Promoting A Healthy Environment For Children Education Essay

Promoting A Healthy Environment For Children Education Essay The proportion of children living in poverty grew from 1 in 10 in 1979 to 1 in 3 in 1998. 30% of children live in poverty in the UK The UK has one of the worse rates of child poverty in the industrialized world Source: www.endchildpoverty.org.uk June 2007 The majority of sleep experts advise parents to abruptly withdraw their attention at bedtime-with no mention of teaching a child self-soothing skills. But many parents are looking for help after having shared their bed or assisted their child to fall asleep for months or even years. When children are abruptly expected to fall asleep without any assistance it sets the scene for the all too familiar nightly bedtime battle. If parents consistently ignore their childrens anguished pleas for attention, after weeks of tears and tantrums, children will eventually begin to fall asleep on their own. But in the same amount of time, parents could have avoided the battles-by teaching their children to relax themselves to sleep while gradually and systematically decreasing their attention. Routine helps establish many aspects of healthy living good ways of life and good behaviour. Even the smallest structure is necessary in day-to-day life. Children want and even need routine and there are lots of ways to get them going byestablishing a schedule that works for al the family. There are so many positive side effects for starting to use strong routines for children. Children do not have a lot of control in their lives and it gives them a sense of organization, steadiness and comfort. This helps develop healthier behaviour and a sense of personal control. Doing things like bathing and brushing teeth as part of morning or nighttime routines can help establish good personal hygiene and health habits. Having built in chore time somewhere in the week or day, having them help pick up at the end of dinner or tidy up the house at the end of a day of playing establishes responsibility and work ethic. Mealtime When it is time to eat it is a perfect time to start good habits. Eating habits, particularly. Always eat breakfast, Lunch and tea, but at set times and with structure for children so there are no surprises and the length between eating isnt so great that hunger takes over the family. That can lead to irritability or impulse snacking and dinner wrecking. Set standards for when snacking can take place and what kinds of foods are eaten. Dont indulge or give in for food whenever a child wants something. The results should always be equal good eating and good eating habits. Mealtimes are a good time to instil family into the children. Always try to find some time to sit down together, preferably at a table, to talk and eat. Also, have children help get dinner started, set the table and clean up afterward to plant a bit of responsibility. A1 My role as an Early Years Practitioner would be to assist with the promotion of health and well-being of children and help maintain a healthy environment for children. I may be responsible for organising a room and making sure that policies and procedures are being followed and recorded. I would have to cater for their needs as young children; developmentally, physically and socially. This would be ensure that I am promoting and maintaining a healthy environment for all children. It is also important that you learn by experiencing and learning from the experiences of others. In my role I would have to plan and provide a caring and stimulating environment that is appropriate for individual children and enables children to reach their full potential and to work within the Children Act and local guidelines, legislation and standards and ensure that Child Protection policies and procedures are adhered to at all times. I would have to plan and prepare exciting play opportunities that meet the childrens developmental needs and stimulates their learning. I would also participate in supervision and staff development processes in support of promoting and maintaining a healthy lifestyle and environment and to undertake training as appropriate to meet any changes in standards or appropriate legal requirements as required. In reviewing and reflection of any issues is an important aspect of a practitioner and to review where, why, how, when, etc. The reflective cycle as developed by Gibbs allows you to think about what you have done, how well it went, get feedback from others and consider alternatives. The reflective cycle is broken down into 6 units 1. Description -what happened 2. Feelings 3. Evaluation Analysis conclusion and finally Action plan what will you do next time. The practitioner should also evaluate their own learning and performance. This can be done through Professional development and discussions with the line manager and other practitioners. For example: Share examples of your practice discuss Get ideas of other practices Visit other practices and observe, discuss. Make sure you keep up to date with current practices Articles in magazines, books, training, etc In house or external training Additional qualifications, etc Observe children / observe other practitioners Planning Childs next steps Try new things Trial and error is also an important reflection and to review how things happen. But in all cases, the safety of children is paramount. Experience is the most important issue and to understand that as an new trainee or new nursery nurse, you dont know everything. That you learn by experiencing and learning from the experiences of others. I would also have to keep in touch with new initiatives that are promoted and keep on top of new legislation.

Sir Thomas More the Martyr Essay -- essays research papers

The definition of a martyr is a person who willingly suffers death rather than renounce his or her religion. When Sir Thomas More died in July of 1535, he became a martyr. In the play A Man for All Seasons, author Robert Bolt shows us his views on how More came to his death . In this play, Thomas Cromwell, Richard Rich, King Henry VIII, and Sir Thomas More himself are responsible for his death. Although it could be argued that many more people in Sir Thomas More’s life had a part in contributing to his death, these four characters had the greatest part in eventually bringing him to his death. Some people may say that Cromwell and Rich were just pawns in the King’s plot, however they can’t possibly argue that they weren’t in control of their actions. Cromwell and Rich are essentially responsible for the final prosecution of More. Together, they are guilty of letting their inner want and need for power cloud their consciences, which led them to bring down a good man of Thomas More. More, being a smart man, could beat them in a court of law. Rather than fighting More with the law, Rich and Cromwell decided to break it. Rich lied under oath sending More to his deathbed, and he responded, â€Å"I am sorrier for your perjury than my peril†(156). Cromwell, in his quest for power, saw a doorway of opportunity where he could bring down More and in the process benefit his own social and economic status. As More stated, â€Å"Silence gives consent† (152) and Cromwell’s silence during Rich’s illegitimate testimony makes him an access ory to the crime and therefore just as guilty as Rich. Together, Rich and Cromwell are partners in the crime, whether they are accomplices to King Henry or for their own reasons. Either way, they are still responsibl... ...and, â€Å"I don’t believe this had to happen†(144). At least twice Sir Thomas More made poor choices and put himself into bad situations in the play, which ultimately took him closer and closer to his death. Sir Thomas More never had to die. He was the only person that really understood the implications that complying with the King’s desires would cause and yet he still ended up in the most undesirable position one could imagine. Many people caused the death of Sir Thomas More in A Man for All Seasons, however those that are most guilty are King Henry, Thomas Cromwell, Richard Rich, and Sir Thomas More. Who of these is most guilty is a matter of opinion, but that these people are truly and completely guilty of ending Sir Thomas More’s life is a fact. From King to commoner each of these people played a vital role in the destruction of one man’s honest and righteous life.

History Of Birth Control :: Contraceptives, Birth Control Essays

History of Birth Control Although birth control has been practiced since ancient times, the first organized efforts developed during the 19th century as population increased dramatically because of improved medical care, nutrition, and sanitation. However, birth control met with resistance. In 1873 the United States Congress enacted the Comstock Law, which prohibited the distribution of birth-control devices and information. During the early 1900s, American nurse Margaret Sanger led the birth-control movement in the United States. She and others opened clinics to provide women with information and devices. Although frequently jailed, she and her followers were instrumental in getting laws changed. In subsequent years, laws against birth control gradually weakened, and more effective methods were developed. Now a days there are several different methods of birth control. The first that I am going to talk about is called the rhythm method. As its synonym implies, this method is based on the assumption that, for each women, there is a rhythmic pattern of menstruation and ovulation that can be identified by keeping a careful record of the dates of menstruation. A second assumption is that ovulation occurs 14 days before the onset of the next menstruation. The rhythm method is the most commonly used of the natural methods. To be used successfully a record should be kept for at least six menstrual cycles. The fertile period is then defined by a set of rules for example: The length of the shortest cycle less 18 days marking the start of the fertile period and the length of the longest cycle less 11 days marking the end of the fertile period. This is the only birth control method that has received the Catholic Church’s seal of approval. The next natural way of avoiding the use of contraceptives is called the Basal body temperature method. In a normal, ovulatory cycle the temperature of the body measured on awakening, called the basal state, rises by 0.2C to 0.5C during two or three days following ovulation. This rise is defined as one in which three consecutive daily temperatures are at least 0.2C higher than the six daily temperatures preceding the shift. This rise reflect the secretion of progesterone from the corpus luteum. The unplanned pregnancy rate of this method is about 11.

Revenue Management and Pricing Essay

Springfield Nor’easters was a new Class A minor league baseball team, which would start the first season in June 2009. The marketing director, Larry Buckingham, had to design the price scheme for the new season. Springfield was the third largest city in Massachusetts with 55,338 residents and around 60% of the households were families with children below 18. However, Springfield offered few spectator opportunities for sports fans, the only way to attend a professional baseball game is to drive to other cities. Springfield Nor’easters, the first professional baseball team in the region, will compete in one of the 19 regional leagues under Minor League Baseball (MiLB). Each of the 30 teams in Major League Baseball (MLB) was affiliated with minor league teams and they funded players’ salaries as well as bat and ball expenses, while minor league teams were responsible for uniform expenses, league dues, office and travel expenses, etc. Nor’easters’ financial goal for the first year is break even and their income will come from tickets sales, concession sales and sponsors from local institutions and organizations. To design his tickets offers, Buckingham found that it’s important to both analyze the remaining data from a survey done in 2005 by League Sports Association and conduct a more detailed survey specific to the local market. Buckingham then figured out that his primary research objectives were to know how many people would come to the games and how much to charge them, and he made several observations while interviewing some counterparts of other minor league teams. First off, he needed to price seats on par with competition such as movies, bowling and other sporting events. Secondly, it’s important to have a well-designed mix of season tickets, group sales and individual tickets. Thirdly, he should consider promoting group sales with special promotions. Last but not least, concessions were critically important with at least a 39% profit margin. Buckingham kept three criteria in mind while designing the survey questions: maximum information yield for management decisions, question clarity for respondents, and ease of data analysis. He decided to conduct this survey by  mailing 10,000 postcards that would direct recipients to a website where they could complete a questionnaire and then get entered into a drawing. The online questionnaire was pretested three times and several questions were changed afterwards according to the feedback. The mailing list for the postcard was drawn from two sources. One half was taken from Springfield census tracts of households with income above the poverty level and the other was obtained from the mailing lists of four sports-related organizations in Springfield. Ultimately, 625 responses were tabulated. Luckily, Buckingham found that the sample respondent characteristics were fairly representative of the Springfield market. Buckingham knew that his real goal was to maximize not only ticket income but also concessions. He wanted to make sure the prices of different packages were set appropriately. Also, while calculating the concession sales, he was told to note that attendance would drop from around 100% (individual game) to 97% (5-game), 95% (20-game), 90% (38-game). With these things in mind, Buckingham started to analyze the survey data and calculated the optimal prices. We found that the actual pricing policy is much more complicated, there are a wide variety of seats, and more games (full season = 70 games). To have a more-close-to-situation price for comparison, we exclude the special and upscale tickets. Then average the rest’s ticket price (â€Å"Diamond Boxes†, â€Å"Field Boxes†, â€Å"Dugout Boxes†, and â€Å"General Admission†), and come up with a result of $9.25 per game. To sum up, our proposed price ($10/game) is slightly higher than the actual price, and the reasons are as followed. 　　First, in the actual stadium, there are some high-class club and seat that will compensate for other cheaper tickets. Second, there may be more advertisement, sponsorship, and special event revenue which haven’t been counted in the case. Third, the actual stadium may have more seats (ex. grass seating), so the ticket price can be lower ours. Lastly, however, global recession may be a cause, but we do not consider it to take a great part. Though the ticket price per NBA game actually increases through years, taking into account the improving but still sluggish economy in 2012 and the difference in popularity, it’s not likely that Springfield Cardinals is able to set price high.

Lady Macbeth, an honoured hostess and a fiend-like Queen Essay

The audience witness a total transformation of Lady Macbeth from a powerful, scheming woman to a sad and lonely wretch. By the end of this tragedy she has nothing to live for, is riddled with guilt and has lost all sanity. At the opening of the play the audience see how fervent her hunger for power and status is when she summons evil spirits; â€Å"Fill me from the crown to the toe top-full of the direst cruelty;† (Act One, Scene 5, lines 40-41). This statement displays Lady Macbeth’s character deeply nefarious, it would perturb the superstitions of the Christian spectators. The audience might also perceive her to be disturbed as in that same soliloquy she asks the spirits to, â€Å"Make thick my blood,† At the time that the play was written thick blood was associated with illness and derangement. It would have been most horrific for the audience to listen to the character persisting that she did not want to be womanly, especially for someone of her status is society. Pronouncing that she wished to be unsexed and that she wanted the spirits to â€Å"Come to my woman’s breasts, and take my milk for gall,† would outrage their perfervid Christian views as women were supposed to be maternal and loving whereas she uses the oxymoron to intensify her wish to become corrupt and inhuman. Immediately after she calls the spirits, Shakespeare returns Macbeth to the stage, scheduling his wife the ideal time to discuss her plan. Lady Macbeth begins to instruct him as she says, â€Å"Look like th’ innocent flower, but be the serpent under’t.† She uses this metaphor to reassure her husband and make known to him that others won’t realise he’d be doing anything wrong but at the same time urging him to commit the deed,ergo underlining the way in which it is her evil inventions which will destroy Duncan. The Shakespearean audience would be very disturbed to witness such wicked schemes emanating from a female character; women were particularly governed by society’s expectations and considered to be the fairer, gentler sex, leaving political machinations to their male counterparts. Along with manipulating Macbeth into executing all of her schemes, she also is competent to cover up after him when he is vulnerable to suspicion. Without her help and guidance, Macbeth would have not been able to consummate his feats. After Macbeth’s first act in which he commits regicide by killing his dear king Duncan, he is incapable of coming to terms with his actions and returning with the weapons to Duncan’s chamber. His ever-dutiful wife finishes the task. â€Å"Give me the daggers. The sleeping and the dead are but pictures.† Her control here reveals her power and determination. We see her draw a veil over Macbeth’s behaviour again after he has taken King Duncan’s life as Macbeth makes the mistake of killing the guards, when he knows that as a soldier himself he should interrogate suspects. After Macduff attempts to question Macbeth on his reasons, Lady Macbeth faints (Act 2 Scene 3 line 112). This shows her ability to extemporise when the situation requires it. Indeed there are several occasions when Lady Macbeth steps in to avoid her husband being put under suspicion. Her role in the banquet scene after Macbeth sees Banquo’s ghost has a reason. Macbeth shows signs of weakening before the spirit of Banquo. However, Lady Macbeth shows her authority over the proceedings. She instructs all but herself and Macbeth in Act 3 Scene 4 lines 118-9 to â€Å"Stand not upon the order of your going. But go at once,† thus managing to clear their estate of all the guests who had been visiting, which would have been a difficult feat especially for a woman yet her determination impels her capable. We sporadically notice that she is not such a nefarious character, as she would like to believe. An example of her vulnerability is when she needs a drink to give her courage in order to go through with the plan for the murder of Duncan, â€Å"That which hath made them drunk hath made me bold.† If she were truly a ‘fiend’ she would feel nothing. Similarly, when she is anxious and awaiting Macbeth’s return she utters that, â€Å"Had he not resembled my father as he slept, I had done’t.† Had she been entirely evil she would have distanced herself more and be unable to draw comparisons. The decisive moment however for Lady Macbeth is when she detects that she is no longer needed. Act 3 Scene 3 lines 6-7 describe this further when she asks Macbeth, â€Å"What’s to be done?† and he proves to her that he is no longer the mere student but the master as he replies, â€Å"Be the innocent of the knowledge, dearest chuck, till thou applaud the deed.† Macbeth’s use of ‘dearest chuck’ would have been supposed to be playful however in this context would have aggravated his wife and spurred on the doubts that would have been forming in her mind. The quotation is also analogous to what Lady Macbeth had said to him in Act 1 Scene 5 about looking innocent, thus extra proof of his imitation of his wife’s influence. Lady Macbeth’s return to the action in Act 5, scene 1 is dramatic in its irony. She is a mere shadow of her former self, unable to sleep and riddled with guilt she re-enacts the role she played in Duncan’s murder, and in so doing betrays her guilt to her waiting woman and, of course, the audience. The constant washing of her hands and utterances â€Å"Out damned spot†¦ Who’d have thought the old man to have so much blood†¦Ã¢â‚¬  serve to expose her crimes, her sentiments in Act Two â€Å"A little water cleans me of this deed† are shockingly highlighted in the closing Act with poignant irony. Delirious and disturbing outbursts: â€Å"Here’s the smell of blood still; all the perfumes of Arabia will not sweeten this hand. Oh, oh, oh!† (Line 44-6) and her use of metaphor amplifies her acute mental torture and pain, she is a woman so construed by guilt that she loses all sanity. Lady Macbeth’s downfall, like her husband’s, is a tragic one as she ultimately dies from her terrible crime. Like Macbeth, Lady Macbeth enjoyed reputation and status as the wife of the greatest Scottish warrior, much loved and honoured by king and county. However, she is as much Macbeth, guilty of ‘vaulting ambition’ and when she succumbs to that fatal flaw she can no longer function. Indeed, so consumed by guilt, Lady Macbeth commits suicide knowing that her crimes have involved interfering with the divine right of kings. Interestingly, however, the audience see many times throughout this drama when Lady Macbeth is not so cold as she is made out to be. We know that she is not a ‘fiend’ as we see on numerous occasions her inability to carry out acts herself, act 2 Scene 2, line 13-4, â€Å"Had he not resembled my father as he slept. I had done’t.† She is unable to distance herself from the stunt and even helping to carry out the act she finds difficult as she needs help to bring the courage she needs: â€Å"That which hath made them drunk hath made me bold;† illuminating further how she has some empathy for Duncan. The audience see just how terrible an effect all the events since the witches first met Macbeth have had on her mental state as they hear how she has taken her own life in Act 5 scene 5 from Malcolm. To conclude, it is clear that Lady Macbeth begins her role as ‘honoured’; she certainly enjoys the wifely role of Scotland’s hero. However, through greed and ambition, she forfeits her reputation and status. Certainly her actions are ‘fiend-like’ but she does betray some small shreds of conscience and is therefore well aware of her choices. A totally fiendish character would not experience guilt, but Lady Macbeth goes insane simply because she knows she has been immoral and sinful. Lady Macbeth, â€Å"an honoured hostess† and â€Å"a fiend-like Queen†.

Human effects on environments Essay

Human effects on environments is increasing during the past few years. Those trash and pollution made by people is becoming detrimental to local environment. There is a survey done in Xingqing park in Xian about human effects on natural environment. Water quality including turbidity and pH were tested, also the quality of soil was tested. In addition human effects were found in order to see how deep the damage is. Food web provides a view of creatures live in there in order to give an opinion on how much the pollution is. The result was that human activities does have negative effects on natural environment in various ways, so in conclusion people should care moe about loca environment instead of through trash. Introduction Human activities sometimes contaminates the nature, it can be seen in many parts of city such as parks and lakes. Here the environment of Xingqing park is damaged by people for many years. As a park, it locates in the center of the city which means the majority of people come there frequently. In order to find the damage, items such as pH, turbidity and others were tested to find out how much the negative effects are. Human activities like footprints and trashes are also counted in. The thesis is that human activities has detrimental damage on environment because of trash and lack of cleaning. Method In order to find out the quality of water, first we tested the water turbidity using Secchi disk, measured the length of the line to calculate the turbidity. Then the pH of water was tested using pH paper. Soil pH is a little different, we have to put soil and water in a ratio of 1 over 5, then wait until water and soil separated into layers, the clear part of the water will be tested by pH paper. For plants distribution and food chain we use a map to mark every time we see certain creatures. Human activities including foot prints and trash are marked in the map also. Then results will be analyzed to reach the conclusion. Findings Based on research, there are something in the park represents environmental damage. Walking around the lake there is died fish over the corner spreads smelly smell, it seems that the quality of water is not good enough to support such big creatures. Also there are not enough decomposers to break it down. In addition, there are several insects float on the water, also some trash such as plastic bags are around corner of the lake edge. The water turbidity is 33cm in Secchi disk measurement, another thing is seen commonly is massive of bacteria on the surface of water floating around,which is disgusting. On the ground there is a wild crab found in the bush, also there are wild sparrows and magpies found in the tree but not so many. For plans distribution, since it is an artificial lake, the plants are mostly planted by human, rings of tress surrounded the whole lake. But the grass cover is not in a high rate, hard soil is everywhere due to human walking, about 40%of land is covered by grass. Another thing need to consider is soil and water pH, however both the soil and lake have water in basic levels of 7 to 8, which is just ok for creatures to survive. Finally we noticed that there are a huge amount of ants, including big ants and small ants. Small ants stay together meanwhile big ants going around alone. As internet shown the air quality is not as bad, pm2.5 is in a level of 110 in general.

Chapter summaries for Better by Atule Gawande Essay

Mr. Gawande starts his literature on washing hands. He introduces two friends a microbiologist and an infectious disease specialist. Both work hard and diligently against the spread of diseases just like Semmelweis who is mentioned in the chapter. Something I learned, that not many realize, is that each year two million people acquire an infection while they are in the hospital. Mainly because the clinicians only wash their hands one-third to one-half as many times as they should. Semmelweis, mentioned earlier, concluded in 1847 that doctors themselves were to blame for childbed fever, which was the leading cause of maternal death in childbirth. The best solutions are apparently the sanitizing gels that have only recently caught on in the U.S. Then there was an initiative to make the sanitizing easier for all. The engineer Perreiah came up with solutions that gave the staff more time which was revolutionary in itself but the format worked only under his supervision. After he left it all went down the drain, so, Lloyd a surgeon who had helped Perreiah decided to do more research and was excited when he encountered the positive deviance idea, the idea of building on people’s capabilities instead of trying to change them. The idea worked and even got funding for ten more hospitals across the country. At the end of the chapter Dr.Gawande ponders upon the idea of how many he has infected because of his lack of cleansing. Chapter 2: The Mop-Up This chapter starts off with the difficulty of diligence. Yet there are some who have managed to deliver that expectation on an incredible scale. The task of distributing polio vaccines to millions of people, many in rural areas, was evidently a long and complicated task. The WHO had a team of only hundreds and had to teach the necessary vaccination procedures to the volunteers and local representatives, people who went door to door in all of these areas. Their target for the introduction of the vaccine was 90%.It was definitely complicated to try to keep the supplies in a constant outpour when there were only so many. For example, the vaccines needed to stay on ice to be effective. Something that seemed counterproductive and bothersome was the lack of information in some places. For example, some villagers didn’t even know the vaccines were coming that day so they had been missed and others blinded by their ignorance didn’t want to vaccine their children. One such case led to a woman who refused the vaccines for her child but later went on to regret it when her own daughter’s legs lay limply aside. Gawande traveled with a Pankaj who made rounds checking on the progress of the volunteers and making corrections as necessary. The diligence in reporting gave the WHO the necessary information to learn from that mop-up. The commitment to accumulating meaningful data and the commitment to studying and learning from that data is just as important as the actual process of vaccination itself. Chapter 3: Casualties of War Casualties of War, covers the efforts of battlefield surgeons in Iraq and Afghanistan to save as many wounded in the wars as possible. A Forward Surgical Team (FST) can set up all their equipment in the combat zones in less than 60 minutes. The travel time of a seriously wounded soldier from the frontlines back to the US averages 4 days; in Vietnam, it occurred in an average of 45 days, which as any doctor knows every second is crucial. The focus of the FSTs is â€Å"damage control, not definitive repair.† The wounded are then sent on to a temporary treatment facility immediately; if their injuries are serious they are then sent back to the US within a few days. The goal is for each level of treatment to give the patient the best chance for survival and then trust the next step in the chain to do its part to carry on the treatment. Gawande relates the incredible story of one individual with blast injuries who was opened up at the FST, received life-saving surgery and had arteries tied off, then he was cleaned out, packed with ice, and sent on an air evacuation; still left open from surgery with a note taped to him explaining what was done to the nearest combat hospital and a new surgical team. By analyzing the patterns of injuries and treatment, other basic life-saving measures were implemented. For example, soldiers coming into treatment were found to be without their Kevlar. When asked why? They would complain about the weight, the heat, and the discomfort. Orders were issued that Kevlar was to be taken seriously and the injuries became less frequent. Gawande’s point is that reporting is vital to diligence just as it was for the WHO supervisor fighting malaria; these doctors recorded the details and results of each case. They understand, as Gawande writes, that â€Å"vigilance over the details of their own performance offered the only chance to do better. Chapter 4: Naked The chapter is titled â€Å"Naked† and concerns the exam room etiquette that doctors and patients expect from one another and often uncomfortably tiptoe around. There is an allusion to a movie that has the female patient separated by a dark blanket like screen from the doctor. The doctor’s son who is about six years old is the communicator. Even though they are clearly audible to each other they wait until the boy speaks to them. This is the matter of decency. According to this literature some doctors feel uncomfortable with the whole process. There is really no established ground as to how to go about it. The author relates anecdotally that some patients and doctors find that having a â€Å"chaperone† present makes things worse. For example, when asking a female nurse to come in when a male doctor is examining a female patient makes the patient more nervous than before. The patient perhaps did not sense a cause for concern and is then put on the defensive. Most of all it’s about trust. The author relates occasions in which he felt aversion for the gowns but when the matters seemed to get to awkward or difficult he resulted to the exposing gowns. One out of every two hundred physicians is disciplined for sexual misconduct. Interns of both sexes on an average have had at least one incident of patient-initiated sexual behavior. So it is not uncommon for the situation to be more than just tricky. The chaperone helps both sides, the patient and the doctor, if any situation were to arise. Chapter 5: What Doctors Owe What Doctors Owe, the fifth chapter of Better continues the discussion of doing right and focuses on malpractice lawsuits. The main focus of this chapter is a doctor-turned-malpractice lawyer; he stands out because most doctors hate malpractice suits. Even the lawyer says he hated them as a doctor. He said he was sued three times and two were nuisance suits with no basis, but the third was a case in which he made a medical error which led to the harm of his patient. He appeared to feel legitimately bad about it. He argued that the system allows those who are harmed to come forward and receive some compensation which makes them better able to deal with their injury. Former Dr.Lang took up a case against Dr.Kenneth Reed for the Barbara Stanley trial. Reed had diagnosed melanoma on Barbara and insisted an extensive surgery was needed and she refused it because it seemed disfiguring to her. He got a ‘second opinion’ and the tests for melanoma came back negative. Two years later the growth reappeared. She died but not before telling Lang she wanted to sue Reed. Doctors strive to care for patients as best as possible, but of course there are instances where they make honest mistakes or are plain negligent, and that has to be addressed because it is the patient who pays. The downside of malpractice, as Gawande argues it, is that it is an essentially adversarial system which pits patients against doctors against insurance. He argues that it brings out the worst in all parties involved. Chapter 6: Piecework Piecework, is on doctors’ pay and its inevitable connection to the health insurance industry. According to this chapter every hospital has a Master Chart of prices for every imaginable health care procedure. Everything from a checkup to a surgery is listed with the price which is later charged to a patient, which inevitably is forwarded to an insurer. This raises an interesting question because it also sets limits on what doctors can make. If you are paying doctors via the Master Chart, then the more diagnosis they perform, the more they are getting paid. Either that or they can charge above the standard rate. One such doctor mentioned in this chapter did just that. He was considered an expert in a certain field and charged nearly ten times the standard rate. He also mandated payments in full by patients, none of this pay-through-insurance mess. He did great business and was paid more than most doctors while doing less work. Another potential solution was attempted by a doctor-run health care cooperative in Vermont. Several doctors with different specializations grouped together and charged patients a flat rate, while they took flat salaries. They were therefore able to manage the efficiency of their medical care. Their network grew, and eventually they added doctors of other specializations. Eventually the co-op became one of Vermont’s biggest insurers, ironic because they were trying to get away from the big insurance methods. Sure enough, size brought problems. The head and founder of the network left after a certain point, somewhat disappointed with the outcome. He cautions at the end of the article that at some point soon, the apparently untenable insurance and reimbursement system will need to be changed for the benefit of do ctors and patients. Chapter 7: The Doctors of the Death Chamber The Doctors of the Death Chamber. This sections starts off with the death of Michael Morales by lethal injection. Under the typical protocol the anesthesiologist administers the sodium thiopental which is expected to halt breathing within a minute of the administration. Then the paralytic agent is introduced, followed by a fatal dose of potassium chloride. Then later, the judge found that at least eight patients had not stopped breathing when the technicians gave the paralytic agent. The California Medical Association, the AMA, and the ASA immediately opposed such participation in a prisoner’s death as a clear violation of the medical ethic codes. The author was intrigued by how the Doctors and Nurses sorted between acting skillfully, acting lawfully, and acting ethically in such situations. Ever since the Gregg v. Georgia matter only two prisoners were executed by firing squad, three by hanging, and eleven by gas chamber. Pages 132 and 133 had details about the extent of each form of punishment. Some like the famous George Wallace were unlucky and had to endure physical pain for an extended amount of time. Many doctors, even though forbidden from participating, still take part in the execution. Some will help or just pronounce the prisoner dead, either way they can’t help feeling they are doing something wrong as reported by some of the interviewed doctors. They can’t help but feel they themselves are the executioners. Chapter 8: On Fighting This chapter is based on the â€Å"fight† so to say some patients have to deal with. The story of a high school history teacher is an example of someone who was willing to risk the complications of life just to be able to live it. He had a reappearing cancer in his left kidney. Through many setbacks he was last seen in a long-term care facility. Despite the great advancements in his health he seemed to be in worse shape physically than before and then he was confronted with the realization that he might not be able to walk ever again. Not only are they, the patients like Thomas, fighting but so are the doctors in charge. Another story about a young twelve year-old Callie had a similar reappearing tumor that came back just as big as before despite all the treatment. Although her family kept fighting, eventually her parents thought it was too cruel to keep Callie living such a difficult life. Many cases have been found that just by the doctors’ fight for a patient’s survival the odds get better for the patient. Many premature babies thought dead were brought back to life and were even able to live as a normal a life as possible. The topic of this chapter was: Never Stop Fighting, because even when the odds are against your favor there is always that one person we wished the doctors never stopped fighting for. Chapter 9: The Score The Score starts off with Rourke’s experiences as a doctor delivering babies. Then the moment comes when she herself has to give birth. She knew the process and wanted the procedure to go as smoothly as possible. The thing she was most afraid of was losing control of what was done to her. The chapter delves deeply into the process of giving birth. For example, the dilation of the cervix, etc. Needless to say it is a complicated process which in consequence led to many child and young women’s deaths earlier on in history. The most problematic is the exiting of the child’s head. There have been many methods that can be effective if used correctly, but deadly in other situations for liberating the child. The concept of the forceps when it first appeared had been kept secret for more than a century. The device was developed by Peter Chamblin. The score relates to the Apgar score that was created to ‘measure’ the child’s chance of survival rate. Th is helped some cases that looked frugal before that, look hopeful. Chapter 10: The Bell Curve This chapter deals with the outliers overall. Dr. Gawande relates a story about a child named Annie. Annie was diagnosed with cystic fibrosis. It is a recessive disorder therefore, despite ten million people carrying the gene; about a thousand American children are diagnosed with it per year. Her parents took her to Cincinnati Children’s and despite the hospitals effort they were negligent to say that they were not among the country’s top centers for children with cystic fibrosis. It used to be assumed that differences between doctors and facilities were insignificant. When plotting a graph of the results for each hospital it was expected to see a shark’s fin but instead what was seen was a bell curve. LeRoy Mathews was at the top of that bell curve. As other hospitals adapted to Mathew’s ideas his facility just kept improving at a tremendous rate. In 2001 CF tried a new approach with its patients. They were open. They were willing to speak about how other facilities were doing versus theirs. Berwick a former pediatrician was giving grants to hospitals that were willing to try his idea. Not a single family left the program. CF improved greatly after that. Warwick was another positive deviant. He was aggressive, and inventive. He came up with a cough to be able to get the more accumulated mucus out. The chapter sums up with the overall constant fight against settling for the average. Chapter 11: For Performance For Performance. This chapter sums the book up and is its own piece. It starts off with an introduction of a fellow doctor of his who has CF. Then we are led to a see how a certain Dr.Motewar in the Nanded hospital deals with the mass of people needing attention and care. The man was of ordinary appearance yet he saw at least 36 patients in three hours, most had serious complications. What was astounding to the author were the many skills developed by these doctors. He had lower expectations so to say. There was a man who died from a treatable lung collapse because of the lack of instruments. It is very common for patients to have to go out and buy their own medical instruments and medications for the procedures to be held. Dr.Motewar and his colleagues had developed a better procedure for ulcer removal despite the conditions and lack of equipment they have. Many techniques that seem almost crude and basic were actually life saving. The doctors from which the author observed in the chapter had their own methods which would not have ‘flown’ in the United States. This chapter’s topic was about the never-ending search for a better performance in any situation you have.