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At first some- thing may appear very significant cheap leflunomide 20mg fast delivery medications that cause high blood pressure, but later it might be- come a minor detail order cheapest leflunomide and leflunomide medications side effects. However buy 10 mg leflunomide with amex treatment 5th metatarsal shaft fracture, you will not know this until you have started to analyse what is going on. You need to have a good memory as in many situations it is not possible to take notes at the time. You need to have a notepad with you at all times so that you can write down your thoughts as soon as possible after the encounter. However, in the beginning stages of a participant observation study, it is better to seek information by not asking questions. In- 106 / PRACTICAL RESEARCH METHODS stead, you will find that people come to you and ask ques- tions. This in itself is valuable information and can tell you a lot about those people, so all questions should be noted and analysed. Or they might be methodological notes concerning your role, your influence on the encounter, your relation- ship with the informants, sampling procedures and so on. As time moves on your notes will be to do with a prelimin- ary analysis and the forming of hypotheses which you can go on to check out with your informants. Also, as your research progresses you will start to code and classify your notes (see Chapter 11). Taking notes is a very personal process and you need to find a method which will suit you. Many researchers de- velop their own form of shorthand, but if you do this keep it simple because, if your contact is over a long period of time, you may not understand the shorthand you used at the beginning. Most researchers keep a day-to-day diary in addition to all the other field notes. You will also need to keep all transcripts of interviews, photographs, maps, tapes, video recordings, diagrams and plans. Everything needs to be recorded and stored systematically so good or- ganisational skills are important if you wish to undertake participant observation. HOW TO CARRY OUT PARTICIPANT OBSERVATION/ 107 Most of your analysis takes place in the field so that you can cross check and verify your hypotheses. At this stage you will find that you will have a number of key infor- mants who will be able to help you with this process. WITHDRAWAL FROM THE FIELD When you have been immersed in a particular culture for a long period of time, it can be hard to break away. In- deed, some researchers have found that they do not want to break away, although this only happens rarely. If, how- ever, you have remained connected to your role as re- searcher, you will know when it is time to break away, write up your results and pass on what you have learnt. Many researchers find that it is helpful to stay in touch with their contacts – these people will want to see what is written about them. You may also wish to return to your community several years later and conduct a fol- low-up study. Finally, you must make sure that you try not to do any- thing which will give researchers a bad name and cause problems for other researchers who may wish to follow in your footsteps (see Chapter 13). SUMMARY X In participant observation, the researcher immerses herself into a community, culture or context. The ac- 108 / PRACTICAL RESEARCH METHODS tion is deliberate and intended to add to knowledge. X To gain access a researcher must be non-threatening, displaying appropriate behaviour and body language and wearing appropriate dress. X A useful way of gaining access is to find a gatekeeper who can introduce you to other members of the com- munity. X A researcher needs to do much soul-searching before going into the field as the experience can raise many ethical, moral and personal dilemmas. X It is sometimes quicker and more economical to wait for questions to come to the researcher, rather than ask questions of informants in the early stages of a study. X Field notes may record practical details, methodologi- cal issues, personal thoughts, preliminary analyses and working hypotheses. X Data analysis takes place in the field so that hypotheses can be discussed with key informants. X The community should be left on good terms and any written reports should be given back to the people for their interest and personal comments. It could be influenced also by the methodo- logical standpoint of the person who teaches on your re- search methods course. DECIDING WHICH APPROACH TO USE For quantitative data analysis, issues of validity and relia- bility are important. Quantitative researchers endeavour to show that their chosen methods succeed in measuring what they purport to measure. They want to make sure that their measurements are stable and consistent and that there are no errors or bias present, either from the respon- dents or from the researcher. Qualitative researchers, on the other hand, might ac- knowledge that participants are influenced by taking part in the research process. They might also acknowledge that researchers bring their own preferences and experience to the project. Ask two researchers to analyse a transcript and they will probably come up with very different results. This may be because they have studied different subjects, 110 HOW TO ANALYSE YOUR DATA/ 111 or because they come from different political or methodo- logical standpoints. It is for this reason that some re- searchers criticise qualitative methods as ‘unscientific’ or ‘unreliable’. This is often because people who come from quantitative backgrounds try to ascribe their methods and processes to qualitative research. For qualitative data, the researcher might analyse as the re- search progresses, continually refining and reorganising in light of the emerging results. For quantitative data, the analysis can be left until the end of the data collection process, and if it is a large survey, statistical software is the easiest and most efficient method to use. For this type of analysis time has to be put aside for the data input process which can be long and laborious. However, once this has been done the analysis is quick and efficient, with most software packages producing well presented graphs, pie charts and tables which can be used for the final report. QUALITATIVE DATA ANALYSIS To help you with the analysis of qualitative data, it is use- ful to produce an interview summary form or a focus group summary form which you complete as soon as possible after each interview or focus group has taken place. This includes practical details about the time and place, the participants, the duration of the interview or focus group, and details about the content and emerging themes (see Figures 2 and 3). It is useful to complete these forms as 112 / PRACTICAL RESEARCH METHODS soon as possible after the interview and attach them to your transcripts. The forms help to remind you about the contact and are useful when you come to analyse the data. The method you use will depend on your research topic, your personal preferences and the time, equipment and fi- nances available to you.

C Roentgenogram of the hip 44 months postoperation Slipped Capital Femoral Epiphysis Retrospective 75 Discussion In our patients order leflunomide 20 mg fast delivery symptoms congestive heart failure, the correct initial diagnosis rate was only 31 purchase leflunomide 20 mg visa shinee symptoms mp3. The coefficient of the correlation between the duration until diagnosis and the slipping angle was 0 discount leflunomide 10mg overnight delivery treatment 4 hiv. Some patients in this study required a considerably long time for diagnosis, increasing the slipping angle, and thus we confirmed the importance of early diagnosis. In patients in whom instability is suspected at the first visit and reduction can be expected, direct wire traction is per- formed, and the severity of the disease is evaluated based on the posterior tilting angle. In situ pinning is performed when the angle is less than 30° and Southwick intertrochanteric osteotomy when the angle is ≥30°. Because no manual reduction is performed either before or during operation, there is no method of confirming insta- bility. Therefore, we perform direct wire traction in patients with a posterior tilting angle of ≥30° on the affected side and prophylactic pinning on the contralateral side in principle. We perform prophylactic pinning because we have previously encountered children with contralateral slip and fully realized that children at this age when this disease frequently develops do not often follow instructions to rest. We perform in situ pinning in patients with a posterior tilting angle of <30°. However, some studies have shown good results after in situ pinning in patients with an angle of ≥30°. In patients with this disease not complicated by femoral head necro- sis or acute cartilage necrosis, short-term results are good. Even if short- or middle- term results are good, however, because osteoarthrosis of the hip develops at middle age or later, the expansion of the indications of this method should be carefully evaluated. Slipped capital femoral epiphysis Contralateral hip Instability Yes No Direct wire traction Skin traction or rest Posterior tilting angle 30° 30° Southwick intertrochanteric In situ pinning Prophylactic osteotomy pinning Fig. We use Southwick intertro- chanteric osteotomy because operation-associated femoral head necrosis rarely occurs, no high-level technique is necessary, and stable results can be expected. Noguchi Y, Sakamaki T(2004) Epidemiology and demographics of slipped capital femoral epiphysis in Japan. Southwick WO (1967) Osteotomy through the lesser trochanter for slipped capital femoral epiphysis. Saisu T, Kamegaya M, Ochiai N, et al (2003) Importance of early diagnosis for treatment of slipped capital femoral epiphysis. Kocher MS, Bishop JA, Weed B (2004) Delay in diagnosis of slipped capital femoral epiphysis. Castro FP Jr, Benett JT, Doulens K (2004) Epidemiological perspective on prophylactic pinning in patients with unilateral slipped capital femoral epiphysis. Schultz WR, Weinstein JN, Weinstein SL (2002) Prophylactic pinning of the contralat- eral hip in slipped capital femoral epiphysis: evaluation of long-term outcome for the contralateral hip with use of decision analysis. J Bone Joint Surg [Am] 84A(8): 1305–1314 Part II Avascular Necrosis of the Femoral Head Osteotomy for Osteonecrosis of the Femoral Head: Knowledge from Our Long-Term Treatment Experience at Kyushu University Seiya Jingushi Summary. Many young patients suffer from osteonecrosis of the femoral head (ONFH). For this reason, osteotomy is considered to be an important treatment option, and their survival after osteotomy of the hip is expected to be of long duration. Cases that survived more than 25 years after osteotomy were investigated to reconfirm the principles or the indication based upon our previous experience about osteotomy treatment for ONFH. Fifteen cases were divided into two groups with or without advanced osteoarthritis at the last follow-up and were compared. All the cases with advanced osteoarthritis (OA) had collapse progression. All the cases in which the preoperative stage was advanced were included in those with advanced OA at the last follow-up. In contrast, collapse progression was not observed in the cases without advanced OA at the last follow-up. According to these data, we reconfirmed that collapse progression is the main cause for poor outcome after osteotomy, and that cases operated on at an early stage are apt to experience a good prognosis. When the indication and the operation are appropriate, osteotomy could prevent disease deterioration even more than 25 years after the operation. Osteonecrosis of the femoral head, Osteotomy, Transtrochanteric anterior rotational osteotomy, Collapse, Clinical outcome Introduction Once collapse occurs at the necrosis area of the femoral head, it usually progresses. Collapse causes incongruity and instability of the hip joint, and the progression of collapse causes incongruity and instability to increase and finally results in secondary osteoarthritis (Fig. The purpose of osteotomy for osteonecrosis of the femoral head (ONFH) is to prevent the progression of collapse and secondary osteoarthritis. A principle of osteotomy is to support weight-bearing with intact or live bone instead Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan 79 80 S. The dashed line shows the osteonecrosis area of the femoral head from the anterior view of the necrotic bone and to restore the subluxated femoral head (Fig. In other words, osteotomy is on-site vascularized bone grafting with articular cartilage and with good congruency. Options of osteotomy for ONFH are transtrochanteric anterior or posterior rotational osteotomy (ARO or PRO) developed by Sugioka et al. The treatment option is chosen depending on the lesion of osteonecrosis or on where and how wide is the osteonecrosis area in the femoral head. Especially for young patients, oste- otomy is an important treatment option to be considered, and they are expected to survive for a long time after their hip osteotomy. Sugioka developed transtrochanteric rotational osteotomy Long-Term Experience of Osteotomy for Femoral Head Osteonecrosis 81 Fig. Sequential photographs of anterior rotation of the femoral head show a model of ante- rior rotational osteotomy (ARO) with 20° varus position and indicate how ARO results in weight-bearing with the living posterior surface of the femoral head (a–f). According to anterior rotation, the osteotomy line is 10° inclination away from the perpendicular to the neck (a) and 10° ret- roversion. The result is 20° varus position after anterior rotation of the femoral head (f) of the femoral head, so-called “rotational osteotomy” or “Sugioka’s osteotomy”. Anterior rotation of the femoral head with vascularity results in weight-bearing with the live posterior surface of the femoral head (Fig. Experience of Osteotomy in Kyushu University Between 1972 and 1979 The cases that survived more than 25 years after the operation were investigated to reconfirm the principles or the indication based upon our previous experience with osteotomy treatment for ONFH [1,2,4]. Patients and Methods Between 1972 and 1979, 128 patients with idiopathic ONFH underwent osteotomy in our department. Fifteen hips of 9 patients, who had been visiting our outpatient office and had their living hip joints more than 25 years after operation, were examined. One group includes the hips that had advanced or terminal osteoarthritis (OA) at the last follow-up.

It is suggested that global assessment of the whole portfolio is preferred to analytical marking to ensure that the broader purposes of students reporting and evaluating their learning are preserved and not broken down into discrete elements order leflunomide online from canada ombrello glass treatment. ASSESSING STUDENTS WITH A DISABILITY Institutions have implemented many policies and practices to assist students with a disability purchase leflunomide online medications or drugs. Unfortunately discount 20mg leflunomide amex medications quinapril, con- sideration of their special needs is not always extended to the assessment of their learning. It is good practice for staff in departments to review and share alternative assessment arrangements on a regular basis as such arrangement are likely to be specific to both the kind of disability and to the nature of the discipline. Thus, you may need to make adjustments to assessment tasks once you understand how the particular disability affects performance. Space does not allow us to go into all the possible options here, but the following suggestions listed in Figure 8. Common strategies will be to simply follow good assessment practices we have described elsewhere and to be flexible in your insistence on assignment deadlines and in the time allowed in formal examinations. ASSESSING STUDENTS AS GROUPS With the increasing use of group and team-based learning, such as in problem-based learning, there is the related challenge of assessing the outcomes of group learning in ways that are fair to individuals but which recognise the particular dynamics and realities of such learning. More detailed descriptions of this assessment approach are given in Miller et al. Remember to keep group size down (greater than six members is too large); help students to work as effective group members; form groups randomly and change membership at least each semester; and ensure all students understand the assess- ment mechanisms you will use to encourage the diligent and forewarn the lazy. Marking group submissions can be a way of assessing more students but taking up less time on your part. When allocating marks, the following strategies will be helpful: Give all members of a group the same mark where it was an objective to learn that group effectiveness is the outcome of the contribution of all. For example, if the group report was given a mark of 60 per cent and there were 4 members, give the group 240 (4 x 60) to divide up. This will be best managed if you have forewarned the group and assisted them with written criteria at the onset as to how they will allocate marks. An alternative is to have members draw up a contract to undertake certain group responsibilities or components. Components may be marked separately, or students may be given the task of assessing contributionsthemselves. Enhance the reliability of this form of assessment by conducting short supplementary interviews with students (e. USING TECHNOLOGY IN ASSESSMENT Computer technologies can be used to support assessment and we suggest you explore the facilities that are likely to be available to you in your own institution. These include: As a management tool to store, distribute and analyse data and materials. An assessment system should be integrated with larger systems for curriculummanage- ment such as processing of student data and delivery of course materials. Answers from objective- type tests can be read by an optical mark reader and results processed by computer. However, more elaborate tools are now available to assess students work directly. Software can be purchased that enables you to prepare, present and score tests and assign- ments. You should check to see if your institution has a licence for some of these software products. Basically, this involves students using technology to prepare and present work for assessment. Some simple examples include students preparing essays using a word processor or completing tasks using a spreadsheet application and submitting their work via e-mail. E-mail can also be used to provide a mechanism for the all-important feedback process from the teacher or from other students if collaborative group work or peer assessment is being used. We recognise that information technology and telecommu- nications can be helpful and positive tools or resources for assessment. But we also have serious reservations about the way technology is being used as a tool in the assessment process. This is because the technology is so well suited for the administration and scoring of objective- type tests of the multiple-choice or true/false kind. We are seeing something of a resurgence of this kind of assessment in higher education with all of the well-known negative influences this may have on learning when items are poorly constructed or test only recall. All we can do here is urge caution, use good-quality test items, and to always ensure that students receive helpful feedback on their learning. FEEDBACK TO STUDENTS Major purposes of assessing student learning are to diagnose difficulties and to provide students with feed- back. Several approaches to doing this have already been identified in this chapter and some of the methods described readily lend themselves to providing opportu- nities for feedback. To be specific: 161 use structured written feedback on essays; provide immediate feedback on technical, interperso- nal, or oral skills as an outcome of direct observations, orals or practical assessments; and use self-assessment which includes feedback as part of the process. Some guidelines for giving feedback include the following: keep the time short between what students do and the feedback; balance the positive with the negative; indicate how the student can improve in specific ways; encourage students to evaluate themselves and give feedback to each other; and make the criteria clear when setting work and relate feedback to the criteria. REPORTING THE RESULTS OF ASSESSMENT In many major examinations you will be required to report the results as a final mark or grade based on a number of different assessment methods. What usually happens is that marks from these different assessments are simply added or averaged and the final mark or grade awarded, Simple though this approach may be, it can introduce serious distortions. Factors contributing to this problem may be different distributions of marks in each subtest; varying numbers of questions; differing levels of difficulty; and a failure to appropriately weight each component. This is not the place to do more than alert you to the need to do so and refer you to a text on educational measurement or to advise you to enlist the aid of an educational statistician, who can usually be found by contacting the teaching unit in your institution. GUIDED READING There are many useful general texts on educational measurement. Linn’s Measurement and Evaluation in Teaching, Merril Press, Bellevue, Washington, 2000. Most will have useful discus- sions of broad assessment considerations such as objec- tives, planning, reliability, validity and scoring, and also 162 will provide a wide range of examples of test items that you could use as models for your own tests. Glasner, SRHE and Open University Press, Buckingham, 1999 is another general overview text that we recommend because of the many examples relevant to higher education. Cox, Kogan Page, London, 1998, Assessing Student Learning in Higher Education by G. Brown and others, Routledge, London, 1997 and Chapter 9 in Teaching for Quality Learning at University by J. A useful adjunct to this chapter is Assessing Clinical Competence at the Undergraduate Level by D. Constructing Written Test Questions for the Basic and Clinical Sciences, 2nd edition, National Board of Medical Examiners, Philadelphia. Assessment of medical competence using an objective structured clinical exam- ination (OSCE) Medical Education, 13, 41-54.

There were many times during the writing of this book when Lynn and I would howl with laughter about what cripples we were—she couldn’t sit and I couldn’t see purchase leflunomide 10mg mastercard treatment for vertigo. To date buy online leflunomide administering medications 8th edition, Jerry has not been able to get the correct diagnosis order leflunomide 10mg line symptoms influenza, but he has gained some symptomatic relief. His armor was shattered, but in its place, he has emerged a more whole human being. He is much more in touch with who he is and his value as a human being without the need for the white coat. The Corporate Practice of Medicine: Competition and Innovation in Health Care, by James C. Experiencing Politics: A Legislator’s Stories of Government and Health, by John E. Deceit and Denial: The Deadly Politics of Industrial Pollution, by Gerald Markowitz and David Rosner 7. When Walking Fails: Mobility Problems of Adults with Chronic Conditions, by Lisa I. In the Fund’s own publications, in reports or books it publishes with other organizations, and in articles it commissions for publication by other organizations, the Fund endeavors to maintain the highest standards for accuracy and fairness. Statements by individual authors, however, do not necessarily reflect the opinions or factual determinations of the Fund. University of California Press Berkeley and Los Angeles, California University of California Press, Ltd. London, England © 2003 by the Regents of the University of California Library of Congress Cataloging-in-Publication Data Iezzoni, Lisa, I. When walking fails : mobility problems of adults with chronic conditions / Lisa I. A To Reed Contents List of Illustrations and Tables ix Foreword xi Acknowledgments xiii Preface xv 1. Selected Resources 281 Notes 297 References 319 Index 335 Illustrations and Tables Photographs follow p. Reason for having no usual source of health care 135 x / Illustrations and Tables 13. Working-age people who did not get or delayed care in the last year 226 17. People with major mobility difficulties getting help with daily activities 269 Foreword The Milbank Memorial Fund is an endowed national foundation that en- gages in nonpartisan analysis, study, research, and communication on sig- nificant issues in health policy. The Fund makes available the results of its work in meetings with decision makers, reports, articles, and books. When Walking Fails is the eighth of the California/Milbank Books on Health and the Public. The publishing partnership between the Fund and the Press seeks to encourage the synthesis and communication of findings from research that could contribute to more effective health policy. This book is about statistics, health services, policy, and the experience of people whose mobility is limited as a result of chronic, progressive diseases or disorders. Lisa Iezzoni conducted more than one hundred interviews in preparation for writing this book. The stories she tells make her analysis of how clinical and financing policy could improve the quality of life for mil- lions of people uncommonly compelling. Iezzoni brings unusual skill and experience to her exploration of the im- plications of mobility difficulties for the estimated 10 percent of adult Americans who currently experience them, for the health-care profession- als who treat them, and for makers of policy for coverage and payment. She synthesizes evidence and insight that she has acquired as a physician, re- searcher, and essayist as well as from personal experience in addressing mo- bility difficulties by, in her words, riding a “battered old scooter held to- gether by bright red airline baggage tape. Milbank Chairman Acknowledgments The Robert Wood Johnson Foundation Investigator Award in Health Pol- icy Research allowed me to do the project described in this book. In par- ticular, all the 119 persons who were interviewed for this project gave gen- erously of their time, answering virtually every question without demur. Many people recommended potential interviewees and assisted actively in recruiting participants. Lisa LeRoy conducted four focus groups and pro- vided invaluable encouragement and professional guidance on interpreting the results. Stone interviewed ten primary care physicians and of- fered many suggestions about the findings. Jena Beach, then my adminis- trative assistant, organized several focus groups with reassuring compe- tence. Ron Bouchard, my administrative assistant before Jena, cheerfully drove me many miles north, south, and west, to interviewees’ homes and other meetings. Melissa Wachterman, then my research assistant, now a medical stu- dent, found everything I ever asked her for and, with good humor and care, read and proofread my earliest and much, much longer manuscript. Rosenberg provided photographs, assisted in their array, and helped tell their stories. Mark, a former professor of mine, xiii xiv / Acknowledgments took the pictures of me that start and end the photo essay. He shot them very early one morning (hence the relatively empty streets and sidewalks) outside a federal office building in Washington, D. Fred gen- erously shared some of the photographs he uses to further the mission of Project for Public Spaces (PPS), of which he is president: to create and sus- tain public places that build communities (more information and photo- graphs documenting PPS’s approach and activities are available on their web site at http://www. Fox for his critical and constructive re- views, and for motivating, engineering, and helping tell the stories of the photographs. Lynne Withey’s encouragement and support repeatedly lifted my spirits, as she patiently steered me through the submission and publication process. I also appreciate the thoughtful critiques from thirteen people who reviewed an early version of the book: Susan Edgman-Levitan, Edith Gladstone, Harlan Hahn, Margo B. Again, the Milbank Memorial Fund supported these reviews and other details that made this book possible and provided special creative opportunities. Finally, I am grateful to my family, friends, and colleagues for their many kindnesses and continuing steadfast support, not just with writing this book, but along the way. Although the day was glorious, I could think only about the conversation with my former professor, who seemed saddened to see me in a scooter-wheelchair. My multiple sclerosis (MS), a chronic neurologic disease, does not feel like “a trouble”—just the landscape I now live in with my motorized chair. For most of us, the pas- sage between twenty-two and forty-two brings greater equanimity and sense of place in the world. Each of us carries private histories of the hand xv xvi / Preface life has dealt us and how we have survived. As a physician, I know that my hand is much better than that of many people; in important ways, I have been very lucky.