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Y. Luca, M.A., M.D.

Professor, New York Medical College

This "can-do" and "everyone-can-make-a-difference" spirit has caught on with the rising middle classes around the world, which are increasingly self-reliant. Hence, for the rising middle classes, working outside and around government has been the way to be upwardly mobile. Denied entry at the national level, many-when they seek elected office-see cities as steppingstones to political power. This new global elite and middle class also increasingly agree on which issues are the major global challenges. For example, they want to stamp out cronyism and corruption because these factors have been at the root of what has sustained the old system or what they term the ancien regime. The new elites believe strongly in rule-of-law as a way of enforcing fairness and opportunity for all. This has been disconcerting to central governments-particularly the remaining authoritarian ones- which do not know whether to treat them as friend or foe. Owing to the wider access to more sophisticated technologies, the state does not have much of an edge these days. Small militias and terrorist groups have precision weaponry that can hit targets a couple hundred miles away. Terrorists hacked into the electric grid and have brought several Middle Eastern cities to a standstill while authorities had to barter and finally release some political prisoners before the terror-hackers agreed to stop. Many people fear that others will imitate such actions and that more attacks by ad hoc groups will occur. We have seen in the past decade what many experts feared for some time: the increasing overlap between criminal networks and terrorists. Fortunately, the outcry and panic led to stronger domestic regulations in many countries and enormous public pressure for greater international regulation. As an example of the enhanced public-private partnership, law enforcement agencies are asking the bio community to point out potential problems. In light of what could happen, the vast majority of those in the bio community are more than eager to help. However, most everyone has recognized that action at the country level is needed too. Thus, the original intent of the Westphalian system-to ensure security for all-is still relevant; since the near-miss bioterror attack, no one is talking about dispensing with the nation-state. On the other hand, in so many other areas, the role of the central government is weakening. Of course, all the G-20 leaders agreed, but when they got back home, the momentum fell apart. Five years later no progress has been made in restarting a World Trade Organization round. On the frontlines in dealing with food riots when they happen, many far-sighted mayors decided to start working with farmers in the countryside to improve production. At the same time, "vertical farming" in skyscrapers within the cities is being adopted. This effort of each megacity looking after itself probably is not the most efficient. Many people not living in well-governed areas remain vulnerable to shortages when harvests fail; those living in the better-governed areas can fall back on local agricultural production to ride out the crisis. In general, expanded urbanization may have been the worst-and best-thing that has happened to civilization. On the one hand, people have become more dependent on commodities like electricity and therefore more vulnerable when such commodities have been cut off; urbanization also facilitates the spread of disease. On the other hand, it has also boosted economic growth and meant that many resources-such as water and energy-are used more efficiently. This is especially true for many of the up-and-coming megacities-the ones nobody knew about 10 or 15 years ago. In contrast, Shanghai and Beijing are losing businesses because they have become so congested.

For example, cancer treatments may dictate when patients have to be admitted to the hospital or they may require frequent outpatient visits. While in the hospital, patients have schedules dictating when they can eat, shower, take medications, or have visitors. Thus, it is not uncommon for patients with cancer to experience a loss of personal control. These include organ dysfunction or failure, infection, bone deterioration, cataracts, or even a secondary diagnosis of cancer (Knobf, Pasacreta, Valentine, & McCorkle, 1998). For example, Byrd (1983) found that as a result of certain treatments being carcinogenic, the incidence of developing a second malignancy 20 years after treatment is approximately 17%, about 20 times that of the general population. Common psychosocial consequences related to various cancer treatments are discussed next. Surgery Surgery can be very stressful for the patient and family because of the diagnostic and prognostic information that follows most procedures. Also, surgery can result in scarring or tenderness in the site of operation, impeding functioning as well as patients· appraisal of their attractiveness (Jacobsen, Roth, & Holland, 1998). Strain and Grossman (1975) identi"ed several patient concerns that can be elicited before surgery,threats to your sense of personal invulnerability, concerns about entrusting your life to strangers, fears about separating from home and family members, fears of loss of control or death while under anesthesia, fears of being partially awake during surgery, and fears of damage to body parts. There are often psychological reactions related to the site of surgery or to the loss of a particular function, such as bowel function as a result of a colostomy. Often these negative emotional reactions arise from the signi"cance of the loss, especially when involving the face, genitals, breast, or colon. For example, research suggests that women receiving a mastectomy are likely to suffer from body image disturbance and sexual and marital disruptions (Mock, 1993). In addition, patients undergoing head and neck surgery must cope with subsequent speech, taste, sight, and smell impairments. The Psychosocial Effects of Cancer 275 more severe the structural and functional loss, the slower the recovery, the more prolonged the isolation, the lower the selfesteem, and the more pronounced the postoperative depression (Krouse, Krouse, & Fabian, 1989). Chemotherapy Along with physical side effects, such as nausea, diarrhea, fatigue, cognitive changes or anorexia, chemotherapy treatments can result in time lost from work, family disruption, and depressed mood. The end of treatment also signi"es a loss for the patient because of the decreased medical surveillance and the loss of support and communication with the medical personnel (Hart, McQuellon, & Barrett, 1994). Approximately 45% of adult cancer patients experience nausea, vomiting, or both in the 24 hours preceding their chemotherapy (Burish & Carey, 1986). Anticipatory nausea and vomiting is a psychological consequence resulting from an associative learning process. These symptoms are often embarrassing for patients and can lead to discontinuation of treatment, resulting in more detrimental conditions (Carey & Burish, 1988). After treatment, these symptoms can persist and may actually generalize to other situations (Andrykowski, Redd, & Hat"eld, 1985). Radiation Therapy Similar to patients experiencing chemotherapy, patients· receiving radiotherapy may become anxious. Some reports indicate that the waiting room experience triggers anticipatory anxiety. Women also fear recurrence after treatment because of the decreased medical attention from the radiotherapy staff (Greenberg, 1998). Radiation often arouses associations in individuals with an atomic bomb, nuclear accidents, radiation sickness, and ionizing radiation in the atmosphere. Patients can also experience claustrophobia, fear that the machine will not release the appropriate amount of radiation, and fear of burns to the skin. Greenberg (1998) found that 26% of a sample of oncology patients undergoing radiation treatment experienced signi"cant apprehension and anticipation due to the fear that radiation may damage their bodies. The acute physical side effects of radiotherapy depend on the site, dose, and volume of treatment. However, anticipatory or conditioned nausea is prevalent in 60% of cases (Greenberg, 1998). Dry skin, desquamation, and darkening as a result of the treatment, may cause body image concerns in patients. Other side effects impacting the patients· quality of life include fatigue, sore throat, anorexia, and diarrhea. Waiting for a donor, fearing relapse, the threat of infection in the isolated rooms, as well as the threat of death can also produce anxiety (Wochna, 1997).

To achieve the stage 2 quali"cation, candidates must demonstrate competencies in all 19 areas. The role of the supervisor is to: Oversee the preparation and review of the supervision plan. Countersign the supervision plan, supervision log, and supporting evidence, and "ll in the required sections of the completion forms. Listen to the views and concerns of the candidates concerning their work in progress and advise as appropriate. Encourage re"ection, creativity, problem solving, and the integration of theory into practice. The examination consists of an oral examination and the submission of a portfolio of evidence of competencies. The portfolio should include a practice diary, supervision log, records of completion, supporting evidence, and any additional clari"cation. When full membership of the Division of Health Psychology has been gained, members become Chartered Health Psychologists and they are listed in the British Psychological Society·s Register. All practicing health psychologists need to acquire these skills for their professional work whether they are working in the United States or Europe. In the United States, health psychologists are trained to carry out therapies and interventions alongside their clinical colleagues. Perhaps more than in some other areas of applied psychology, the core competencies of the health psychology practitioner in the United Kingdom show considerable overlap with those of the academic psychologist. However, this is likely to change as the profession becomes more con"dent about what it has to offer. Differences between Regions or Countries and Gaps in Training Some skills that are seen as essential in one region or country are seen as optional in others, for example, interventions aimed at change in individuals and systems, counseling, management, liaison, and health promotion skills. There are some signi"cant omissions in training requirements that warrant further discussion by the relevant committees. Can health psychologists really practice to their maximum potential without competence in these areas? Merely having access to research information about these subjects is insuf"cient: Knowing about is not the same as knowing how. Why should health psychologists be any better at communication, without special training, than physicians? Without mandatory training, these competencies are left to individual practitioners to pick up when, where, and however they can. The quality of services and health improvements may be less than optimum as a consequence. Another surprising gap is the lack of assessment and evaluation training in the U. Assessment is a necessary stage in the choosing and tailoring interventions for individual clients. Evaluation of effectiveness is paramount to the assessment of ef"cacy and effectiveness. Perhaps these differences and gaps re"ect the histories and cultures of professional psychology in different regions and countries. A summary of the competencies included in the three models are presented in Table 1. Provide expert opinion and advice, including the preparation and presentation of evidence in formal settings. Perhaps they also re"ect the lack of consensus about the de"nition of health psychology. Should it strive to become the overarching health care profession of Matarazzo·s (1980) de"nition, or a more specialized profession focusing on the maintenance of health and prevention of illness in currently healthy persons in line with Matarazzo·s (1980) de"nition of behavioral health, as recommended by McDermott (2001)? One of the main issues of concern has been whether health psychology is ready yet to become a profession, and if so, how this change in status is to be accomplished. Developing the profession too early may result in a profession with too little to deliver, a ·naked emperorZ (Michie, 2001). Worse, a naked emperor, or empress, might cause offense and do harm to , rather than improve, the health of his or her subjects! Similar periods will, no doubt, be required for any new system to be thoroughly tried and tested.

Syndromes

• Holes (necrosis) in the skin or tissues underneath
• General anesthesia. You will be asleep and not feel any pain during the surgery.
• Pneumonia
• A blistering solution 
• Activated charcoal to soak up aspirin in the stomach
• Bloody
• Using scissors, and eventually cutting a straight line
• Early vomiting of large amounts, which may be greenish (containing bile)
• Your surgeon will also take out the adrenal gland and some lymph nodes.
• Getting early diagnosis and treatment of all infections caused by sexual relations (STDs) 

Life-threatening cardiovascular consequences of anger in patients with coronary heart disease. Mental health status as a predictor of morbidity and mortality: A 15-year follow-up of members of a health maintenance organization. Racial inequalities in the use of procedures for patients with ischemic heart disease in Massachusetts. Do patient preferences contribute to racial differences in cardiovascular procedure use? Racial differences in the use of invasive cardiovascular procedures in the Department of Veterans Affairs medical system. Social class disparities in risk of factors of disease: Eight year prevalence patterns by level of education. In addition, it offers research strategies to address stigmatization caused by biases and unexamined assumptions. In part, some of the decisions may have been due to the predominance of female patients with this illness, whose medical complaints have historically been discredited by the predominantly male establishment (Richman & Jason, 2001; Richman, Jason, Taylor, & Jahn, 2000). Many physicians and other professionals have continued to believe that most individuals with this syndrome have a psychiatric illness. Chronic fatigue has been described clinically for more than 150 years, and the term neurasthenia (fatigue as an illness in the absence of disease), which was coined in 1869 by George Beard, was one of the most prevalent diagnoses in the late 1800s (Wessely, Hotopf, & Sharpe, 1998). However, by the early part of the twentieth century, the diagnosis neurasthenia was used infrequently, and those with a diagnosis of severe fatigue were often considered by medical personnel to have either a depressive illness or another psychiatric condition. However, the requirement of a high number of unexplained somatic complaints can inadvertently select individuals with psychiatric problems (Straus, 1992). Katon and Russo (1992) classi"ed 285 chronic fatigue patients into four groups, with each group having a higher number of unexplained somatic symptoms. Patients with the highest numbers of unexplained physical symptoms had very high rates of psychiatric disorders. Patients in the group with the lowest number of unexplained symptoms displayed a prevalence of psychiatric symptoms similar to that reported for other clinic populations with chronic medical illnesses. If the physician attributed the patient·s symptoms to nerves, unknown factors, or a psychiatric disorder, the patient would automatically receive a score counting toward a psychiatric diagnosis, regardless of whether the patient agreed with the physician. Also, if several physicians diagnosed a patient as having a medical disorder, but only one attributed the symptom to a psychiatric disorder, the item would be scored to count toward a psychiatric diagnosis. This new case de"nition requires a person to experience chronic fatigue of new or de"nite onset that is not substantially alleviated by rest; that is not the result of ongoing exertion; and that results in substantial reductions in occupational, social, and personal activities. In addition, the criteria require the concurrent occurrence of at least four of eight minor symptoms (sore throat, muscle pain, etc. Jason, Torres-Harding, Taylor, and Carrico (2001) compared the Fukuda and Holmes criteria and found that the Holmes criteria did select a group of patients with higher symptomatology and functional impairment. This is particularly important because it is possible that some patients with major depressive disorder also have chronic fatigue and four minor symptoms that can occur with depression. To accomplish this important task, it is relevant to examine the signi"cant improvements made in the reliability of clinical diagnoses in the "elds of psychology and psychiatry over the past 50 years. In the 1950s, researchers in the "eld of diagnostic reliability recognized that one of the key factors contributing to the problem of low interrater reliability in psychiatric diagnosis was the inability of two or more examiners to achieve a consensus on the symptoms or behaviors that characterized a speci"c diagnosis (Matarazzo, 1983). Because a diagnosis or classi"cation can be no more accurate than the classi"er ·s knowledge and understanding of what he or she is classifying, it was determined that the "rst step to improving diagnostic reliability was the development of operationally explicit and objectively denotable criteria (Feighner et al. By the 1970s, researchers in the "eld of diagnostics also recognized that the provision of operationally explicit, objectively denotable criteria was not enough to ensure that clinicians would know how to elicit the necessary information from a clinical interview to permit them to apply it to the reliable criteria (J. These concerns led to the development of a series of structured interview schedules. Structured interview schedules ensure that clinicians in the same or in different settings conduct clinical interviews using standardized questions that maximize the accuracy of clinical diagnosis (J. Thus, structured interview schedules serve to remove unreliability introduced by differences in the way clinicians elicit clinical information. Together, the provision of operationally explicit, objectively denotable criteria and standardized interviews were found to signi"cantly improve the reliability of clinical diagnosis for a number of psychological and psychiatric conditions (Leckliter & Matarazzo, 1994). Diagnostic and epidemiological research requires diagnostic categories that are both reliable and valid (Cantwell, 1996).