Learning from the patient
There are many different kinds of ways that people and animals learn. People can adjust the way they learn to the different situations in which they are learning and what they have to learn. One form of learning is known as conditioning. Conditioning emphasizes the relationship between stimuli and responses. The two types of conditioning found are Classical conditioning and Operant conditioning. Learning may occur in different ways. Psychologists have distinguished between different types of learning, these being Observational Learning and Insight Learning. Classical conditioning refers to ? simple form of learning, which occurs through the repeated association of two or more different stimuli. Learning is only said to have occurred once ? particular stimulus always produces ? response which it did not previously produce. Classical conditioning involves an unconditioned stimulus and an unconditioned response, as well as ? conditioned stimulus and ? conditioned response. (Horney 2002)
The unconditioned stimulus is any stimulus, which consistently produces ? naturally occurring, automatic response. The unconditioned response is ? reflexive and involuntary response, which occurs as ? result of the unconditioned stimulus. The conditioned stimulus is the stimulus that is neutral at the beginning of the conditioning process and does not produce the unconditioned response. But through repeated association with the conditioned stimulus, triggers the same response as the unconditioned stimulus. The conditioned response is the learned response that is brought forth by the conditioned stimulus. The conditioned response occurs after the conditioned stimulus has been associated with the unconditioned stimulus. An example of classical conditioning is when ? person walks past ? certain house each day and every time is attacked by ? large dog. They then associate that house with the dog and avoid walking past there again. In this example the unconditioned stimulus is the dog, the unconditioned response is fear, the conditioned stimulus is the house, and the conditioned response is avoidance of the house. Operant conditioning is the learning process in which the likelihood of ? particular behavior occurring is determined by the consequences of that behavior. It is based on the assumption that ? person or animal will tend to repeat behavior that brings forth ? positive consequence such ? praise, and tend not to repeat behavior that brings forth negative consequences such as punishment. And example of operant conditioning is the training of rats to press ? lever in order to obtain ? food reward. The pressing of the lever (conditioned response) is associated with the food reward (unconditioned stimulus). After ? training period, the rat will show the conditioned response of pressing the lever even without the presence of the unconditioned stimulus of the food. (Wolff and Hausberger 1996)
Theories and learning from the patient
Many theorists have emphasis to believe on the patient’s wisdom. Observational learning occurs when ? person or an animal uses observation of another’s actions and their consequences to guide their own future actions. The person being observed is referred to as ? model. For this reason observational learning is also referred to as modeling. Observational learning involves four stages, attention, retention, reproduction and motivation-reinforcement. Attention is when the learner observers the actions of the model (The higher the status of the model the more attention the learner will pay and the closer their imitations will be to the models actions). Retention is when the learner retains in their memory what they have just observed. Reproduction is when the learner will reproduce or imitate the actions of the model that they have just observed. Reproduction is when the learner reproduces or imitates what they have just observed. Motivation-reinforcement can come in various ways. External reinforcement, through praise for doing something well, self-reinforcement, through the learner setting themselves ? goal in which they must achieve, and vicarious self-reinforcement, in which the learner can see others joy in their achieving this goal. An example of observational learning is when ? person begins to learn ? dance. The person will observe their dancing instructor (attention) when they are shown the dance moves. They then retain the information that they have just observed. The person will then reproduce/imitate the dance moves that they have just been shown (reproduction). The motivation reinforcement can come from praise from the instructor or fellow dancers, or seeing others dance well and wanting to be able to do the same. There are many ways of framing the patient role. (Ramsay and Rostain 2005)
One helpful way is to consider what is possible for patients and the public as clients, consumers or citizens in healthcare. There is ? continuum of patient participation in the decision-making process. These roles can be characterized as patient as client, patient as consumer and patient as citizen. Clients traditionally play no role in evaluating the solutions to their problems, let alone deciding on the solution or even defining the problem. Consumers can evaluate solutions but the availability of choices is limited by the provider. Citizens in healthcare, on the other hand, join in to set the agenda, define the problem and evaluate the solution. As patients move from the client role to role of citizen they take ? more active and equal part in the decision-making process. In the present experimental world of primary healthcare we, like others, have found that regarding patients as citizens is helpful for successful learning from patients. This means acknowledging and developing patients’ capacities in order to enable them to contribute at every level of encounter, including face-to-face. We mentioned earlier how patients can go unheard during primary care encounters. Practitioners working from ? ‘narrative base’ take care to elicit and help develop patients’ stories in the context of their family and community. The ‘citizen’ concept of the patient is also consistent with the model of consultations as ‘meetings between experts’ where sharing understanding is the key task. Such ? model is used in the current curricula for communication skills teaching in UK medical schools. One government initiative that directly supports learning from patients as experts are the paper The Expert Patient: This builds on the strengths of patient self-help groups and is directed at preparing those with chronic illness to become enablers of other patients, sharing ideas for self-care. We describe later how ‘expert patients’ also help professionals to learn. The practice team had already been involved in ? team learning program which aimed to enable practitioners to embrace public/patient participation. They focused on the changing role of the health visitor. (Scheurich 2005)
The health visitor then brought the following problems to the attention of ? practice meeting:
• The recent discontinuation of routine monitoring of families at home
• The probable imminent disappearance of routine child surveillance
• The need for ? review of baby clinics from the patient’s perspective, do they meet the needs of children and parents in their present form? Subsequently ? steering committee was formed involving members of the primary healthcare team and patients. The steering committee was empowered to design the future of the baby clinics in response to feedback. At present the practice is developing ? proposal to address all the issues. ? key feature of the structure of this initiative is that each contribution is equally valued; to the extent that each participant working in their own time (receptionist, patient lead and mothers are involved) receives the same standard payment. The preparation that this team had undergone for working with patients had allowed them to explore their anxieties about involving patients. This meant they could move towards ? constructive dialogue and realize the benefits of ? less hierarchical, more patient-focused organization. At the first point in the team process of engaging with the patient perspective, the health practitioners were being sensitized to understanding the patient perspective in their terms, and representing that in professional conversations. The professional/patient steering committee is ? further step in developing ? partnership approach. The next part of the process would be enabling patients to develop and represent their own perspective, e.g. in ? patients’ forum. we argue that involving patients as active partners in learning organizations can help change the construction of patients as helpless recipients to active partners. (Draper et all 1999)
There are ? number of steps that need to be undertaken to prepare the ground:
• prepare patients and professionals for partnership: this means allowing both parties ? voice to express their creative ideas and difficult feelings.
• involve patients near the beginning of any learning or development exercise, to help set the agenda
• give professionals opportunities to reflect on personal practice and experiment with new ways of seeing and behaving. Establish clear structures to encourage ? feeling of safety and openness to change.
• establish similar ground rules with patients from the beginning
• encourage professionals and patients in such learning to support each other to build on their strengths. This parallels and reinforces an empowerment model for individual patients
• ensure agreed outcomes from shared learning and development are jointly evaluated and followed up. Given the Stoics’ physical theory about the perfect rational structure of the world, it is sometimes objected that such ? world does not allow human freedom. Indeed, the Stoics are often accused of holding ? sort of fatalism that that makes ethics inconsistent with anything other than passively accepting one’s fate in ? deterministic world. If, for instance, it is one’s fate to suffer from ? certain sickness, the proper Stoic response is said to be passive acceptance. (Scaturo et all 1998)
This, however, is an oversimplification of ? complex Stoic doctrine. Everything, then, is in relationship with everything else. The Stoic doctrine of fate is ? doctrine of determinism, although it is ? determinism linked with providence. This raises some difficulties for the idea of moral responsibility. If everything is predetermined, how can one be held morally responsible for one’s actions? By differentiating antecedent and proximate causes, Chrysippus can maintain that our voluntary cooperation is necessary to bring about what is already fated. ? person’s moral character is the primary cause of the good or bad acts that the person performs. However, each act requires additional, auxiliary or ‘‘triggering’’ causes, such as sense impressions. The major part of responsibility for the action lies in the primary cause, and so the auxiliary cause cannot itself bring about assenting to the act. ? dangled carrot does not compel ? donkey to move, however inevitable that might be. The primary cause lies in the nature of the donkey’s limited intelligence For the Stoic, happiness consists in living in accord with nature. We have already seen that disease, although an indifferent, is contrary to our nature. However, it is certainly fated, in the Stoic sense that we all will die, and disease is usually associated with death in ? strong causal way. How, then, is the Stoic to react to sickness? Wisdom is called for if one is successfully to navigate the hazards of this problem. Hence, we propose to examine the nature of one who is characterized by wisdom, namely, the Stoic sage. This will give us valuable insight into how to respond to sickness – how to become ? wise patient. The Stoic is sometimes portrayed as an apathetic fatalist, silently accepting whatever misfortune might come along. As we have seen, however, this is ? misunderstanding of the Stoics’ understanding of fate.5 It is also ? misunderstanding of the Stoics’ understanding of the emotions. The Stoic sage is not apathetic in the sense of being unfeeling. Feelings, especially feelings of sympathy, are necessary for ? moral life. If so, it cannot be that the Stoic wants to discard emotions altogether. Most people immediately seek relief from illness. The Stoic, when faced with illness, sees an opportunity to make ? choice about seeking relief. The proper choice is the one that is in accord with nature – what fate has ordained for the individual. The ability to know such things is wisdom. Wisdom is an art of living; it is ? craft. To understand the nature of Stoic wisdom, it is necessary to distinguish between two types of crafts: those that are ‘‘stochastic’’ and those that are not. The goals of non-stochastic crafts are formulated in such ? way that the goals are necessarily reached if the craft is performed perfectly. Stochastic crafts, on the other hand, are those in which the craft can be practiced perfectly without necessarily achieving the craft’s goal. The success of stochastic crafts depends on factors that are beyond the control of the craft. Medicine is ? good example of ? stochastic craft. The aim of medicine is to cure patients. However, ? physician can practice medicine perfectly and still fail to cure ? patient. (Antonuccio et. all 2005)
Animal intelligence is something that is some what taken for granted. Animals are looked at to be species that are totally beneath humans in intelligence. What most people are afraid to admit is that ? lot of animals are able to do the same things as humans can. Animals can speak ? language, whether it is in the wild or taught to them by humans, they can perform tasks that make them able to survive, such as making tools to hunt down food. The most interesting thing we learned while doing some research was the fact that certain animals use and make tools. Thos was first discovered in the 1960s that ? chimpanzee was using ? grass stems to fish out termites that they eat for ? dessert. This shocked ? lot of scientists and was felt to unbelievable. As time has gone on scientists have found more animals that use tools. Along with chimps, apes also have been known to make and use tools throughout their lifetime in the wild. Surprisingly birds are also capable of using tools. Crows are said to be able to use specially selected twigs to peck beneath the ground to help them find grubs. Crows using tools and other birds was originally thought to not exist at all as unlike chimps and apes birds only have two legs and ? pair of wings, but not arms that apes and chimps have. When this was discovered it gave ? new meaning to the word intelligent when talking about animals. (Saslow 1999)
When scientists studied animals in their habitat they were able to realize how much intelligent things that animals have to do to survive. Things that people take for granted in our lives also come easy for animals. Almost all animals do something that is hard to believe and they have to do it to survive. While studying meerkats scientists found that these small rodents actually have their own language of sounds and pitches to communicate with other meerkats. They use this communicating skill to notify each other of certain predators that are nearby. These sounds and pitches are used as warning calls. Any type of communication is considered to be ? true sign of intelligence in any species. Dogs are known to be house pets. But what makes them ? good house pet is the fact that they are to learn tasks due to ? high capacity of trial and error learning. Dogs are capable of leading blind people, responding to ? command right away, and all sorts of different tricks, this is all because of the high capacity of trial and error learning. Dogs and meerkats have special unique traits that make them intelligent species. (Harman et all 1999)
Insight learning is ? kind of learning involving ? period of mental manipulation of the information associated with ? problem prior to the realization of ? solution to the problem. The learning is said to have occurred when the relationships relevant to the solution are grasped. The learning appears to occur in ? ‘flash’ and what has been leaned is usually performed smoothly and without error. Insight learning involves four stages; preparation, incubation, insightful experience and verification. Preparation is ? ‘getting ready’ period in which the person gathers as much information as possible about what needs to be done. Incubation is ? period of mental ‘time out’ in which the information gained is put aside. However the information continues to be reflected upon on ? sub-conscious level. Insightful experience is often referred to as the ‘ah ha experience’ because of its suddenness. This experience seems to occur because of some mental event that unexpectedly bridges the gap between the problem and its solution. Verification represents the final stage of insight learning, when the visual image that flashed into the mind during the insightful experience is acted upon and is tested if the solution proves to be ineffective the learner with then return back to the stage of incubation. (Stempsey 2004)
An example of insight learning is that of an experiment performed by psychologist Wolfgang Kohler. Kohler presented ? Chimpanzee with ? problem by placing ? banana just outside of its cage close enough for the Chimp to clearly see, yet too far away for it to reach. Inside of the cage were two hollow bamboo sticks, one slightly shorter and thinner than the other. Each stick was too short to enable the Chimp to reach the banana however the shorter stick could be placed inside of the larger one making it long enough to reach the banana. After many futile attempts to reach the banana with his hands, the Chimp then tried other solutions, which included using each stick independently to reach the banana. Failing once again the chimp sat down with the two sticks in his hands, appearing as though he had given up. But then, seeing that both sticks could be put together to make one long stick (insightful experience), the Chimpanzee placed the small stick ? little way inside of the larger one and was able to reach the banana and pull it toward himself. There are many differences and similarities between each of these learning processes. For example, classical conditioning involves only involuntary or reflex responses where as operant conditioning involves both involuntary and voluntary reflexes. These different learning processes can be used independently in many different situations. Where Classical conditioning may be more effective in one situation it may be useless in another. For this reason each of these learning processes, Classical and operant conditioning and observational and insight learning are each as important and effective as the other. (Stempsey 2004)
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