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By F. Silvio. City Colleges of Chicago.

He could not have been farther from the position of those who buy generic citalopram 40mg medicine effexor, in his day and after purchase citalopram 40 mg online treatment kawasaki disease, posited as real only those entities and relations which could fit (exemplify) those of a formal system. Reflection, which is well epitomized by the phrase "looking before (and while) you leap" appears to have four main aspects in Dewey’s work. First, there is considering and evaluating the claims of all the impulses; second, there is review of all the consequences ("imaginative rehearsal") of alternate actions; third, there is thoughtful assessment of the relevance and applicability of established habits; and finally, there is creative engagement in action, which involves imagination, new discovery and the renewal of previous valuations. But a recent writer, Rignano, working from a biological basis, has summed up his conclusions as follows: ‘The analysis of reasoning, the highest of our mental faculties, has led us to the view that it is constituted entirely by the reciprocal play of the two fundamental and primordial activities of our psyche, the intellectual and the affective. The incidents in which emotion leads to misinterpretation and misunderstanding are the exception, not the rule. We could not possibly navigate the world without love, fear, suspicion, trepidation, gratitude, relief, shame, hope and trust to name just a few. Sometimes these emotions are misplaced, usually because of a misunderstanding of facts. But just as illusions do not invalidate the great preponderance of sensory experience, occasional examples of misplaced emotion do not invalidate its overarching role in connecting us to people, things and events. So full-bodied reasoning not only makes use of the typically special image schemas discussed in Chapter I, but also of the full spectrum of emotion. And especially, this spectrum of reasoning is needed to cope with the non-absolutes of medical care. JOHN DEWEY’S PERSPECTIVES ON MEANS AND ENDS 89 For all these reasons, "intelligence" replaces "reason" in Dewey’s philosophy, " the marks of ‘reason’ in its traditional sense are necessity, universality, superi- ority to change, domination of the occurrence and the understanding of change. Far from the empyrean realm where "reason" dealt with the immutable, abstract, universal, certain and necessary, "intelligence" delves into the messy practical world of the evolving, concrete, particular, uncertain (the "merely probable") and contingent. THE IMPORTANCE OF CONTEXT Dewey addresses the importance of context repeatedly, but gives it the central place in the essay "Context and Thought" (1931) and in the section of his Logic entitled "Judgment as Spatial-Temporal Determination: Narration-Description. Context is first the relatively stable background of interest, belief and knowledge which forms the setting for narration and description. This provides the physical, cultural and historical locus of activity and concern. Stories, the temporal accounts of events and acts, as well as descriptions, which are primarily spatial accounts, are the "ground" of propositions, whereas propositions themselves tend to be about central foci of concern. Background is relatively "stable," "settled," "assumed" and "inexplicit" whereas the most salient elements in means/ends problems, those "in play," are changing, "unsettled," and attended to explicitly. However, the great point that Dewey makes is just how the meaning of foreground action is context- dependent. Acts and events relate to specific beginnings and ends, and cannot be understood or evaluated apart from the contexts in which they occur. Context itself, while mainly assumed, can also be a matter of selective interest, particularly when there is the leisure to reflect. Otherwise, resolution of any dispute or deliberation needed for action cannot occur, and paralysis ensues. There is always that which continues to be taken for granted, which is tacit, being ‘understood. In a medical emergency, for example, decisions open for reflection must be very few, else the outcome will be decided by default. Additionally, no suffering is relieved when debates about 90 CHAPTER 3 which type deserves priority are unduly extended, and no problem is solved when attention is on them all at once. It turns out that any expenditure of concern and effort can be questioned on the grounds that something else was more important. And any action whose meaning relates to a stable background can be called meaningless when it is pointed out that "in the long run" even the background will disappear. As we have seen, Dewey begins with the idea that value generation does not depend on reference to an outside eternal or absolute standard. Nevertheless a background which is sufficiently stable even though empirical in origin must be assumed. We use clinical judgment, or "informal reasoning" to look at entire situa- tions both as "given" by circumstance and "taken" by us in our present configuration as subjects. We inquire in order to decide not only what information is relevant, but what and how much can or should be called into question at one time.

However purchase citalopram 10mg with mastercard medications for bipolar disorder, as discussed here buy 10mg citalopram with amex treatment xanax withdrawal, these aspects of the marketing mix do not necessarily have the same meaning for health professionals as they do for marketers in other contexts. Product The first P—the product of healthcare—represents what healthcare providers are marketing. The product represents goods, services, or ideas offered by a healthcare organization. The product is difficult to precisely define in healthcare, creating a challenge for healthcare marketers. A good refers to a tangible product typically purchased in an impersonal setting on a one-at-a-time basis. It is more difficult to quantify services, and consumers evaluate them differently from more tangible products. For health plans, for exam- ple, the product may be thought of as the sense of security and protection against financial hardship or catastrophe that could arise from a serious ill- ness or injury and the assurance that personal finances will not stand in the way of getting needed care. Healthcare providers have seldom given much thought to the prod- uct concept in the past. A surgical procedure was considered just that, not something that had to be packaged. Today, however, the design of the product, its perceived attributes, and its packaging are all becoming more important concerns for both healthcare providers and marketers. Basic M arketing Concepts 91 Price The flip side of product benefits is product costs to the purchaser. Price refers to the amount charged for a product, including the fees, charges, premium contributions, deductibles, copayments, and other out-of-pocket costs to consumers for health services. In economics, the price is thought of in terms of exchanges—that is, a healthcare provider offers a service in exchange for its customers’ dollars. An employee paying an annual pre- mium to a health plan, an insurance company reimbursing a physician’s fee, and a consumer purchasing over-the-counter drugs are all exchanges involving a specified price. These costs could also include the pain, dis- comfort, embarrassment, anxiety, frustration, and other emotional costs of dealing with providers, plans, and the disease or injury that prompts the experience. That these costs must be at least perceived to be worth the investment, considering the benefits available from the relationship, reflects the reality of marketing and the definition of the value of the product for the price. The issue of pricing for health services is becoming a growing con- cern for marketers as the healthcare environment changes, and a number of factors are contributing to the greater role of the pricing variable in developing marketing strategy. For marketers the challenge is in develop- ing (1) an understanding of what a customer is willing to exchange for some want-satisfying good or service and (2) a pricing approach compatible with the goals of the organization and its cost constraints. Place The third P—place—represents the manner in which goods or services are distributed for use by consumers. Increasingly, as more healthcare organiza- tions establish relationships with managed care plans, the place variable assumes a more critical role. Companies offering health plans must consider location and primary-care access for potential enrollees. While in past years a physician could establish an office in a location convenient for him or her, today the consumer increasingly dictates the role of place in the marketing mix. Place relates to all factors of the transaction or relationship expe- rience that make it easy rather than difficult for consumers to obtain an organization’s products. While the obvious factors of location and lay- out are included, so are hours, access procedures, obstacles, waits for appointments, claims payment, and so on. In most cases the negative place aspects of the encounter impose costs such as lost time, frustration in finding the service site, parking fees, boredom, or other emotional 92 arketing Health Services burdens. Positive place aspects minimize such costs, as when a physician who offers early morning or evening hours enables patients to obtain care on the way to or from work and thus avoid time off from work, travel costs, and lost wages. In some cases place factors may enhance perceptions of the quality of the product, as when the physician’s office or hospital is in a trendy loca- tion or on a campus that facilitates efficiency of care. Doctors who make house calls may be the only way that homebound patients can get routine care. Systems or health plans may speed up or hinder the setting of appoint- ments by making them available through online communications, for exam- ple. Offering health-plan sign-up and status access and benefit-change capacity online at a worksite kiosk or home computer adds place value. The ability to have one’s medical record available online has added a different dimension to the concept of place. Promotion represents any way of informing the marketplace that the organization has developed a response to meet its needs and includes the mechanisms available for facilitating the hoped-for exchange.

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