Themes in between a rock and a hard place to cohort
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Finally, we suggest a unifying “rock and a hard place” or “differentiate or Between a Rock and a Hard Place: An Epigenetic-Centric View of Testicular. Currently graduating US students, even Millennial and Xer cohorts are arguably the opposite in their view of employers. They have a built-in. This thesis presents research into the housing pathways of newcomers in Ireland who receive status to remain in the country and come through the Irish. GLOBAL CRYPTOCURRENCY PRICE GECKO
The most common actions related to misprescribing are reviewed below. Medical Malpractice The general public is most apt to think of medical malpractice as a regulator of physician conduct although it is, at best, an extreme indicator of quality of care. This creates perverse incentives to avoid malpractice actions, which may lead to overtreatment. As such, physicians are held to a higher standard of moral and personal conduct than the general population … actions that reflect poor judgment, flawed character, and sub-standard decision-making may trigger state medical board sanctions.
In , there were , actively licensed physicians in the United States, of whom—about one-half of one percent of all licensed physicians—were disciplined by SMBs. One patient at a time, the physician hopes to meet a secondary goal of improving the public health and safety. In an atmosphere of relational trust, physicians trust that patients are truthful, while patients trust that physicians are discreet and interested in improving their well being, thus allowing disclosure of deeply personal information to facilitate personalized care.
It is no surprise that there are continuing tensions between these professionals, especially in the context of drugs. Law enforcement inhabits a professional space in which drugs including abused prescription drugs are the enemy: dangerous, deadly, and harmful.
Physicians inhabit a professional space in which prescription drugs are useful tools, often helpful, and rarely deadly. It is in interpreting those circumstances where the clash is most profound. Professionals have been negotiating this clash for a century. The first legal foray into the domain of prescribing was the Harrison Narcotic Tax Act of , a response to societal concerns about substance abuse that required prescriptions for narcotics exceeding certain dosages.
While state licensure through SMBs authorizes the general practice of medicine and prescribing, authority to prescribe controlled substances is granted through state controlled substance authorities and by the DEA at the federal level. Physicians, however, are free to use their medical judgment to prescribe approved drugs for conditions that are not part of the labeling off-label prescribing.
As a corollary, the provision also bars doctors from peddling to patients who crave the drugs for those prohibited uses. Criminal Standard for Liability Misprescribers may face criminal charges at both the state and federal levels. Criminal law violations require both a criminal act actus rea and a criminal intent or mental state mens rea.
On the other hand, gross deviations from the standard of care can rise to the level of criminal culpability under state laws that include reckless or negligent mens rea requirements. Law enforcement faces complex determinations of 1 the point at which a medical purposes becomes illegitimate; 2 the boundaries of usual practice; and 3 the extent at which crossing those boundaries warrants criminal liability. Then, if the jurors were persuaded there was such a departure, they faced the perhaps even more difficult task of deciding whether such behavior constituted a kind of medical malpractice, which, although negligent, is not criminal, or whether the doctor had knowingly and intentionally left the field of medicine altogether to become a criminal drug dealer.
Good faith connotes an observance of conduct in accordance with what the physician should reasonably believe to be proper medical practice. Penalties Penalties for CSA violations range from civil to criminal penalties, including mandatory incarcerations and monetary penalties. Loss of Authorization to Prescribe Controlled Substances Absent or alongside criminal charges for violating the CSA, physicians may have their authority to prescribe controlled substances revoked or suspended; this is a regulatory process separate from criminal proceedings.
According to a DEA administrative law judge: [o]ne inexorable result of federal efforts to react reasonably to an immense growth in prescription medication dependence is an increasingly complex and nuanced practice of administrative law before the Drug Enforcement Administration…. The practice has morphed into a more contested and complicated dynamic that now requires litigation and academic skills that far exceed those previously demanded.
Increased Opioid Prescribing Scrutiny There are continued concerns about the chilling effect of investigations on legitimate physician prescribing. The DEA has the authority to investigate for any reason, but also asserts that they do not target physicians or prescribers for investigation.
A study revealed a number of prosecutors surveyed understood the complexity of misprescriber situations; however, the majority of prosecutors did not regard physicians as effective self-regulators. Opioids, especially when combined with other drugs such as benzodiazepines and alcohol, are particularly dangerous.
Law enforcement is obligated to conduct informed and contextual investigations; overreach can destroy the professional and personal lives of wrongfully prosecuted physicians and cause additional harms to patients in pain by worsening the chilling effect. Drummond describes the struggles of residents in a palliative care rotation treating terminal, self-identified addicts for pain at the end of life.
Crossing the line in this manner has disrupted the ability of real doctors to treat patients with real pain when opioids are involved. Debra Roggow, a pain management physician who is board certified in physical medicine and rehabilitation, seemed to focus only on the amount of opioids prescribed.
In this case, however, the physician kept very good medical records and regularly performed physical examinations and monitored her patients for functional improvements and drug side effects. Had this not been the case, you might be better able to understand how the case could be brought. An improved model of opioid prescribing behavior that warrants investigation could facilitate the collaboration of SMBs and law enforcement, and provide much needed guidance to physicians who wish to treat pain adequately while managing the risk of investigation.
Refining the basic model of physician misprescribing based on updated evidence is a modest, macro level step. Part II. This Article argues that this approach better aligns with determinations of culpability. Careless Physicians For reasons other than impairment, physicians in this category are practicing below the appropriate standard of care and causing harm to others.
In this category, the behavior is taking place within the practice of medicine—that is, there is no intent to engage in criminal activity—but the practice patterns are careless and even reckless. These misprescribers fail to attend to basic procedural requirements for competent and careful practice. In general, sanctions by SMBs are most appropriate. The misprescribing in the careless category typically consists of procedural failures under conditions with no or limited physician oversight.
Jarrott is illustrative: he was disciplined by the Louisiana SMB for a pattern of misprescribing in the late s and early s. All of these sources would have revealed that the patient was hospitalized for medication overdoses once or twice per year for four years. Thus, subjecting them to disciplinary action is fair and serves to protect the public.
At the same time, there is no evidence that such careless prescribers personally benefit from their negligence and it would be hard to prove that their failure to practice up to the standard of care is due to a willful blindness or a willing embrace of criminal identity. Other common factors include dispensing from within the clinic rather than sending patients to a pharmacy , solo practice or practice with non-licensed personnel, prescribing doses and combinations of medications that no level of tolerance could account for, and leaving reports of concerned patient family members, friends, other physicians, and pharmacists unaddressed.
At one time, Dr. David Brizer was a successful academic physician with a record of publications and a faculty appointment at New York University. Brizer was an active scholar in the s and s, publishing a number of articles on psychiatry, addiction, and violence. Brizer appears to be working as a life coach; he also is soliciting work as a house sitter and a writer.
A notable example is that of Paul Volkman, a former emergency medicine and pediatric physician. In one case, a toddler with epiglottitis died in his pediatric office after Volkman insisted on attempting to intubate her in the office without emergency equipment and despite clinical contraindications, close proximity of multiple emergency departments, and the objections of hospital and emergency personnel.
Volkman applied for a distributor license and the clinic began directly dispensing controlled substances. Volkman would see them. The clinic has no equipment to view X-rays and MRI results. Miscellaneous pills were strewn all throughout the clinic premises. It wont [sic] save us all from the evils of drug addiction.
In fact, the DEA is a vicious, criminal organization, corrupt from top to bottom. In fact, the DEA has no desire to stop drug diversion. In fact, the DEA fosters and controls drug diversion, taking a healthy cut of the cash flow from the sale of illegal drugs on the street. The DEA brings bogus charges and stages sham trials to cover up their own criminal role, and to put doctors out of business.
Pain doctors, after all, make it possible for patients to obtain pain medicine legally from pharmacies, instead of having to buy it on the street, thus taking business away from the DEA. The presenter went straight into exploring in this case social change in sustainable communities at the conclusion of which I left puzzled about this field called futures.
Curious, and seeing some parallel principles between CLA and agonistic dialogic accounting I decided to utilize the futures methodology and conducted interviews and a workshop applying the method. Manual coding of interviews was acceptable to this cohort. On presenting findings at an accounting colloquium there appeared to be an element of skepticism evident along with the suggestion that an analytical tool be applied in the interview analysis.
These two early experiences led to my investigating a possible mismatch of some kind. I soon discovered that I had embarked on an interdisciplinary study. The unsettling consequences continued as the study progressed. I wrote several papers and was successful in their publication in futures journals but, with a single exception, struggled with publishing in appropriate accounting journals.
Moreover, on completion of the research scholars from futures lauded the study. On circulation to colleagues from accounting, however, the study was mainly met with silence. This has led to a yet closer examination into the nature of interdisciplinary research especially as it relates to accounting.
Interdisciplinarity and a Critique of Case Study Strategies To assess the value of the bridge-building strategies applied in the case study the essentials of interdisciplinary research are discussed. There are innumerable books and articles written by scholars on the benefits, challenges, and considerable barriers to interdisciplinary research.
Books and articles from a sample of these scholars are drawn on here. An overview of the key features of interdisciplinary research is provided, such as a definition and what constitutes interdisciplinary research, why it is important, and examples of approaches to interdisciplinary research relevant to this paper. This overview assists in understanding findings. A definition sourced through the work of various scholars by Klaassen reads: Interdisciplinary research can be defined first and foremost as a team or an individual expert scientist or otherwise , who integrates methods, knowledge and skills, theories, perspectives and different disciplinary knowledge bodies, to realize innovative solutions and knowledge advancement in uncharted problem areas.
Figure 11 below demonstrates the significance of differing levels of integration to interdisciplinarity. Figure 11 also assists with the understanding that interdisciplinary research is on a continuum. The definition by the Amsterdam Institute for Interdisciplinary Research in Klaassen further confirms the significance of integration. The Amsterdam Institute for Interdisciplinary Research defines a gradual scale in which multidisciplinary, interdisciplinary and transdisciplinary are defined as the degree of integration of different knowledge sources.
Collaboration and integration Klassen also stated , p. Therefore, at one end of the continuum is the simple incorporation of ideas, at the other end mutual and extensive collaboration to integrate all research elements. Why interdisciplinary research is necessary While disciplinary research is necessary for problems requiring a specialized path, interdisciplinary research is necessary as a way forward in addressing the increasingly complex problems of today  , and an awareness of the growing necessity for integrated interdisciplinary research.
There are numerous examples of uncharted problem areas. The following outlines some approaches to interdisciplinary research of relevance to the two types of bridge-building strategies applied in the case study as described earlier, and the subsequent findings. It is a pragmatic approach that focuses on research, borrowing from disciplines, and practical problem solving in response to the external demands of society.
Bridge-building strategies applied Two types of bridge-building strategies emerged from the case study in an attempt to straddle both fields. The first during the analysis of the data, the second in bringing the fields together to conclude the study. To do this, manual colour coding of words and sentences across the various CLA layers was applied.
Later, equipped with critique from presenting at an accounting colloquium, along with reviewer feedback from accounting, additional tools for coding of data were considered necessary. One such software tool, Leximancer, was used to identify high level themes and concepts to validate the categories formulated earlier.
The rationale for these strategies was that the additional analytical tools may provide a more acceptable method of analysis to the accounting cohort. Strategy Two To conclude the case study, a narrative was composed that offered connection and a bridge between the fields refer to Appendix 11 to access the narrative. A significant article which helped in framing the dilemma of epistemological and disciplinary separation, is an article by Hendry Hendry argues that all inquiry, including science, can be reconceptualized as narrative.
Findings CLA methodology was introduced to operationalize the theory of agonistic dialogic accounting and thereby provide a link between theory and practice. The following reintroduces interdisciplinary approaches to identify where the two strategies applied sit in terms of the continuum of interdisciplinarity and whether they were adequate. You will recall that the first strategy occurred during the analysis of the data so that methods straddle both fields, the second strategy brought the fields together through narrative as a means of concluding the study.
These additional methods of analysis Leximancer and GVPA were acceptable to, but not necessarily required by futures studies. The application of Leximancer was however problematic for CLA-sourced data containing text at a myth and metaphor level. The predominantly futures-oriented approach was to apply narrative to nurture meaning-making across disciplines. Futures studies is considerably more likely to welcome the application of narrative than is accounting. The strategy was however weighted towards futures as a response to the quandary of bringing two fields together.
The strategies had varying levels of success in terms of satisfying both fields. The first strategy may have partially satisfied accounting, the second satisfied futures, and one can only presume it may not have satisfied accounting. While both strategies of bridge-building were somewhat effective, implications related to working in the interdisciplinary space are now discussed.
Discussion The case study featured an instrumental component with agonistic dialogic engagement requiring a practice base, and CLA being introduced in efforts to supply one. The research can be described as problem-driven, instrumental interdisciplinary research exhibiting a degree of integration through the application of Strategy Two. The study could not draw on the full benefits of integrated interdisciplinary research as collaboration between those from the two fields was absent.
It is therefore located at the lower end of the continuum in relation to the levels of interdisciplinarity and collaboration. As Figure 11 illustrated, creatively combining concepts results in new knowledge and the ultimate level of integration, transdisciplinarity. A more fully integrated approach to interdisciplinary research through dialogue and collaboration would have increased both acceptance and effectiveness of the study.
To sum up issues concerning the case study, a stronger integrative approach would have been preferable. This would have been achieved by bringing together scholars from both fields to collaborate on research objectives, questions, methodologies, and methods. This is not to deny the epistemological and disciplinary gulf between the two fields as is evident by field differences. Field differences As stated earlier the first futures presentation I attended left me confused.
There were no parallels with my previous exposure to traditional research which resulted in cognitive barriers to understanding. Examples of differences from traditional research includes that CLA is an interdisciplinary methodology. However, as I came to better comprehend futures thinking I could appreciate its strengths and its value.
Clarity around the differences between accounting and futures studies is expressed in the following. The two fields differ in their epistemological underpinnings. While accounting is technically focused, tight, exact, and truth seeking, futures studies [is often]exploratory and [can be]concerned with stimulating imagination and creativity, [and]deepening understanding… Holdaway , p. There is a need for fields to reach across chasms and grasp a better understanding of the other.
This could in turn give rise to moving firms, and indeed civil society, closer to reaching preferable social and environmental outcomes. The next section examines the state of play of interdisciplinarity within accounting. Agonistic dialogic accounting is one such example where social and environmental accounting has been informed by political theory.
Accounting places a high value on a particular way of knowing, not venturing too far from a positivistic approach about what constitutes rigor, validity, and reliability. For example, although a Byrch et al. It is to that article which we now turn. Although differing from Figure 11, their concept of interdisciplinary research being along a continuum contains some parallels. Then, at mid-point, there are studies that err from others in their field by utilizing a different theoretical framing.
These fall short by not integrating the thinking from those other studies. Their assessment about the current state of play is as follows p. Indeed, we have often observed a somewhat purist tendency where individual researchers seem rather intolerant to work that uses a different theory from their own preferred and reasonably well-established theoretical framing.
Moving beyond comfort zones and silos Parker and Guthrie , p. While acknowledging that futures thinking and CLA is unfamiliar territory, I would echo the sentiments of the need to take risks. This is, after all, partly what science is about. Conclusion While integration of commonalities had been achieved by applying narrative, integrating conflicting assumptions occurring with both fields awaits creation.
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Disobedience to God. How do we get ourselves in some messes were in? After years of captivity- prophesied by God to Abraham years before, The Lord raises up His Servant Moses to set the captives free and offer to bring His people back to a better life. Most of us know the story of Israel crossing the Red Sea- right? Charlton Heston portrays Moses and we see him raise his staff and miraculously two million people cross the Red Sea and we watch the Egyptians swallowed up by the waters crashing in on them.
Select few put their trust in a God that is able to do miracles and take us out of the situations we find ourselves in. Few see that blatant sin is keeping us from receiving some of the blessings God wants for us. Illustration A nine year old boy was asked by his mother what he had learned in Sunday School. He said, well, Mom our teacher told us how God sent Moses behind enemy lines on a rescue mission to lead the Israelites out of Egypt.
When he got to the Red Sea he had his engineers big a big bridge and all the people walked across the Red Sea. He then uses his walkie-talkie to radio in to get a B52 bomber to blow up the bridge and all the Israelites were saved and all the Egyptians were destroyed. Was stuck between a rock and a hard place? If you are caught between a rock and a hard place, you are in a difficult situation where you have to choose between two equally unpleasant courses of action. Is idiom and metaphor the same?
A metaphor simply states that one thing is just another thing. The difference lies in the fact that an idiom is a saying or a phrase that is used to describe a situation, a metaphor is an indirect comparison to describe something. And a simile is a direct comparison. Is hours a true story? The new film from Oscar-winning director Danny Boyle tells a remarkable true story of courage and survival. What genre is between a rock and a hard place?
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