INDUSTRY CALLING!—Is There a Doctor in the House?

Medical service is needed in industry by both management and labor as never before. Industry is just beginning to awaken to this need. The medical profession is largely unaware of it. Unless physicians are prepared to heed this call, there is danger that management and labor will come to a bipartisan agreement over the bargaining table which will specify the amount, quality, and price of medical service irrespective of the effects of such an agreement on the practice of medicine. Such agreements should invariably be tripartite—between management, labor and medicine—if we are to continue to strive for medicine''s traditional ideals: The best of medical care for all alike.This situation imposes at least two important obligations on organized medicine at the national level and especially at state and local levels where there is industrial concentration:1. Provision of a strong and competent committee or council whose members are especially interested in occupational medicine and who will make their presence known to management and labor alike, offering to advise with them on all medical problems, to mediate their disagreements or medical questions, and to help them attain a common goal.2. Assisting the members of organized medicine who are interested, to learn more about the medical problems peculiar to occupational health.     

THE THORNY CHILD

Too many physicians—and parents—hide behind the overworked excuse that “Johnny is just going through a stage.” If the remark is inaccurate a great disservice can be done to both mother and child, and ultimately to society. The well oriented physician would no more permit a young mother to unwittingly feel “guilty” because her two-year-old “little stinker” behaves like a two-year-old little stinker than he would casually reassure when a ten-year-old behaves as though he were two.Actually much of the unpleasant behavior of children is quite normal. If physicians would help all young mothers to recognize this without dismissing abnormal behavior, it would do much to avert the overwhelming sense of inadequacy that so many modern young mothers feel—especially with their first baby. If they can be made comfortable with their first the others usually come easily. Many physicians who care for children are not trained in the rudiments of developmental behavior. By means of a simple outline and drawing of “the thorny child” even the least of the experts can better understand some of the chronologic variations in developmental behavior.     

The future of family practice training in California.

Although the number of physicians in California has doubled since 1963, the number of family and general practice physicians has declined. The ratio of office-based primary care physicians to population has also decreased. Graduate medical education is funded largely from patient care revenues, but the low rate of reimbursement for ambulatory care makes training in primary care specialties especially dependent on public support. Medicare, the Veterans Administration, and the University of California provide more than $325 million a year in support of graduate medical education in California. Federal and state grant programs provide $5 million a year for family physician training in the state, but appropriations to these programs have been reduced in real terms. California family practice residencies are disproportionately located at county hospitals, where funding shortfalls make them especially vulnerable to cuts in grant programs. Additional resources will be needed if more family physicians are to be trained.     

EDWIN L. BRUCK,M.D

The progressive fall in the status and numbers of general practitioners has produced a dangerous void in the field of comprehensive medical care. The Millis Commission and other national study committees have recommended that family practice be made a board-certified specialty in order to restore the status and numbers of family physicians. The scope of family practice that is envisioned, however, would be so restricted in depth as to raise serious doubts that sufficient medical graduates would be attracted to careers in this new specialty. Better training in broadly-based general or family practice—rather than a specialty board, per se—is the only realistic way to elevate status and attract more medical students to this field.     

Placebo Trends across the Border: US versus Canada

Background

Physicians around the world report to using placebos in a variety of situations and with varying degrees of frequency. Inconsistent methodologies, however, complicate interpretation and prevent direct comparisons across studies. While US- and Canada-based physicians share similar professional standards, Canada harbours a less-litigious universal healthcare model with no formal placebo-related policy—factors that may impact how physicians view and use placebos.

Methods

To compare American and Canadian data, we circulated an online survey to academic physicians practicing in Canada, collected anonymous responses, and extracted those of internists and rheumatologists for comparison to US data obtained through parallel methodologies.

Results

Whereas our data show overall concordance across the border—from definitions to ethical limitations and therapeutic potential—differences between American- and Canadian-based placebo practices merit acknowledgement. For example, compared to 45%-80% among US-based respondents, only 23±7% of Canada-based respondents reported using placebos in clinical practice. However, 79±7% of Canada-respondents—a figure comparable to US data—professed to prescribing at least one form of treatment without proven or expected efficacy. Placebo interventions including unwarranted vitamins and herbal supplements (impure placebos) as well as sugar pills and saline injections (pure placebos) appear more common in Canada, where more doctors described placebos as “placebos” (rather than “medications”) and used them as a “diagnostic” tool (rather than a means of placating patient demands for treatment).

Interpretation

Cross-border variation in the use of clinical placebos appears minor despite substantial differences in health care delivery system, malpractice climate, and placebo-related policy. The prevalence of impure placebos in both Canadian and US clinics raises ethical and practical questions currently unaddressed by policy and warranting investigation.     

The relation between personal characteristics of physicians and practice location in Manitoba.

A questionnaire survey of 562 physicians in Manitoba who had graduated from the University of Manitoba was carried out to assess the effect of personal characteristics on choosing a practice location. The results closely resemble those of studies performed in the United States: the choice of a nonurban practice location is significantly more likely if the physicians and their spouses have nonurban backgrounds and if the physicians have had a nonurban preceptorship during undergraduate medical education. In this study practitioners who were male and whose fathers were farmers or health care professionals were also more likely to practise in nonurban areas. These findings will help in making physician distribution more equitable.     

Establishment of a General Medicine Residency Training Program in Rural West Africa

Ghana, a developing country in West Africa, has major medical burdens in taking care of a large population with limited resources. Its three medical schools produce more than 200 graduates per year, but most emigrate to developed lands after training. Ghana is working to educate and retain locally trained physicians, but it is difficult to get them to work in rural settings where the need is greatest. This article details the establishment of a General Medicine residency at a 150-bed hospital in rural Ghana. Early training comprises 6 months each in Medicine, Surgery, OB/GYN, and Pediatrics; the hospital in Techiman also has a Surgery residency. House officers choose the program for more hands-on experience than they can get in larger centers. They perform many tasks, including surgery, sooner and more independently than do residents in developed countries. The training program includes a morning report, clinical teaching rounds, and rotations on in-patient wards and in the Emergency Department and clinics. Teaching focuses on history, physical examination, good communication, and proper follow-up, with rigorous training in the OR and some clinical research projects pertinent to Ghana. Trainees work hard and learn from one another, from a dedicated faculty, and by evaluating and treating very sick patients. Ghana’s rural residencies offer rigorous and attractive training, but it is too soon to tell whether this will help stem the “brain drain” of young physicians out of West Africa.     

Another Look at the Medical “Generation Gap”—Second Triennial Survey of Attitudes of Medical Students and Recent Graduates

A 1969 survey of attitudes held by medical students and recent graduates was repeated in 1972, using the same samples of respondents and adding a new freshman group. Findings from both surveys showed that a “generation gap” existed on many issues.Furthermore, a comparison of the two studies suggested that two kinds of attitude change are occurring simultaneously. On some issues, the next generation of physicians will probably continue to differ from their predecessors. Perhaps the primary thread woven through this cluster of attitudes is that today''s medical students and young physicians perceive themselves as members of a larger structure for providing health care.However, many of the students'' attitudes held early in their medical careers appear to have been modified in the process of becoming physicians. It appears that medical education continues to convey many traditional professional values to students, and it seems likely that tomorrow''s physicians will retain a core of those values.     

青年教师对医学临床课程教学能力现状调查及应对策略研究

如何提高我国临床课程青年教师团队的素质与教学能力,是近年来伴随国内医学教育发展扩大而日益突出的问题。作为当前医学临床课程的教学主力,青年教师的教学能力会对医学临床课程教学效果产生重大影响。但绝大部分临床课程青年教师都毕业于医学院校,未曾接受专业的师范类培训,导致尽管自身临床知识丰富,但教学水平明显受限的情况发生。本研究采取对我院各科室青年临床教师进行问卷调查的方法,深入分析青年教师的临床教学能力现状与问题,并提出改进方案,以使他们能够更快完成青年临床医师与青年临床教师之间的角色变换,提升自身教学能力,进而提高我院临床课程的教学质量。     

Mind to Mind: Persuasion in Medical Writing

Much can be done to improve the quality of oral and written communication among physicians, particularly among young physicians. Good communication can be taught. Clear writing is only the reflection of clear thinking. The strong determination to make oneself unmistakable will carry the writer a long way toward his goal; indeed, the determination to be unmistakable is far more important to a writer than rules of grammar or composition. Hitherto neglected, remedial instruction in medical writing is a valuable adjunct to medical education, specifically because the conscious and unremitting attempt to make oneself clear has great catalytic influences. This effort releases hidden energies in the medical writer as is suggested by the cryptic but illuminating remark made by one of E. M. Forster''s characters, an old lady who said: “How do I know what I think until I hear what I say.”     

Industry calling! Is there a doctor in the house?

Medical service is needed in industry by both management and labor as never before. Industry is just beginning to awaken to this need. The medical profession is largely unaware of it. Unless physicians are prepared to heed this call, there is danger that management and labor will come to a bipartisan agreement over the bargaining table which will specify the amount, quality, and price of medical service irrespective of the effects of such an agreement on the practice of medicine. Such agreements should invariably be tripartite-between management, labor and medicine-if we are to continue to strive for medicine's traditional ideals: The best of medical care for all alike. This situation imposes at least two important obligations on organized medicine at the national level and especially at state and local levels where there is industrial concentration:1. Provision of a strong and competent committee or council whose members are especially interested in occupational medicine and who will make their presence known to management and labor alike, offering to advise with them on all medical problems, to mediate their disagreements or medical questions, and to help them attain a common goal.2. Assisting the members of organized medicine who are interested, to learn more about the medical problems peculiar to occupational health.     

The young physician: types of practice.

An inquiry was conducted into the type of practice (whether solo, group or salaried) entered by young physicians graduating from Canadian medical schools in 1970. Twenty-one percent entered solo practice, 57% joined a group practice or partnership, and 22% became salaried physicians in a number of different categories. Surgeons and psychiatrists, more than other types of specialist, were inclined to select solo practice. Group practice was more popular in the western provinces and in rural than in urban areas. More than half of the physicians recently established in urban solo practice complained of having too few patients. Lack of patients was a lesser problem in smaller towns and rural areas.     

The Hospital Medical Advisory Committee—The Cabinet of the Medical Staff

Before a hospital medical staff can realistically accept responsibility for the professional practices of its members, a principle initially fostered by the American College of Surgeons and adopted by both the Canadian and American accreditation programs, it must have an effectively functioning medical staff organization. The medical advisory committee is the most important committee of the medical staff organization. A representative composition, adherence to sound administrative principles, and recognition of its prime functions of co-ordination, supervision and jurisdiction will permit this committee—and the total medical staff organization—to discharge adequately the very important responsibilities delegated to them by the governing board of the hospital. Properly structured medical staff bylaws with clearly defined terms of reference assist the smooth functioning of the “cabinet” of the medical staff and safeguard the prerogatives of the individual members of the staff.     

AIDS in children

The application of medical quality assurance principles to ambulatory patient care using the traditional methods of medical chart audit, process review, and physician education has yielded generally disappointing results in improving patient care and physician performance. Newer methods assist physicians by providing patient and medical reference data at the time of a patient''s visit. Techniques for tracking treatment outcomes and patients'' test results and for providing instructions to patients may improve both care and patients'' and physicians'' satisfaction.This feature appears regularly in THE WESTERN JOURNAL OF MEDICINE. It is intended to cover recent developments in a broad range of issues that will have an impact—either directly or indirectly—on clinical practice. Occasionally the seminars may include informed speculation about likely future developments.     

Norwegian Physicians' Knowledge of and Opinions about Evidence-Based Medicine: Cross-Sectional Study

Objective

To answer five research questions: Do Norwegian physicians know about the three important aspects of EBM? Do they use EBM methods in their clinical practice? What are their attitudes towards EBM? Has EBM in their opinion changed medical practice during the last 10 years? Do they use EBM based information sources?

Design

Cross sectional survey in 2006.

Setting

Norway.

Participants

966 doctors who responded to a questionnaire (70% response rate).

Results

In total 87% of the physicians mentioned the use of randomised clinical trials as a key aspect of EBM, while 53% of them mentioned use of clinical expertise and only 19% patients'' values. 40% of the respondents reported that their practice had always been evidence-based. Many respondents experienced difficulties in using EBM principles in their clinical practice because of lack of time and difficulties in searching EBM based literature. 80% agreed that EBM helps physicians towards better practice and 52% that it improves patients'' health. As reasons for changes in medical practice 86% of respondents mentioned medical progress, but only 39% EBM.

Conclusions

The results of the study indicate that Norwegian physicians have a limited knowledge of the key aspects of EBM but a positive attitude towards the concept. They had limited experience in the practice of EBM and were rather indifferent to the impact of EBM on medical practice. For solving a patient problem, physicians would rather consult a colleague than searching evidence based resources such as the Cochrane Library.     

Medicaid and the Mainstream: Reassessment in the Context of the Taxpayer Revolt

California''s Medicaid program—Medi-Cal—attempted to implement the ideal of mainstream medical care for the poor by giving program beneficiaries a “credit card” for use in the private health care marketplace. This exposed the program to the perverse economic incentives of the fee-for-service, costplus health care system, and contributed to a high rate of increase in program costs. Attempts to control costs have been equally perverse, resulting in low payment rates, the second-guessing of physician professional judgments, the probing of medical and fiscal records, and the use of computerized surveillance systems.Attempts to shift to the use of more efficient delivery systems have had small success. Attempts to attain cost containment through restructuring the Medi-Cal program have been rejected in the name of the mainstream ideal. Costs have continued to escalate, with annual increases as high as 20 percent in some years. Medi-Cal now costs $4 billion per year, the largest single program in California state government.The taxpayer revolt in California is creating a fiscal crisis that will force rethinking of the premises of publicly funded health care for the poor, and a restructuring of strategies for reaching that objective. In the short run, it appears that the issue may not be whether the indigent will have access to mainstream medical care, but whether they will have access to any medical care. In the longer run, the crisis should represent an opportunity for building a system of health care that can serve the financially disadvantaged at a cost tolerable to our society.     

The General Practitioner in a Changing World

Throughout the world there is need for physicians to render primary and continuing health care to individuals, families, and communities; and there is growing concern over the deficiency in the numbers of such doctors. In the U.S.A. there has been a decrease in the number of general practitioners and others who are in the best position to render this kind of service, and the number of medical graduates entering this field continues to decline. Many reasons for this state of affairs have been offered, but one fact stands out above all others: the majority of medical students wish to engage in a career of service and significance but are unwilling to become second-class physicians. If young men are to be recruited into family practice we must build for them a clinical and academic specialty in which research is being done, and in which they can obtain significant qualifications.     

Behavioral convergence and institutional separation: An analysis of plural medicine in Sri Lanka

In Sri Lanka, as in India, two formally structured systems of medical service exist side-by-side. While Western-style biomedicine is believed to be useful, Ayurvedic medicine is also well established and commonly used. Underlying one explanation for the existence of plural medical systems is the idea that traditional and Western systems of medicine provide unique treatments for distinct problems, and patients having certain characteristics select them accordingly. A brief review of several studies in Sri Lanka suggests, however, that Western and Ayurvedic physicians practice medicine in similar ways, are selected for treatment of very similar symptoms, and from the patient's point of view are aften indistinguishable from each other. A second structural explanation rests on the fact that, as institutions, Western and Ayurvedic medicine have effectively divided up territory and jobs to the satisfaction of each; this division allows for upward mobility, through medicine, for young people from different segments of society. Thus these medical systems persist, not because each provides something unique for patients, but because they provide access to status and power for the physicians themselves.     

Almost 20 years of Neanderthal palaeogenetics: adaptation,admixture, diversity,demography and extinction

Nearly two decades since the first retrieval of Neanderthal DNA, recent advances in next-generation sequencing technologies have allowed the generation of high-coverage genomes from two archaic hominins, a Neanderthal and a Denisovan, as well as a complete mitochondrial genome from remains which probably represent early members of the Neanderthal lineage. This genomic information, coupled with diversity exome data from several Neanderthal specimens is shedding new light on evolutionary processes such as the genetic basis of Neanderthal and modern human-specific adaptations—including morphological and behavioural traits—as well as the extent and nature of the admixture events between them. An emerging picture is that Neanderthals had a long-term small population size, lived in small and isolated groups and probably practised inbreeding at times. Deleterious genetic effects associated with these demographic factors could have played a role in their extinction. The analysis of DNA from further remains making use of new large-scale hybridization-capture-based methods as well as of new approaches to discriminate contaminant DNA sequences will provide genetic information in spatial and temporal scales that could help clarify the Neanderthal''s—and our very own—evolutionary history.