ARS MEDICA - Penta PCO

ARS
MEDICA
science, clinical practice and art
TODAY AND TOMORROW
FINAL PROGRAME
ABSTRACTS
Inter-University Centre (IUC), Dubrovnik, Croatia
28 May - 1 June 2014
www.penta-pco.com/arsmedica2014.com
Inter-University Centre (IUC), Dubrovnik, Croatia / 28 May - 1 June 2014
What is ARS MEDICA?
Is medicine a science or it is both a science and art; or, ir it is also an art, what is
artistic about medicine. ARS MEDICA is at the same time the art in medicine, and
medicine of art, but also a journey from the culture of disease to the culture of
health, from symptoms and diagnosis to the person as a whole. In the course ARS
MEDICA-science, clinical practice and art we will discuss how to make a bridge
between science, clinical practice and art in four important public health problems:
depression, dementia, pain and palliative care. Join us and be important part of
May course in beautiful Dubrovnik!
ORGANIZERS
CEPAMET - Centre for Palliative Medicine, Medical Ethics and Communication
Skills, School of Medicine, University of Zagreb (Zagreb, Croatia)
CROATIAN MEDICAL ASSOCIATION - Croatian Society for the Protection and
Promotion of Mental Health (Zagreb, Croatia)
CO-ORGANIZERS
University of Zagreb, Croatia:
Academy of Fine Arts
Academy of Dramatic Art
Academy of Music
SCHOOL DIRECTORS
Veljko –oreviÊ
Lukasz Konopka
Trevor Walker
Marijana Braπ
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SOME USEFUL INFORMATION
COURSE VENUE: IUC - Inter-University Centre - address:
Don Frana Bulica 4, 20000 Dubrovnik
phone: +385 (0) 20 413 626, www.iuc.hr
All lectures will take place at the classroom no. 2 (1st floor).
The following equipment is available at the classroom:
screen, projector and computer.
All registered persons will receive corresponding course materials
and IUC diploma.
Lunches will take place at various restaurants at town.
If accommodation is booked thru Penta Ltd., please note it is on bed and
breakfast basis; all other charges have to be covered on spot by the client/s.
Croatian participants will receive Croatian Health Chamber credits.
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GODINE
S VAMA
Inter-University Centre (IUC), Dubrovnik, Croatia / 28 May - 1 June 2014
www.genera.hr
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HR-GELI /MKT/ 005-14
FINAL PROGRAME
Wednesday, 28th May 2014 / srijeda, 28. svibnja 2014.
9:00 - 17:00
Postgraduate course: Communication skills in oncology and
palliative care - in Croatian language
Komunikacijske vještine u onkologiji i palijativnoj medicini
(lecturers: Veljko ĐoreviÊ, Marijana Braš and
Lovorka BrajkoviÊ)
8:00 - 9:00
Registracija
9:00 - 9:30
Osnove komunikacijskih vještina u onkologiji i palijativnoj
medicini (predavanje) Veljko ĐoreviÊ
9:30 - 10:15
Verbalna i neverbalna komunikacija (vježbe) Lovorka BrajkoviÊ
10:15 - 10:45
Pauza za kavu
10:45 - 11:15
PriopÊavanje loših vijesti bolesniku (predavanje) Marijana Braš
11:15 - 11:45
Emocionalne reakcije bolesnika (predavanje) Veljko ĐoreviÊ
11:45 - 12:30
PriopÊavanje loših vijesti bolesniku vježbe (fishbowl tehnika)
Veljko ĐoreviÊ, Lovorka BrajkoviÊ
12:30 - 13:15
RuËak
13:15 - 13:45
Kako voditi obiteljski sastanak (predavanje) Marijana Braš
13:45 - 14:30
Obiteljski sastanak vježbe (fishbowl tehnika)
Veljko ĐoreviÊ, Lovorka BrajkoviÊ
14:30 - 15:00
Pauza za kavu
15:00 - 15:30
SpecifiËnosti komunikacijskih vještina u palijativnoj medicini
Marijana Braš
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Inter-University Centre (IUC), Dubrovnik, Croatia / 28 May - 1 June 2014
15:30 - 16:00
Komunikacijske vještine u palijativnoj medicini (seminar)
Lovorka BrajkoviÊ
16:00 - 16:30
Komunikacija s javnosti (predavanje) Veljko ĐoreviÊ
16:30 - 17:00
Pisanje eseja, zakljuËci teËaja
18:00
Get together party (IUC Atrium)
Thursday, 29th May 2014
10:00 - 10:30
Person centered medicine in Croatia: the role of CEPAMET
Veljko –oreviÊ, Marijana Braš, Lovorka BrajkoviÊ
10:30 - 12:00
Neuroscience Prospective on Depression: Person Centered
Approach Lukasz M. Konopka
12.00 - 13.00
Examining the Relationship between Place-based Food
Security, Access, and Depression (Growing Mental health
Research, Assessment, and Programs Rooted in Food Justice
and Community Health) Kristin Nelson
13.00 - 14.00
Lunch
14.00 - 16.00
Art therapy, neuroscience and trauma Juliet King
16.00 - 17.00
Dementia in everyday practice Nataša Klepac
Dementia - important public health problem in the 21st century
Mirea HanËeviÊ
17.00 - 19.00
Workshop - performing, sharing and discussion:
Theatre and pain: the expression of pain trough theatre
performance Marina PetkoviÊ Liker
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Friday, 30th May 2014
10.00 - 11:30
Person centered approach in psycho-oncology
Marijana Braš, Veljko –oreviÊ, Nada John
Working together: The education of multidisciplinary palliative
care team Lovorka BrajkoviÊ
Psychosocial determinants of satisfaction with hospital care
in adult patients with advanced cancer (PhD thesis)
Maja Boban
11.30 - 13.30
Cancer Tales Trevor Walker
Home Death Trevor Walker
13.30 - 14.30
Lunch
14.30 - 16.30
From genius to insanity Vassilka Nikolova
17:00 - 18.30
The art of communication skills in person-centered pain
management Marijana Braš, Veljko –oreviÊ
Play: Silent screams (video presentation and discussion)
19.00 - 21.00
Project: Communication against Pain Veljko –oreviÊ
Research project: Communication against pain
(drama and discusssion)
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Inter-University Centre (IUC), Dubrovnik, Croatia / 28 May - 1 June 2014
Saturday, 31st May 2014
10.00 - 12:30
Art Therapy and the Brain: The role of image making in
self - regulation Christopher M. Belkofer
12.30 - 13.30
Lunch
13.30 - 15.30
Making an Art (workshop) Aisling Kerns
15.30 - 16.30
Medicine and Law (round table discussion)
Christopher Kerns, Veljko –oreviÊ, Slobodan Lang
16.30 - 18.30
Improvisational Theatre for Medical Students Brian Melamed
Sunday, 1st Jun 2014
10.00 - 13.00
Dermatology in Art - Art in Dermatology Branka MarinoviÊ
The impact of communication skills on Quality of Life in women
with breast cancer; Quality of Life in women with breast cancer:
How to make better life after cancer Lovorka BrajkoviÊ
The role of psychologist in palliative care Josip LopiæiÊ
Pain management in palliative care Ante CrnËeviÊ
Palliative Medicine in Croatia Marijana Braš
Presentation of social programs in media Vlado »utura,
Jadranka PaviÊ
Closing
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ABSTRACTS
Inter-University Centre (IUC), Dubrovnik, Croatia / 28 May - 1 June 2014
Person centered medicine in Croatia: the role of CEPAMET
Veljko –oreviÊ, Marijana Braš, Lovorka BrajkoviÊ
Croatia has a rich heritage of person-centered medicine and people-centered healthcare. Professor Andrija Stampar made an enormous contribution to this field by pioneering various public health projects in Croatia and abroad. Stampar took it upon
himself to visit Croatia’s rural regions in order to acquaint himself with the problems
faced by the segment of the population that resided there and soon realized that there
was a great deal of work to be done in improving the hygiene of the rural population,
and with great enthusiasm he organized various public health campaigns for the eradication of infectious disease. His work included direct actions in promoting health and
organizing healthcare, as well as presenting it professionally. He was instrumental in
the creation of the World Health Organization, serving as president of the 1948 inaugural Assembly Meeting of the WHO and was an early advocate of the now-popular idea
of health for all. Person-centered medicine has seen an enthusiastic advancement in
the last five years in Croatia. Among other things, a multitude of programs were introduced to the curriculum of the University of Zagreb School of Medicine at the undergraduate and post-graduate levels, with the aim of perfecting the curriculum to reflect
the concepts of person-centered medicine. The Centre for Palliative Medicine, Medical Ethics, and Communication Skills (CEPAMET) was founded as part of the University
of Zagreb School of Medicine. It is within this centre that the education of students and
healthcare professionals takes place on the topic of communication in medicine and
the person-centered medical interview . Person-centered medicine relies on strong
teamwork, and teamwork is a subject of interest of CEPAMET. The interdisciplinary
team is one of the most widely accepted innovations in the delivery of health care and
social services. It is important to identify the competencies related to effective teamwork within a health service workplace, such as interpersonal skills and professionalism,
interactions with patients and family and mentoring/teaching students.
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Inter-University Centre (IUC), Dubrovnik, Croatia / 28 May - 1 June 2014
Neuroscience Prospective on Depression:
Person Centered Approach
Lukasz M. Konopka
Chief Neuroscientist , Yellowbrick , and Department of Psychiatry Loyola
Medical Center, USA
Depression is a disorder that penetrates cultural and ethnic boundaries it is observed
in variable clinical presentations throughout the life span. The duration of depressive
episodes has an intrinsic property that is modified by successful or unsuccessful treatment. Significant diversity of clinical presentations is covered by the umbrella of “depression”. Since the development of the objective neuro-imaging techniques we are
beginning to gain more clear understanding of the potential mechanisms involved in
the presentation of clinically defined depression. Because of the diverse biological
substrates contributing to the symptoms of depression is becoming clear that individualized approach to each patient is the key successful treatment. To this end presented Bio-Psycho-Social-Spiritual model with the focus on the biological aspects will
be presented. Utilizing neuroimaging in parallel with the objective neurobehavioral
assessment targeting the cognitive, as well as the limbic systems will be demonstrated.
Case presentations will illustrate the concept s of converging objective data in understanding the individual patient and developing appropriate personalized treatments.
Therapeutic approaches such as: genetically determined pharmacological treatment,
acute pharmacological challenge with pharmaco-EEG monitoring , Alpha stimulation,
art therapy will be discussed.
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Examining the Relationship between Place-based Food
Security, Access, and Depression: Growing Mental Health Research,
Assessment, and Programs Rooted in Food Justice and Community Health
Kristin Nelson
Community Psychology Graduate Student, Therapist in training, and Research
Assistant at Alverno College in Milwaukee, Wisconsin, USA
Health, emotion, autonomy, culture, and meaning-making are intrinsically linked to
food. The availability of nutritious, quality food is interwoven within complex social,
economic, and political systems. This workshop will present basic concepts of food
justice and equity by examining food security and access through a trauma-informed
public health framework applied to chronically stressed communities. Participants will
receive an overview of previous research connecting place-based food security and
depression, focusing on community interventions, assessment tools, and culturally appropriate food access in Milwaukee, Wisconsin and other areas of the United States.
Bronfenbrenner’s Ecological Systems Model will be applied as a theoretical framework
for examining food insecurity and access through multiple embedded environmental
systems. Finally, participants will learn about interdisciplinary research potential that
applies mental and public health methodologies, innovative assessment strategies,
and program development initiatives to explore the relationships between low levels
of food access and depression in underserved, vulnerable populations.
Objectives
1. P
articipants will be able to describe three ways that food systems are related to
mental health and community-level trauma.
2. P
articipants will be able to demonstrate an increased understanding of how mental
and public health theory and practice can be integrated.
3. P
articipants will have the opportunity to share feedback and cross-cultural
perspectives regarding the development of research and programs that address
food access and mental health issues.
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Inter-University Centre (IUC), Dubrovnik, Croatia / 28 May - 1 June 2014
Art therapy, neuroscience and trauma
Juliet L. King
Herron School of Art and Design, IUPUI, Indianapolis, IN, USA
Art therapy is a profession that facilitates psychic integration through the creative process and within the context of the therapeutic relationship. Conscious and unconscious
mental activity, mind-body connectedness, the use of mental and visual imagery, bilateral stimulation, and communication between limbic system and cerebral cortex functioning underscore and illuminate the healing benefits of the profession.
The bulk of art therapy research with patients who have experienced trauma is supported with neuroscientific findings. Art therapists have developed specific protocols
to test the efficacy of art therapy and treatment interventions with the traumatized
populations (Chapman et. al, 2001; Hass Cohen & Carr, 2008; McNamee, 2005, 2006;
Tripp, 2007). These authors have demonstrated that art therapy: (1) facilitates the organization and integration of traumatic memories; (2) reactivates positive emotions
and serves as a vehicle for exposure and externalization of difficult content; (3) reduces
heightened arousal responses; (4) enhances emotional self-efficacy and maintains a
space for the exploration of self perception and psychic integration; and (5) enhances
the development of identity.
I propose to present the benefits of trauma informed art therapy assessment and intervention in a neurobiological context. The primary objective of this presentation is
to describe and articulate how art therapy is a useful and effective intervention for
children, adolescents and adults who have endured various types of traumatic experiences. A secondary objective will be to explore how art therapy intervention strategies
can be applied in the context of both clinical treatment and community outreach.
REFERENCES
Chapman, L., Morabito, L., Ladakakos, D., Schreier, C., Knudson, H. (2001). The effectiveness of art therapy
interventions in reducing post traumatic stress disorder (PTSD) symptoms in pediatric trauma patients. Art
Therapy: Journal of the American Art Therapy Association Vol 18(2), 100-104.
Hass Cohen, N., Carr, R. (2008). Art therapy and clinical neuroscience. London, UK: Jessica Kingsley Publishers.
McNamee, C. M. (2005). Bilateral art: Integrating art therapy, family therapy, and neuroscience. Contemporary Family Therapy, 27(4), 545-557.
McNamee, C. M. (2006). Experiences with bilateral art: A retrospective study. Art Therapy Journal of the
American Art Therapy Association, 23(1), 7-13.
Tripp, T. (2007). A short term therapy approach to processing trauma: Art therapy and bilateral stimulation.
Art Therapy Journal of the American Art Therapy Association, 24(4), 176-183.
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Dementia in everyday practice
Nataša Klepac
Dementia Unit, Department of Neurology, Clinical University Hospital Zagreb
The prevalence of dementias is expected to increase three-fold over the next 35 years
since the population of world is aging. Given the enormous number of patients in the
near feature and financial demands of dementia, the number one priority of modern
health system is to identifies and implement effective ways to address and better manage the care, services and supports for people living with dementia. A person-centered
model of care reorients the medical-disease model of care that can be experienced as
impersonal and fragmented to one oriented to holistic well-being that encompasses
all four human dimensions - bio-psycho-social-spiritual. This approach takes into account everyone’s needs within the context of their network of relationships, identity,
history, health, religion, and culture and it focuses on a patient’s remaining abilities.
Person oriented approach to patients with dementia challenge the way that people
with dementia are now treated and move away from viewing dementia from purely a
medical viewpoint. As dementia progresses, cognitive functions diminish and patients
lose the ability to communicate and express their feeling and needs. However, numerous studies have revealed that people living with dementia still maintain qualities such
as self-awareness, autonomy, individuality, and sense of identity. Unfortunately core
social and emotional needs are often neglected for people with dementia when they
are in long-term care settings. This “new” approach offers to plan for each person with
dementia individually and to have the best possible outcome by meeting their needs.
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Inter-University Centre (IUC), Dubrovnik, Croatia / 28 May - 1 June 2014
Workshop - performing, sharing and discussion:
Theatre and pain: the expression of pain trough theatre
performance
Performed by: Marina PetkoviÊ Liker
theatre director, Academy of Dramatic Art, University of Zagreb and actresses
performing in „Away from terror…“, Arts organization Fourhanded, Zagreb
Duration: 2 hours
From its beginnings theatre was involved in the expression of pain. From rituals,
through tragedies to dramas, the audience felt compassion for the actor, which formed
the basis of each plot, catharsis and co-play. The participation in a play was important
for personal and social development of the audience. Throughout history we separated ourselves from that kind of theatre. Social changes and the development of arts
brought about the diminishing power of theatre in the context of social compassion,
while the artistic expression of the painful emotion was transferred to some other,
colder contexts. However, the practice of theatre, with its live performance using body
and voice, could not be stopped wherever there was the possibility of emapathy.
Is the theatre practice of today able to live up to this challenge and does the theatre of
today offer the catharsis in order to purge ourselves from the feelings of fear and pity,
to be compassionate, to understand others, their tragic, painful and intimate story?
This workshop and the presentation of the artistic project “Away from terror…” will
be aimed at sharing several theatrical and performing moments in order to take the
audience on a journey towards the painful emotion, through the moments of being
and compassion, while at the same time “depriving them of fear” or offering the communication through artistic response. The workshop will be an opportunity for the participants to take part, discuss and perform.
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Person centered approach in psycho-oncology
Marijana Braš, Veljko –oreviÊ, Nada John
Centre for Palliative Medicine, Medical Ethics and Communication Skills,
University of Zagreb School of Medicine
Psycho-oncology is an interdisciplinary field which connects different clinical disciplines (oncology, psychiatry, surgery, family medicine, pediatrics, radiotherapy), with
public health disciplines and the basic sciences. Psychooncology, as a subspeciality,
addresses two psychological dimensions of cancer: the psychological reactions of patients during all stages of their cancer and the stresses on their families and clinical staff
(oncopsychology) and the study of psychological, social, and behavioral factors that
contribute to cancer cause and survival (psychosocial oncology). The person-centered
approach is essential in psychooncology. Person-centered medicine is dedicated to
the promotion of health as a state of physical, mental, socio-cultural and spiritual wellbeing as well as to the reduction of disease, and founded on mutual respect for the
dignity and responsibility of each individual person. Therefore, this biopsychosocialspiritual model defines four dimensions of care of the whole person, and attention is
equally focused on physical, psychological, social and spiritual needs. All four dimensions affect quality of life. The World Health Organization (WHO) has said that this
model of care is very important for better patient outcomes. The person-centered
medical interview is essential for good communication. It is important to balance between the physician-oriented medial interview and the patient-oriented medical interview. A patients’ understanding of cancer can be influenced by many factors, including
spiritual and religious beliefs and practices. Health professionals, as humanists, must
be fully attentive to the suffering of their patients. The proper care of cancer patients
does not begin with costly procedures, but with good communication. Everything is in
the human relationship.
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Inter-University Centre (IUC), Dubrovnik, Croatia / 28 May - 1 June 2014
Working together: The education of multidisciplinary
palliative care team
Lovorka BrajkoviÊ
Palliative care is an area of healthcare that focuses on relieving and preventing the suffering of patients, and it is appropriate for patients in all disease stages, including those
undergoing treatment for curable illnesses and those living with chronic diseases, as
well as patients who are nearing the end of life. Palliative medicine utilizes a multidisciplinary approach to patient care, relying on input from physicians, pharmacists, nurses,
chaplains, social workers, psychologists and other allied health professionals in formulating a plan of care to relieve suffering in all areas of a patient’s life. This multidisciplinary approach allows the palliative care team to address physical, emotional, spiritual
and social concerns that arise with advanced illness. Only good education of palliative
care team can reach patient’s needs. In this lecture it will be presented ten core competencies which are based on the key principles that working in partnership as a team,
sharing discipline-specific skills with colleagues and having a willingness to learn from
each other will improve the overall outcomes of palliative care for patients and families.
The degree to which the ten palliative care competencies may be achieved depends
as much on the professional’s own view of how competent they are as on how they are
perceived by others. Competencies should never be seen as a tool to judge practitioners, but rather as a benchmark that all should aspire to reach over time
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Psychosocial determinants of satisfaction with hospital
care in adult patients with advanced cancer (PhD thesis)
PhD candidate: Maja Boban, MA psychologist
Centre for Palliative Medicine, Medical Ethics and Communication Skills,
University of Zagreb School of Medicine
Part of the thesis: The aim of the research is to determine the moderator and mediation effect mechanisms of coping styles on the relationship of symptoms of depression, anxiety, hopelessness and pain with satisfaction with hospital care in patients with
advanced cancer.
Mentor/s: Marijana Braš, MD, PhD
Affiliation: research place: Clnical Hospital Center Zagreb, Oncology department. Job
post: Agency for quality and accreditation in health and social welfare
Introduction: According to Engel’s biopsychosocial model, human beings and their
diseases are complex system, caused by interplay of many factors. Direct observation
of the outcome of the disease through one or more of the factors is insufficient, that it
is necessary to understand and indirect (moderator and mediator) effects in order to
obtain a complete picture of the needs of patients. Because of the long duration of
treatment and invasive treatment satisfaction medical care is particularly important in
the field of oncology, and can be thought of as the success or failure of oncology. Research on possible intervening factors correlation of symptoms of depression, anxiety,
hopelessness and pain with pleasure medical care in patients with advanced cancer,
almost nonexistent.
Hypothesis: There is a significant moderator and mediation effects of coping with the
stress on the relationship between symptoms of depression, anxiety, hopelessness and
pain with satisfaction with hospital care in patients with advanced cancer.
Aims: To determine is there moderator and mediation effects of stress coping styles on
the connection between symptoms of depression, anxiety, hopelessness and pain with
satisfaction with hospital care in patients with advanced cancer.
Materials and methods: The study will engage adult patients of both sexes suffering
from advanced cancer (N = 250-300) who are being treated at the Clinical hospital
center Zagreb, Department of Oncology
Inclusion Criteria
TNM classification of advanced malignancies
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Inter-University Centre (IUC), Dubrovnik, Croatia / 28 May - 1 June 2014
Inability second curative approach
The criterion for non-inclusion proven metastatic disease of the central nervous system and / or a primary malignancies of the central nervous system presence of acute
psychosis, delirium, dementia and psychoorganic syndrome exclusion criteria: inadequately completed questionnaires
Instruments
General questionnaire
Beck’s depression scale
Beck anxiety scale
Beck hopelessness scale
EORTC cancer in-patient satisfaction with care measure
Inventory Coping with stressful situations
Expected scientific contribution: With the obtained data we will be able to more
clearly define the needs of patients with advanced cancer, to clarify the relationship
between the mechanisms of coping with stress, symptoms of psychological distress
and satisfaction with hospital care that will, hopefully, contribute to the improvement
of care for this very vulnerable group of patients
Acknowledgments: The survey is conducted as part of Palliative Medicine in Croatia
needs and attitudes of patients with advanced malignant disease and their physicians
conducted by the Center for Palliative Medicine, Medical Ethics and Communication
Skills School of Medicine, University of Zagreb (CEPAMET) and funded by the Adris
Foundation.
MeSH/Keywords: patients with advanced cancer, depression, anxiety, hopelessness,
pain, satisfaction with hospital care, coping with stress
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Cancer Tales and Home death
Trevor Walker
St. Mary’s University, Twickenham, UK
Cancer Tales is a verbatim play written by the award-winning playwright and author,
Nell Dunn.
In 2001 she invited me to work on transcripts of conversations she had had with healthcare professionals, patients and carers who had all been touched by cancer. We gathered some actors together to experiment with Nell’s initial monologues and from
these early workshops Nell went on to edit, shape and finally publish the play, Cancer
Tales, in 2002.
The play charts the experiences of five women as they or their loved ones cope with
cancer. The characters are real people and their stories are told in their own words.
Over the following few years we were invited to perform extracts of the play at various
medical conferences and training seminars organised by teaching hospitals and cancer
charities.
In 2007 a pharmaceutical company republished the play together with commentary
from healthcare professionals in the form of a workbook - Cancer Tales: Communicating in Cancer Care. The workbook received a number of awards and the play was
invited to medical conferences across Europe. So far it has played across the U.K. and
in Oslo, Copenhagen, Stockholm, Malmo, Gothenburg, Amsterdam, Brussels, Berlin,
Hamburg, Rovinj, Geneva, Lisbon and Valencia. It has also visited the U.S. and toured
Ireland where it won a number of awards including the National Allianz Business to Arts
award which was presented in Dublin by Mary Mcaleese, the Irish President. In 2010 I
directed a film version which is available online for healthcare professionals.
Home Death is a play by Nell Dunn which tells the true stories of people who choose
to die at home. The stories are told in the words of the people who cared for them and
describe the events leading up to their deaths.
The characters in the play are real people, some ordinary, some extraordinary and one celebrity, the jazz musician George Melly, whose story is told in the words of his wife, Diana.
The play was first performed at the Royal Society of Medicine in London in 2011 to
launch the Dying Matters Awareness week and celebrate the 20th anniversary of the
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Inter-University Centre (IUC), Dubrovnik, Croatia / 28 May - 1 June 2014
National Council for Palliative Care. Following the performance, a number of speakers discussed the play including Professor Mayur Lakhani CBE of the NCPC, Professor
Sir Mike Richards, National Director for Cancer and End of Life Care and the Rt. Hon
Andrew Lansley MP, then Secretary of State for Health.
A number of performances followed at medical conferences across the U.K. and then
in 2013 we were invited by Baroness Joan Bakewell to present a production of Home
Death at the House of Lords. The event was attended by Peers of the House and was
followed by a discussion of the issues raised by the play led by Lord Falconer, whose
bill on assisted dying was being presented to Parliament.
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From genius to insanity
Vassilka Nikolova
Medical University of Sofia
The lecture centers on the legacy of some of the famous European artist and the influence of their psycho-physiological state on their life and art. As we look through
history, it doesn’t take a magnifying glass to determine that many of the great artists
have had a shred of strangeness running through their veins. Which brings up a valid
question, do you have to be “crazy” in order to be a true artist?
Leonardo’s ADHD, Michelangelo’s melancholia and Aspi syndrome, the “criminal
mind” of Caravaggio, the Oedipus complex of Modigliani and Paul Klee, the manias
of Caspar Friedrich and Goya - these are just a part of the diagnoses which the lecture
dwells on. The data are taken from written evidences left both from the artists themselves and from their contemporaries, diagnoses set later by modern specialists on the
basis of these evidences or on the specific features of their artistic legacy, etc. A long
list of suicides committed by artists strengthens the question about vulnerability of
artistic soul and persisting problems with their mental health.
The lecture is accompanied by large number of pictures which visualize the contents.
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Inter-University Centre (IUC), Dubrovnik, Croatia / 28 May - 1 June 2014
The Art of communication skills in person-centered
pain management
Marijana Braš, Veljko –oreviÊ
Centre for Palliative Medicine, Medical Ethics and Communication Skills,
University of Zagreb School of Medicine
We are witnessing the unimagined development of medical science and the clinical
profession in the treatment of patients with chronic pain, but what is left and what will
always stand is a relationship between a health professional and a patient; a relationship that opens the door to a successful diagnosis, treatment and healing. Therefore,
together with the development of personalized medicine, there has been a parallel
development of person centred medicine, which is extremely important for patients
with chronic pain. Treatment outcome often depends on the art of communicating
with patient suffering from chronic pain, and proper communication with the patient’s
family, within the medical team, among medical teams, with insurers, pharmaceutical
companies, patient organizations and others is extremely important. It is extremely important to develop and implement educational programs about communication skills
in the field pain medicine at all levels of health care and for all the members of the
medical team. It is especially necessary to develop educational programs dedicated
to challenging situations in communication (how to break bad news, conduct a family
meeting, communicate about risks and prognosis, shared decision making and communication about end of life decisions). It is necessary to apply experiential learning
methods with the constant use of feedback. During the lecture we will present possible
models for health professional education on the topic of good communication in person centred pain medicine, with the presentation of the medical interview, which was
developed in our laboratory of communication skills at the University of Zagreb, School
of Medicine. We will present, with video, several examples of medical interviews in
working with patients with chronic pain.
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Silent Screams - PLAY
Art can be one of the most powerful tools in the education of healthcare professionals
and the general public about the importance of multidisciplinary pain management.
Among the complex medical issues connected with pain, self-harm is especially interesting.
In the monodrama SILENT SCREAMS, based on the authentic story of a patient, we will
shed some light on the internal experiences of a person dealing with self-harm. This
is an internal scream, a scream for life which sometimes, under certain circumstances,
appears to be unbearable. This drama is also a way of sensitising society in addition to
engaging professionals and all humanitarians in finding a solution to the problem collectively. SILENT SCREAMS is also a civilisational test meant to encourage the public
to reconsider just how much it is ready and able to hear and feel the outcries of those
in need of help, as well as react promptly as a parent, a neighbour, a friend, a teacher
in order to understand and ensure help for those in need. This monodrama is also a
call for us to look within ourselves and find out how much we are ready to change by
helping others. Our goal is to highlight the problem, but, above all, to make sure that
young people who have faltered, hesitated and turned to destruction as a way out are
behind a story like this. It is up to all of us to prevent this, because this planet has no
people to spare, especially the young who are most at risk. We haven’t invited you to
merely watch, we have invited you so that we could learn and change collectively, for
through understanding others, understanding those who are different, we learn and
change. Change in order to help. Help ourselves and those who most need it. Silent
Screams is a cry for change, ours, as well as the community’s which we live in. Silent
Screams is a cry for life, not death.
We believe that this monodrama will empower you to see the patient as a person, and
not merely as a disease.
26
Inter-University Centre (IUC), Dubrovnik, Croatia / 28 May - 1 June 2014
Starring NATALIJA ĐORĐEVI∆
Directed by BORIS SVRTAN
Written by MAJA »ERNELI
Music by DAMIR URBAN
Voice SANJA CRLJEN
Translation and editing by VEDRAN BRATUŠEK and GEA BAHUN-VLAŠI∆
Language adviser NAĐA KOMNENI∆
Project coordinators VELJKO ĐORĐEVI∆, MARIJANA BRAŠ,
BORNA BALETI∆, BORIS SVRTAN
Hello reader,
I write to you from the hurricane inside of me. I’m in the waiting room, just like you’re
waiting for the play. We can both taste the air and the autumn outside. But can you
look into my eyes and see the pain? Can you hold my hand and help me cure the scars?
For once, I want to feel the sun without burning my skin.
Can you help me create the spring?
With hope,
The patient
27
Project Communication against pain
Marijana Braš, Veljko –oreviÊ
Centre for Palliative Medicine, Medical Ethics and Communication Skills,
University of Zagreb School of Medicine
Pain is the most common reason why people consult a doctor, but also the most common symptom indicating the onset of an illness or illness itself. Pain is the oldest evolutionary reaction of an organism to any kind of attack or destruction. Is pain a signal,
a symptom, an emotion or an illness? Why do we feel pain? The cause can be physical,
psychological, social or spiritual. Pain is a subjective feeling and it is not easy to measure it. Since no two people are the same, no two reactions to pain are the same. It is
difficult, almost impossible to compare biologically caused pain with emotional, social
or spiritual pain, but all of them can cause great suffering. Pain and comfort are closely
connected, as a kind of a single continuum, and they are often divided only by a thin
line. Regardless our viewpoint on pain, we all agree that pain is a dominant public
health problem in the world which requires a multidisciplinary approach. Getting free
from pain and suffering is a basic human right and a civilisational breakthrough of the
21st century which must not be limited by numerous prejudices or ignorance. Everybody should be involved in addressing this problem, because nobody should suffer in
silence or die in pain. Modern science and clinical practice already enable us to significantly reduce pain and suffering regardless the cause and kind of pain. Pain should be
prevented and a multidisciplinary approach should be used, because this problem is
not reserved or meant to be dealt with by one profession only. Doctors, psychologists,
social workers, priests, scientists, philosophers, artists, pedagogues, as well as patients
and members of their families should all be involved because we all communicate and
need to recognise pain and suffering of the people living and working with us. One of
the important principles of human existence is NOT to cause pain to oneself and others and we should use our knowledge to help those who suffer from it.
There is a strong and unbreakable bond between pain and art. Pain can really motivate
us, warn us, and initiate a new way of expressing ourselves though a painting, composition, novel or song. Pain is often the bridge connecting, elevating, moving, collecting
and unifying all the layers of human sensibility making us move, scream, show our existence and create and change something in pain. That’s why, behind the pain, there
is often pleasure of creating, pleasure the artist feels in his body and soul as a kind of
unity of the biological, psychological, social and spiritual. How to describe the minor
key of pain, since we assume major keys are defined by joy and pleasure? Which tonality is pain? Which colour and shape is pain? What is the movement of pain?
28
Inter-University Centre (IUC), Dubrovnik, Croatia / 28 May - 1 June 2014
Many works of art have resulted from pain, which should be respected, but it also
shows us that art should be used as a therapeutic technique for people who suffer
from pain, as well as one of the most powerful ways of raising public awareness of this
problem. Art can also be one of the best forms of educating medical professionals and
people working in government institutions who decide on the importance of recognising and treating pain. These are the reasons why we have decided to start the “Using Communication against Pain” project to point through different media to pain as
an omnipresent world phenomenon and cause of human suffering. We, as humanists,
need to and want to solve this problem.
We invite you to stop for a moment, become aware of the problem of pain and draw
public attention to the fact that thousands, millions of people around us suffer from
and die of pain. Common goal of scientists, experts and artists is to build a bridge of
co-operation and joint action to reduce human greatest suffering. Only our creativity
and doing good will make us feel good. Do good - feel good. Solution to all problems
lies in human relationships. Homo homini remedium!
29
ISTRAŽIVA»KI PROJEKT KOMUNIKACIJOM PROTIV BOLI
voditelj: Veljko ĐoreviÊ
Bol je najËešÊi problem zbog kojeg se ljudi javljaju lijeËniku, ali i najËešÊi simptom koji
ukazuje na poËetak bolesti ili bolest samu. Uzroci boli mogu biti fiziËki, psihiËki, socijalni
i duhovni. Bol je subjektivan osjeÊaj i nije ju jednostavno mjeriti. Bol treba prevenirati i
lijeËiti multidisciplinarno, jer problem boli nije rezerviran i predodreen za jednu struku
ili profesiju. Umjetnost može biti vrlo snažno srestvo za senzibilizaciju javnosti o problem kroniËne boli, metoda poduËavanja zdravstvenih profesionalaca te terapijska tehnika za oboljele. U radu s oboljelima od razliËitih oblika kroniËne boli iznimno su važne
komunikacijske vještine. Cilj je ovoga projekta istražiti stavove studenata Medicinskog
fakulteta i zdravstvenih profesionalaca (lijeËnika i medicinskih sestara) o komunikacij
skim vještinama vezanim uz oboljele od kroniËne boli, njihovo znanje o tome te usta
noviti njihovu eventualnu povezanost (stavova i znanja) ali i pratiti promjenu znanja i
stavova korištenjem simuliranih pacijenata koji Êe na temelju realnih priËa pacijenata
uprizoriti najËešÊe probleme u komunikaciji s kojima se susreÊu oboljeli od kroniËne
boli i zdravstveni profesionalci. Upitnici koji Êe se koristiti u ovom istraživanju sastojat Êe se od opÊeg upitnika (posebno za studente i posebno za zdravstvene profesionalce), upitnika za procjenu stavova prema komunikacijskim vještinama u medicini (CSAS) te upitnika (testa znanja) o osnovama komunikacijih vještina u medicini.
Istraživanjem Êe se obuhvatiti ukupno 300 studenata od 1-6. godine studija medicine te
300 zdravstvenih profesionalaca (lijeËnika i medicinskih sestara). U svrhu istraživanja Êe
se napraviti posebna dramska predstava (tzv. verbatim kazalište) s glumcima (simulira
nim pacijentima), a u suradnji tri umjetniËke akademije SveuËilišta u Zagrebu. Promjena
znanja i stavova pratit Êe se prije i poslije dramske izvedbe.
30
Inter-University Centre (IUC), Dubrovnik, Croatia / 28 May - 1 June 2014
Art Therapy and the Brain:
The role of image making in self-regulation
Christopher M. Belkofer
Mt. Mary University, Milwaukee, WI, USA
The following presentation explores the hypothesis that art-based and client-centered
approaches to art therapy treatment are effective interventions for working with traumatized populations (Klorer, 2005). Process oriented creative-based interventions may
help treat traumatized populations by targeting the underlying neurological and bodily features of their emotions (Hass-Cohen, 2009). The inability of clients to tolerate,
manage, or experience their own internal reality can lead to dissociative states as well
as physical outbursts, such as aggression and self-harmful gestures. Through engagement with art materials, traumatized clients may learn how to understand and manage
their thoughts and feelings. Potential changes that occur in the brain may create the
building blocks for healthy emotional development.
Central to this approach is the belief that creative and action-oriented approaches to
treatment, such as art, dance/movement, drama, and music therapy have the potential
to rewire the brain (Belkofer & Konopka, 2008; Hass-Cohen, 2009). The results of preliminary research using qEEG (quantitative electroencephalogram) measures to study
the impact of drawing on the brain will be provided and applied to art therapy theory and treatment. In addition, clinical vignettes will be presented to explore how the
qEEG can be used in conjunction with the utilization of various art materials, aesthetics
intentions, and the therapeutic relationship to promote opportunities for therapeutic
change. This presentation explores the possibility that clients can learn how to practice
self-regulation through art making and outlines how this approach can be applied in
clinical practice.
REFERENCES
Belkofer, C., & Konopka, L. (2008). Conducting art therapy research using quantitative EEG measures. Art
Therapy: Journal of the American Art Therapy Association, 25(2), 56-63.
Hass-Cohen, N. (2009). Partnering of art therapy and neuroscience. In N. Hass-Cohen & R. Carr (Eds.) Art
therapy and clinical neuroscience (pp. 21-42). New York: Jessica Kingsley.
Klorer, G. P. (2005). Expressive therapy with severely maltreated children: Neuroscience contributions. Art
Therapy: Journal of the American Art Therapy Association, 22(4), 213-219.
31
Improvisational Theatre for Medical Students
Brian Melamed, Nadja KomneniÊ, Marijana Braš, Veljko –oreviÊ
The teaching of proper communication skills to medical students has historically taken
a backseat to the teaching of basic science and clinical knowledge, and while this paradigm has been expanding, teaching methods still tend to focus on a more classical
approach to learning (i.e theoretical rather than practical). Our objective is to introduce
medical students to instruction on interpersonal communication, beginning from the
first year of medical school, with a practical component that will allow them to establish
an empathetic mindset as a basis for the future, when students are exposed to their
first patient, as well as to develop teamwork skills and trust in their colleagues. It is
important to ingrain this culture of open communication among students and their
educators in order for them to continue this approach when presented with their own
patients. Improvisational theatre (IT) can be a useful tool in teaching students and
healthcare professionals to improve their bedside manner and patient rapport. This
technique can improve teamwork skills, as it allows participants to practice empathy.
The nature of IT forces the participants to consider each other throughout the duration
of the encounter, and maintain focus and active listening not only on the content of
what others are saying, but also the manner in which it is being said. IT is a collaborative
effort, often performed in front of an audience and this requires proper teamwork as
well as attention to detail from the participants. When performing IT, the performer not
only has to consider what (s)he is saying, but how it affects the other members of the IT
team. An area where medical students or young medical professionals frequently have
issues due to inexperience is breaking bad news or broaching uncomfortable subjects
with patients or their family members. IT enables clinicians to “improvise appropriate
responses to unpredictable situations while interacting with a wide variety of individuals” [1]. Healthcare professionals often find themselves in unpredictable situations with
their patients and with each other. It is therefore exceedingly important for healthcare
practitioners to be comfortable with spontaneity and quick thinking while maintaining
excellent communication skills.
REFERENCES
Watson K. Medical Improv. http://www.medicalimprov.org (accessed March 9, 2014).
32
Inter-University Centre (IUC), Dubrovnik, Croatia / 28 May - 1 June 2014
Dermatology in Art – Art in Dermatology
Branka MarinoviÊ
Department of Dermatology and Venereology, University Hospital Center
Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia
Dermatology is defined as the science of the skin and its diseases. The skin is outer covering of the human body serving many vital protective and sensory roles. The diseases
of the skin are varied and plentiful owing to the large size of the skin, its complex structure and its permanent exposure to environemntal influences. Skin is the most visible
organ of our body, and due to that is is present in different fields of art - paintings, film,
theater.... Beside that skin and its diseses was for a long time presented and learned
from moulages, wax models of different skin conditions, which are dermatology in art.
And what about art in dermatology. Art is to recognize, diagnoze and cure different
diseases of the skin. Art is way of knowning how to choose and perform best method
for rejuvenation - to help people in their permanent wish to stay young and beautiful.
Art is camouflaging different skin defects with make-up. Art is to interpret different
laboratory microscopical findings.
But today, maybe the biggest and most valuable art is to take a part of our time and
to dedicate it to our patient, because in this part of time, when talking with our patient
we can discover is the disease on the skin just the invoving the skin or mirroring some
other, very often psychological problems.
33
The impact of communication skills on Quality of Life
in women with breast cancer
Lovorka BrajkoviÊ
Communication is an integral part of any relationship with patients and their families,
and represents the key to the success of the medical team. Communication and relationship have been demonstrated to have an impact on patients’ experience of care,
to improve patients’ adherence to treatment regimens, clinical outcomes and quality, patient safety, teamwork, cultural sensitivity, and to reduce medical malpractice
risk. Healthcare professionals with effective interpersonal skills will have more satisfied
patients, and they will be able to give more emotionally to patients and will, in turn,
get more satisfying responses from them. Physicians’ comprehensive knowledge of
patients and patients’ trust were the most strongly associated with adherence, and
trust was the most strongly associated with patients’ satisfaction with physician. And
only good communication can prove above mentioned. Building relationships is extremely important, not only in the beginning, but during the whole patient - physician interaction. If physician provide more information to patients about the disease
that will reduce psychological stress, symptoms will disappear quickly, and outcome
of treatment will be increased. So, it is very important for healthcare professionals to
learn and improve communication skills and to be aware of patient’s biological as well
as psychological, social and spiritual needs.
34
Inter-University Centre (IUC), Dubrovnik, Croatia / 28 May - 1 June 2014
Quality of Life in women with breast cancer:
How to make better life after cancer
Lovorka BrajkoviÊ
Quality of life in patients with breast cancer is an important outcome and now is considered an important endpoint in cancer clinical trials. It has been shown that assessing
quality of life in cancer patients could contribute to improved treatment and could
even be as prognostic as medical factors could be prognostic. Research, conducted
in 2011 on Croatian sample showed that younger women and women who had 2 and
above stage of tumour had worse quality of life than older women and women with 0 or
1 stage of tumour. It was indicated that depression, anxiety, age, stage of tumour and
avoidance as coping mechanism, bio-socio-demographic factors as well as psychological support were predictive of global health status. Psychological support has had significant impact on all aspect of quality of life. So, it is suggested that psychological support must be one of the important factor in treatment of women with breast cancer in
order to improve the quality of life of patients and to improve the effects of treatment.
35
Palliative Medicine in Croatia
Marijana Braš
Centre for Palliative Medicine, Medical Ethics and Communication Skills,
University of Zagreb School of Medicine
A World Health Organization statement describes palliative care as “an approach that
improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by
means of early identification and impeccable assessment and treatment of pain and
other problems, physical, psychosocial and spiritual”.
While palliative care may seem to offer a broad range of services, the goals of palliative treatment are concrete. Palliative medicine is one of the best examples of personcentered medicine, which is evidenced by the principles of modern palliative medicine.
National strategies of palliative care may vary, because they depend on the various factors and specificities of individual nations. The government of Croatia adopted a Strategic plan for palliative care in 2013, the efforts towards which lasted a few years and
demanded great multiprofessional collaboration from over one hundred participants.
One of the basic directives in this strategic document is universal access to palliative
care for all the citizens of a nation, as well as integrated care. The goal of this presentation is to demonstrate the opportunities for and barriers to the creation of high-quality,
accessible palliative medicine within a community as an example of person-centered
medicine and people-centered healthcare.
36
Inter-University Centre (IUC), Dubrovnik, Croatia / 28 May - 1 June 2014
bilješke / notes
37
Travel, accommodation and registration:
Creating value. Together.
Danijela ∆urËiÊ
PENTA Ltd.
PCO & Travel agency
Izidora Krsnjavoga 25, 10000 Zagreb, Croatia
phone direct: +385 1 4628 607
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38
Jučer navečer
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Sutra ujutro
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3
Sildenafil
Vardenafil
2
1
Cialis
Cialis omogućuje :
Nenadmašnu učinkovitost i tvrdoću erekcije
j u usporedbi sa sildenaﬁlom4
Neusporedivo trajanje učinkovitosti do
36
sati5
Uzimanje uz obrok ili natašte1
Kliničku učinkovitost unutar 16 minuta nakon uzimanja kod 32% muškaraca
te unutar 30 minuta kod 52% muškaraca6
Muškarci i njihove partnerice radije odabiru Cialis® nego sildenafil
7
Cialis (tadalafil) Sažetak opisa svojstava lijeka
CIALIS 10 mg filmom obložene tablete
CIALIS 20 mg filmom obložene tablete
tadalafil
Broj odobrenja za stavljanje lijeka u promet: Cialis (4 tablete od 10 mg): EU/1/02/237/001, Cialis (2 tablete od 20 mg):
EU/1/02/237/002
Način i mjesto izdavanja lijeka: Lijek se izdaje na recept. Ime i adresa nositelja odobrenja: Eli Lilly Nederland B.V., Grootslag 1-5,
NL-3991 RA, Houten, Nizozemska Terapijske indikacije: Liječenje erektilne disfunkcije u odraslih muškaraca. Za djelotvornost tadalafila
potrebna je seksualna stimulacija. CIALIS nije indiciran za primjenu u žena. Kontraindikacije: Preosjetljivost na djelatnu tvar ili neku od
pomoćnih tvari. CIALIS se ne smije primjenjivati u muškaraca sa srčanim bolestima kojima se ne preporučuje seksualna aktivnost. Liječnici
moraju razmotriti potencijalni rizik za srce tijekom seksualne aktivnosti u bolesnika s postojećom kardiovaskularnom bolešću. Posebna
upozorenja i posebne mjere opreza pri uporabi: Prije razmatranja farmakološkog liječenja treba uzeti anamnezu bolesnika te obaviti
fizikalni pregled kako bi se dijagnosticirala erektilna disfunkcija i utvrdili njezini mogući uzroci. Prije uvođenja bilo kakvog liječenja erektilne
disfunkcije liječnici trebaju razmotriti kardiovaskularni status svojih pacijenata jer se uz seksualnu aktivnost veže određen stupanj srčanog rizika.
Tadalafil ima vazodilatacijska svojstva koja dovode do blagih i prolaznih sniženja krvnog tlaka i tako pojačavaju hipotenzivni učinak nitrata.
Nuspojave: Najčešće prijavljena nuspojava u bolesnika koji uzimaju CIALIS za liječenje erektilne disfunkcije ili benigne hiperplazije prostate
bile su glavobolja, dispepsija, bolovi u leđima i mialgija, a njihova je incidencija rasla s povećanjem doze lijeka CIALIS. Prijavljene nuspojave
bile su prolazne te u pravilu blagog ili umjerenog intenziteta. U većini se slučajeva glavobolja prijavljena kod primjene lijeka CIALIS jedanput
na dan javila unutar prvih 10 do 30 dana nakon početka liječenja. Doziranje i način primjene: Općenito se preporučuje doza od 10 mg
koja se uzima prije očekivane seksualne aktivnosti, s hranom ili bez nje. U bolesnika u kojih tadalafil u dozi od 10 mg ne izazove odgovarajući
učinak može se pokušati s dozom od 20 mg. Lijek se može uzeti barem 30 minuta prije seksualne aktivnosti. Najčešća učestalost doziranja smije
biti jednom na dan. Tadalafil od 10 i 20 mg namijenjen je za primjenu prije očekivane seksualne aktivnosti i ne preporučuje se kontinuirana
svakodnevna primjena.
Ovaj promotivni materijal sadrži bitne podatke o lijeku koji su istovjetni cjelokupnom odobrenom sažetku
svojstava lijeka te cjelokupnoj odobrenoj uputi sukladno članku 15. Pravilnika o načinu oglašavanja o
lijekovima i homeopatskim proizvodima („Narodne novine“ broj 118/2009). Prije propisivanja molimo
pročitajte zadnji odobreni Sažetak opisa svojstava lijeka i Uputu o lijeku. Detaljnije informacije o ovom
lijeku dostupne su na web stranici europske agencije za lijekove http://www.ema.europa.eu.
SAMO ZA ZDRAVSTVENE RADNIKE HRCLS00044, SVIBANJ 2014.
Eli Lilly (Suisse) S.A. Predstavništvo u RH,
Ulica grada Vukovara 269 G, 10 000 Zagreb
Tel: +385 1 2350 999, Fax: +385 1 2305 870
1. Cialis, Sažetak opisa svojstava lijeka, zadnja odobrena verzija koja je dostupna uz materijal; 2. Vardenafil, Sažetak opisa svojstava lijeka, Lipanj 2012; 3. Sildenafil, Sažetak opisa svojstava lijeka, Rujan 2011; 4. Eardley I, Mirone V, Monitors F, et al. Br J Urol Int 2005;96:1323-1332; 5. Levine SB. Erectile dysfunction: Why drug therapy isn’t always
enough. Cleve Clin J Med 2003;70(3):241-246; 6. Rosen CR et al. Determining the Earliest Time within 30 Minutes To Erectogenic Effect after Tadalafil 10 and 20 mg: A Multicenter, Randomized, Double-Blind, Placebo-Controlled, At-Home Study. J Sex Med 2004;1:193-200; 7. Lee J, Pommerville P, Brock G, et al, Physician-rated patient preference
and patient- andpartner-rated preference for tadalafil or sildenafil citrate:results from the Canadian ‘Treatment of ErectileDysfunction’ observational study,BJU International 2006; 98: 623-29
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