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At this stage buy 50 mg kamagra with amex causes of erectile dysfunction in 40s,once you have decided on a basic career path (that is medicine kamagra 50mg sale young husband erectile dysfunction, surgery purchase kamagra 50mg with mastercard erectile dysfunction signs, general practice buy kamagra with a mastercard erectile dysfunction 3 seconds, obstetrics and gynaecology, etc. Rotations These are a series of six-month posts linked to one hospital, but usually based at several hospitals within close proximity. There is an SHO for each hospital post and at the end of each six months all SHOs rotate until each has spent six months in each post. When you apply for a rotation you are applying for all of these posts in one go. Rotations may last between 18 months (three posts) and three years (six posts). The three-year posts take you through the ﬁrst sets of postgraduate examinations (parts 1 & 2 and 3) and can lead directly to a specialist registrar (SpR) post. Rotations are based within a region when outside London (for example East Anglia or Yorkshire) or within a section of London (north east London). Rotations are a good choice if you wish to settle down in one region for a period of time, but there are a few draw- backs. You may have to rotate into a post you do not wish to do (for example urology, ear, nose and throat, etc. All rotations have excellent posts,mediocre posts and one or two posts that are not liked. Rotations are good as you need not worry about the hassle of applying for jobs and interviews every six months, but they do tie you down for the duration of the rotation. It is becoming increasingly common for SHOs to organise themselves to do the post they least like at the end of the rotation. This then leaves the option of dropping out of the 1 This changes as an SHO, as the postgraduate deanery pays 50% of your salary and the hospital itself pays 50%,which means that your role as an SHO is 50% learning and 50% service provider. Getting Registered and Applying for Senior House Ofﬁce Posts 75 rotation six months early (this does not have a detrimental effect on your career if planned early). Stand Alones These posts are, as they sound, single six-month posts that you must apply for indi- vidually. They have the beneﬁt that you can apply for posts you would like to do in hospitals you wish to work in. However, each post must be applied for, four to six months in advance, so once into a post you must immediately start thinking about the next one. If you like moving around or want to tailor your rotation then stand alones are perfect for you. I should point out I have chosen the path of stand alone posts as I wanted to take a year out for sports and to travel. In the last 12 months, the number of stand alones has decreased considerably as they have been absorbed into rotations and F2 year programmes. It is my suspicion that the number of stand alones will gradually decline over the next few years making it more and more difﬁcult to complete your training this way. The upside to this is that interview panels are becoming increasingly aware that junior doctors wish to take time out of their training to pursue other avenues that life has to offer. It is therefore becoming easier to take time out within a rotation (that is complete one year, then have a year off and defer the rest of the rotation), but this question should be raised at interview if you are thinking about it. Location Once you have decided which type of post you want you need to decide on your loca- tion: London or outside London? Many juniors, particularly those who graduate from London schools, have the false belief that if you want to end up in London as a consultant then you must do all your training in London ‘to get your foot in the door’. This is not strictly true although there is a signiﬁcant ‘old boy’ network and culture, which some would say is in decline. The bottom line is that, if you are proﬁcient in your work, good humoured, enthusiastic and diligent, then you will be able to get a job anywhere at any time. It is certainly true that, as an SpR, you will ﬁnd it easier to get a consultant post in the region in which you have been an SpR. However, to add complications to my previous statement, it is also easier to get your SpR number in the area in which you have done your senior SHO training as, at this stage in your career, many things work by word of mouth. At the time of writing 1 in 3 PRHOs ﬁnishing their PRHO year have no SHO training post to go to. I know of at least 3 doctors from my hospital who cannot get an SHO post so have decided to move to Australia (2 are so fed up that they are emigrating). At present doctors applying for SHO training posts in medicine will send off on average 112 applications before obtaining a post and the average number of applicants per post is about 150. The next few years while the Foundation Scheme is being phased in are going to be difﬁcult for those desperately trying to obtain posts as it is my understanding that the number of doctors exceeds the number of posts available. Inevitably some of you will be forced into Trust grade posts or locum work, but I would strongly advise you not to be disheartened as you will certainly not be alone. Patience and an ear-to-the-ground will be required but if you do ﬁnd yourself unemployed, make the most of that time. You could gain experience overseas,perform voluntary work (it doesn’t help with paying off those student loans though) or gain new skills. Whatever you do, make sure that you keep applying for posts well in advance and have at least 2 SHOs and 2 SpRs look at your CV. Consultants can be very useful but you have to pick the right one,as some are happy to say that every detail is ﬁne when in reality your CV needs a revamp. Juniors and mid- dle grades are more likely to spend time giving you an honest opinion. Some of you may have performed minor surgical procedures either in the operating theatre or in the accident and emergency (A&E) department. All new senior house officers (SHOs) should be competent in basic ward-based practical procedures, for example pleural taps, chest drain inser- tions, arterial blood gas, etc. As an SHO you have already started down the road to specialisation by deciding on general practice, medicine or surgery. The majority of you will be on a rotation that will lead to becoming a specialist registrar (SpR). As such,you are expected to be far more dedicated and enthusiastic in your work, as well as more proﬁcient than when you were a PRHO/FY1. This is a daunting situation to be thrown into overnight, from being a PRHO/FY1 to SHO/FY2. In this respect taking an A&E post in your ﬁrst six months as an SHO is highly advisable to bridge the transition, as it encourages development of diagnostic skills, how to cope with life-threatening situations and practical procedures. As an SHO you are expected to be a fully integrated (that is a working part of your team) and functional individual (that is able to perform tasks as opposed to just being there for training purposes). As such, you will be taught how to see and manage patients on your own in order to aid the smooth running of the ﬁrm. However, you will also be taught your own limitations and when to call more senior members for advice. You will be taught in the out-patients department as well as on the ward.
Norton recalled buy kamagra online erectile dysfunction patient.co.uk doctor,“one of his sons said to him cheap kamagra 50mg with mastercard erectile dysfunction statistics worldwide,‘You know purchase kamagra 100 mg without prescription impotence urologist, Dad 100 mg kamagra for sale impotence word meaning, we had a president in a wheelchair. In 1963 the sociologist Erving Goffman published his classic book on stigma—attributes that leave people “discredited... Being “lame,” “crippled,” or “multiple sclerotic” qualiﬁed as stigmatized attributes (along with minority race and religion), which taint, discount, or discredit people in their own and society’s eyes. Here are some examples: When the stigmatized person ﬁnds that normals have difficulty in ignoring his failing, he should try to help them and the social situa- tion by conscious efforts to reduce tension... It requires that the stigmatized individual cheerfully and unselfconsciously ac- cept himself as essentially the same as normals, while at the same time he voluntarily withholds himself from those situations in which normals would ﬁnd it difficult to give lip service to their simi- lar acceptance of him. Many interview- ees use humor to diffuse discomfort, and courtesy is certainly preferable to Society’s Views of Walking / 53 rudeness. Stigmatization may dissuade people from taking inappropriate advantage of economic support programs, such as disability insurance (Minow 1990, 91). Nevertheless, “the stigmatized” today would shrug aside Goffman’s depiction of what they should do (especially to help out “normals”). Nowadays people with disabilities often ﬁnd themselves not only in- cluded but celebrated. Centers for independent living, run by people with disabilities, address daily concerns within communities and teach self- empowerment; state and local governments sponsor offices on disability to ensure accessibility to services and spaces; disability rights centers offer legal counsel and advocacy; hundreds of internet sites provide disability- related services, advice, information, and support; numerous companies market products, from customized wheelchairs to accessible vacations; wheelchair users roll through television shows, commercials, and movies; dance troupes and other cultural organizations feature artists using wheel- chairs; wheelchair athletes compete at elite levels; and a vibrant community of disability scholars carefully observes and chronicles societal attitudes. The disability rights movement, which began several decades ago, de- serves credit for this change (West 1991b; Shapiro 1994; Pelka 1997; Young 1997; Francis and Silvers 2000; Longmore and Umansky 2001). In 1964 Gallagher (1998, 111–13), a wheelchair user, served as legislative assistant to Bob Bartlett, U. Gallagher occasionally needed to conduct research at the Library of Con- gress, which was not wheelchair accessible. Senator Bartlett contacted Quincy Mumford, librarian of Congress, requesting that a ramp be built at the back entrance that only had two steps. Mumford responded that adding to the library’s physical plant might need a speciﬁc act of Congress. Frus- trated by Mumford’s stonewalling, Senator Bartlett inserted $5,000 explic- itly for the ramp into Congress’s budget, and the ramp was built. Gallagher’s efforts culminated in the Architectural Barriers Act of 1968, which required all buildings constructed with federal funds to be physically accessible. The disability rights movement, however, reached beyond individual battles to seek broad societal recognition of basic human and civil rights for people with disabilities (Bickenbach 2001). The hard-won achievements of racial minorities and women in the mid 1960s offered little to persons with disabilities. Unlike during these civil rights movements, disability rights advocates had not ﬁlled the streets. The critical precursor to the ADA, Sec- tion 504 of the Rehabilitation Act of 1973, was “a stealth measure in the midst of a backlash against civil rights” (Young 1997, 12). Section 504 of the Rehabilitation Act of 1973 was no more than a legislative afterthought.... Atthe very end of the bill were tacked 54 / Society’s Views of Walking on four unnoticed provisions—the most important of which was Section 504—that made it illegal for any federal agency, public uni- versity, defense or other federal contractor, or any other institution or activity that received federal funding to discriminate against any- one “solely by reason of... Congressional aides could not even remember who had sug- gested adding the civil rights protection. But the wording clearly was copied straight out of the Civil Rights Act of 1964, which ruled out discrimination in federal programs on the basis of race, color, or national origin. Members of Congress were either unaware of it or con- sidered it “little more than a platitude” for a sympathetic group. In April 1977 frustrated disability activists, lead by wheelchair users, took over federal offices in San Francisco, holding them for twenty-ﬁve days. When one administration official suggested setting up “separate but equal” facilities for disabled people, the proposal, with its unfortunate phraseology, backﬁred. The civil disobedience tactics surprised the nation, but this victory marked “the political coming of age of the disability rights movement” in the United States (Shapiro 1994, 68). The di- versity of disability advocates and difficulties identifying with each other occasionally threatened their success. Political fears about costs, litigation, and burden on business posed perhaps the biggest hurdle. The ADA is unique in the context of civil rights legislation because it requires that businesses and government do more than just cease discriminatory actions. They must also take proactive steps to offer equal opportunity to persons with disabilities, commensurate with their economic resources. Most people either have a disability or know someone who does: the cause seems universal. The full legacy of the ADA is still unfolding (Francis and Silvers 2000), with the U. Unlike prior civil rights legisla- tion, the ADA requires businesses to take positive steps, to make “reasonable Society’s Views of Walking / 55 accommodations,” which they assume will cost money. Some accommoda- tions cost nothing, as when the Supreme Court required the Professional Golfers Association to allow Casey Martin, who has painful swelling of his right leg, to ride a cart while competing in tournaments. Supreme Court heard two cases from people claiming dis- abilities, neither related to mobility. The National Council on Disability, a federal agency, warned that the Supreme Court had left millions of Americans “with signiﬁcant mental or physical impairments unprotected against egregious discrimina- tion” (Silvers 2000, 128). With other ADA cases pending, these deﬁnitional debates are far from over. Today, when the public equates claims of disability with expectations of entitlement—even for something as minor as a parking spot—hackles rise. Drivers in crowded malls can almost come to ﬁsticuffs over perceived usurpation of handicapped parking spots. In three recent sketches (Figures 3 to 5), a peg-legged sailor leaves his skiff at a mooring marked with a wheel- chair symbol; an elderly man rolls his scooter down a grocery store aisle, followed by the grim reaper, scythe held aloft, also riding a scooter; and a stout woman crosses a street with her cane, arm grasped by a Boy Scout who says, “I also do suicides. No single viewpoint encapsulates today’s attitudes toward disability in general, walking problems in particular, or the ADA. Attitudes are evolving, probably soon to be shaped by aging “baby boomers. Over three decades after Erving Goffman’s 1963 injunctions on how “cripples” should behave, the 1996 comments of the novelist Nancy Mairs, who uses a wheelchair because of MS, offer an eerily parallel counterpoint but with an entirely different sensibility. If I want people to grow accustomed to my presence, and to view mine as an ordinary life, less agreeable in some of its particulars than theirs but satisfying overall, then I must routinely roll out among them. I must be “on” all the time, since people seldom glance down to my height and so tend to walk into me as though I were immaterial. Unless paradise is paved into a parking lot, most of the earth’s surface is going to be too rough for my wheelchair....
In such patients order kamagra with a mastercard erectile dysfunction naturopathic treatment, implantation of the component at the level of the original ace- tabulum is recommended buy generic kamagra on-line outcome erectile dysfunction without treatment, while equalizing leg length through the improvement of static body balance buy generic kamagra on line erectile dysfunction pumps review. For patients with an extremely narrow acetabulum and slender femur generic kamagra 50 mg amex erectile dysfunction korea, a technique for enlarging the hypoplastic structure with subsequent use of normal-sized components is advantageous. The method mentioned in this chapter is not suitable for all patients with a high dislocation of the hip joint, but it is indicated when preoperative CT scanning indi- cates the need for enlargement of the acetabulum and of the medullary canal. Selective enlargement of only the acetabulum or femoral side can be performed in selected instances. Sofue M, Dohmae Y, Endo N, et al (1989) Total hip arthroplasty for secondary osteo- arthritis due to congenital dislocation of the hip (in Japanese). Crowe JF, Mani J, Ranawat CS (1979) Total hip replacement in congenital dislocation and dysplasia of the hip. Eftekhar NS (1993) Congenital dysplasia and dislocation in total hip arthroplasty. Azuma T (1985) Preparation of the acetabulum to correct severe acetabular deﬁciency for total hip replacement—with special reference to stress distribution of periacetabu- lar region after operation (in Japanese). Yamamuro T (1982) Total hip arthroplasty for high dislocation of the hip (in Japanese). Harris WH, Crothers O, Indong AO, et al (1977) Total hip replacement and femoral- head bone-grafting for severe acetabular deﬁciency in adults. Nagai J, Ito T, Tanaka S, et al (1975) Combined acetabuloplasty for the socket stability by the total hip replacement in dislocated hip arthrosis (in Japanese). Buchholz HW, Baars G, Dahmen G (1985) Frueherfahrungen mit der Mini- Hueftgelenkstotalendoprothese (Modell “St Georg-Mini”) bei Dysplasie-Coxarthrose. Matsuno T (1989) Long-term follow-up study of total hip replacement with bone graft. Paavilainen T, Hoikka V, Solonen KA (1990) Cementless replacement for severely dysplastic or dislocated hip. Charnley J, Feagin JA (1973) Low-friction arthroplasty in congenital subluxation of hip. Kinoshita I, Hirano N (1985) Some problems about indication of total arthroplasty for secondary coxarthrosis (in Japanese). Kuroki Y (1986) Total hip arthroplasty for high dislocation of the hip joint (in Japanese). Kerboull M, Hamadouche M, Kerboull L (2001) Total hip arthroplasty for Crowe type IV developmental hip dysplasia. Inoue S (1983) Total hip arthroplasty for painful high dislocation of the hip in the adult (in Japanese). Kanehara, Tokyo, pp 257–266 A Biomechanical and Clinical Review: The Dall–Miles Cable System Desmond M. The Dall–Miles Cable System (Stryker Orthopaedics, Mahwah, NJ, USA) has been in clinical use since 1983. It was initially developed for reattachment of the greater trochanter in low-friction arthroplasty of the hip. It is now used largely as a cerclage system, par- ticularly in revision total hip arthroplasty (THA). A biomechanical review includes a comparison of the mechanical strength of different cerclage systems. The relationship between tensile strength and fatigue per- formance is analyzed, and comparative data are presented. A review of the clinical use of cable cerclage is presented, including ﬁxation of the greater trochanter in various trochanteric osteotomy approaches to the hip, the use of the system in revi- sion THA, femoral allografts, its use in ﬁxation of periprosthetic fractures of the femur in THA, and the use of the system in augmentation of other forms of fracture ﬁxation, emphasizing its value in the treatment of fractures in soft bone. Dall–Miles, Cable, Biomechanical, Clinical Introduction Cerclage systems have been used in many clinical situations, mainly to provide, or assist in, ﬁxation of bony fragments and occasionally of long bones. Materials have included stainless steel, chrome cobalt, titanium alloy, and nylon. Monoﬁlament wires or bands have been used for many decades, but it was not until the late 1970s that Dall and Miles were the ﬁrst to use multiﬁlament cable in the ﬁxation of the greater trochanter when osteotomized as an approach to the hip in total hip arthroplasty. Emeritus Professor of Clinical Orthopaedics, University of Southern California, Los Angeles, CA, USA 239 240 D. Dall The Strength of Cerclage Systems It is important to appreciate that the stress–strain curves of different cerclage systems (e. However, the load-deﬂection curves will be different because of the structural differences even in the same material. Thus, yield and break- ing loads are the most useful measurement of mechanical strength. The other impor- tant aspect of strength in cerclage systems is that of fatigue strength, which I discuss later. Figure 1a shows the comparative yield and ultimate tensile strengths of different systems in the same material, and Fig. Strength of Fastening Methods in Different Cerclage Systems There are great variations in the method of fastening used in cerclage systems. There is also great variation in the measurements used, and these could include measure- ments of displacement, slip or yield, and failure loads. Comparative yield and ultimate tensile strength of different geometric structures made of the same materials (a) and different geometric structures made of different materials (b). Dark gray bars represent yield strength; light gray bars represent ultimate strength The Dall–Miles Cable System 241 a b Fig. There is therefore a plethora of comparative data, sometimes comparing apples with oranges. We have tended to use the split metal cylinder to measure the strength of fastening by measuring the amount of displacement in the split at varying loads. We believe this is the most reproducible and clinically relevant method. Whatever the cerclage system and whatever the fastening method, the strength of any fastening method is always signiﬁcantly weaker than the strength of the material used in a cerclage system (Fig. Nevertheless, there are signiﬁcant differences in the strength of various fastening systems in different materials (Fig. Clinical Performance of Dall–Miles Trochanter Cable Grip System In a series of 595 hips (many of which were revisions), we reported a non-union rate of 2. They reported on a non-union rate of 5%, of which half had been attached to cement or allograft. Their cable breakage rate was 9%, with a high incidence occurring in lateral anchor holes. In their discussion, they state that this failure rate might have been contributed by stainless steel cable contact with the titanium prosthesis. In my opinion, some of the case illustrations demonstrated splaying of the cut end of the cable, rather than fragmentation. However, their cable was not fastened by a crimping technique; it was fastened by knotting.
One of the main sources of such demands in the late 1990s was the burgeoning men’s health movement order generic kamagra line impotence in xala, associated 62 SCREENING with the wave of men’s magazines kamagra 100 mg without a prescription erectile dysfunction freedom book, one of the publishing successes of the decade buy kamagra 100 mg on line impotence drugs over counter. Though it lacked the early radical impulse of feminism discount kamagra 100 mg on line erectile dysfunction doctors knoxville tn, the men’s health movement adopted the later preoccupation of some feminists with health as their model. Far from challenging medical authority, men’s health promoters urged men to submit themselves to it on a greater scale than ever before. In choosing campaigning issues, they proceeded by analogy with the feminists: they had cervical smears—we demand prostate examina- tions; they can do breast self-examination—we can feel our testicles. Though prostate cancer is relatively common in older men (95 per cent of 15,000 cases a year occur in men over 60), testicular cancer is a rare disease of younger men (causing around 100 deaths a year). Though treatment is often effective for both cancers, screening tests for early detection are generally considered unreliable. To detect prostate cancer it is possible to have a regular digital rectal examination, a blood test for the Prostate Specific Antigen, and a local ultrasound scan, but the predictive value of all these tests is low. Urologist Peter Whelan suggested that ‘Promotes Stress and Anxiety’ was an accurate description of the effect of the blood test. Given the rarity of testicular tumours, a high rate of false positive results is the inevitable outcome of any promotion of self- examination (Austoker 1994b). It is however striking that, long after medical authorities have accepted the ineffectiveness of screening tests like the PSA, or self- examination of breasts and testicles, pressure groups and popular magazines continue to promote them. The extent of popular approval of these techniques, which is grossly disproportionate to any value they might have in reducing the impact of cancer, is a potent indicator of the pathological preoccupation with health that now prevails in society. It is ironic that young women are often advised to examine their breasts every month—an arbitrarily selected frequency that happens to coincide with the menstrual cycle — though the large majority of women with breast cancer are post- menopausal. Similarly, young men now turn up at the surgery after reading about prostate cancer in their men’s magazines and request screening for a condition that only rarely appears before retirement age. The parallel between screening tests for cervical and prostatic cancer is symbolic. Just as the smear test exposes women not merely to the medical gaze but to vaginal penetration, so the palpation of the 63 SCREENING prostate involves digital penetration of the male rectum. The slippery finger may be less impressive than the metal speculum, but it is no less significant as an instrument of symbolic domination. Rejecting the evidence of the ineffectiveness of mammography, Delyth Morgan of Breakthrough Breast Cancer insisted that ‘what we should be debating is how best to screen women’ (Guardian, 7 January 2000). This response provides striking confirmation of the observation made fifteen years earlier in another critique of screening: ‘In “keeping the faith”, screening advocates may find themselves forced to accept or reject evidence not so much on the basis of its scientific merit as on the extent to which it supports or rejects the stand that screening is good’ (Sackett, Holland 1975). The danger of this approach is not only that it leads to the continuation of costly and ineffective programmes. It also means that the harms of screening are passed over in silence: to mention them could discourage people from taking up the offer of testing. Indeed this was the first concern of the cancer charities in response to reports of the Danish study of mammography quoted above; public reassurances about the quality of the national cervical screening programme accompany every exposure of poor standards. Yet the harms resulting from screening are substantial: for every woman who benefits, tens of thousands undergo testing and hundreds receive unnecessary treatment. In presenting screening as an unequivocal benefit to women, doctors become advocates of state policy rather than of their patients’ interests. State intervention in personal life In the screening programme the author was assigned an ‘adviser’ who would ‘help her with her health’ on an ongoing basis and monitor her progress towards ‘better health’. The extensive questionnaire Taking the first step to better health’ included the tendentious and extraordinarily patronising statement that the screening ‘has been devised to help you change the way you look after your health. The author took umbrage at (a) the assump-tion that she was not healthy already, and (b) the assumption she didn’t know how to look after herself… 64 SCREENING The questionnaire also included a ‘Women’s section’ of questions from the banal to the intrusively, impertinently and offensively intimate to ‘help her with her health’. The author objected and was told that she was unusual in questioning the questions (most women, apparently don’t because they trust doctors and have been brainwashed into believing that they need this nonsense). Over the past twenty years there has been, in the name of health promotion, a dramatic increase in state intervention in the personal life of the individual—ironically in a period when the state has been inclined to withdraw from economic and social commitments. The immediate consequence has been a stricter regulation of individual behaviour, though because this has been justified in the cause of improving the health of both the individual and the nation, it has not generally been experienced as coercive. The changed relationship between the state and the individual that is reflected in the greatly enhanced role of health has also changed the role of the medical profession and has given rise to a range of new institutions and professionals working in the sphere of health promotion. The origins of each of the lifestyle interventions we have examined lie within the world of medicine and its attempts to tackle the ‘modern epidemics’ of heart disease and cancer. However, as is clear from our brief survey of the development of these interventions, at a certain point each was taken up by the state and transformed into a major national initiative. In the case of smoking, this occurred with the shift of focus to passive smoking in the late 1980s; in relation to CHD, government promotion of ‘healthy eating’ began earlier but also became a major campaign in the late 1980s and in the Health of the Nation initiatives of the early 1990s; both the cervical and breast screening programmes were nationalised in 1987–88. The state’s assumption of a leading role in health promotion inevitably changed the character of these initiatives. Once they had acquired a wider political and ideological role, their contribution to health became of secondary importance. At a time when politicians were preoccupied with the declining prestige of government, projecting an image of concern with health helped to shore up public 65 SCREENING approval. Successive governments recognised the potential of health as a means of establishing points of contact between the state and an increasingly atomised society, a trend which reached its apotheosis in NHS Direct, the 24-hour telephone advice line set up in 1999, claimed by Tony Blair as one of the greatest achievements of his first 1,000 days in office. Employers too recognised the potential of health promotion in managing relations with workers. In a perceptive study, Margaret May and Edward Brunsdon noted the shift in the 1980s away from traditional ‘occupational health’ concerns towards ‘new “wellness” interventions’, including medical ‘check-ups’, ‘health risk appraisal’, screening tests and preventive lifestyle advice (May, Brunsdon 1994). They characterised this as ‘a new form of employee control’, far beyond the familiar organisation of work, as the jurisdiction of the employers extended into workers’ private lives. They commented on the convergence of management theory and government health policy around the themes of personal responsibility. The proliferation of workplace smoking bans in the 1990s was another indication of the extension of managerial authority justified by concern for employee’s welfare. As health promotion assumed an ever greater profile, there was some divergence between the ways in which prevention strategies were presented to the public and how they were perceived within the private world of medicine. The politicians and the media wanted simple messages, soundbites, and doctors who took the lead in health promotion campaigns were happy to provide them—on the evils of passive smoking, the dangers of dairy products or the need for screening tests. Meanwhile, as we have seen, a high—and often increasing—level of scepticism came to prevail among medical experts about the value of all these interventions. In fact, in private, many doctors in all specialities are doubtful of the value of much of the work of health promotion. However, recognising the strength of the health promotion consensus, solidly backed by government funding, medical vested interests and compliant journalists, they think it best to keep their reservations to themselves. Indeed, as any of the sceptics who have spoken out could testify, the price of making private reservations about fashionable health promotion interventions public is high. The intellectual insecurity underlying the health promotion consensus is expressed in a dogmatic intolerance of criticism and intense hostility towards any dissident opinion. Anybody who ventures criticism of these policies—or has the temerity to publish research revealing their ineffectiveness—can 66 SCREENING expect a tirade of abuse and little prospect of academic advance- ment. A spirit of ‘not in front of the children’ governs debate as medical science is subordinated to political expediency. The second theme that emerges from our discussion of health promotion interventions is the resulting restriction on individual liberty.
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