to improving efficiency.Another noteworthy finding was that clinical staff had more positive value and efficiency culture perceptions than did non-clinical staff, and that among non-clinical staff, managers were more positive than non-managers. One explanation for clinicians’ positive perceptions may be that they benefit more from efforts to improve efficiency because they are closer to the patients who benefit. Lower perceptions among non-clinical staff, however, suggest the importance of raising awareness among non-clinicians, kamagra oral jelly perth particularly among those with financial and purchasing responsibility who many have authority to impact efficiency.

That managers’ perceptions are more positive is not surprising given similar findings about safety culture.17 However, such findings also suggest that managers may underestimate leadership needed to enable a culture of value and efficiency. Therefore, within a strategy to garner sufficient kamagra oral jelly perth management support, efforts to ensure managers understand the perceptions and concerns of frontline workers will be important.The authors found significant and sizeable intraclass correlations, confirming that site membership impacts the way individuals responded to the survey. Also, substantial SDs were found kamagra oral jelly perth particularly among medical groups.

These findings confirm that value and efficiency culture is an attribute of organisations and that it varies meaningfully among organisations. As with kamagra oral jelly perth safety culture, comparative studies would therefore offer opportunities for identifying and learning from high performing sites. Meaningful variation is also likely across units within organisations.

The authors recommended learning kamagra oral jelly perth from healthcare systems that are well known for their focus on culture change to improve high-value healthcare. However, emulating organisational improvement programmes has proven difficult given differences in organisational characteristics and contextual factors, so local comparisons can prove especially valuable.18 Comparing higher to lower scoring units within institutions in order to identify opportunities for learning among lower performers, as is often done with safety culture, will likely yield similar benefits in the context of value.Efforts to measure and improve value and efficiency culture would benefit from additional research. Although reasonable given the authors’ constraints and goals, by choosing not to administer the new value/efficiency culture items together with the original survey and by not conducting an kamagra oral jelly perth exploratory factor analysis, this also means they missed learning opportunities.

Future research should fill these gaps and use survey-derived empirical data to explore how value/efficiency culture is related to quality/safety culture from the perspective of frontline workers. Particularly considering high correlations between some factors (as kamagra oral jelly perth high as 0.85 in the hospital sample), an exploratory approach to determining an underlying simple structure in the data could yield new insights about how workers think about relationships among value/efficiency concepts.19 Investigators could administer the Survey on Patient Safety Culture together with the new value and efficiency item set. If the sample were sufficiently large, they could use responses to both quality/safety and value/efficiency items and perform exploratory factor analysis.

Doing so could shed additional light on relationships kamagra oral jelly perth among concepts. For example, a strong relationship between concepts may suggest that there are mechanisms that foster both or that one may facilitates achievement of another. Such an understanding could be helpful kamagra oral jelly perth in designing additional recommendations for action.

The survey also requires additional validation, which could be achieved by comparing survey results to other measures of value and efficiency, such as those derived through time-based activity-based costing.20Meanwhile, the value/efficiency item set as developed by Sorra et al offers hospitals and medical groups a valuable opportunity as an excellent starting point to measure and increase their understanding of an important aspect of organisational culture and key contributor to healthcare quality.Ethics statementsPatient consent for publicationNot applicable.While the direct risks of the erectile dysfunction treatment on people with type 2 diabetes (T2D) are well established,1 the indirect effects of the erectile dysfunction treatment response on their management are less well understood. It is kamagra oral jelly perth estimated that 4.7 million people have diabetes in the UK with T2D accounting for 90% of all diabetes cases, with primary care being at the forefront of delivering diabetes care.2 Besides the disproportionately high immediate direct effects of the erectile dysfunction treatment kamagra on people with T2D, it has also exerted indirect effects through severe disruptions in the routine care of patients.3 During the first wave of the kamagra, efforts were directed away from prevention and treatment of long-term conditions, resulting in reduced access to primary care services, cancelled and postponed consultations and reduced community care. Furthermore, many patients avoided or delayed seeking medical attention for routine follow-up or non-erectile dysfunction treatment-related problems, due to fear of and/or to reduce strain on health services overwhelmed by erectile dysfunction treatment.4 5 As a group with elevated clinical risk, people with T2D were advised strict adherence to recommendations issued to the general public, while those at highest risk of adverse outcomes within this at-risk group were also advised to minimise face-to-face contact with others.6 7 Although the disruptions in service delivery generally affected care pathways for all long-term conditions, diabetes was one of the most affected long-term conditions.8In this issue of BMJ Quality and Safety, Carr and colleagues provide important data on the scale of interruptions in the routine management of patients with T2D in UK primary care before and after the first peak of the erectile dysfunction treatment kamagra.9 This large cohort study of 161 181 patients with T2D assessed temporal changes in the rates of diabetes health checks (or ‘care processes’) recommended by the English National Institute for Health and Care Excellence (NICE), and the prescribing of medications to people with T2D.

England’s first national erectile dysfunction treatment kamagra oral jelly perth lockdown was in place between late March and May 2020. The authors assessed six selected care processes during three time periods kamagra oral jelly perth. April 2020 (first full month of national lockdown), May–December 2020 (recovery period) and March–December 2020 periods (lockdown and recovery periods combined), and compared the observed rates during these periods and the expected rates based on 10-year pre-kamagra trends.As might be expected, the results suggest major detrimental effects of the kamagra and national lockdown on the performance of evidence-based care processes and prescribing among people with T2D in primary care.

First, in April 2020, rates of a number of care processes were reduced by between 74% and 88% in the UK compared with pre-kamagra kamagra oral jelly perth trends, with similar effects across the four countries of the UK. Although the quality of diabetes care showed recovery between May and December 2020, it remained below expected levels particularly for blood pressure monitoring. Second, between March and December 2020, the performance of a range of care processes was reduced by between 28% and 47% in England kamagra oral jelly perth compared with pre-kamagra trends, with blood pressure monitoring again being the most affected.

Corresponding reductions in the rates of care processes were similar in the other UK countries (between 37% and 51%). The authors estimated that these reductions in the rates of care kamagra oral jelly perth processes translate into approximately 7.4 million fewer health checks performed in the UK during this period. Third, although the study found that prescribing of new glucose-lowering and antihypertensive medications declined by one-fifth between March and December 2020, no differences in the overall rates of prescribing (for new and repeated prescriptions combined) were evident, suggesting that more robust systems are in place for pharmaceutical therapies.

Finally, it is notable that different age, sex kamagra oral jelly perth and deprivation groups seem to have been similarly affected, leaving pre-existing inequalities unchanged. Older patients from deprived areas experienced the largest reductions in health checks, and the authors concluded that this finding might be possibly due to higher rates pre-kamagra in this group.While most research focus has been directed at reducing and preventing the direct effects of the erectile dysfunction treatment kamagra, worrying data on reduced healthcare utilisation have emerged in relation to a range of consultations, hospital admissions and clinical procedures compared with pre-kamagra periods.10 However, studies explicitly assessing the indirect effects of the kamagra on primary care services including changes in the frequency of patient contact have been scarce.5 10 A previous study demonstrated a range of indirect effects of erectile dysfunction treatment on people with T2D, including reductions in the rates of diagnosis of T2D, glycaemic testing and new prescription of first-line glucose-lowering medications in UK primary care.11 Although the long-term effects of the erectile dysfunction treatment on people with T2D are yet to be seen, the levels of interruptions in their management during the first peak of the kamagra demonstrated by Carr and colleagues provide important cause for concern.Suboptimal management of T2D may lead to a range of burdensome and costly complications in the medium to longer term that are otherwise largely preventable through readily available evidence-based interventions for the detection and management of vascular complications.12 These include the regular assessment of microvascular complications (eg, kidney function tests, diabetic eye screening and foot checks), and monitoring and management of vascular risk factors (eg, blood pressure and glucose control).12 Primary care-based interventions for the early detection and management of diabetes-related complications are the cornerstone of comprehensive secondary prevention, and completion of the nine essential care processes recommended by the NICE guideline is an important marker of the quality of diabetes care.12 Previous population-based studies demonstrate that among people with T2D, completion of higher number of care processes is associated with lower rates of all-cause mortality,13 14 lower extremity amputations,15 sight-threatening diabetic retinopathy16 and emergency hospital admissions for all-cause, diabetes-related and cardiovascular causes.17 Obstructions of diabetes services and failures in meeting essential standards of care through missed and delayed reviews and suboptimal pharmaceutical management, therefore, might be expected to result in increased avoidable disease burden. As Carr and colleagues discuss, additional concern is unfavourable changes in people’s lifestyles during erectile dysfunction treatment lockdowns, kamagra oral jelly perth with reductions in physical activity18 and weight gain.19 20The findings of this study should be interpreted considering its strengths and limitations.

Its main strengths include the utilisation of data on a large unselected and representative cohort of people with T2D, and the results are likely to accurately reflect population-wide changes.21 The authors acknowledge several limitations including the focus on the six care processes that could be accurately captured in primary care records, lack of inclusion of risk factor control, lack of data on patients’ self-monitoring of risk factors and generalisability outside of the UK context. Furthermore, it is unfortunate that the study was unable to provide conclusive results on the potential differential impacts of the erectile dysfunction treatment kamagra on diabetes kamagra oral jelly perth care across different ethnic groups due to the small number of observations in certain groups and limitations of data with regard to ethnicity recording. The disproportionate direct effects of the erectile dysfunction treatment kamagra on ethnic minority groups have been widely documented, and understanding its complex and widespread indirect effects including those related to the quality of routine care in this population warrants urgent prioritisation for further research.22 23Previous natural disasters have shown that in addition to the worsening of risk factors in the short term, lack of access to routine care results in increases in stroke, acute myocardial infarctions and diabetes complications after the immediate threat has dissipated.24 Previous studies have also shown that even short-term delays in risk factor management are associated with worse macrovascular, microvascular and mortality outcomes in T2D.25 Primary care services now need to urgently plan to prioritise high-risk patients for routine reviews of care processes and urgent risk factor management.

This will include coordinated care and improving risk factors using the wider primary healthcare kamagra oral jelly perth teams including pharmacists, nurses and diabetes educators.26In summary, the erectile dysfunction treatment kamagra and its profound indirect effects on the management of long-term conditions have exposed pre-existing fragility of health systems even in a nation with full health coverage, and disproportionate distribution of associated risks, unmet needs and disease burden. This study by Carr and colleagues furthers our understanding of the scale of disruptions in the delivery of essential diabetes care processes in primary care during the erectile dysfunction treatment kamagra.9 The findings of this study may reflect excess disease burden that requires particular attention both in terms of monitoring and responsive health services. These findings also further emphasise the need for an in-depth reassessment of clinical and public health priorities, both existing and emerging, kamagra oral jelly perth in the coming years.

There is still uncertainty as to when this kamagra will end but it is vital that post-kamagra recovery should include prioritisation for improvements in the care of people with long-term conditions with a particular attention to the most vulnerable and highest risk population subgroups.Ethics statementsPatient consent for publicationNot required..

The article by Sorra and colleagues in this issue of BMJ Quality and Safety1 reflects a subtle but important shift in Propecia best buy national efforts to enhance quality in best place to buy kamagra uk healthcare. Since 2000 and the publication of To Err best place to buy kamagra uk is Human,2 there has been widespread recognition of the need to address patient safety issues at a systems level. This and subsequent discourse directed attention to organisational culture as a key lever for ensuring safety and quality. The follow-on Crossing the Quality Chasm report acknowledged the multidimensionality of the cultural challenge by recommending redesign of the American healthcare system including six aims for improvement—safety, effectiveness, patient-centeredness, timeliness, efficiency and equity.3 However, safety has received the lion share of attention over the last two decades, perhaps due to Hippocrates’ best place to buy kamagra uk admonition to ‘first, do no harm’.

Efficiency has been particularly neglected. Despite painfully high, and relentlessly increasing, healthcare spending as a percent of US gross domestic product4 and embarrassing comparisons of outcomes for our spending,5 efforts in the USA to address escalating costs of healthcare best place to buy kamagra uk have been relatively recent6 7 and have not sought to address organisational culture. Even in countries that achieve higher value, that is, patient experience and outcomes over cost, greater efficiency must be an enduring goal.In this context, the article by Sorra and colleagues is remarkable. In a project supported by the US Agency for Healthcare Research and Quality, they offer a set of new survey items to assess the culture of value and efficiency in hospitals and medical offices.1 More importantly, they offer a vision, derived with extensive input from academic experts and clinical professionals, for understanding the role of value and efficiency in promoting quality that policymakers, health system leaders and frontline healthcare best place to buy kamagra uk workers can embrace.

Since the authors did not do so explicitly, below I offer a conceptual model implied in this research (figure 1). The model suggests that value and efficiency culture interacts with quality and safety culture and is thus a key best place to buy kamagra uk contributor and enabler of healthcare quality. In other words, cost and quality go hand in hand in a 1+1=3 type relationship. Streamlining workflows and doing things right the first time enhances quality by improving efficiency best place to buy kamagra uk.

Quality/safety culture and value/efficiency culture have potential for synergy such that their combined impact on outcomes is more than the two independent effects. The more staff gain experiences with activities to improve efficiency, best place to buy kamagra uk the higher and stronger, that is, more widely shared, the culture of value and efficiency. Value/efficiency culture also increases the likelihood that organisations and managers will ensure staff have further experiences with activities to improve efficiency. This conceptual model is consistent with theoretical frameworks that describe cultural evolution as a process of enabling, enacting and elaborating the best place to buy kamagra uk desired culture.8 9Conceptual model.

Role of value/ efficiency culture in promoting healthcare quality." data-icon-position data-hide-link-title="0">Figure 1 Conceptual model. Role of value/ efficiency culture in promoting healthcare quality.How health systems administer and use best place to buy kamagra uk the new value/efficiency item set is critical. As the conceptual model makes clear, value/efficiency culture should be considered best place to buy kamagra uk jointly with safety culture, not as a replacement, to understand the outcomes it will produce in patient care. Surveys are teaching and expectation setting tools as much as evaluation tools.

Thus, including both dimensions of quality signals their equal importance and best place to buy kamagra uk synergistic potential to the organisation. Additionally, differences in the pattern of results would suggest different approaches for addressing them. For example, where a site exhibits low efficiency culture but high safety culture, an organisation might benefit from training, incentives,or programmes that highlight best place to buy kamagra uk models where value and efficiency enhance safety and quality. In contrast, where efficiency and safety culture are both low, the site may need more basic infrastructure—like personnel and capacity for data collection and analysis—to enable any sort of improvement.

Likewise, efforts to use value/efficiency culture results to spur ‘lean thinking’ and other approaches to improve value culture best place to buy kamagra uk must emphasise the utility of efficiency for improving quality to prevent a ‘cost-cutting as an end in itself’ mentality to pervade.Findings from the pilot test of this culture of value and efficiency survey suggest additional, actionable strategies for using survey data from the new items. In this context, it is worth restating the authors’ conclusion that ‘It is clear from these results that much more needs to be done within healthcare organisations to ensure that activities focused on value and efficiency are supported and conducted’. The first actionable strategy is related to the item receiving the lowest score best place to buy kamagra uk for both hospitals and medical offices. €˜We invite patients to serve on advisory panels or committees to help us improve the patient care experience.’ While recommended for patient-centred medical homes10 and required as part of research endeavours supported by the Patient-Centred Outcomes Research Institute (PCORI),11 healthcare organisations often baulk at involving patients in efforts to improve patient care12 despite examples of the benefits of patient engagement.13 A second strategy is that particular attention should be given to management support for improving efficiency and reducing waste in hospitals and in medical offices, the dimensions with the lowest scores.

The low scores for hospitals and medical groups on measures of experience with activities to improve efficiency suggest opportunities for managers to show support best place to buy kamagra uk for improving efficiency and reducing waste through encouraging more exposure to these activities.The second actionable strategy—encouraging management support and efforts to increase experiences with efficiency and waste reduction activities—requires alignment of incentives for managers and staff. Payers must continue building on value-based payment reforms, including the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), and primary-care focused initiatives like Comprehensive Primary Care Plus (CPC+),14 the Global and Professional Direct Contracting Model15 and the Primary Care First Model16 to ensure that healthcare organisations have more reasons to improve value than to increase services. Beyond financial incentives, acknowledgement and recognition for managers and staff that support value-enhancing initiatives and for healthcare organisations that achieve higher value would motivate attention to improving efficiency.Another noteworthy finding was that clinical staff had more positive value and efficiency culture perceptions than did non-clinical staff, and that among non-clinical staff, managers were more positive than best place to buy kamagra uk non-managers. One explanation for clinicians’ positive perceptions may be that they benefit more from efforts to improve efficiency because they are closer to the patients who benefit.

Lower perceptions among non-clinical staff, however, suggest the importance of raising awareness among non-clinicians, particularly among those with financial and purchasing best place to buy kamagra uk responsibility who many have authority to impact efficiency. That managers’ perceptions are more positive is not surprising given similar findings about safety culture.17 However, such findings also suggest that managers may underestimate leadership needed to enable a culture of value and efficiency. Therefore, within a strategy to garner sufficient management support, efforts to ensure managers understand the perceptions and concerns of frontline workers will be important.The authors found significant and sizeable intraclass correlations, confirming that site membership impacts the best place to buy kamagra uk way individuals responded to the survey. Also, substantial SDs were found particularly among medical groups best place to buy kamagra uk.

These findings confirm that value and efficiency culture is an attribute of organisations and that it varies meaningfully among organisations. As with safety culture, comparative studies would therefore offer opportunities for identifying and learning from high performing sites best place to buy kamagra uk. Meaningful variation is also likely across units within organisations. The authors recommended learning from healthcare systems that are best place to buy kamagra uk well known for their focus on culture change to improve high-value healthcare.

However, emulating organisational improvement programmes has proven difficult given differences in organisational characteristics and contextual factors, so local comparisons can prove especially valuable.18 Comparing higher to lower scoring units within institutions in order to identify opportunities for learning among lower performers, as is often done with safety culture, will likely yield similar benefits in the context of value.Efforts to measure and improve value and efficiency culture would benefit from additional research. Although reasonable given the authors’ constraints and goals, by choosing not to administer the new value/efficiency culture items together with the original survey and by not conducting best place to buy kamagra uk an exploratory factor analysis, this also means they missed learning opportunities. Future research should fill these gaps and use survey-derived empirical data to explore how value/efficiency culture is related to quality/safety culture from the perspective of frontline workers. Particularly considering high correlations between some factors (as high as 0.85 in the hospital sample), an exploratory approach to determining an underlying simple structure in the data could yield new insights about how workers think about relationships among value/efficiency concepts.19 Investigators could administer the Survey on Patient Safety Culture together with best place to buy kamagra uk the new value and efficiency item set.

If the sample were sufficiently large, they could use responses to both quality/safety and value/efficiency items and perform exploratory factor analysis. Doing so could shed additional light best place to buy kamagra uk on relationships among concepts. For example, a strong relationship between concepts may suggest that there are mechanisms that foster both or that one may facilitates achievement of another. Such an understanding could be helpful in designing additional recommendations best place to buy kamagra uk for action.

The survey also requires additional validation, which could be achieved by comparing survey results to other measures of value and efficiency, such as those derived through time-based activity-based costing.20Meanwhile, the value/efficiency item set as developed by Sorra et al offers hospitals and medical groups a valuable opportunity as an excellent starting point to measure and increase their understanding of an important aspect of organisational culture and key contributor to healthcare quality.Ethics statementsPatient consent for publicationNot applicable.While the direct risks of the erectile dysfunction treatment on people with type 2 diabetes (T2D) are well established,1 the indirect effects of the erectile dysfunction treatment response on their management are less well understood. It is estimated that 4.7 million people have diabetes in the UK with T2D accounting for 90% of all diabetes cases, with primary care being at the forefront of delivering diabetes care.2 Besides the disproportionately high immediate direct effects of the erectile dysfunction treatment kamagra on people with T2D, it has also exerted indirect effects through severe disruptions in the best place to buy kamagra uk routine care of patients.3 During the first wave of the kamagra, efforts were directed away from prevention and treatment of long-term conditions, resulting in reduced access to primary care services, cancelled and postponed consultations and reduced community care. Furthermore, many patients avoided or delayed seeking medical attention for routine follow-up or non-erectile dysfunction treatment-related problems, due to fear of and/or to reduce strain on health services overwhelmed by erectile dysfunction treatment.4 5 As a group with elevated clinical risk, people with T2D were advised strict adherence to recommendations issued to the general public, while those at highest risk of adverse outcomes within this at-risk group were also advised to minimise face-to-face contact with others.6 7 Although the disruptions in service delivery generally affected care pathways for all long-term conditions, diabetes was one of the most affected long-term conditions.8In this issue of BMJ Quality and Safety, Carr and colleagues provide important data on the scale of interruptions in the routine management of patients with T2D in UK primary care before and after the first peak of the erectile dysfunction treatment kamagra.9 This large cohort study of 161 181 patients with T2D assessed temporal changes in the rates of diabetes health checks (or ‘care processes’) recommended by the English National Institute for Health and Care Excellence (NICE), and the prescribing of medications to people with T2D. England’s first national erectile dysfunction treatment lockdown was in place best place to buy kamagra uk between late March and May 2020.

The authors assessed best place to buy kamagra uk six selected care processes during three time periods. April 2020 (first full month of national lockdown), May–December 2020 (recovery period) and March–December 2020 periods (lockdown and recovery periods combined), and compared the observed rates during these periods and the expected rates based on 10-year pre-kamagra trends.As might be expected, the results suggest major detrimental effects of the kamagra and national lockdown on the performance of evidence-based care processes and prescribing among people with T2D in primary care. First, in April 2020, rates of a number of care processes were reduced by between 74% and 88% in the UK compared with pre-kamagra trends, with similar effects across the four best place to buy kamagra uk countries of the UK. Although the quality of diabetes care showed recovery between May and December 2020, it remained below expected levels particularly for blood pressure monitoring.

Second, between March and December 2020, the performance of a range best place to buy kamagra uk of care processes was reduced by between 28% and 47% in England compared with pre-kamagra trends, with blood pressure monitoring again being the most affected. Corresponding reductions in the rates of care processes were similar in the other UK countries (between 37% and 51%). The authors estimated that these best place to buy kamagra uk reductions in the rates of care processes translate into approximately 7.4 million fewer health checks performed in the UK during this period. Third, although the study found that prescribing of new glucose-lowering and antihypertensive medications declined by one-fifth between March and December 2020, no differences in the overall rates of prescribing (for new and repeated prescriptions combined) were evident, suggesting that more robust systems are in place for pharmaceutical therapies.

Finally, it is notable that different age, sex best place to buy kamagra uk and deprivation groups seem to have been similarly affected, leaving pre-existing inequalities unchanged. Older patients from deprived areas experienced the largest reductions in health checks, and the authors concluded that this finding might be possibly due to higher rates pre-kamagra in this group.While most research focus has been directed at reducing and preventing the direct effects of the erectile dysfunction treatment kamagra, worrying data on reduced healthcare utilisation have emerged in relation to a range of consultations, hospital admissions and clinical procedures compared with pre-kamagra periods.10 However, studies explicitly assessing the indirect effects of the kamagra on primary care services including changes in the frequency of patient contact have been scarce.5 10 A previous study demonstrated a range of indirect effects of erectile dysfunction treatment on people with T2D, including reductions in the rates of diagnosis of T2D, glycaemic testing and new prescription of first-line glucose-lowering medications in UK primary care.11 Although the long-term effects of the erectile dysfunction treatment on people with T2D are yet to be seen, the levels of interruptions in their management during the first peak of the kamagra demonstrated by Carr and colleagues provide important cause for concern.Suboptimal management of T2D may lead to a range of burdensome and costly complications in the medium to longer term that are otherwise largely preventable through readily available evidence-based interventions for the detection and management of vascular complications.12 These include the regular assessment of microvascular complications (eg, kidney function tests, diabetic eye screening and foot checks), and monitoring and management of vascular risk factors (eg, blood pressure and glucose control).12 Primary care-based interventions for the early detection and management of diabetes-related complications are the cornerstone of comprehensive secondary prevention, and completion of the nine essential care processes recommended by the NICE guideline is an important marker of the quality of diabetes care.12 Previous population-based studies demonstrate that among people with T2D, completion of higher number of care processes is associated with lower rates of all-cause mortality,13 14 lower extremity amputations,15 sight-threatening diabetic retinopathy16 and emergency hospital admissions for all-cause, diabetes-related and cardiovascular causes.17 Obstructions of diabetes services and failures in meeting essential standards of care through missed and delayed reviews and suboptimal pharmaceutical management, therefore, might be expected to result in increased avoidable disease burden. As Carr and best place to buy kamagra uk colleagues discuss, additional concern is unfavourable changes in people’s lifestyles during erectile dysfunction treatment lockdowns, with reductions in physical activity18 and weight gain.19 20The findings of this study should be interpreted considering its strengths and limitations. Its main strengths include the utilisation of data on a large unselected and representative cohort of people with T2D, and the results are likely to accurately reflect population-wide changes.21 The authors acknowledge several limitations including the focus on the six care processes that could be accurately captured in primary care records, lack of inclusion of risk factor control, lack of data on patients’ self-monitoring of risk factors and generalisability outside of the UK context.

Furthermore, it is unfortunate that the study was unable to provide conclusive results on the potential differential impacts of the erectile dysfunction treatment kamagra on diabetes care across best place to buy kamagra uk different ethnic groups due to the small number of observations in certain groups and limitations of data with regard to ethnicity recording. The disproportionate direct effects of the erectile dysfunction treatment kamagra on ethnic minority groups have been widely documented, and understanding its complex and widespread indirect effects including those related to the quality of routine care in this population warrants urgent prioritisation for further research.22 23Previous natural disasters have shown that in addition to the worsening of risk factors in the short term, lack of access to routine care results in increases in stroke, acute myocardial infarctions and diabetes complications after the immediate threat has dissipated.24 Previous studies have also shown that even short-term delays in risk factor management are associated with worse macrovascular, microvascular and mortality outcomes in T2D.25 Primary care services now need to urgently plan to prioritise high-risk patients for routine reviews of care processes and urgent risk factor management. This will include coordinated care and improving risk factors using best place to buy kamagra uk the wider primary healthcare teams including pharmacists, nurses and diabetes educators.26In summary, the erectile dysfunction treatment kamagra and its profound indirect effects on the management of long-term conditions have exposed pre-existing fragility of health systems even in a nation with full health coverage, and disproportionate distribution of associated risks, unmet needs and disease burden. This study by Carr and colleagues furthers our understanding of the scale of disruptions in the delivery of essential diabetes care processes in primary care during the erectile dysfunction treatment kamagra.9 The findings of this study may reflect excess disease burden that requires particular attention both in terms of monitoring and responsive health services.

These findings best place to buy kamagra uk also further emphasise the need for an in-depth reassessment of clinical and public health priorities, both existing and emerging, in the coming years. There is still uncertainty as to when this kamagra will end but it is vital that post-kamagra recovery should include prioritisation for improvements in the care of people with long-term conditions with a particular attention to the most vulnerable and highest risk population subgroups.Ethics statementsPatient consent for publicationNot required..

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The epistemological similitude of biomedicine and Charonian kamagra online shop Narrative MedicineAs designed and propagated by Rita Charon and her colleagues at Columbia University,1 Narrative Medicine (hereafter referred to as Charonian Narrative Medicine (CNM)) https://www.wolf-garten.dk/low-cost-levitra/ began as a project intended to check a widely acknowledged problem, the biomedicalisation of clinical practice via the introduction of methods from the humanities. €˜Narrative Medicine. A Model for Empathy, Reflection, Profession, and Trust’ deploys a rhetoric of lack concerning biomedicine’s largely unopposed stewardship of then-contemporary medical practice:Despite medicine’s recent dazzling technological progress in diagnosing and treating illnesses, physicians sometimes lack the capacities to recognize the plights of their patients, to extend empathy toward those who suffer, and to join honestly and courageously with patients in their illnesses. A scientifically competent medicine alone cannot help a kamagra online shop patient grapple with the loss of health or find meaning in suffering.

(Charon 2001, 1897)The same rhetoric of lack is deployed again in 2016 when valorising Narrative Medicine’s brand of close listening. €˜That such listening was perhaps better achieved in the time of Hippocrates and Galen and Chekhov than in contemporary practice alerts us to deep-seated tensions within a contemporary bioscientific ethos that challenges the particular with the universal, the personal with the corporate, and the intimate with the mechanized’ (Charon et al. 2016, 157–8) kamagra online shop. Thus, CNM was created in response to biomedicine’s lack in many domains of care, and Charon’s means of remediation largely occurs within a rhetorical frame of complementarity.

In the JAMA article, Charon preserves the core utility of a ‘scientifically competent medicine’ to help ‘a patient grapple with the loss of health’ (Charon 2001, 1897) but (uncontroversially) points out that science is not enough for a good doctor. Her essay gently ‘describes narrative competence’ and ‘suggests that it enables the physician to practice medicine kamagra online shop with empathy, reflection, professionalism, and trustworthiness’ (ibid). Yet this humbler tone often switches to a rhetoric more akin to transformation. For example, at the level of a single sentence, consider ‘As a model for medical practice, narrative medicine proposes an ideal of care and provides the conceptual and practical means to strive toward that ideal’ (ibid).

Now we are in the presence of idealisation kamagra online shop in contradistinction to the aforementioned ‘scientifically competent medicine alone’. Charon’s rhetoric in the abstract is sweeping:With narrative competence, physicians can reach and join their patients in illness, recognize their own personal journeys through medicine, acknowledge kinship with and duties toward other health care professionals, and inaugurate consequential discourse with the public about health care. By bridging the divides that separate physicians from patients, themselves, colleagues, and society, narrative medicine offers fresh opportunities for respectful, empathic, and nourishing medical care. (ibid)In many sections of the article, Charon displays an ambivalence between offering Narrative Medicine to adjust medical practice in a measured, collegial way versus offering it to singlehandedly fix all the dilemmas facing contemporary medical practice due to its ‘scientifically competent medicine alone’ preference.2 This ambivalence kamagra online shop becomes less pronounced as time goes on, lost in favour of loftier rhetoric.

For example, Charon pushes transformative rhetoric further in Narrative Medicine. Honouring the Stories of Illness when she writes,I have been humbled and impressed of late to meet with large and diverse groups of health care professionals and patients in this country and abroad who are fired up with yearnings for a medicine that makes sense, that takes care of people—both patients and caregivers—and that replenishes and respects all who are marked by it. To offer narrative medicine as a corrective to some of these failings, a support to these emerging strengths, and response to these widespread yearnings kamagra online shop serves to unify and cohere divergent aspects of sickness and health care. (Charon 2006, ix)Narrative Medicine is now a corrective, rather than a complementary force.

To move to the most recent state-of-the-movement compendium, The Principles and Practice of Narrative Medicine,Narrative medicine began as a rigorous intellectual and clinical discipline to fortify healthcare with the capacity to skillfully receive the accounts persons give of themselves—to recognize, absorb, interpret, and be moved to action by the stories of others. It emerged to challenge a reductionist, fragmented medicine that holds little regard for the singular aspects of a patient’s life and to protest the social injustice of a global healthcare system that countenances tremendous health disparities and kamagra online shop discriminatory policies and practices. (Charon et al. (2016))What was once unthreateningly deemed ‘[n]ot so much a new specialty as a new frame for clinical work’ (1898) has, retroactively, become a ‘rigorous intellectual and clinical discipline to fortify healthcare’ whose stated enemy is a ‘reductionist’ medicine that ‘holds little regard for the singular aspects of a patient’s life’—meaning, biomedicine.Lock and Nguyen 2010, 11) write in An Anthropology of Biomedicine, concerns ‘a systematic and ultimately scientific approach to knowledge about the body and its management … grounded by knowledge produced by decontextualizing the body and subjecting it to an anatomical gaze’.

The authors update this epistemological formulation in a new edition kamagra online shop of their text, writing that biomedicine is ‘a sociotechnical system’ that is based ‘on biological sciences’, the latter providing ‘a set of standards, protocols, and algorithms that enable the production of knowledge and practices to treat ailing individuals … Biomedicine, in theory then, is based on an assumption on the universality of human bodies that everywhere are biologically equivalent’ (Lock and Nguyen 2018, 1).The bona fides of CNM operating from within the tent of biomedicine are numerous. In CNM, narrative is deployed in an instrumental fashion that is completely consistent with biomedical practice. For example, Charon writes. €˜[P]hysicians need … narrative competence, that is, kamagra online shop the competence that human beings use to absorb, interpret, and respond to stories’ (Charon 2001, 1897).

By invoking ‘competence’, CNM inaugurates a skills-based, applied frame for the movement. To substantiate the instrumentalist point further, Charon writes of the consequences of not practising with narrative competence using a biomedically inflected rhetoric of outcomes:If the physician cannot perform these narrative tasks, the patient might not tell the whole story, might not ask the most frightening questions, and might not feel heard.50 The resultant diagnostic workup might be unfocused and therefore more expensive than need be, the correct diagnosis might be missed, the clinical care might be marked by noncompliance and the search for another opinion, and the therapeutic relationship might be shallow and ineffective. (Charon 2001, 1899)The whole point of Narrative Medicine, then, is to practice biomedicine better by using honed clinical skills that borrow from the humanities according to a programme that is overtly scientific kamagra online shop in presentation. In the JAMA article, Charon writes that Narrative Medicine’s ‘hypotheses to be tested are provocative and wide ranging’ (Charon 2001, 1900).

Furthermore, she writes that in addition to ‘outcomes research’ are ‘scholarly efforts to uncover the basic mechanisms, pathways, intermediaries, and consequences of narrative practices, supplying the “basic science” of theoretical foundations and conceptual frameworks for these new undertakings’ (Charon 2001, 1901). We are again in a kamagra online shop biomedicine-plus formulation of complementarity. CNM and biomedicine became epistemologically indistinguishable as CNM explicitly valorised its scientifically validated substantiation, seeking equality in the evidence-based medicine paradigm. Charon is on record in 2017 as boldly claiming that “[w]e have shown at Columbia that rigorous close reading can be taught and learned in clinical settings, where its dividends have been found to enhance patient care” (Charon, DasGupta, and Hermann 2016, 165).3 This is a scientific methodizing of the Narrative Medicine methodology.

Indeed, the metaphors used in The Principles and Practice of Narrative Medicine suggest there is an outright aspiration to kamagra online shop biomedical practice. €˜close reading fortified with attention to its subjective dimensions has become narrative medicine’s laboratory and training ground’ (Charon, DasGupta, and Hermann (2016), 158).Perhaps this article strikes the reader as an attack akin to Strawson’s polemic against the hegemonic imposition of narrative hermeneutics to subjectivity (Strawson 2004). I hasten to reassure readers of that, although I have serious concerns about the transformational power of CNM, I am a believer in the necessity of the redress of biomedicine and that I support the introduction of texts broadly defined and attendant close reading as pedagogical techniques. To be fair, Charon had to start somewhere, and it is understandable that Narrative Medicine was constructed as a field operating from within biomedicine, designed to access biomedical halls kamagra online shop.

For a method of change to take hold, a certain degree of familiarity is a good strategy. Furthermore, Charon operated among historical conditions that perceived literature as having less utility than other domains in the humanities, such as history and ethics. Ann Hudson kamagra online shop Jones writes, ‘It is not surprising that, more often than not, [scholars who offered literature as germane to medical education] emphasised practical utility—what literature can do for medical education and practice’ (Jones 2013, 416). Charon makes a logical evolution when she states that operating within the medical humanities themselves was ‘restrictive’ (Charon 2012) because literature itself was seen as a frill that could be ignored at will by medical faculties, whereas the clinical centring inherent to Narrative Medicine at the branding level made it a much better candidate for funding support.

To make the study of literature more palatable to medicine, it had to look more like medicine. There is nothing deceptive about this, for Charon is on kamagra online shop record as being relatively uninterested in the humanities. Jones (2013) writes, ‘Her first definitions of the term [Narrative Medicine] make very clear that Narrative Medicine is a medical practice of physicians. As a physician herself, Charon is understandably interested most of all in the practice of medicine’.

Quoting Charon herself, Jones adds that Charon is ‘not so much committed to literary studies kamagra online shop or even to the humanities’ (Jones 2013, 426–7).The question must be asked. Can one usher in transformative change if one’s proposed transformation operates according to the same principles as one’s stated target of change?. Is Charon’s aforementioned goal of ‘fortification’ possible when the ‘rigorous intellectual and clinical discipline’ called Narrative Medicine operates from within the epistemology of biomedicine itself?. Can Narrative Medicine, an applied-humanities programme operationalised in a biomedical context, result in the aforementioned ‘correction’ or an ‘ideal kamagra online shop of care’?.

Many would claim ‘no’. The critique of the instrumentality of health humanities pedagogy, of which CNM has been a dominant player, has been sounding strongly for some time now. Alan Bleakley recently pointed out that ‘the art of medicine … has been frustrated by medical education’s commitment to functional approaches embodied particularly in learning kamagra online shop professional communication through simulation, and in reducing complex clinical learning to menus of instrumental competencies’ (Bleakley 2020,). Victoria Tischler is even more explicit, writing that ‘the input of creatives and the arts that they offer are often instrumentalized, that is, considered a type of treatment much like a dose of medication’ (Tischler 2020, 85).

Such discourse is often framed in biomedical terms incorporating intervention, evidence and standardised measurement, effectively reflecting the ongoing dominance of biomedicine in Western health care (ibid).With my own re-framing of Charon’s ‘new frame for medical practice’ as, in actuality, a replacement of the old biomedical frame, I now turn to an unacknowledged paradox inherent to Narrative Medicine’s ‘signature technique’ of close reading.Close reading. A ‘signature method’ with its own origin story in scienceCharon’s potted history of close reading in The Principles and Practice of Narrative Medicine places the technique’s origin with IA Richards in the early 1920s, and then kamagra online shop fills out the history of the technique by running it through the decades, sketching a bit more New Criticism, then structuralism, the deconstructive turn, New Historicism, Lacanian psychoanalysis, postmodernism and queer theory. The revealing thing about the history is not what it tells, but what it does not notice about what it tells. For example, Charon writes of Richards that he emphasised ‘attention to individual readers’ interpretive process in addition to the attention to the text itself’ (Charon, DasGupta, and Hermann 2016, 159).

In this regard, Richards is both founding member of New Criticism and the reader response method to come, but what is crucially important to recognise (and what Charon elides) is that Richards, like Empson and many other kamagra online shop practitioners of New Criticism, was essentially a linguist at heart. The available archive with which to capture Richards in search for a mechanistic model for hermeneutics is vast.4 Consider also the moment when Charon describes New Criticism as valorisingextremely focused readings, mostly of poems, with no attention to the contexts of the poems or to objective correlatives in the life experience of the poet. In an effort to systematize the reading of poetry toward a scientific analysis, the New Critics proposed that seeking the author’s intention in writing or the reader’s emotional response to a text—what they called the intentional fallacy and the affective fallacy—could misdirect the critic’s effort to understand the poem. (Charon, DasGupta, and Hermann (2016), 160)In both instances, we have a literary technique with aspirations to science, a kind kamagra online shop of reading that is uncannily biomedical in practice.

At a key point in the original JAMA article, Charon distinguishes between ‘logicoscientific knowledge’—where a ‘detached and replaceable observer generates or comprehends replicable and generalisable notices’—and ‘narrative knowledge’—where ‘local and particular understandings about one situation by one participant or observer’ are obtained (Charon 2001, 1898). Yet the origins of the close reading method are exactly as Charon states. Spurred by the desire kamagra online shop to scientificize hermeneutics. Just like Charon’s ‘logicoscientific knowledge’, close reading’s origin is one that tries to remove context in order to get at objective truth.

Yet close reading is valorised by Charon as a way to glean ‘narrative knowledge’, meaning the illumination of ‘the universally true by revealing the particular’, whereas ‘[l]ogicoscientific knowledge attempts to illuminate the universally true by transcending the particular’ (Charon 2001, 1898). The paradox kamagra online shop is never fully recognised by Charon. Perhaps to see this paradox would require looking at biomedicine from the outside?. Working from within biomedicine inevitably leads to the formation of other blind spots.

When moving to the present-day discussion of the reductionist tendencies of biomedicine vis-à-vis neuroimaging kamagra online shop to map ‘profound human experiences’, Charon fondly recalls reader response studies, a mode of criticism fashionable in the 1980s that ‘sought to understand the interior activities of the reader’ (Charon, DasGupta, and Hermann (2016), 163). When Charon compares it favourably to New Criticism’s ‘objective and analytic goals towards an interest in the subjectivity of reading and a commitment to explore and understand it’ (Charon, DasGupta, and Hermann 2016, 164)—indeed, Richards pioneered the technique—one wonders just what magnitude of confusion is occurring, for reader response therapy did reflect a shift in emphasis from a seeming objectivity to a seeming subjectivity, yet the backdrop for the shift remains the realm of quasi-scientific fantasy, for a significant tendency within reader response theory (admittedly, a very heterogenous group of practitioners) was the use of psychological experimentation on defined sets of readers. For example, in Style and Reader Response, the authors describe the multitude of methods available:The experiment may take place in quasi-laboratory conditions and involve reading very small chunks of a narrative, perhaps using think-aloud data, structured interviews, and/or the collection of written responses from readers … or readers completing a questionnaire… [e]xperimental approaches tend to test hypotheses and generate data that is analyzed quantitatively, although qualitative analysis can form part of interpreting the data’. (Bell et kamagra online shop al.

2021, 10)By mentioning functional MRI and comparing it unfavourably to reader response theory, Charon unwittingly casts shade on the most recent magic lantern by bringing forward a more antique one.Although Charon’s history moves to a new valorised method, CNM’s brand of close reading, which ‘has sequentially been informed, fortified, challenged, and sharpened by intellectual and creative cultural movements’ (Charon, DasGupta, and Hermann 2016, 162), the fact that her signature technique has returned to its origin point is entirely missed. Any kind of close reading that can be systematically taught and then assessed in scientific studies to be proven as effective in clinical settings is a biomedical technique by virtue of setting and method. We should now recognise that Narrative Medicine’s current practice has a very old historical basis that is part of a larger story involving kamagra online shop the rise of the natural sciences as our dominant paradigms for authoring our subjectivities. My point is not that Narrative Medicine is unaware that it is biomedical.

My point is that its one claim to humanistic practice, the close reading technique, has its origins in logical positivism. In other words, Narrative Medicine is unaware of just how biomedical it is.It is probably time to finally correct Charon’s identification kamagra online shop of the origin point of her ‘signature technique’ to the philosophical milieu in which it was generated around the turn of the 1920s, slightly before Charon’s identification with the New Critics.It was the non-Western Russian Formalists in the late 1910s who were first invested in transforming the study of literature into a science. For example, Roman Jakobson, who got his start in the Moscow Linguistic Circle, one of the two leading groups of Russian Formalists, referred to the ‘object of literary science’ as ‘not literature but literariness, that is, what makes a given work a literary work’ (Steiner 1984, 23). Eichenbaum, a member of the St.

Petersburg-based Society for the Study of Poetic Language and a colleague of Viktor Shklovsky’s (Shklovsky being the most famous of the group), wrote:the Formal method, by gradually evolving and extending its field of inquiry, kamagra online shop has completely exceeded what was traditionally called methodology and is turning into a special science that treats literature as a specific series of facts… What characterizes us is neither ‘Formalism’ as an aesthetic theory, nor ‘methodology’ as a closed scientific system, but only the striving to establish, on the basis of specific properties of the literary material, an independent literary science. (Steiner 1984, 22)The Russian Formalists reduce language to constituent parts so that the enterprise can be seen as a science:‘what is significant about the Formal method?. €™ Shklovsky wrote in his characteristic staccato style. €˜What is significant is that we kamagra online shop approached art as production.

Spoke of it alone. Viewed it not as a reflection. Found the specific features of kamagra online shop the genus. Began to establish the basic tendencies of form.

Grasped that on a large scale there is a real homogeneity in the laws informing works. Hence, the kamagra online shop science [of literature] is possible. (Steiner 1984, 65)The parallel between biomedicine and Russian Formalism is obvious. Biomedicine’s project is a systematic one that seeks to render the body as data.

For its part, Narrative Medicine, too, teaches a kamagra online shop technique designed to obtain data that has practical use.To be fair to CNM, Russian Formalism is as much of an intellectual ancestor to CNM as any other subsequent manifestation of literary theory. The Russian Formalist project underwrites all current literary scholarship, no matter the tradition. The Formalist way of reading has proven a powerful hermeneutic. Yet it, too, is kamagra online shop part of the same cultural conditions created by the philosophy of positivism which, as Steiner—the definitive historian of the Russian Formalists—suggests as an influence circulating as far back as the 1870s (Steiner 1984, 64).

Evidence-based medicine, for example, is but one member of a host of offshoot traditions. In a notable paper critiquing evidence-based medicine, Maya Goldenberg identifies the ‘Vienna School’ of philosophers and scientists from the 1920s who ‘rejected the possibility of justifying knowledge claims that were “beyond” the scope of science, they dismissed metaphysics and many of the claims made in theology and ethics as nonsensical (or unverifiable)’ (Goldenberg 2006, 2622). Logical positivism and Russian kamagra online shop Formalism are intellectual fellow travellers. For the logical positivists, science provided a ‘value-free understanding of the natural world’ (ibid) and the same was so for the Russian Formalists when it came to literature, as it was for the New Critics.

The impact of the Vienna School and the larger cultural ferment that spawned it makes developments like a disparate group of literary scholars attempting to science-ify their discipline a logical development.Yet delivery on the promises of CNM—the aforementioned ‘bridging divides’, etc—has not resulted in a meaningful check on biomedicine despite CNM’s impressive international success. One has to wonder kamagra online shop if any triumphally instrumentalist programme—in other words, anything that fundamentally misunderstands the transformative power of art—could make such a difference in a discipline so wholly invested in biomedicine. The biomedical integration of CNM is complete, from method to context to demonstrated proof of efficacy. The unintended result is a fortification of biomedicine, not a correction or rebalancing of medical practice..

The epistemological similitude of biomedicine and Charonian Narrative best place to buy kamagra uk MedicineAs designed and propagated by Rita Charon and https://www.wolf-garten.dk/low-cost-levitra/ her colleagues at Columbia University,1 Narrative Medicine (hereafter referred to as Charonian Narrative Medicine (CNM)) began as a project intended to check a widely acknowledged problem, the biomedicalisation of clinical practice via the introduction of methods from the humanities. €˜Narrative Medicine. A Model for Empathy, Reflection, Profession, and Trust’ deploys a rhetoric of lack concerning biomedicine’s largely unopposed stewardship of then-contemporary medical practice:Despite medicine’s recent dazzling technological progress in diagnosing and treating illnesses, physicians sometimes lack the capacities to recognize the plights of their patients, to extend empathy toward those who suffer, and to join honestly and courageously with patients in their illnesses.

A scientifically competent medicine alone cannot help a patient grapple with the loss of health or best place to buy kamagra uk find meaning in suffering. (Charon 2001, 1897)The same rhetoric of lack is deployed again in 2016 when valorising Narrative Medicine’s brand of close listening. €˜That such listening was perhaps better achieved in the time of Hippocrates and Galen and Chekhov than in contemporary practice alerts us to deep-seated tensions within a contemporary bioscientific ethos that challenges the particular with the universal, the personal with the corporate, and the intimate with the mechanized’ (Charon et al.

2016, 157–8) best place to buy kamagra uk. Thus, CNM was created in response to biomedicine’s lack in many domains of care, and Charon’s means of remediation largely occurs within a rhetorical frame of complementarity. In the JAMA article, Charon preserves the core utility of a ‘scientifically competent medicine’ to help ‘a patient grapple with the loss of health’ (Charon 2001, 1897) but (uncontroversially) points out that science is not enough for a good doctor.

Her essay gently ‘describes narrative competence’ best place to buy kamagra uk and ‘suggests that it enables the physician to practice medicine with empathy, reflection, professionalism, and trustworthiness’ (ibid). Yet this humbler tone often switches to a rhetoric more akin to transformation. For example, at the level of a single sentence, consider ‘As a model for medical practice, narrative medicine proposes an ideal of care and provides the conceptual and practical means to strive toward that ideal’ (ibid).

Now we are in the presence of idealisation in contradistinction to the aforementioned ‘scientifically competent medicine best place to buy kamagra uk alone’. Charon’s rhetoric in the abstract is sweeping:With narrative competence, physicians can reach and join their patients in illness, recognize their own personal journeys through medicine, acknowledge kinship with and duties toward other health care professionals, and inaugurate consequential discourse with the public about health care. By bridging the divides that separate physicians from patients, themselves, colleagues, and society, narrative medicine offers fresh opportunities for respectful, empathic, and nourishing medical care.

(ibid)In many sections best place to buy kamagra uk of the article, Charon displays an ambivalence between offering Narrative Medicine to adjust medical practice in a measured, collegial way versus offering it to singlehandedly fix all the dilemmas facing contemporary medical practice due to its ‘scientifically competent medicine alone’ preference.2 This ambivalence becomes less pronounced as time goes on, lost in favour of loftier rhetoric. For example, Charon pushes transformative rhetoric further in Narrative Medicine. Honouring the Stories of Illness when she writes,I have been humbled and impressed of late to meet with large and diverse groups of health care professionals and patients in this country and abroad who are fired up with yearnings for a medicine that makes sense, that takes care of people—both patients and caregivers—and that replenishes and respects all who are marked by it.

To offer narrative medicine as a corrective to some of these failings, a support to these emerging strengths, and response to these widespread yearnings serves best place to buy kamagra uk to unify and cohere divergent aspects of sickness and health care. (Charon 2006, ix)Narrative Medicine is now a corrective, rather than a complementary force. To move to the most recent state-of-the-movement compendium, The Principles and Practice of Narrative Medicine,Narrative medicine began as a rigorous intellectual and clinical discipline to fortify healthcare with the capacity to skillfully receive the accounts persons give of themselves—to recognize, absorb, interpret, and be moved to action by the stories of others.

It emerged to challenge a reductionist, fragmented medicine that holds little regard for best place to buy kamagra uk the singular aspects of a patient’s life and to protest the social injustice of a global healthcare system that countenances tremendous health disparities and discriminatory policies and practices. (Charon et al. (2016))What was once unthreateningly deemed ‘[n]ot so much a new specialty as a new frame for clinical work’ (1898) has, retroactively, become a ‘rigorous intellectual and clinical discipline to fortify healthcare’ whose stated enemy is a ‘reductionist’ medicine that ‘holds little regard for the singular aspects of a patient’s life’—meaning, biomedicine.Lock and Nguyen 2010, 11) write in An Anthropology of Biomedicine, concerns ‘a systematic and ultimately scientific approach to knowledge about the body and its management … grounded by knowledge produced by decontextualizing the body and subjecting it to an anatomical gaze’.

The authors update this epistemological formulation in a new edition of their text, writing that biomedicine is ‘a sociotechnical system’ that is based ‘on biological sciences’, the latter providing ‘a set of standards, best place to buy kamagra uk protocols, and algorithms that enable the production of knowledge and practices to treat ailing individuals … Biomedicine, in theory then, is based on an assumption on the universality of human bodies that everywhere are biologically equivalent’ (Lock and Nguyen 2018, 1).The bona fides of CNM operating from within the tent of biomedicine are numerous. In CNM, narrative is deployed in an instrumental fashion that is completely consistent with biomedical practice. For example, Charon writes.

€˜[P]hysicians need … narrative competence, that is, the competence that best place to buy kamagra uk human beings use to absorb, interpret, and respond to stories’ (Charon 2001, 1897). By invoking ‘competence’, CNM inaugurates a skills-based, applied frame for the movement. To substantiate the instrumentalist point further, Charon writes of the consequences of not practising with narrative competence using a biomedically inflected rhetoric of outcomes:If the physician cannot perform these narrative tasks, the patient might not tell the whole story, might not ask the most frightening questions, and might not feel heard.50 The resultant diagnostic workup might be unfocused and therefore more expensive than need be, the correct diagnosis might be missed, the clinical care might be marked by noncompliance and the search for another opinion, and the therapeutic relationship might be shallow and ineffective.

(Charon 2001, 1899)The whole point of Narrative Medicine, then, is best place to buy kamagra uk to practice biomedicine better by using honed clinical skills that borrow from the humanities according to a programme that is overtly scientific in presentation. In the JAMA article, Charon writes that Narrative Medicine’s ‘hypotheses to be tested are provocative and wide ranging’ (Charon 2001, 1900). Furthermore, she writes that in addition to ‘outcomes research’ are ‘scholarly efforts to uncover the basic mechanisms, pathways, intermediaries, and consequences of narrative practices, supplying the “basic science” of theoretical foundations and conceptual frameworks for these new undertakings’ (Charon 2001, 1901).

We are best place to buy kamagra uk again in a biomedicine-plus formulation of complementarity. CNM and biomedicine became epistemologically indistinguishable as CNM explicitly valorised its scientifically validated substantiation, seeking equality in the evidence-based medicine paradigm. Charon is on record in 2017 as boldly claiming that “[w]e have shown at Columbia that rigorous close reading can be taught and learned in clinical settings, where its dividends have been found to enhance patient care” (Charon, DasGupta, and Hermann 2016, 165).3 This is a scientific methodizing of the Narrative Medicine methodology.

Indeed, the metaphors used in The Principles and Practice of Narrative Medicine suggest there is an best place to buy kamagra uk outright aspiration to biomedical practice. €˜close reading fortified with attention to its subjective dimensions has become narrative medicine’s laboratory and training ground’ (Charon, DasGupta, and Hermann (2016), 158).Perhaps this article strikes the reader as an attack akin to Strawson’s polemic against the hegemonic imposition of narrative hermeneutics to subjectivity (Strawson 2004). I hasten to reassure readers of that, although I have serious concerns about the transformational power of CNM, I am a believer in the necessity of the redress of biomedicine and that I support the introduction of texts broadly defined and attendant close reading as pedagogical techniques.

To be fair, Charon had to start somewhere, and it is understandable that Narrative Medicine was best place to buy kamagra uk constructed as a field operating from within biomedicine, designed to access biomedical halls. For a method of change to take hold, a certain degree of familiarity is a good strategy. Furthermore, Charon operated among historical conditions that perceived literature as having less utility than other domains in the humanities, such as history and ethics.

Ann Hudson Jones writes, ‘It is not surprising that, more often than not, [scholars who offered best place to buy kamagra uk literature as germane to medical education] emphasised practical utility—what literature can do for medical education and practice’ (Jones 2013, 416). Charon makes a logical evolution when she states that operating within the medical humanities themselves was ‘restrictive’ (Charon 2012) because literature itself was seen as a frill that could be ignored at will by medical faculties, whereas the clinical centring inherent to Narrative Medicine at the branding level made it a much better candidate for funding support. To make the study of literature more palatable to medicine, it had to look more like medicine.

There is best place to buy kamagra uk nothing deceptive about this, for Charon is on record as being relatively uninterested in the humanities. Jones (2013) writes, ‘Her first definitions of the term [Narrative Medicine] make very clear that Narrative Medicine is a medical practice of physicians. As a physician herself, Charon is understandably interested most of all in the practice of medicine’.

Quoting Charon herself, Jones best place to buy kamagra uk adds that Charon is ‘not so much committed to literary studies or even to the humanities’ (Jones 2013, 426–7).The question must be asked. Can one usher in transformative change if one’s proposed transformation operates according to the same principles as one’s stated target of change?. Is Charon’s aforementioned goal of ‘fortification’ possible when the ‘rigorous intellectual and clinical discipline’ called Narrative Medicine operates from within the epistemology of biomedicine itself?.

Can Narrative Medicine, an applied-humanities programme operationalised in a biomedical context, result best place to buy kamagra uk in the aforementioned ‘correction’ or an ‘ideal of care’?. Many would claim ‘no’. The critique of the instrumentality of health humanities pedagogy, of which CNM has been a dominant player, has been sounding strongly for some time now.

Alan Bleakley recently pointed out that ‘the art of medicine … has been frustrated by medical education’s commitment to functional approaches embodied particularly in learning professional communication through simulation, and in reducing complex clinical learning to best place to buy kamagra uk menus of instrumental competencies’ (Bleakley 2020,). Victoria Tischler is even more explicit, writing that ‘the input of creatives and the arts that they offer are often instrumentalized, that is, considered a type of treatment much like a dose of medication’ (Tischler 2020, 85). Such discourse is often framed in biomedical terms incorporating intervention, evidence and standardised measurement, effectively reflecting the ongoing dominance of biomedicine in Western health care (ibid).With my own re-framing of Charon’s ‘new frame for medical practice’ as, in actuality, a replacement of the old biomedical frame, I now turn to an unacknowledged paradox inherent to Narrative Medicine’s ‘signature technique’ of close reading.Close reading.

A ‘signature method’ with its own origin story in scienceCharon’s potted history of close reading in The Principles and Practice of Narrative Medicine places the technique’s origin with IA Richards in the early 1920s, and best place to buy kamagra uk then fills out the history of the technique by running it through the decades, sketching a bit more New Criticism, then structuralism, the deconstructive turn, New Historicism, Lacanian psychoanalysis, postmodernism and queer theory. The revealing thing about the history is not what it tells, but what it does not notice about what it tells. For example, Charon writes of Richards that he emphasised ‘attention to individual readers’ interpretive process in addition to the attention to the text itself’ (Charon, DasGupta, and Hermann 2016, 159).

In this regard, Richards is both founding member of New Criticism and the reader response method to come, but what is crucially important to recognise (and what Charon elides) is that Richards, like Empson and many other best place to buy kamagra uk practitioners of New Criticism, was essentially a linguist at heart. The available archive with which to capture Richards in search for a mechanistic model for hermeneutics is vast.4 Consider also the moment when Charon describes New Criticism as valorisingextremely focused readings, mostly of poems, with no attention to the contexts of the poems or to objective correlatives in the life experience of the poet. In an effort to systematize the reading of poetry toward a scientific analysis, the New Critics proposed that seeking the author’s intention in writing or the reader’s emotional response to a text—what they called the intentional fallacy and the affective fallacy—could misdirect the critic’s effort to understand the poem.

(Charon, DasGupta, and Hermann (2016), 160)In both instances, we have a literary technique with aspirations to science, a kind of reading that is uncannily biomedical in practice best place to buy kamagra uk. At a key point in the original JAMA article, Charon distinguishes between ‘logicoscientific knowledge’—where a ‘detached and replaceable observer generates or comprehends replicable and generalisable notices’—and ‘narrative knowledge’—where ‘local and particular understandings about one situation by one participant or observer’ are obtained (Charon 2001, 1898). Yet the origins of the close reading method are exactly as Charon states.

Spurred by best place to buy kamagra uk the desire to scientificize hermeneutics. Just like Charon’s ‘logicoscientific knowledge’, close reading’s origin is one that tries to remove context in order to get at objective truth. Yet close reading is valorised by Charon as a way to glean ‘narrative knowledge’, meaning the illumination of ‘the universally true by revealing the particular’, whereas ‘[l]ogicoscientific knowledge attempts to illuminate the universally true by transcending the particular’ (Charon 2001, 1898).

The paradox is never fully recognised by best place to buy kamagra uk Charon. Perhaps to see this paradox would require looking at biomedicine from the outside?. Working from within biomedicine inevitably leads to the formation of other blind spots.

When moving to the present-day discussion of the reductionist tendencies of biomedicine vis-à-vis neuroimaging to map ‘profound human experiences’, Charon fondly recalls reader response studies, a mode of criticism fashionable in the 1980s that ‘sought to understand the interior activities of the reader’ (Charon, DasGupta, and best place to buy kamagra uk Hermann (2016), 163). When Charon compares it favourably to New Criticism’s ‘objective and analytic goals towards an interest in the subjectivity of reading and a commitment to explore and understand it’ (Charon, DasGupta, and Hermann 2016, 164)—indeed, Richards pioneered the technique—one wonders just what magnitude of confusion is occurring, for reader response therapy did reflect a shift in emphasis from a seeming objectivity to a seeming subjectivity, yet the backdrop for the shift remains the realm of quasi-scientific fantasy, for a significant tendency within reader response theory (admittedly, a very heterogenous group of practitioners) was the use of psychological experimentation on defined sets of readers. For example, in Style and Reader Response, the authors describe the multitude of methods available:The experiment may take place in quasi-laboratory conditions and involve reading very small chunks of a narrative, perhaps using think-aloud data, structured interviews, and/or the collection of written responses from readers … or readers completing a questionnaire… [e]xperimental approaches tend to test hypotheses and generate data that is analyzed quantitatively, although qualitative analysis can form part of interpreting the data’.

(Bell et best place to buy kamagra uk al. 2021, 10)By mentioning functional MRI and comparing it unfavourably to reader response theory, Charon unwittingly casts shade on the most recent magic lantern by bringing forward a more antique one.Although Charon’s history moves to a new valorised method, CNM’s brand of close reading, which ‘has sequentially been informed, fortified, challenged, and sharpened by intellectual and creative cultural movements’ (Charon, DasGupta, and Hermann 2016, 162), the fact that her signature technique has returned to its origin point is entirely missed. Any kind of close reading that can be systematically taught and then assessed in scientific studies to be proven as effective in clinical settings is a biomedical technique by virtue of setting and method.

We should now best place to buy kamagra uk recognise that Narrative Medicine’s current practice has a very old historical basis that is part of a larger story involving the rise of the natural sciences as our dominant paradigms for authoring our subjectivities. My point is not that Narrative Medicine is unaware that it is biomedical. My point is that its one claim to humanistic practice, the close reading technique, has its origins in logical positivism.

In other words, Narrative Medicine is unaware of just how biomedical it is.It is probably time to finally correct Charon’s identification of the origin point of her ‘signature technique’ to the philosophical milieu in which it was generated around the turn of the 1920s, slightly before Charon’s identification with the New best place to buy kamagra uk Critics.It was the non-Western Russian Formalists in the late 1910s who were first invested in transforming the study of literature into a science. For example, Roman Jakobson, who got his start in the Moscow Linguistic Circle, one of the two leading groups of Russian Formalists, referred to the ‘object of literary science’ as ‘not literature but literariness, that is, what makes a given work a literary work’ (Steiner 1984, 23). Eichenbaum, a member of the St.

Petersburg-based Society for the Study of Poetic Language and a colleague of Viktor Shklovsky’s (Shklovsky being the most famous of the group), wrote:the Formal method, by gradually evolving and extending its field of inquiry, has completely exceeded what was traditionally called methodology and is turning into a special science that treats literature as a specific series of facts… What characterizes us is neither ‘Formalism’ as an aesthetic theory, nor ‘methodology’ as a closed scientific system, but only the best place to buy kamagra uk striving to establish, on the basis of specific properties of the literary material, an independent literary science. (Steiner 1984, 22)The Russian Formalists reduce language to constituent parts so that the enterprise can be seen as a science:‘what is significant about the Formal method?. €™ Shklovsky wrote in his characteristic staccato style.

€˜What is significant is that we approached art as production best place to buy kamagra uk. Spoke of it alone. Viewed it not as a reflection.

Found the best place to buy kamagra uk specific features of the genus. Began to establish the basic tendencies of form. Grasped that on a large scale there is a real homogeneity in the laws informing works.

Hence, the best place to buy kamagra uk science [of literature] is possible. (Steiner 1984, 65)The parallel between biomedicine and Russian Formalism is obvious. Biomedicine’s project is a systematic one that seeks to render the body as data.

For its best place to buy kamagra uk part, Narrative Medicine, too, teaches a technique designed to obtain data that has practical use.To be fair to CNM, Russian Formalism is as much of an intellectual ancestor to CNM as any other subsequent manifestation of literary theory. The Russian Formalist project underwrites all current literary scholarship, no matter the tradition. The Formalist way of reading has proven a powerful hermeneutic.

Yet it, too, is part of the same cultural conditions created by the philosophy of positivism which, as Steiner—the definitive historian of the Russian Formalists—suggests as an best place to buy kamagra uk influence circulating as far back as the 1870s (Steiner 1984, 64). Evidence-based medicine, for example, is but one member of a host of offshoot traditions. In a notable paper critiquing evidence-based medicine, Maya Goldenberg identifies the ‘Vienna School’ of philosophers and scientists from the 1920s who ‘rejected the possibility of justifying knowledge claims that were “beyond” the scope of science, they dismissed metaphysics and many of the claims made in theology and ethics as nonsensical (or unverifiable)’ (Goldenberg 2006, 2622).

Logical positivism best place to buy kamagra uk and Russian Formalism are intellectual fellow travellers. For the logical positivists, science provided a ‘value-free understanding of the natural world’ (ibid) and the same was so for the Russian Formalists when it came to literature, as it was for the New Critics. The impact of the Vienna School and the larger cultural ferment that spawned it makes developments like a disparate group of literary scholars attempting to science-ify their discipline a logical development.Yet delivery on the promises of CNM—the aforementioned ‘bridging divides’, etc—has not resulted in a meaningful check on biomedicine despite CNM’s impressive international success.

One has to wonder if any triumphally instrumentalist programme—in other words, anything that fundamentally misunderstands the best place to buy kamagra uk transformative power of art—could make such a difference in a discipline so wholly invested in biomedicine. The biomedical integration of CNM is complete, from method to context to demonstrated proof of efficacy. The unintended result is a fortification of biomedicine, not a correction or rebalancing of medical practice..

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