Wednesday, January 11, 2023

Magic Methyl Effects in Drug Design - Juniper Publishers

 Pharmacy & Pharmaceutical Sciences - Juniper Publishers

Abstract

Methyl group is one of the most commonly occurring substituents in drugs. More than 50% of drugs with high market value have methyl groups in their structures. Methyl group has a capacity to act as Electron Donating Group and modulating physicochemical and biological properties of drug molecules. These properties include effect on half-life on a drug, selectivity, potency and binding affinity. When introduction of methyl group results in profound increase biological activity of molecules, it is known as Magic Methyl Effect. These enhancements in biological activity are attributed to effect of methyl group on free energy of Desolvation. The present review explores the origin of this magic methyl effect along with some supporting case studies in drug design.

Keywords: Drug design; Magic methyl; Methyl group; Molecules; Drug molecules; Physicochemical; Methylating; Synthetic chemistry; Side effects

Introduction

Methyl group is one of the most common substituents occurring in design of many drugs and research molecules. Methyl group has a capacity to act as electron donating group and is known to modulate physicochemical and biological properties of drug molecules. A survey of Njardarson’s Top 200 Drugs of 2011 showed that more than 67% of small-molecule drugs at that time contained at least one methyl group bound to a carbon atom [1]. Some of the drugs containing methyl group have been listed in the following figure (Figure 1).

Importance of Methylation

Substituting methyl group in drug design can have various benefits on pharmacokinetics and pharmacodynamics of drug molecules. Some of the effects of methylation are described below.

Alternation in half-life of the drug

Methylation can increase or decrease the half-life of the drug as seen from the examples of simvastatin where it is increased 2-fold while in case of Etoricoxib addition of methyl group decreases the half-life by more than 10- fold (Figure 2)

Increase in selectivity

Addition of methyl group may enhance the selectivity of the molecules as can be seen from the example below where selectivity of the molecule towards a particular target increased by almost (Figure 3) 87-fold.

Increase in binding affinity and potency

Increased methylation reduces free energy of desolvation required to remove a ligand of solvated water molecules when it transfers from an aqueous environment to the lipophilic environment (Figure 4). This results in increase binding leading to increased potency of the molecule. Jorgensen and co-workers suggested that a single methyl group might boost potency approximately 10-fold if the new methyl group sits nicely in a hydrophobic pocket of the active site. Methylation can bring in optimum lipophilicity in order to cross the phospholipid bilayer of the target organ from an aqueous environment like blood.

This stripping into the organ requires desolvation free energy so by methylating the drug the desolvation energy expenditure is minimized to a greater extent. This process allows an optimum balance between hydrophilic and lipophilic of a drug. This is termed as ligand lipophilicity efficiency (LEE).

Alteration of metabolism

Similar to the interaction between a drug and its biological target, the metabolism of a drug molecule requires it to interact with the active site of the enzyme that catalyzes its metabolism. Steric hindrance is a common strategy used to block or slow a specific metabolic pathway. In this approach, additional atoms are added adjacent to the functional group undergoing metabolism in order to block the interaction of the drug molecule with the enzyme carrying out the metabolic transformation. In many cases, these additional atoms need not be very large. In acetylcholine and bethanechol (Figure 5), the additional methyl group seen on bethanechol prevents the enzyme acetyl cholinesterase from cleaving the ester bond.

General role in drug design

The methyl group plays an important role in the rational drug design. Introducing methyl into small molecule has become an important strategy of a lead compound optimization. Methyl can modulate the physicochemical, pharmacodynamics and pharmacokinetic properties by ortho effect, inductive effect and conformational effect. It also improves the metabolic stability as a soft metabolic point [2].

Magic Methyl Effect

The ‘magic methyl effect’ refers to the large and unexpected change in drug potency resulting from the addition of a single methyl group to a molecule [3]. Dramatic change in affinity that can be seen with the addition of a single methyl group in just the right place [4]. The methyl group is one of the most prevalent functionalities in biologically active molecules. A study revealed that 10-fold boost in potency with a methyl is seen in 8% of the cases, while a 100-fold difference is seen in 0.4% [3].

Origin of magic methyl effect

This effect was originally reported when Jorgensen and his co-workers studied set of MAP kinase inhibitors computationally in which just by adding a single methyl group the IC50 value had changed from 2500 nM to 12 nM (Figure 6). The research group observed a torsional twist induced by ortho-methyl group and concluded that this leads to a low energy conformation that closely resembles the conformer observed in X- ray crystal structure of the protein inhibitor complex. They hypothesized that an introduction of methyl group at ortho position induces aryl ring to rotate perpendicular leading to effective binding affinity with the target active site and in turn shows profound increase in potency as shown in Figure 6. It was further noticed that the dihedral angle of the biaryl bond in structure A was 50°C whereas addition of methyl at ortho twisted this angle out to 65°C making it similar to its protein bound conformer. This was hailed to be the reason behind surprisingly beneficial effect on binding affinity (Figure 7).

Some Guidelines for The Strategic Introduction of The Methyl Group [5-14]

After studying this effect scientists have discovered some common strategies which could be used as starting point to introduce methyl group in the design of molecules. These strategies includes:

a) Methyl group ortho to a large rotatable substituent on an aryl ring as shown in Figure 8

b) On substituted rings where an axial or equatorial preference of substituents can be influenced in Figure 9

c) Between two freely rotatable bonds that are substituted with bulky groups influenced in Figure 10

Conclusion

The biggest gains in the potency in drug design phase will be realized when the interplay of conformational, hydrophobic, desolvation and other effects are cooperatively aligned. The likelihood of discovering an increase in 100-fold boost in potency by installing a single methyl group is extremely low. However, with the advent of synthetic chemistry and availability of easy and simple reactions, methylated analogues of a drug lead merit such an exploration. If simple methylation could result in most effective potent drug with least side effects, then it would be indeed magical.

Tuesday, January 10, 2023

Empirical Examination of the Moderating influence of Dogmatism on the relationship between Adult Attention Deficit and the Operational Effectiveness of Project Managers - Juniper publishers

 Intellectual & Developmental Disabilities - Juniper Publishers

Purpose: Empirical examination of the moderating influence of dogmatism (DG) on the relationship between adult attention deficit (AAD) and operational (traditional) project manager effectiveness (OPME).

Design/methodology/approach: 160 actively employed business graduate students participated in a business courses where they were assigned to 4-person project teams responsible for completing a major business project. The project contained 4 sub-projects each of which was managed by a different team member. At the end of semester each team member rated the others on their project management effectiveness. Each subject completed a self-report measure of dogmatism and identified a close associate who completed an observer version of the Brown Attention Deficit Scale. Linear regression was used to test the hypothesis that DG moderates the relationship between AAD and OPME.

Findings: DG is a statistically significant moderator of the relationship between AAD and OPME. The negative relationship between AAD and OPME significantly declines as DG increases.

Research limitations/implications: Future research requires use of samples that are more directly associated with the workplace. Further investigation of the impact of AAD symptoms, including potentially positive manifestations like entre/intrapreneurial cognition and creativity, is needed to fully understand the impact of the disorder within the project management nomological network.

Practical implications: Organizations need to be aware of the impact of AAD and DG on OPME. The provision of adapted project management training, productivity tools, a workspace free of unnecessary distractions and both professional and peer coaching is suggested for disordered project managers and participants. Organizations need to help disordered employees find substitutes for dogmatic thinking processes that possess similar protective and decision-making benefits but avoid the related inflexibility and social challenges. Employee assistance programs that raise awareness and provide access to assessment are an important part of multimodal management of the disorder in the workplace.

Social implications: Employers are facing increasing social, legal and economic pressures to support and make effective use of functional but disordered employees. This research provides constructive suggestions for how to accommodate and support disordered project managers.

Originality/value: This is the first empirical examination of the relationships between AAD, DG and OPME and is of value to researchers, organizational development specialists, human resource management specialists, managers and employees who are seeking effective multimodal management of attention related disorders in the workplace.

Keywords: Attention deficit disorder; Adult attention deficit; Adult attention deficit disorder; Attention deficit hyperactivity-impulsivity disorder; Adult attention deficit hyperactivity-impulsivity disorder; Project management; Project manager performance; Project manager effectiveness; Dogmatism

Introduction

At least 5% of the adult global population have clinical levels of attention deficit disorders [1] costing the global economy approximately 144 million days of lost production per annum [2]. Changing role requirements for many workers is delegating and distributing increasingly complex responsibilities and associated competencies throughout organizations [3]. These new role requirements are dependent on higher order cognitive processes often disrupted by adult attention deficit disorders (AADDs) [4,5]. Managing this challenge requires research on how AADDs influence individual and team performance [6].

Working conditions that engage more complex higher order cognitive processes intensifies the need for coping responses among disordered adults [7]. Recent research suggests that disordered adults develop rigid attachments to particular sets of beliefs in order to constrain the extent to which self-directing (higher order) cognitive processes are disrupted by external or internal stimulus [8].

This research study examines the moderating influence of dogmatism on the relationship between adult attention deficit (AAD) and the operational effectiveness of project managers (OEPM), the component of project management most dependent on the higher order cognitive processes typically disrupted by AAD.

The independent variable - adult attention deficit Definition

Research conducted by Brown [9] on symptoms that commonly occur among adults with attention deficits produced the following 5 symptom clusters (factors):

a) difficulty activating and organizing to work (difficulty getting organized and started on tasks predominantly caused by a relative higher arousal threshold and/or chronic anxiety).

b) difficulty sustaining attention and concentration (difficulties staying focused on priority tasks that are not of high personal interest, receiving and organizing information and resisting distraction).

c) difficulty sustaining energy and effort (insufficient and/ or inconsistent levels of general energy and difficulty sustaining effort required to complete important tasks).

d) difficulty managing emotional interference (difficulty with intense, negative and disruptive mood states; relatively high and sustained levels of irritability and emotional reactivity; difficulty managing emotions that constrain the development of constructive relationships).

e) difficulty utilizing working memory and accessing/ recalling learned material (episodic or consistent chronic forgetfulness, difficulty organizing, sequencing and retaining information in short term memory, and problems accessing and using learned material).

Brown [9] uses dimensional (gradations of severity) as opposed categorical (non-disordered vs disordered) measurement of the symptom clusters to determine the overall level of AAD. This is consistent with evidence that AAD symptoms and associated impairment fall along a continuum [10,11]. AAD is defined as a persistent pattern of inattention and related cognitive, emotional and effort related symptoms that occur with varying levels of severity and creates progressively greater challenges within the personal, academic and work life of adults as severity increases [9,12]. The use of dimensional measurement and correlational analysis helps to reveal the influence of AAD within nomological networks that influence organizational behavior [12,13].

Impact of AAD on organizational behavior and management

Research studies using dimensional measurement of AAD has identified associations with difficulty with teamwork [14-16]; greater reliance on co-workers [17] difficulty managing conflict [16], increased stress [18], lower self-efficacy [18] and less effective task management systems [15].

Attention related disorders are also associated with positive behaviors like the ability to work in a fast paced environment, ingenuity, innovation, creativity, determination, perseverance, risk taking and intense focus on things of interest [19,20] which may explain why entrepreneurs appear to have significantly higher prevalence rates [19]. Recent research by White & Shah [21] suggests that the disorder is associated with higher overall levels of creative achievement across a variety of occupational and task domains.

The ability of an organization to foster employee innovativeness, creativity and an entre/intrapreneurial orientation may be one of the most significant contributors to sustained organizational success within an increasingly globalized economy [22]. Research by Zhou [23] suggests that employees with low creativity benefit from working closely with highly creative employees. Organizational innovation, creativity and success is therefore potentially influenced by the manner in which highly creative employees, many of whom may be disordered to varying degrees, are distributed and deployed throughout the organization.

Managerial strategies that appropriately leverage the potential strengths of the disorder while removing, reducing or mitigating the deficits are needed to ensure successful deployment of disordered employees. Most researchers and practitioners agree that multimodal management of the disorder involving a combination of medicinal and non-medicinal support (counseling, coaching, training, supportive conditions and conditions aligned with strengths) has the greatest potential for success [24]. This requires a comprehensive understanding of the impact of the disorder on personal performance capacity (core workplace competencies, motivation and other performance supporting personal states); performance behavior including key mediators and moderators; and performance outcomes at the individual and team level [17].

Dependent variable - project management

Definition and impact

Project management is defined as the application of knowledge, skills and techniques for executing a temporary endeavor undertaken to create a unique product, service or result [25]. The project management process (cycle) includes a variety of phases or stages that are often dependent on the type of project but typically include the stages of initiating, planning, executing, monitoring and controlling, handing off and closing the project [26].

There are a wide variety of project types determined by the nature of the output (e.g. building a skyscraper, developing a new engine, designing and delivering a training service, producing a software update etc.), the size of the project (e.g. scope, number of stakeholders etc.), the execution culture (numerous stakeholder checks due to security issues, established and standardized processes, high level of execution autonomy etc.) and the conditions within which project execution occurs (e.g. industry, sector, organizational culture, time pressures, resource constraints etc.). Projects are also completed by either individuals or teams. In an attempt to identify the key differentiating features of projects, Shanhar & Dvir [27] and others have suggested the following general differentiating dimensions:

a) complexity (extent of scope, number of elements that must be considered when making project decisions, project organization requirements, number and nature of constraints that must be addressed, number of participants and stakeholders, diversity of output requirements and success criteria).

b) uncertainty (degree of clarity about project goals and execution requirements, rate and degree of change influencing project goals and execution requirements).

c) technology (level of technology required to support the project).

d) novelty (the level of originality in project goal, processes and/or output).

e) pace (the criticality and rigidity of the project time frame).

f) Obeng (1994) provided a simple classification of project types based on two dimensions - the level of clarity and detail at the outset of the project about what needs to be done and how to do it. These dimensions are used to create the following classification:

i. closed (stakeholders know what to do and how to do it at the outset).

i. closed (stakeholders know what to do and how to do it at the outset).

iii. semi-closed (stakeholders are given a reasonable level of clarity about what needs to be done, although often somewhat general, but still need to figure out how to do it).

iv. open (stakeholders are unsure of what needs to be done and unsure of how things will be done when the project is initiated and in some cases at various points along the way).

Closed conditions are generally associated with low levels of complexity, uncertainty, technology, novelty and pace. Contemporary conditions have elevated all of the key differentiating factors resulting in a shift away from closed conditions toward more semi-closed and open conditions [28].

Measurement of project success has traditionally focused on what is referred to as the golden triangle – meets the deadline, within budget and addresses the established scope [29]. This approach has been criticized for being too narrow [30] especially when considering the broader impact of key projects like Microsoft Windows which was considered a significant failure relative to the original deadlines, budget and scope. Criteria used to measure project performance has expanded to include the following levels [27,31]:

a) process (optimal identification, selection, implementation and management of project processes).

b) project management (meets time, budget, scope requirements).

c) customer/deliverable (quality, quantity, specifications, acceptance, use, impact, satisfaction).

d) business success (impact on business goals and performance).

e) strategic success (impact on market, competitors, investors and other key stakeholders).

e) strategic success (impact on market, competitors, investors and other key stakeholders).

g) team impact (extend to which the execution of the project supports the capacity of project team members to continue working together in an efficient and effective manner).

The clarification and expansion of performance criteria has improved the ability to identify the key determinants, mediators and moderators of project performance, including the contribution of the personality, management/leadership style and associated competencies of project managers and participants [32].

Research on the influence of the project management competencies suggests a contingent relationship and the need for alignment with project type, conditions and stage [33,34]. In an attempt to categorize the expanding domain of project management competencies, Shenhar & Div [27] suggest that project management competencies be organized into 4 groups:

a) traditional/operational excellence (planning and executing a sequence of project activities to ensure completion of the project scope on time and within budget).

b) dynamic adaption (management of change within the project).

c) strategic focus (strategic alignment of the project, creating a competitive advantage for the organization and adding value at the strategic level of the organization).

d) inspired leadership (motivating and managing project team members and other stakeholders to evoke and maintain their support and commitment to the project, creating project spirit through supporting vision, values and artifacts) [35].

They suggest that the profile of required project management competencies depends on the complexity, uncertainty, technology, pace and novelty of the project. Traditional (operational excellence) competencies may be both necessary and sufficient within closed project conditions that are relatively stable, simple, low tech and do require high levels of novelty. Although the traditional competencies remain necessary, they become increasingly insufficient as the complexity, uncertainty, technology, novelty and pace increase (project conditions become more open). Increasingly open project conditions requires the addition and integration of dynamic adaptation, strategic focus and inspired leadership with the traditional (operational excellence) competencies.

Although the failure rate of projects remains a concern [32], research suggests that effective project management is a contributor to business success in a variety of industries and sectors [36,37] and that project performance is influenced by the personality, management/leadership style and competencies of the project manager [38-42].

Many of the core project manager competencies rely on higher order cognitive processes which are typically disrupted by attention related disorders [43,44]. The significant reliance of traditional (operational excellence) competencies on higher order processes like impulse inhibition, planning, modeling, prediction, goal and priority setting, sequencing and problem solving suggests that operational effectiveness may be particularly impacted by the disorder. These are also referred to as the process competencies. The ongoing necessity and foundational nature of traditional competencies (operational excellence) in spite of growing insufficiency as project conditions become more open, suggests that AAD may have an important influence within the nomological network that determines both project manager, team member and project performance. A search of multiple databases (medline, psyc-info, academic source premier, business source premier etc.) produced no empirical studies on the relationship between attention related disorders/conditions and project management.

Moderating variable - dogmatism

Definition and impact

Belief and disbelief systems satisfy the need for a cognitive framework that defines situations and provides protection from threats [45]. Dogmatism is generally defined as a closed belief system resulting from a rigid attachment to particular beliefs that are resistant to opposing beliefs. Rokeach [45] suggests that dogmatism is defensive in nature and encompasses a constellation of psychoanalytic defenses that help to shield a vulnerable mind. More recently, Altemeyer [46] defined dogmatism as “an unjustified and unchangeable certainty in one’s beliefs, reflecting conviction beyond the reach of evidence to the contrary” (p. 201). Rigid attachment to a particular set of beliefs helps to protect self-directing processes that are relatively more vulnerable to disruptive external and internal stimulus [47]. Defensive cognitive closure, rigid certainty and isolating (compartmentalizing) contradictory beliefs is a way to protect higher order cognitive processes from complex external stimulus that may create the experience of cognitive chaos, confusion, vulnerability and anxiety. Rigid cognitive structures are also a way to defend against the disruptive impact of emotions like anxiety, fear or anger that have reached a level of intensity that disrupts self-directing cognitive processes.

Developmental psychologists have consistently identified early psychosocial conditions in the parenting process and a biological vulnerability for hyper-arousal, environmental stressors and disrupted socio-culture learning as the distal causes [47]. Anxiety that arises in childhood and persists through adolescence and into adulthood will help to rigidify the belief system as a means of personal defense. Recent research by Brown [44] identified an association between disrupted functioning of short-term memory and dogmatism suggesting a link between rigid (defensive) thinking and adult attention deficit.

Research on the impact of dogmatism on mental health and general functioning has identified mostly detrimental but some beneficial effects [48-50]. Research on the occupational impact of dogmatism has revealed an association with both high and low performance [51,52]. Dogmatic workers are likely to struggle in situations that are dynamic, uncertain, and complex, and require high levels of reflection, flexibility and cooperation with others [7]. However, a dogmatic thinking style may be useful when performance supporting cognitive and emotional states are particularly vulnerable to external and internal stimuli that may produce disruptive cognitive dissonance [53]. The impact of dogmatism on health and performance appears to be moderated by personal vulnerability to disruptive dissonance. For workers who are prone to confusion and indecision as the complexity and intensity of external and internal stimulus increases, the benefits of a dogmatic style may outweigh the costs.

The Relationship between AAD, dogmatism and the operational project management

Hypotheses

The proposition guiding this research study is that dogmatism moderates the negative relationship between AAD and the operational effectiveness of project managers (referred to as operational effectiveness). Project managers who use a more dogmatic orientation toward managing the operational aspects of a project, especially under closed or semi-closed conditions (low need for dynamic adaption), may be able to generate a higher level of cognitive protection from the disorganizing effects of the disorder.

Employees with operational project management responsibilities who experience difficulties with getting organized and started on tasks, concentration, sustaining effort, managing emotional interference, using short term (working memory) and accessing learned material, will have greater difficulty achieving operational competence. They will be less able to activate and organize the project initiation stage, establish clear and appropriate project goals, map out and schedule the require tasks, organize and integrate the tasks into an efficient project plan, manage project participants and ensure timely completion of the project within scope and budget. Difficulties with attention and concentration will undermine the ability to consistently pay attention to the details of the project plan resulting in inefficient reexamination. Difficulties with energy and effort will constrain the consistency and duration of effort needed to ensure timely completion of critical end-to-end tasks.

Impulsivity and emotional reactivity may be viewed by others as impatience and a lack of confidence in others which may constraint the formation of trusting, constructive and supporting relationships. Disordered adults are often indecisive [54] when facing conflicting goals and disproportionately attentive to tasks that are immediately gratifying and of relatively greater personal interest [13]. This should further constrain operational efficiency and effectiveness.

H1: Adult attention deficit is negatively associated with the operational effectiveness of project managers

Disordered project managers may be able to constrain the level of manifest disorganization, indecision and confusion associated with the disorder by using a more dogmatic orientation. This is more likely to be beneficial within closed/semi-closed project conditions that don’t require high levels of flexibility and dynamic adaptation. The use of a dogmatic orientation may help to shield a vulnerable mind from internal and/or external stimuli that promotes disorganization, indecision and confusion, and/ or constrain the behavioral manifestation of these symptoms resulting in levels of decisiveness expected from the operational role of a project manager.

H2: Dogmatism moderates the relationship between adult attention deficit and the operational effectiveness of project managers

Methods

Subjects and procedures

The subjects were 160 actively employed business graduate students attending a university in the United States. Subjects participated in business courses that required them to work in 4 person autonomous project teams. Each team was responsible for completing a major business project which required the completion of 4 sub-projects. Each team was required to complete a strategic planning process and produce a strategic plan based on the 4 traditional elements of strategic planning - external opportunities and threats plus internal strengths and weaknesses (SWOT). Each team member was required to manage one part of the SWOT analysis and the other team members were required to work for them on that particular sub-project. Each of the 4 subproject managers (team members) were expected to integrate their sub-projects into an overall strategic plan and manage the progress of the overall project. The general operational phases of project management, related competencies and tools were briefly reviewed at the beginning of the course.

The project conditions were semi-closed because the project outcomes (scope and timeline) were specified with a reasonable level of clarity and detail from the outset but the process of further defining the outcomes where necessary, and determining the process for achieving the outcomes, was delegated to the project managers. The project conditions represent low to medium complexity, uncertainty, technology, novelty and pace. These conditions mostly emphasize the need for operational project management competence.

At the end of the semester each of the team members completed an assessment of the operational project management effectiveness of the other team members. Each subject was also asked to identify someone who knew them well and would be willing to complete an honest assessment of their behavior. The identified observers completed an observer version of the Brown Adult Attention Deficit Scale (BAADS) under conditions of anonymity. Each of the subjects completed a self-report measure of dogmatism.

Principle components factor analysis with a varimax rotation was used to confirm the dimensionality of the project manager effectiveness measure, and examine the contribution of the individual items to the factors. Product moment correlations were used to test all the hypotheses regarding associations between the measures. Linear regression that included the multiplication of standardized independent and moderator variables (moderator variable) was used to test for a significant moderating effect.

Measures

Adult attention deficit (ADD)

The Brown (1996) Adult Attention Deficit Scale (BAADS) contains forty self-report items that measure the five symptom clusters. Organizing and activating to work (cluster 1) measures difficulty in getting organized and started on tasks (e.g., “experiences excessive difficulty getting started on tasks”). Sustaining attention and concentration (cluster 2) measures problems in paying attention and concentrating while performing tasks (e.g., “listens and tries to pay attention but soon becomes distracted”). Sustaining Energy and effort (cluster 3) measures problems in maintaining the required energy and effort while performing tasks (e.g., “runs out of steam and doesn’t follow through”). Managing affective interference (cluster 4) measures difficulty with moods, emotional reactivity and sensitivity to criticism (e.g., “is easily irritated” and “has a short fuse with sudden outbursts of anger”). Utilizing working memory and accessing recall (cluster 5) measures forgetfulness in daily routines and problems with recall of learned material (e.g., “intends to do things but forgets”). The questions are phrased in third person singular to support observer ratings (e.g., “” the person being described is disorganized”). The instrument uses a four-point behavioral frequency scale (0=never, 1=once a week, 2=twice a week, 3=almost daily). A total score for AAD was generated by adding up the scores on all of the questions.

Dogmatism

The new dogmatism scale (DOG) [46,55] was used to measure dogmatism. The instrument was designed and validated for use with adults and contains 20 items that measure general dogmatism. Example items for the scale include the following: “I am absolutely certain that my ideas about the fundamental issues in life are correct”; “The things I believe in are so completely true, I could never doubt them”; and “I have never discovered a system of beliefs that explains everything to my satisfaction” (reverse coded). Subjects used a seven-point Likert scale (1=strongly disagree, 2=disagree, 3=slightly disagree, 4=neutral, 5=slightly agree, 6=agree, 7=strongly agree) to rate the extent to which they agreed with each item. Each of the subjects completed the dogmatism measure and a total score was derived by adding up the scores on the individual items (some items needed to be reversed).

Operational project management effectiveness

Items for measuring the operational effectiveness of project managers were developed after reviewing the core project management competencies outlined by the International Project Management Association [56], the Project Management Institute in the United States (2008) and recent research on the assessment of project managers [57-60]. There was no well-established instrument that focused exclusively on measuring the operational effectiveness of project managers as outlined by [27]. However, most existing instruments and competency profiles contained parts that referenced the operational effectiveness component of project manager performance.

Thirteen items that represent the key operational (traditional/ process) project management responsibilities described by Shenhar and Dvir [27] were selected and worded in a general manner that encompassed most project management situations, including the situation that the subjects were embedded in (Table 1). Example items are “mapped out all the key project tasks and milestones”, “identified the critical path that determined the duration of the project” and “secured the input and support of project team members.” Observers used a seven-point Likert scale (1=strongly disagree, 2=disagree, 3=slightly disagree, 4=neutral, 5=slightly agree, 6=agree, 7=strongly agree) to rate the extent to which the project manager demonstrated each competency. Each project manager was rated by the other three members of the project team and the scores on each question were averaged and then added to get a total operational effectiveness score.

Results

Descriptives, factor analysis, correlations and regression

A principle components factor analysis with an orthogonal rotation (varimax) was conducted to examine the structure of the project manager effectiveness instrument. The factor analysis for the project manager effectiveness items produced a single factor with factor loadings ranging from 0.65 to 0.82 suggesting that each item is making a meaningful contribution to the measure. The Cronbach alpha internal reliability coefficient was α = 0.89 and could not be improved by eliminating items. This suggests that the instrument has good internal reliability, and each item is making a meaningful contribution (Table 2).

The average intra-class correlations (two-way mixed effects model with absolute type agreement) among team member ratings of project manager effectiveness ranged from 0.71 to 0.90 suggesting acceptable inter-rater reliability. Means, standard deviations and correlations among the variables appear in Table 1. All variable distributions were approximately normal and demonstrated reasonable variation across their respective scales. No univariate or bivariate outliers were considered problematic, and the product moment correlations revealed significant associations between the variables. The mean, standard deviation and maximum score for AAD (avg = 39.24, std dev = 18.34, max score = 104) are not significantly different from the instrument validation samples and previous samples of subjects taken from the same university and a similar university in western Canada.

Cronbach alpha internal reliability coefficients ranged from (α = 0.89) to (α = 0.93) suggesting good internal reliabilities. The linear regression for testing the moderation effect produced no problematic residuals (Table 1).

Empirical test of hypothesis

The significance threshold for empirical tests was set at α = 0.05 (2 tailed). The correlation between AAD and project manager effectiveness (Hypothesis 1) was statistically significant (r = -0.35, p < 0.01). The linear regression of project manager effectiveness on adult attention deficit, dogmatism and the moderator (multiplication of the standardized dogmatism and adult attention deficit variables) produced a statistically significant moderator effect (β = 0.29 p = 0.000). An examination of the moderator graph (Figure 1) confirms that the negative relationship between adult attention deficit and the operational effectiveness of project managers declines as dogmatism increases (Table 3).

Discussion

General

The results suggest that AAD constrained the operational (traditional/process) effectiveness of project managers and that the negative relationship between AAD and operational effectiveness declines as dogmatism increases. The directionality of this relationship cannot be confirmed from this research study and both opposite and bi-directional effects are possible. The large number of studies confirming the significant contribution of genetic factors to the manifestation of the disorder [43] provides general support for the hypothesized direction in this study. Recent research suggesting that certain contextual conditions like parental conflict and inconsistent parenting may help manifest a genetic predisposition or strengthen existing symptoms [61] suggests that certain project conditions may contribute to AAD.

Implications for organizations and education institutions

Organizations wishing to ensure the success of key projects need to be aware of the influence of adult attention deficit and dogmatism on project manager effectiveness. The emergence of more empowered work cultures, tighter deadlines, the need for creativity/innovation and project-oriented work represents both an opportunity and challenge for disordered employees. Disordered employees without the necessary support will not be able to leverage their strengths and may constrain the performance of interdependent others.

The protective influence of dogmatism on the execution of operational project tasks by disordered project managers suggests the need for conditions, tools and competencies that protect higher order cognitive resources from disruptive external and internal stimulus. The provision of project management training/coaching, project management tools and a workspace free of unnecessary distractions may be especially important for project teams containing disordered employees. Although a dogmatic style may be beneficial under relatively simple and stable conditions, it is unlikely that a defensive and rigid cognitive style will support project management effectiveness under increasingly dynamic and open project conditions. Organizations need to help disordered project managers and participants find substitutes for dogmatic thinking processes that possess similar protective benefits but avoid the related inflexibility and social challenges associated with being dogmatic. Helping disordered project managers to better manage anxiety, stress, emotional disruption, and find an appropriate balance between assertiveness and collaboration, is likely to play an important role in developing constructive substitutes for dogmatic thinking.

The increasing availability of effective coaches (life, organizational, task, peer, manager as coach etc.) [62] offers a potential substitute for close supervision and a potentially more accepted and developmental resource for keeping disordered employees oriented toward successful completion of priority tasks and projects. Effective organizational coaches could address a wide range of cognitive, emotional and behavioral deficits, and protect the employee from the reinforcing cycles of failure that many disordered employees experience [63]. Establishing reciprocal peer coaching systems within project teams or the organization as a whole, that addresses challenges at the individual and relational level may add considerable mutual value, especially for disordered employees [64,65]. Coaching processes that contain the necessary structure and content for supporting disordered employees are needed.

The effective use of project teams represents an opportunity for distributing the creative benefits associated with the disorder while managing the deficits. Team members and peer coaches can help disordered employees to activate, organize, stay on track, maintain a balance between organizational citizenship opportunities and priority work tasks, avoid experiences of failure and manage challenging emotions. They can also help disordered employees address the pitfalls of rigid thinking and behavior. In return, team members can benefit from the creativity that disordered employees may offer. This will require the careful design of teams to ensure optimal person-role fit and supportive team development interventions. Team building that educates team members about the disorder and addresses the social and task performance challenges while taking advantage of the benefits is required. Structured collaborative decision-making processes that provide team members with the opportunity to optimally locate themselves within the process should improve person-role fit, avoid the problems of excessive rigidity and ensure timely decisions. Shared management of projects that partner disordered project managers with someone who is flexible and has strong administration and social skills may support both individual and project effectiveness.

The multi-modal approach to managing the disorder in the workplace suggests that sustained improvement will depend on other forms of support like the general education of both managers and employees, establishing supportive organizational cultures and climates, appropriate medication and coaching/training that address key underlying cognitive, emotional and behavior deficits (e.g. retention training to support effective and efficient use of short term memory). The provision of employee assistance programs that provide disordered, potentially disordered and non-disordered employees with information about the disorder and opportunities for assessment is an important part of the constructive management of employee diversity. This will help to create a more inclusive, supportive and responsive organizational culture. This will also increase the likelihood of the employee seeking out other important parts of multimodal treatment, particularly medicinal support.

Education institutions, like management programs within universities, need to assist new project managers to recognize and respond to the symptoms of the disorder in both themselves and others. Early diagnoses and treatment may help to prevent the exacerbating cycles of failure that often accompany the condition. Educating future managers about the condition will help to ensure that they do not become a contributor to the emergence and reinforcement of such cycles through ignorance or the inability to be supportive. Project management training, peer coaching systems and student team interventions that address the disorder in a constructive manner will help prepare all future managers for the challenges of the contemporary workplace. Education and training that improves self-awareness, emotional intelligence, effective use of working memory and constructive assertiveness may help substitute for the protective use of dogmatic thinking styles.

Increasing social, economic and legal pressures to provide reasonable accommodation for functional but disordered employees and take appropriate advantage of employee diversity underscores the general social value of this research.

Limitations and suggestions for future research

Future research requires use of samples that are more directly associated with the workplace. The influence of creativity within the relationship between AAD and project manager effectiveness requires further investigation and may reveal beneficial aspects of the relationship. Measures of project management effectiveness that include items related to the creative dimensions of a project, when such dimensions are required, are needed to support this research. A system for classifying the creative requirements of projects will help develop the moderating variables needed to reveal project management situations within which the disorder may be beneficial. This research supports the general proposition that the disorder has significant influence within the nomological network that determines individual, team and organizational performance.


Monday, January 9, 2023

Motivation in School Physical Education: A Path to The Education of Physically Active Individuals - Juniper Publishers

 Physical Fitness, Medicine & Treatment in Sports - Juniper Publishers

Abstract

The World Health Organization recommends the promotion of quality physical education for young people in school curricula. The school as a democratic institution that reaches society, as well as physical education as a curricular component, plays an important role in educating citizens who are physically active in the future. However, studies have shown a growing disinterest of students in physical education classes. The aim of this opinion article is to describe a proposal for diagnosing the motivation of students from southeastern Brazil in physical education classes to guide quality practical interventions that encourage them to value physical activity as a means of health promotion. The premise is that young people educated for active life will become aware and autonomous adults who will maintain an adequate level of physical activity.

Keywords: School physical education Motivation Physical activity Physical inactivity

Introduction

This article aims to highlight the importance of school physical education to educate and raise awareness about the importance of physical activity as one of the factors for maintaining a healthy life. The narrative develops in the context of the Brazilian reality since official and international censuses have reported high levels of physical inactivity. In addition, national studies point to substantial disinterest of young people and adolescents in physical education classes [1], in agreement with international evidence [2]. In view of these critical problems, studies conducted by the Research Group on Physical Education and Sport Pedagogy, of which we are a part, have sought to identify the causes of the demotivation of students to participate in physical education classes. The self-determination theory (SDT) was adopted as a conceptual framework because it is a widely investigated and empirically validated theory on the satisfaction of basic psychological needs. Based on the premise that active children and adolescents tend to become active adults [3], it will be important to know the rea son that attracts them to or alienates them from physical activity since school age. Health and education are two strategic areas for human development and therefore deserve the attention of gov ernment bodies because policies that integrate these areas allow both the prevention of diseases and the emancipation and autonomy of citizens. Physical education is considered a key element in disease prevention and health promotion programs because it is present and operates in both areas, either through the participation of physical education professionals in public health programs or the presence of this discipline in school curricula.

The benefits of physical activity are well established and include the prevention of overweight/obesity, hypertension and diabetes, as well as a positive effect on mental health [4]. The World Health Organization (WHO) [5] alerts to the association between obesity in childhood and adolescence and an increased risk of obesity in adulthood, which may even result in death due to heart diseases, respiratory problems, diabetes, and liver disease. In addition, considering that adolescence is a critical phase of development, obesity can also cause serious psychological problems related to the self-perception and low self-esteem of young people. To prevent obesity in adolescents, the WHO [5] recommends, among other measures, ensuring quality physical education for young people in school curricula, as well as disseminating national guidelines for young people and family members that regulate screen entertainment, sleep and healthy nutrition. Within thiscontext, school physical education as a curricular component of formal education can contribute not only to increasing levels of physical activity in elementary, middle and high school but also to teach young people the key concepts that would raise their awareness about the importance of physical activity for maintaining an active life and, consequently, for health preservation. Therefore, quality school physical education for children and adolescents has the potential to directly influence the development of active behavioral patterns throughout life [6], contributing to the prevention of health risk factors.

Context and physical inactivity among youth and adults

Studies reported a global prevalence of insufficient physical activity in 2016 of 81% among young and adolescents (11-17 years; M=77.6% and F=84.7%) [7] and of 27.5% among adults (≥18 years; M=23.4% and F=31.7%) [4]. In Brazil, the same studies indicate percentages of insufficiently active young/adolescents of 83.6% (M=78.0% and F=89.4%) [7] and of insufficiently active adults of 47.0% (M=23.4% and F=31.7%) [4]. This scenario is a matter of concern because it predicts a considerable proportion of adults with a high risk of developing serious health problems in the future. In Brazil, the National Survey of School Health (PeNSE) [8] and the Surveillance of Risk Factors for Chronic Diseases through Telephone Interview (Vigitel) [9] are official studies of the Ministry of Health for monitoring the health of schoolchildren and adults, respectively. The latest edition of the PeNSE conducted in 2015 [8] involved 113,227 schoolchildren aged 13-17 years (elementary to high school students) representative of the Brazilian territory. The percentage of students considered active by the globally estimated physical activity indicator was 20.0% in the 13-15-year age group and 19.2% in the 16-17-year age group. These percentages increased when the indicator of accumulated physical activity was considered, with students with an active profile accounting for 32.4% in the 13-15-year age group and for 30.3% among those aged 16-17 years. Regardless of the indicator adopted, the proportion of boys was significantly higher than that of girls. With respect to the nutritional status of students aged 13- 17 years, the overall proportion of overweight and obese individuals was 23.7%, with no significant difference between sexes [8]. The latest edition of the Vigitel survey was conducted in 2018 [9] and involved 52,395 adults (age ≥18 years) representative of all states of the Brazilian federation. The percentage of adults in the sample who performed moderate leisure-time physical activity of ≥150 minutes/week was 38.1%. Men were more active (45.4%) than women (31.8%), with the difference being significant.

The sum of insufficiently active and inactive adults was 57.8%. Men were found to be less inactive (48.1%) than women (65.9%). A finding that draws attention in this study is that the participation in physical activity decreased with advancing age of the adults. In addition, educational level positively influenced the participation in physical activity, i.e., individuals with a higher educational level tended to have higher physical activity levels.Regarding the nutritional status of the adults studied, 55.7% were overweight and 19.8% were obese. There was a higher percentage of overweight men (57.8%) compared to women (53.9%), while women were more frequently obese (20.7%) than men (18.7%) [9]. The educational level of the adults also influenced the nutritional status, with the prevalence of overweight/obesity decreasing with increasing educational level of the respondents. In view of these findings, school physical education must not be neglected as a tool to reverse this reality. We must be aware of the reasons that have led students to avoid engaging in physical education classes. They are sending us a message and we are not being able to hear them. Our research aims to diagnose the causes of students’ demotivation in order to provide teachers with consistent information that will enable them to adapt physical education programs and to encourage students not only to participate in physical activity, but also to develop conceptual knowledge about physical activity and health. In the next section, we present a brief description of this research project and preliminary results.

Method and diagnosis of reality

A quantitative-qualitative methodology was adopted to analyze objective dimensions-characterizing the needs of students – and subjective dimensions – knowing the causes of disinterest in physical education classes. The database under construction refers to 1,124 elementary, middle and high school students. The Basic Psychological Needs in Exercise Scale (BPNES) [10], adapted and validated for the Brazilian reality, was used to characterize the motivational profile of the students. The causes of the students’ disinterest in physical education classes were obtained by interviews, which were elaborated using the dialectic hermeneutic circle technique [11]. This technique allows all subjects to answer the original and other questions formulated from the conversations with the interviewed peers, permitting that respondents express their opinion about each other. For this analysis, subsamples were created, characterizing a multi-case study.

The SDT has been the most widely used theoretical framework to analyze motivation in physical education classes [12-14]. This approach to human motivation and personality highlights the importance of the individual’s self-regulation of behavior. The theory of basic psychological needs is one of the theories underlying the SDT [15]. From this perspective, the tendency towards development, integration of self-determined psychological elements, and the interaction with a social structure emerge as innate needs of psychological autonomy, personal competence, and social relatedness. [12] refer to the need for competence as feeling competent and capable of carrying out activities; to autonomy as the possibility of having choice and control, and to relatedness as feeling affiliated and belonging to the social context.

The interpretation of the results allows us to infer that students generally feel that their basic psychological needs are moderately satisfied, suggesting that adaptation of the environmentto students’ needs will result in greater satisfaction. Boys generally feel that their basic needs are better met than girls, especially competence needs. Elementary school boys feel that their basic psychological needs are satisfied, but this feeling tends to decrease at the end of middle school and to stabilize during high school. The feeling of competence and autonomy need satisfaction is greater among boys across all school levels. The arguments reported by boys and girls in the interview indicate that it is generally the priority of boys to use the gym and boys also interfere more with the decisions of the teacher.

Boys and girls feel the need to share decisions about the planning and elaboration of classes so that they can explain preferred contents and the types of exercises consistent with their skills and competences. Girls tend to value and feel largely satisfied with relatedness needs in the classroom, while boys of all school levels achieve a higher rate. Bullying is a problem reported by boys and girls as a reason for disinterest in physical education classes. During the classes, the students may find themselves in embarrassing situations in front of the class, which are almost always caused by the patterns of movement and performance in the activities developed.

Conclusion

Male and female students exhibit a more self-determined behavior when their environment provides support for the development of their basic psychological needs. In line with the research objectives, this study indicates that the lack of skills, of content diversification beyond the most popular team sports and of opportunities to participate in classroom decision-making are relevant reasons that lead to students’ disinterest in school physical education. The low competence need satisfaction of girls may be related to the predominance of soccer practice in the classroom context and to the fact that the teaching activities have not provided conditions for the development of their skills. We suggest expanding student experiences based on the diversification of contents, adapting the levels of requirement to the students’ skills and providing activities with high chances of success in order to improve the perception of competence. Resorting to participatory planning is an alternative that can be used to enhance the feeling of autonomy need satisfaction. However, shared decision-making about teaching requires parsimony since the teacher has important didactic-pedagogical tools and knowledge of the content necessary for elaboration of the teaching-learning process. To support autonomy, the teacher needs to provide an environment in which students feel to be co-authors of decisions in different classroom situations. To effectively contribute to the education of physically active citizens, school physical education needs to overcome the concept of a space exclusively dedicated to recreation and leisure and become a training space par excellence to endow individuals with autonomy to manage their health.

Thursday, January 5, 2023

The Doctor Patient Relationship: A Calculus of Two Languages? A Glimpse at VKH Disease Through the Doctor Patient Relationship - Juniper Publishers

 JOJ Ophthalmology - Juniper Publishers

Abstract

Human feelings have been an integral part of the doctor patient relationship from early medical history. Recently, in addition, the role of language of the doctor and the patient has come under scrutiny. In this paper the ebb and flow of the doctor patient relationship is examined through the respective languages of the doctor and the patient under the lens of time.

Keywords: Doctor patient relationship; Calculus over time; Abettors; Disruptors; VKH Disease

Abbreviations: VKH: Vogt Koyanagi Harada’s Disease

Introduction

Feelings in Medicine

Hippocrates, (460-370 BC) was the first physician to place the origins of thoughts, ideas, and feelings in the brain and not the heart. Galen, (126-216) despite his loyalty to humoralism advocated by Hippocrates, was known for his differential diagnosis and emphasized the difference between organic versus emotional diagnosis. Maimonides (1135-1204) believed that passions produce great changes in the body and that the perturbations of the psyche need to be in balance to help serve as a check on disease. Thus, the beginnings of medical science captured the significance of human feelings as one of the essential parts of disease [1].

Evolution of Two Languages

The patient in one language or another has for over two millennia complained of pain or some other feelings of illness in a basic human language to the physician. Over the course of time, however, because of the evolution of voluminous areas of knowledge in medicine, the physician has developed his/her own language. Consequently, there has emerged a dichotomy of language used by the patient and the physician. In addition, the culture, native language, and geographic location have been noted as other problems for the patient side of the equation [2-6].

The Math of Change Over Time

Calculus, a branch of math that looks at changes between two elements and gives them a relationship either by dividing them into smaller pieces, (differential calculus) or by adding smaller pieces together, (integral calculus) helps us look at change over time. In considering the doctor patient relationship it is the changes over time or how the patient’s language varies from that of the physician that can be seen either in terms of constructive additions or by divisive breaks. Not that those divisive breaks necessarily spell the end of the relationship or that those smaller piece additions insure its perpetuation, but rather there is an ebb and flow, which punctuates the course of the relationship. It is the calculus of the two different languages, with an interpreter or without, of the doctor and the patient that will be explored in this essay.

Key Feelings: Abettors and Disruptors

What are some of the emotions or feelings that enable the languages of inception and evolution of the doctor patient relationship? The patient must be comfortable with the doctor’s ability to listen with an open mind, be kind and considerate, putting his/her own preconceived notions aside, especially when first hearing the patient’s anguish, sometimes even in the face of conflicting feelings and symptoms of illness.

The doctor must submerge his/her need to offer quick diagnosis and treatment until the patient has had a chance to feel that he or she can respect and trust the physician and accept what the physician has to offer. These elements of trust and acceptance are the cornerstone to all future communication. The next doctor patient language rift is that of understanding. While the doctor digests the symptoms, signs and emotions of the patient from the history, physical, and lab data, the patient may be in a state of limbo about exactly what is the name of his/her problem and course of treatment. It then behooves the doctor to offer the patient some options regarding his/her understanding, some possible diagnosis, further testing and potential courses of management and time considerations. If the doctor can put the patient into some level of ease to weather the initial clouds of doubt hanging over the diagnosis and treatment, then this will initiate a language of compatibility. This can dispel much of the anxiety sometimes raised by family, friends and other confounders such as generalities about similar diseases from the media or the Internet. Moreover, if this language of compatibility is strong enough, then the role of additional consultants, diagnostic tests, and even treatment can ensue. However, this all comes to a crossroads in the discussion of medical insurance coverage. Like many areas of our lives, the power of the purse plays an important role. Here, even if the physician has more than adequately achieved the acceptance and trust of the patient as well as the compatibility for future communication, all too often one can hear the patient complain that the doctor does not accept the insurance at some or all levels of care. This is the language of disruption of the doctor patient relationship. Another disruption to the doctor patient relationship is the computer. Patients often complain that while the doctor seems to be listening, the doctor is facing the computer with his/her head down or his/her back towards them. See table 1 for abettors and disruptors of doctor patient relationship.

JOJ Ophthalmology

Probably one of the most serious disruptors of the doctor patient relationship is the malfeasance suggested by George Bernard Shaw in the Doctor’s Dilemma, where favorites are played related to the doctor’s personal feelings. Alternatively, the relationship can be ruptured if the doctor somehow commits an error in the dosage or type of medicine or even the diagnosis.

Thus, in the times we live, the doctor patient relationship often rests on precarious grounds, with an uncertain alchemy of feelings, emotions, and economics. So, the differences in language between the doctor and the patient as well as the many unknown curves in the road to disease management create a significant challenge to the science as well as the art of medicine.

A Clinical Case

In the following clinical case of Vogt Koyanagi Harada disease some of the vicissitudes of the doctor(s) patient relationship are manifest. A 28 year old Asian male from the Philippines who was working as a salad chef at one of the upper West Side restaurants and who was otherwise in excellent health with no prior medical history presented to a university hospital ER with bilateral painful blurry vision, headache, stiff neck, some trouble hearing, weakness, fevers and joint pain of two day’s duration. Physical exam by the admitting medical resident revealed a mildly pigmented, thin, weak young man with a fever of 102 degrees F, pulse 86, BP 150/90, respirations 10 and somewhat labored. The skin had some areas along the chest and arms with mild depigmentation, some whitening and erythematous blotches. The pupils were only sluggishly reactive to light and the patient was quite photophobic. There was 2-3+ conjunctival injection and a small hypopion bilaterally. After several attempts at funduscopy, all that the medical resident could see was white lines radiating from the optic nerves and was not sure if there was bilateral papilledema. Hearing, tested by a small bell ringing on the side of each ear, was moderately diminished. There was mild stiffness of the neck to forward and backward movement with considerable pain. Similarly, there was considerable pain to arm elevation, bending at the elbow, and making a fist bilaterally. The patient could barely sit up in bed, let alone get out of bed and walk. The remainder of the exam was unremarkable. Struck by the fever, the CNS findings, the depigmentation, the suggestive uveitis signs and the stiff neck and joints, the medical resident explained to the patient that he might have some infection or inflammatory disease in his body and brain and would have to be admitted to the Neurology Unit of the hospital that night for evaluation by Neurology, Rheumatology, Ophthalmology, Dermatology and Medicine. When asked by the patient what was the name of the disease that the medical resident thought he had, the doctor answered in a sympathetic tone VKH or some type of meningitis. The patient then queried, “Is VKH a familial disease?” The doctor thought for a moment and then answered in the affirmative. The patient said that he could remember one of his cousins having something similar when he was younger. The doctor took his hand and explained that he would need to think about having some tests on his spinal fluid for pigment and white cells to be clearer on the diagnosis, but that there were some good ways of treating the disease with reasonable hope of recovery. “Yes, the patient said, I remember my cousin got better. He was also taken care of in this hospital.” Much to the patient’s chagrin, (The patient’s name was Juan.) he would never see the ER medical resident again but retained a fond place in his heart for that first doctor.

Juan dozed off and on awakening found that he was being asked to sign a consent to have pictures taken of his head in a noisy magnetic machine. He signed and a voice nearby clutching his hand asked him to hold still so the pictures of his head could come out. The next thing he knew he was asked to sign consent to have a needle placed in his back to check for infection, inflammation, white cells and pigment in his spinal fluid. He remembered the ER doctor’s telling him about this and signed the consent. There was some pain from the needle in his back, but his eyes were burning so much, and he had such pain in his joints that he barely felt the needle. Some time passed and he heard a woman’s voice introducing herself as the eye doctor on call; she apologized that it was one AM but because of the threat to his vision with the possible VKH she was called to see him as an emergency. She asked him to read some letters from a hand card with each eye, which he struggled with and then she shined a light into each eye to examine the back of the eyes. She explained to Juan that he had some large white spots around his optic nerves in his retina, which likely represented white cell inflammation and deposits and a little bit of fluid swelling of the optic nerves. She said that it did appear to be VKH which had affected the front and back of the eyes.

She went on that if it were left untreated the structures of the eye would swell, inflame, scar and have irreparable damage. She suggested that prompt treatment at least to the front of the eye with drops that relaxed the muscles and reduced inflammation would help not only the ocular pain but also help the vision and reduce scarring. Juan consented to the drops and she said that she would return in the daytime to check him and they would consider oral medicine to stop the swelling in the back of his eyes and brain, if the spinal tap tests were positive and if no other tests showed bad infections like tuberculosis. She pointed to a quiet site on his left forearm where someone had drawn a circle around a tuberculosis test. He liked her immediately and thanked her.

The next morning, Juan was barely awake at 7AM when an august team of physicians in white coats came to his bedside and said that they were from Neurology. They seemed to be talking to themselves as if he were not there and when he asked what they thought about him they seemed to innocently go on with their conversation amongst themselves in hushed tones as if he had not asked anything. They seemed to be rather pleased with one of the younger doctors who was reading from a slip of paper he had produced during their conversation. One neurology doctor asked him to sit up and shined a light in his eyes, looked into the back of his eyes and tapped on his knees with a little rubber hammer. They were gone in a few minutes and he dozed off.

About an hour later, an elderly doctor came to him and introduced himself as the Rheumatology doctor to check his body and joints. This doctor listened to Juan tell his story, examined Juan fully, and explained the multiple problems that VKH might pose currently and in the future. The rheumatologist explained that with the white cells and pigment found in the spinal fluid, from early this morning, it was quite likely that VKH was the diagnosis. That meant that multiple areas of the body had acquired an excess number of white cell and giant white cell aggregates that could attack his eyes, ears, brain, skin and other parts of his body. Unfortunately, these white cell aggregates carried the potential for vision, hearing and other brain damaging issues that could be irreversible unless high dose anti-inflammatory steroid injections were started today and ultimately adjusted over the next few weeks to oral steroid treatment maintenance. When his usual white cell levels returned and the eyes and ears and brain cleared, the steroid could be tapered and eventually stopped.

The doctor also said that the steroids could have long term effects on his bones, blood sugar levels, weight, sleeping pattern, and intensity of mental agitation (or even the reverse) depression. Juan said that he thought that white cells were good and could fight diseases. The doctor explained that as with most things in the body it is the right balance of white cells that helps. Overages of white cells, especially in the brain could be lethal. Then Juan asked the doctor if there were other medications that could be used that did not have such strong side effects. He was especially concerned about feeling wired. He said that his work in the kitchen was high pressure enough. He didn’t know if he could work with more pressure. The doctor said that there were some newer antibody medicines that were considerably more expensive, that moderated the white cells, but they might create their own problems, such as infections or white cell tumor growth. As to the mental agitation, the doctor explained that after the steroids curtailed the white cell surges in the body, they would be tapered and even stopped. If he still needed them, they would talk about anti-anxiety medications to carry him through the steroid withdrawal.

The doctor said that he expected Juan to be in the hospital for a week and that his wife and his son could visit later today. Juan grew teary eyed and grabbed the old doctor and hugged him.

A Calculus of the Doctor(s) Patient Relationship

Fast forward…it is the end of the week in the hospital. Juan’s vision has returned by about 85%; he has no pain in his eyes; his hearing is slowly improving; his headache and stiff neck are gone and his joints are normal; he is on 40 mg per day of Prednisone by mouth, twice a day after meals, prednisone eye drops every 4 hours in each eye, and has begun to drink a glass of milk twice a day for calcium and take walks three times a day. His wife arrives to take him home where he will have to recuperate for a week and pending clinic follow-ups then he will be able to return to work.

His discharge papers are in order and he is ready to leave when one of the nurses gives him a clipboard with his medication instruction sheet as well as his clinic follow up instructions. On another half sized sheet, the hospital asks him to fill out an evaluation on each doctor involved in his care. The possible ratings for each are: excellent, good, acceptable, poor, unacceptable. He fills it out as follows: ER doctor: good; Neurology doctors: poor; (never really listened to me or spent time); Ophthalmology doctor: good; Rheumatology doctor: excellent (listened to me and checked me every day, answered my questions and cared about me); Dermatology doctor: cannot recall such a doctor; Medical Doctor: cannot recall such a doctor. The medical chart may reflect the presence of all the listed doctors, but as far as the patient’s concept of the relationships, he could only respond to those he had some feelings for or some experience with.

Conclusion

This essay is not meant as a solution to the problems of the doctor patient relationship but rather an illustration of the different feelings and languages that need to be considered both from the spoken side and the listening side so that a fair and balanced relationship can survive and produce a useful outcome for the joint efforts of the doctor and the patient.

Artificial Intelligence System for Value Added Tax Collection via Self Organizing Map (SOM)- Juniper Publishers

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