Different Kinds Of Patients Research Articles

Age-related Vascular Differences among Patients Suffering from Multiple Sclerosis

The aim of our study was to analyze morphological and functional aspects of cerebral veins by means of ecocolor-Doppler in young (i.e., ≤ 30 years old) and older (i.e., >30 years old) patients suffering from multiple sclerosis. 552 multiple sclerosis patients were evaluated by means of a dedicated Echo-Color-Doppler support (MyLab Vinco echocolor Doppler System, Esaote), in both supine and sitting positions. 458 (83%) showed alterations in their morphological and functional structures of cerebral veins and were divided in two different groups: 1) ≤ 30 (110 patients) and 2) >30 years old (348 patients). Young patients showed a statistically significant higher number of both hemodynamically (44% vs. 35%, p<0.01) and non-hemodynamically (51% vs. 45%, p<0.05) significant stenosis in the internal jugular veins as compared to older patients. A lower percentage of young patients showed blocked outflow in the cervical veins (50% vs. 65%, p<0.01) as compared to older ones. Patients >30 years old outlined a significantly higher disability degree (Expanded Disability Status Scale score: 5 vs. 3, p<0.01) as well as higher disease duration (12 vs. 5 months, p<0.01) than younger. No differences could be outlined about multiple sclerosis clinical form of the disease. It was evidenced that young and adult groups are different kind of patients, the former showing much more cerebral veins stenosis and blocked flow in internal jugular veins and vertebral veins than the latter. Duration of disease could explain such differences: the higher the diseases duration, the higher the degree of vascular alterations and, therefore, the disability degree. This could be due to the complex venous hemodynamic impairments induced by alterations in vascular walls: the blocked or difficult blood flow through stenosis could increase the hydrostatic pressure in the skull and this could induce damages to cerebral cells leading to the genesis of more advanced morphological abnormalities. Furthermore, the vessels' alterations could impair venous endothelial functions which could turn in a possible alteration of the controls of cerebral vein return which could worsen the cerebral vascular outflow. It may be possible that early clinical, pharmacological and/or invasive vascular interventions could exert a possible role in the natural history of multiple sclerosis. Nevertheless, further trials are needed in order to confirm such considerations.

Service users of a hospital based Alexander Technique service for pain have decreased pain levels and reduce their NHS costs associated with pain by half: Results of a mixed methods service evaluation

Background: Recent evidence indicates that Alexander Technique (AT) is helpful for relieving the pain of backache (Little et al. 2008), which costs the NHS an estimated £480 million per annum with non NHS costs (such as private consultations and prescriptions) being an additional £197 million (HMSO 1994). The STAT (Society of Teachers of Alexander Technique) approach to AT is a taught approach, where once learned, the ‘student’ (service user) can practise the technique themselves, emphasising self-management. This service evaluation was conducted on the basis that commissioners require information on impact of services on quality of life, health status and NHS costs within a real-world out-patient Pain Management service. The aim of this presentation is to present the results of this service evaluation and discuss with the audience how to disseminate the findings further. Aims and Objectives: The aim of this exploratory mixed methods service evaluation was to explore the role, acceptability and impact of an Alexander Technique service at a hospital out-patient Pain Management Clinic, including service users’ (n=43) experiences of the service and the perceived benefits to the NHS. Methodology: To capture changes in health and quality of life status, as well as record personal and NHS costs amongst service users, we administered four validated, widely used questionnaires: the Brief Pain Inventory, the EQ-5D, MYMOP and the Client Service Resource Inventory at three time points. Independent statisticians analysed each data source separately. For each outcome measure, we calculated mean values at each time point and also the mean change between each pair of time points (baseline and 6 weeks, baseline and 3 months, 6 weeks and 3 months). For all mean values we calculated the associated 95% confidence interval (CI). We also carried out 27 semi-structured telephone interviews with patients, 3 months from baseline. The qualitative data was analysed using a grounded thematic approach, looking for similarities and differences across the accounts to identify patterns and search for ‘deviant cases’. Results: Findings from BPI and MYMOP suggested that overall there was a general trend towards a decrease in scores of approximately one point between baseline and 6 weeks. This improvement was maintained at three months, once the service users were no longer attending Alexander Technique lessons. EQ-5D did not show statistically significant change. Resource use analysis showed that total costs for service users at the three time points did not change over time but standard weekly NHS costs related to pain reduced by over half between baseline and three months (baseline mean = £27.43 [95% CI £19.26 to £35.60], 3 month mean £11.68 [95% CI £4.55 to £18.81]. Thematic analysis of the qualitative data of patient interviews suggest that AT emerged as a technique for managing the perception of pain and patient response to pain; this also led to some behaviour change and changes in self knowledge from the patient. Interviews with Alexander teachers revealed organisational challenges of setting up a new service and the process of learning about a different system with different kinds of patients, which offered a real learning experience. Conclusion: These pilot data appear to suggest that services users of an Alexander Technique service for pain found that their pain decreased and their relationship to their pain changed. Moreover, resource data suggest that these AT service users reduced their NHS costs related to pain by half. This has important implications for the future use of Alexander Technique in pain clinics.

傳統中醫倫理及其對當代醫師職業制度的啟示

LANGUAGE NOTE | Document text in Chinese; abstract also in English.醫療保障不僅需要制度依據，也需要文化底蘊的支撐。傳統中醫倫理蘊含著醫者仁心、精勤不倦的處世道德規範，敬畏生命、人命至重的人道主義精神，公平待人、博施濟眾的普世價值學說，智圓行方、求平執中的整體和諧理論，道生德養、志存救濟的大義博愛觀。這些內容對於當代醫療保障的建設尤其是當代醫師職業制度建設和發展具有重要的借鑒價值，因而是我們不應忽視的文化資源。To establish appropriate medical professionalism in contemporary China, institutional construction, reform and development are certainly necessary. However, they must be conducted by drawing on relevant cultural ideas and values to gain support. In particular, traditional Chinese medical culture and ethics contain a great amount of intellectual and moral resources that are useful for the construction and development of contemporary Chinese medical professionalism. This essay attempts to explore such resources and make relevant recommendations.Traditional Chinese medical culture is informed by Confucian ethical concerns and commitments. It requires that the physician must have a benevolent heart to treat the patient and a diligent mind to pursue health care knowledge. At the same time, the physician must hold reverence for life and appreciate the vital importance of human life. In addition, Confucian culture expects the physician to be fair in treating different kinds of patients and their families, and to be generous in attempting to help people. In the process of providing medical treatment, physicians’ personal integrity and an attitude for pursuing harmonious outcomes (among patient, family and physician) are emphasized. Finally, the Confucian notions of righteousness and fraternity refer to the view that physicians should engage in serious cultivation of virtue so that they may form a firm moral aspiration to help others and be honored to conduct noble actions in helping others. Accordingly, when we attempt to set up effective health care institutions and establish proper contemporary medical professionalism, these traditional values and commitments should be studied and drawn upon.Based on these considerations, the final part of the essay puts forward four suggestions for rebuilding a proper Chinese physician profession. First, the government should provide a reasonable income and effective security for physicians, not only to supervise but also to protect their legitimate interests in providing health care services to the public. Second, pubic hospital administrators should pay attention to physicians’ personal interests and their work conditions, to provide a feasible working environment for them to treat patients effectively. Third, physicians should understand that although the external environment can never be perfect, they should discipline themselves by ensuring good professional, interpersonal and psychological standards in providing health care services to the people. Finally, physicians must recognize that as professionals, they are expected to hold proper virtues and a benevolent heart to overcome their personal difficulties, whatever they are, to treat patients and their families in virtuous and benevolent ways.DOWNLOAD HISTORY | This article has been downloaded 361 times in Digital Commons before migrating into this platform.

Linking Insurance Coverage for Innovative Invasive Procedures With Participation in Clinical Research

A RECENT RANDOMIZED CONTROLLED TRIAL (RCT) evaluating a self-expanding intravascular stent (the Wingspan stent system), a device intended to open stenotic intracranial arteries via angioplasty and thereby prevent thrombotic stroke, reported surprising results. Based on case series data, this type of stent system was expected to be better than usual care; however, patients who underwent the stent procedure were more than twice as likely to experience stroke or death within 30 days compared with patients treated with aggressive medical therapy (14.7% vs 5.8%). These “negative” test results were disappointing. A promising new approach to a serious medical problem turned out to be worse than current best practice. However, within this failure was an important lesson worthy of notice and support from patients, clinicians, and policy makers. Through cooperation between the US Food and Drug Administration (FDA) and the Centers for Medicare & Medicaid Services (CMS), this trial represented the successful use of a policy mechanism that can balance the goal of rapid access to innovative medical procedures with the need to obtain rigorous evidence on the risks and benefits of these procedures before they become widespread in clinical practice. The key was to make initial coverage conditional on participation in clinical research. Expensive invasive procedures often become widely adopted in clinical practice without high-quality evidence of effectiveness. In part, this is because the FDA does not regulate invasive therapeutic procedures unless those procedures involve use of medical devices. Even novel interventions using FDA-approved devices often receive unconditional coverage from public and private insurers without rigorous evidence of effectiveness produced by RCTs, the standard required for new pharmaceutical products. These differences in regulatory scope and evidentiary standards contribute to the proliferation of expensive invasive procedures for which the clinical effectiveness, in comparison with other less expensive and often more extensively studied treatment options, is unknown. Early, unrestricted insurance coverage grants physicians and patients rapid access to “innovative” procedures, but with significant disadvantages— limited understanding of the actual risks and benefits of new procedures for different kinds of patients; barriers to recruiting clinicians and patients to perform subsequent RCTs; and creation of financial incentives that will often fuel overuse of new procedures, increase health care costs, and undermine attempts to gain better evidence of comparative clinical effectiveness to guide treatment decisions for future patients. However, the policy tools to address this problem are available. When novel and promising invasive procedures lack adequate evidence of effectiveness, insurers can decide to offer coverage conditional for patients participating in RCTs designed to develop the needed evidence. Medicare has implemented this approach under the label of “coverage with evidence development in selected cases, including lung volume reduction surgery and home use of oxygen.” The example of the stent for cerebral arterial disease demonstrates how this approach can achieve the difficult but critical balance between rapid access and better evidence on the safety and effectiveness of new procedures. The investigational stent was approved by the FDA under a humanitarian device exemption (HDE) in 2005. The HDE allows device manufacturers to market a device without going through the regular FDA approval process if several criteria are satisfied, including estimated use in fewer than 4000 patients per year in the United States and the existence of preliminary evidence suggesting a favorable riskbenefit ratio. The self-expanding stent system met these criteria, based on a small case series suggesting a low stroke rate compared with historical controls. However, even with the HDE, there was an important barrier to using this procedure in practice or to studying it in randomized trials—Medicare had a standing national coverage determination denying coverage for all intracranial stenting procedures. Once aware of the HDE approval, however, Medicare changed its national coverage determination to cover the device and procedure, but only in the context of an RCT. Unconditional coverage would have inflated the number of patients treated while simultaneously creating major barriers to any attempt to recruit physicians and patients for participation in an RCT. At more than $20 000

The Continuing Paradoxes of Nursing Home Policy

FEW INDIVIDUALS CHOOSE TO LIVE IN A NURSING HOME rather than in their own home. Many older people and their families fear nursing homes; advocates for younger disabled people lobby for alternatives. Only a small fraction of practicing physicians and nurses work in nursing homes, not all as a first choice. Hospital administrators, who rely on nursing homes as a destination for patients who cannot be discharged to home—and in many instances, as a source of admissions as well—tend to not understand them very well. State and federal budgetmakers believe they cannot live without nursing homes, yet fund them reluctantly. For 30 years, public policy toward long-term care has attempted to minimize the number of people residing in nursing homes. Yet every day 1.5 million individuals in the United States are living in nursing homes, half of whom will never again live anywhere else. More than 1 in 3 US residents who reach age 65 years will spend some time in a nursing home before they die. Nobody, it seems, loves nursing homes very much, but nursing homes are as necessary as they are misunderstood. The confusion about nursing homes arises because many clinical practices and public policies about long-term care are unclear and frustrating. In the patchwork of US health care delivery and financing, nursing homes sit squarely atop 2 of the most problematic seams: the disjunction between Medicare and Medicaid and the disjunction between episodic acute care and long-term care. As a result, facilities referred to as “nursing homes” are generally individual facilities with 2 entirely separate—and often conflicting— clinical missions, serving 2 very different kinds of patients (or, as Zweig et al demonstrate with the case of Mrs R when she begins her nursing home stay for rehabilitation and continues as a long-term stay resident, the same person under very different clinical and financial circumstances), under radically different sets of payment rules and incentives of Medicare and Medicaid.

Empirical study on the interests claims of patients in public hospitals

Objective To give an empirical study on the interests claims of patients in public hospitals. Methods By questionnaire investigation, to sum up data using factor analysis and pairedsamples T test, and to compare difference between different kinds of patients using ANOVA. Results The interests claims of patients can be summed up to six factors and there is no significant difference between different kinds of patients. Conclusion At current stage, public hospitals need improve medical technique and cut down medical expenses. Key words: Public hospital; Patient; Interests claims

Antiarrhythmic drugs for atrial fibrillation

Introduction: Atrial fibrillation (AF) is associated with increased mortality and morbidity. Although stroke prevention is the only way to improve prognosis, antiarrhythmic drugs (AADs) are of primary importance both in the conversion to sinus rhythm and in the long-term control of rhythm and rate.Areas covered: We searched the Cochrane Library and Medline Database for articles published in English concerning efficacy and safety of AADs in AF. Particular attention was paid to the recently published European Society of Cardiology guidelines. This review provides an overview of the currently available drugs used in AF, with a particular emphasis on their comparative efficacy and safety in different kind of patients. Recent important findings, and advantages and disadvantages of recently approved drugs such as vernakalant and dronedarone, are also discussed.Expert opinion: AADs remain fundamental in the acute and long-term management of AF, to control symptoms and to reduce the negative impact of the arrhythmia on QoL. The choice of a rate- over rhythm-control strategy should be individualized and based on accurate evaluation of patient medical history and symptoms. New agents will contribute to improve treatment efficacy together with the guarantee of better safety profiles.

More Reasons to Say Goodbye to Glyburide

Sulfonylureas have been used to control hyperglycemia in type 2 diabetes longer than any class of agents except insulins. Their use early in the course of diabetes is supported by evidence of long-term medical benefit (1), and although available in generic form and thus not commercially promoted, they are widely prescribed (2). Given these facts, it is surprising that much remains unknown about these agents, notably how the various members of the class should be deployed in current treatment algorithms. An article by Zeller et al. in this issue of JCEM (3) sheds considerable light on this question. The authors report analyses of prospectively collected data from a French registry concerning experience of patients with type 2 diabetes who were hospitalized for myocardial infarction. The question posed was what association, if any, might exist between prior use of sulfonylureas and death and other in-hospital outcomes in these patients. Analyses included comparisons between the individual sulfonylureas used in this population: glyburide (called glibenclamide in Europe), glimepiride, and gliclazide (in most cases given as an extended-acting formulation). The rationale for the study came from the known adverse effect of glyburide on cardiac ischemic preconditioning, the clinical relevance of which has been uncertain. One key finding of the French study was that, among the 1310 acutely ill patients studied, unadjusted mortality rates were lower for those whose treatment on admission included a sulfonylurea (3.9%) than for those taking insulin (9.4%), those on no antihyperglycemic drugs (8.4%), and those on oral therapies other than sulfonylureas (6.4%). Another was that when patients taking glyburide were compared with those taking gliclazide or glimepiride, two sulfonylureas that appear to lack cardiac effects, early mortality was almost 3-fold higher (7.5 vs. 2.7%) with glyburide. It is well known that epidemiological analyses of “real-world” experiences with prescribed pharmacotherapy may be confounded by incomplete collection of information on actual drug usage, concomitant therapies, and medical outcomes, in addition to biases introduced by physicians’ tendencies to assign different treatments to different kinds of patients. Many of these problems were reduced or eliminated by the prospective design of this study, which included systematic recording of detailed clinical information on all patients in a narrow window of time by a structured team of investigators. The problem of allocation bias in assignment of treatments, however, remains in this study as in others. Hence, the authors used several statistical methods to adjust for this kind of confounding, including an extensive multivariable model, further adjustment using a propensity score for assignment to glyburide treatment, and analysis of findings with glyburide vs. the other sulfonylureas by subgroups. These statistical adjustments did not alter the associations of sulfonylurea use with lower mortality than other forms of therapy, and of glyburide use with higher mortality than seen with the other sulfonylureas. The excess of mortality with glyburide vs. other sulfonylureas showed no tendency toward heterogeneity between subgroups. Thus, several approaches to testing the validity of the observations were supportive, and the magnitude of the effects was substantial. After multivariable adjustment, the risk of death accompanyinguseofa sulfonylureawashalf thatwhena sulfonylurea was not used (odds ratio, 0.50; 95% confidence interval, 0.27–0.94; P 0.03). After similar adjustment for covariates, the risk of early mortality was 85% lower with glimepiride or gliclazide than with glyburide (odds ratio, 0.15; 95% confidence interval, 0.04–0.56; P 0.005), and with the propensity score included in the model, the risk was 87%lower(oddsratio,0.13;95%confidence interval,0.21–

Preparing medical graduates for general practice

We realize that it is common for young doctors to face difficulties in medical problem-solving and decision-making processes. They are not familiar enough with odds and likelihood ratios and can find it hard to accept and handle medical uncertainty something common in general practice settings. Additional difficulties present in the consultation process because the young doctors have to communicate with different kinds of patients, and often fail to establish an effective doctor-patient relationship. We believe that all these issues can be attributed not only to their inexperience, but also to inappropriate training regarding those skills.

1447 Do Different Kind of Angioplasty Patients need Different Kind of Patient Counselling?

1447 Do Different Kind of Angioplasty Patients need Different Kind of Patient Counselling?

Negotiating Managed Care: A Manual for Clinicians

Back to table of contents Previous article Next article Book ReviewsFull AccessNegotiating Managed Care: A Manual for CliniciansJay M. Pomerantz, M.D.Jay M. PomerantzSearch for more papers by this author, M.D.Published Online:1 May 2004https://doi.org/10.1176/appi.ps.55.5.595-aAboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Michael Fauman's little book is a pleasant surprise. It presents a realistic and balanced view of managed behavioral health care from the perspective of an insider, currently the medical director and vice-president for medical services of Magellan Behavioral of Michigan, Inc. Although I approached the book with hesitation—fearing that my clinician self was about to be lectured on how to dance to managed care's tune—that did not happen. Instead, I found a series of patient vignettes that served to illustrate the proper roles of clinician and reviewer in today's managed behavioral health world.According to Fauman, rancor between reviewers and clinicians is avoidable, provided that each is respectful of the other's legitimate function. Mental health practitioners should be able to conceptualize, present, and document clinical care so that the necessity and cost-effectiveness of that care are readily apparent to reviewers. The reviewer's job is to use the information presented to evaluate the patient's need for help and to make sure that it is matched with treatment intensity.Both practitioners and reviewers need to understand where the other is coming from. The key is the proper sharing and documentation of appropriate information in a concise, articulate fashion. Many examples of how to present different kinds of patients—such as inpatients, partial hospital patients, substance abusers, and outpatients—take up most of the book. Clear thinking leads not only to economically sustainable treatment but to better treatment, Fauman argues. A chart that is well documented to allow for the possibility of a retrospective utilization review would also help in any malpractice defense, should there be a bad clinical outcome.As the author makes clear, one of the book's fundamental assumptions is that many of the disagreements between reviewers and providers are caused by honest differences in clinical judgment about the severity of a patient's illness and the type of care the patient needs. Yet Fauman acknowledges that the possibility exists for unethical reviews by reviewers working for managed care companies who have underbid the contract or otherwise need to save money by curtailing needed care. Recognizing such a situation from the nature of the review and knowing how to deal with that situation is one of the best pieces of information imparted by this book.Another thing that won me over to this book was the short but frank discussion of the unequal malpractice liability situation that prevails because of the Employee Retirement Income Security Act (ERISA). This federal law provides de facto legal immunity for managed care reviewers. That makes for an unequal liability situation, because the courts generally find that a provider's clinical obligations to a patient supersede financial considerations.Although it is addressed to clinicians, this book will also be a good primer for managed care reviewers. Proper and improper reviewer responses to clinicians are illustrated and discussed. Interspersed with the cases are handy tables that outline the generally accepted medical necessity criteria that apply at different levels of care.Overall, this short book is worth the two hours or so that it takes to read.Dr. Pomerantz practices psychiatry in Longmeadow, Massachusetts, and is assistant clinical professor of psychiatry at Harvard Medical School in Boston.by Michael A. Fauman, Ph.D., M.D.; Washington, D.C., American Psychiatric Publishing, Inc., 2002, 128 pages, $26.95 softcover FiguresReferencesCited byDetailsCited byNone Volume 55Issue 5 May 2004Pages 595-a-596 Metrics PDF download History Published online 1 May 2004 Published in print 1 May 2004

Enfermería psiquiátrica comunitaria en salud mental de Álava. «Del hospital... a la comunidad»

The present study chronologically develops the evolution of mental health care in Alava together with the influence this mental health evolution has had in the Psychiatric Nursing profession. Since the opening of the Alava's Asilo Provincial (Home), in 1925, where different kind of patients - including mental health patients - received attention, to the present time, those professionals who have worked withing the Home premises, have discovered how care evolution towards these sort of patients has influenced not only the institutional procedures but how it has rendered easy as well the appearing of new roles for the Mental Health Nursing in the Community.

The epidemiology of delays in a teaching hospital. The development and use of a tool that detects unnecessary hospital days.

This study's purpose was to develop a tool that detects, quantifies, and assigns causes for medically unnecessary hospital delays and use it to describe the epidemiology of delays at a teaching tertiary care hospital. Based on observational data, a taxonomy of delays was constructed that included nine major categories and 166 subcategories. This formed the basis for an instrument for detecting inefficiency in hospital care: the Delay Tool. Initially designed for real-time concurrent assessment, in retrospective use it was also reliable, requiring about 6 minutes per medical record. In using the Delay Tool over a 6-month period on general internal medical and gastrointestinal services, it was discovered that 30% of 960 patients experienced delays, the average length of which was 2.9 days. This represented 17% of all hospital days. The most frequent causes of delays were scheduling of tests (31%), unavailability of post-discharge facilities (18%), physician decision-making (13%), discharge planning (12%), and scheduling of surgery (12%). Because of the longer lengths of the delays involved with awaiting postdischarge facilities (primarily nursing home beds), this was the most important cause of delays and represented 41% of all delay days. The general medicine and gastrointestinal services had significantly different distributions of delay types related to their different kinds of patients and care. The Delay Tool should be helpful in addressing hospital, and hospital-related, inefficiencies in health care delivery.

Treatment of Varicella-Zoster Virus Infections

Effective antiviral therapy is now available for many forms of infection due to varicella-zoster virus. Acyclovir is the most widely prescribed treatment, but the virus is not exquisitely sensitive to this drug, and others are under study. The goals of therapy differ among different kinds of patients and must be considered when designing a treatment program.

Selecting optimal treatment in clinical trials using covariate information

We are interested in the question ‘which treatment is best for which kinds of patients?’ rather than the classical question, ‘which treatment is best overall?’. A survivorship function in which the hazard is a function of the covariates is fitted both for all treatments combined and for separate treatments. Likelihood ratio tests are used to detect significant treatment-covariate interactions. If there are none, we test for a best overall treatment. Otherwise we define an optimal treatment for each patient. By studying the combinations of covariates which lead to selection of the various treatments as optimal, we make recommendations of treatment for different kinds of patients.

Nosology of Depression and Differential Response to Drugs

Psychiatric nosology in its present state leaves much to be desired. Some experts would entirely abandon attempts to classify psychiatric patients.1Others would do away with the existing diagnostic nomenclature, substituting empirically identified modal types.2A less extreme approach is exemplified by various attempts to increase objectivity in psychiatric classification without discarding diagnostic concepts that have become highly meaningful among professional groups.3 We believe that an adequate nosology of mental illness is important for treatment. Evidence increases that different types of patients respond best to different treatments. While a completely adequate nosology of mental illness cannot be predicated solely on existing therapeutic methods, patients who respond differently to different forms of treatment are in a very real sense different kinds of patients and it is important that these differences be represented in the nosology. Empirical methods are available for identifying natural groupings of patients in terms of

The 15-minute hour: brief therapy in a military setting.

The usefulness of very brief psychiatric appointments in treating many different kinds of patients is reported. It is suggested that the 15-minute interview is entirely sufficient for many patients who are relatively poor candidates for exploratory psychotherapy. Moreover, it is also an acceptable though limited alternative for some of the patients who ideally would receive more lengthy treatment. A few mornings of 15-minute appointments enable the psychiatrist to expand his practice considerably, while still preserving the great majority of his time for other, more exhaustive psychotherapeutic techniques.