Neurosurgery 1977: problems and attainments. The 1977 AANS presidential address

The President of the American Association of Neurological Surgeons (AANS) discusses the many elements that appear to restrict the professional activities of neurosurgeons and other physicians. He stresses the importance of the active role required of the AANS, the American Medical Association, and the American College of Surgeons in finding solutions to problems related to neurosurgery.     

The formation of the Medical and Scientific Section of the British Diabetic Association

James (Jim) Jackson was the first administrative secretary to the Medical and Scientific Section of the British Diabetic Association (BDA). He played an important part in the creation of the Section and its development, bringing order into what had been rather haphazard medical meetings of the Diabetic Association. He has written this history of the Medical and Scientific Section of the BDA, based upon personal recollection with historical data taken from minutes of meetings. He writes: 'The Medical and Scientific Section emerged from a feeling of dissatisfaction among diabetologists and research workers about the post-war activities and aims of the Medical Advisory and Research Grant Committees of the British Diabetic Association. There was also a perceived need to involve physicians in charge of diabetic clinics countrywide more closely in the activities of the Association as a means of increasing its lay membership. This history is based upon personal recollection, with historical data taken from minutes of meetings'. Jim Jackson's history is accompanied by footnotes provided by Dr David Pyke (DAP), former physician in charge of the diabetes service at King's College Hospital, London, and onetime registrar of the Royal College of Physicians of London.     

The Tarasoff raid: a new extension of the duty to protect

The authors discuss the general outlines of the Tarasoff duty of psychotherapists to protect potential victims of their violent patients. They describe the flexible range of clinical responses that therapists have utilized, as well as their professional concerns about preserving patient confidentiality (or at least strictly circumscribing the scope of disclosure when confidentiality must be breached). A recent case is reported that illustrates a striking new extension of Tarasoff, involving a police search and seizure of a psychotherapist's confidential treatment records and tapes, in response to a third-party complaint that the records contained evidence of his patients' violent acts and propensities. The implications of this case are that the therapist's discretion in the assessment of his duty to protect, the selection of a proper course of action, and the implementation of specific responses may be taken out of his hands, for all intents and purposes, and expropriated by law and order officials. Moreover, regardless of whatever clinical approach he adopts and whether or not he issues a warning, his attempts to preserve patient confidentiality are bound to prove unsuccessful in any future legal proceedings. Patient communications are likely to lose their confidential status on the grounds that they caused or triggered the Tarasoff warning (or that they should have triggered it). If the patient directed serious threats against the therapist himself, the court may find that, as a consequence, a "genuine therapeutic relationship" ceased to exist and thereafter all patient disclosures were no longer confidential on that basis.(ABSTRACT TRUNCATED AT 250 WORDS)     

Quality in restorative dentistry: a report of an advanced postgraduate dental symposium

A joint Royal College of Surgeons of Edinburgh--Royal College of Physicians and Surgeons of Glasgow Advanced Postgraduate Dental Symposium addressed the issue of quality in restorative dentistry. The overall view was that quality in clinical care, including all aspects of restorative dentistry, is the consistent achievement of successful outcome. Ongoing developments and effective audit processes were recognized to provide important opportunities for continuous quality improvement in restorative dentistry.     

A Challenge to the Title of Doctor.

Presents an account of the lawsuit brought against Drs. Jean-Marc Chevrier and Monique Béchard-Deslandes by the College of Physicians and Surgeons of the Province of Quebec regarding the use of the title of Doctor. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

HIV, confidentiality, and duty to protect: A decision-making model.

Mental health professionals are confronted with complex issues surrounding confidentiality and duty to protect when treating clients with HIV. These professionals need to consider various factors when applying Tarasoff principles to protect potential victims, including the foreseeability of harm, the identifiability of the victim, and appropriate protective action. Professional ethical guidelines and legal mandates also need to be considered. The purpose of this article is to discuss the ethical and legal dilemmas faced by clinicians and to introduce a decision-making model that takes into account individual state laws. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

The use of slow-scan video for CME in a remote area

Since August 1977 a slow-scan video system has been operating in a remote area of northwestern Ontario, Canada. This system, using regular dial-up telephone lines, interconnects the local hospital, five remote communities, and two teaching hospitals in Toronto, 1,000 miles distant. Since August 1978 the system has been used on a regular basis for continuing medical education programs, graduate medical education including X-ray rounds, medical rounds, nursing rounds, in-service education, and patient education. These CME programs for physicians have been accepted for study credits by the College of Family Physicians of Canada.     

Claude H. Organ, Jr. Honorary/Sandoz Nutrition Lectureship. Ethics in research and surgical practice

The topic "Ethics in Research and Surgical Practice" appears most appropriate for the 1997 Claude H. Organ, Jr. Honorary Sandoz Nutrition Lecture. With the increasing numbers of ethical problems facing clinicians today, greater emphasis on ethics is demanded. This lecture focuses primarily on the clinical applications of basic science and ethics certainly plays a major role in this regard. Ethical principles espoused by the American College of Surgeons and the American Medical Association will be emphasized. Further, the results of the deliberations of the Advisory Committee on Human Radiation experiments will be discussed. Certainly, the Tuskegee experiment debacle will be mentioned. Ethics remains important if we are to give our patients the best care. We must always keep in the vanguard of our thinking that the welfare of our patients comes first. High ethical principles emphasize our obligations and responsibilities to our patients.     

How to do it: making audit work

The orthodontic Audit Working Party of the Faculty of Dental Surgery, Royal College of Surgeons of England, in collaboration with the Centre for Medical Education, Ninewells Hospital and Medical School, Dundee developed an audit project entitled 'Clinical Audit: Scenarios for Evaluation and Study'. The aim of the project was to contribute to the construction of clinical guidelines for orthodontists. This article, the first of a short series, describes the background to and general results of the study. Further articles will study individual aspects of the project.     

Training for rural family medicine: a cooperative venture of government, university, and community in Alberta

Training, recruiting, and retaining family physicians in rural areas are issues that have attracted the attention of governments, university training programs, medical governing bodies, and rural communities. In this article, the authors describe a cooperative venture between government, university, and community in the province of Alberta to train medical students and residents in rural areas. The Rural Physician Action Plan (RPAP) was developed in the early 1990s to improve the recruitment and retention of physicians in rural areas. The RPAP is coordinated by a committee composed of representatives of the Alberta government, the Alberta Medical Association, the College of Physicians and Surgeons of Alberta, and the faculties of Medicine at the University of Alberta and the University of Calgary. Residents in the University of Alberta Department of Family Medicine are required to do 20 weeks of blocktime training in a community practice, and under the auspices of the RPAP rural training sites were identified and rural rotations developed. Faculty development activities were developed for the community physicians who would host the residents. The RPAP funds 24 third-year residency positions, equally divided between the University of Calgary and the University of Alberta. Beginning in 1994, undergraduate medical students at the University of Alberta were required to complete a four-week family medicine rotation, with a majority of students being posted to rural training sites. The extent to which the RPAP has helped to recruit and retain physicians in rural areas is not clear. The provincial Ministry of Health evaluated the RPAP in 1995 and concluded that, at a minimum, without the RPAP the province would have suffered a net loss of rural physicians. The communities have been very accepting and supportive of the students and residents.     

Silicone elastomer cerebrospinal fluid shunt systems. Council on Scientific Affairs, American Medical Association

A 1995 resolution of the American Medical Association House of Delegates, introduced by the American Academy of Neurology, the American Association of Neurological Surgeons, and the Congress of Neurological Surgeons, asked the American Medical Association Council on Scientific Affairs to add the use of hardened silicone shunts to its study of the effects of silicone gel used in breast implants. On consideration of the important differences between the two materials, silicone elastomer ("hardened silicone") and silicone gel, the Council on Scientific Affairs elected to address the subject of silicone elastomer shunt systems separately. This report describes the different types of medical-grade silicone used in medical devices, the incidence of hydrocephalus and its causes and treatment, and the use of cerebrospinal fluid shunt systems made of silicone elastomer. Published case reports of possible immunological disease in patients who have had silicone elastomer cerebrospinal fluid shunt systems implanted are reviewed. The Council on Scientific Affairs concluded that the evidence presented does not support the occurrence of immune-mediated systemic reactions to implanted silicone elastomer cerebrospinal fluid shunt systems. The local granulomatous or inflammatory responses observed in some patients with silicone shunt systems have not been shown to be immunologically mediated; similar reactions have been described with other implanted foreign bodies.     

Patient-physician sexual involvement: a Canadian survey of obstetrician-gynecologists

OBJECTIVE: To determine obstetrician-gynecologists' (ob-gyns') awareness of and experience with sexual abuse of patients and former patients and their opinions about appropriate consequences. DESIGN: Mailed survey. SETTING: Canada. PARTICIPANTS: All 792 members of the Society of Obstetricians and Gynaecologists of Canada (SOGC); 618 (78%) responded. Approximately half of all ob-gyns in Canada belong to the SOGC. MAIN OUTCOME MEASURES: Knowledge of sexual involvement by an ob-gyn colleague with a patient or former patient (as defined by the respondents and by the College of Physicians and Surgeons of Ontario [CPSO]), self-report of such involvement, attitudes toward physician sexual abuse, desirable length of time a physician should wait before seeing a former patient in a situation that could lead to a sexual encounter, suggested consequences of sexual abuse. RESULTS: Overall, 10% of the respondents indicated that they knew about another ob-gyn who at some time had been sexually involved with a patient. In all, 3% of the male respondents and 1% of the female respondents reported sexual involvement with a patient; the corresponding proportions of those who reported having been accused of sexual abuse by a patient were 4% and 2%. Significantly more of the female ob-gyns than of their male counterparts (37% v. 19%) reported awareness of a colleague's sexual involvement with a patient that would meet the CPSO's definition of sexual impropriety, transgression or violation. Most of the respondents felt that the consequence of proven sexual impropriety should be reprimand and fine (chosen by 33%) or rehabilitation without loss of licence (28%). Most of the physicians supported loss of licence for proven sexual transgression (57%) or proven sexual violation (74%), but fewer felt that loss of licence should be permanent for these types of abuse (4% and 24% respectively). The female ob-gyns supported stronger sanctions against sexual transgression and sexual violation than the male ob-gyns. A wide range of opinion was seen regarding the propriety of sexual relationships with former patients. CONCLUSIONS: Ob-gyns have varied opinions about how sexual abuse of patients should be defined and how it should be sanctioned. There is a discrepancy between proposed public policy and the beliefs of physicians to whom the policy is to be applied.     

Design and assessment of average of normals (AON) patient data algorithms to maximize run lengths for automatic process control

Achieving high quality and high productivity with automated testing processes will require process control systems that are optimized for the necessary error detection, minimum false rejection, and maximum run length. This study investigates whether run length could be monitored by average of normals (AON) algorithms that truncate the patient test distribution and estimate the average of a suitable number of patient results. The design of AON algorithms for individual analytes is facilitated by computer-simulated power curves that consider the ratio of the population biological variation (Spop) to the test method variation (Smeas), represent a range of Spop/Smeas ratios from 2 to 15, and include numbers of patient test results from 10 to 600. The potential applications of AON algorithms are assessed for 38 tests whose quality requirements represent the total error criteria from the Ontario Medical Association Laboratory Proficiency Testing Program, Spop/Smeas ratios from 0 to 32, critical systematic shifts from 0.02 to 10.85 Smeas, and test workloads representative of a regional reference laboratory. Approximately half of these tests provide high potential for applying AON algorithms to monitor run length.     

Impact of managed care on independent practice and professional ethics: A survey of independent practitioners.

Managed care significantly affects the service delivery patterns, business structures, ethics, and professional concerns of independent practitioners. This survey assessed psychologists' perceptions of the effects of managed care on practice and ethics. Most respondents reported significant increases in dependence on managed care services for income. Negative effects included loss of control over ethical decisions and potential harm to patients from erosion of confidentiality. A majority of respondents reported encountering ethical concerns not addressed by the American Psychological Association ethics code. Findings suggest directions for practice development, for public policy addressing confidentiality, and for clarification of ethical responsibilities. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Partnering with physicians to achieve quality improvement

BACKGROUND: The Maine Medical Assessment Foundation (MMAF) has successfully involved hundreds of Maine physicians in study groups to analyze data on small-area variation and assess physician decision-making patterns. In 1991 the MMAF model was replicated across a tri-state area (Maine, New Hampshire, Vermont) in an effort called the Outcomes Dissemination Project, which is funded by a five-year grant from the U.S. Agency for Health Care Policy and Research. THE OUTCOMES DISSEMINATION PROJECT: Five specialty study groups, each meeting three times a year, examine local and national utilization data, examine guidelines and research findings, participate in outcomes studies and patient education, and disseminate their findings through specialty society presentations and other feedback efforts. The MMAF study group process is based on the beliefs that medicine is a subculture with a complex set of professional values, beliefs, socialization processes, and norms, and that quality improvement efforts work best when they are nonpunitive and educational. ISSUES IN OBTAINING PHYSICIAN INVOLVEMENT: (1) Physicians are willing to change their practices if they are brought into a culturally appropriate improvement program. (2) Related specialties (for example, internists and family practitioners) can often work together effectively on issues of common interest. (3) Involving respected clinical leaders has helped establish the legitimacy of MMAF methods among physicians. (4) Area- and physician-specific data are not made public, so as to build a sense of confidentiality among participants. CONCLUSIONS: The project continues to function as a powerful education process and serves as a model for replication elsewhere.     

Quality assurance under professional law and law relating to health services physicians and doctors

Medical quality assurance is guaranteed by a partially supplementary and partially contradictory systemframework of professional provisions as well as the provisions that apply to health service physicians. As far as qualifications are concerned, quality assurance is primarily the responsibility of the medical boards. Competing provisions are to be found particularly in the area of process quality. With a view to co-ordinating them, the Work Group for the Promotion of Quality Assurance in Medicine has been set up, sponsored by the Federal Medical Board, the Federal Association of National Health Service Physicians, the German Hospital Organisation and the leading statutory health insurance associations. The role of the Federal Medical Board in the field of quality assurance has been considerably upgraded pursuant to the Second Reform Index [II. NOG]. The article refers to several quality assurance projects, exploring in depth, for example, quality assurance in the areas of blood group identification and blood transfusion.     

The emergency physician and patient confidentiality: a review

Confidentiality is a promise rooted in tradition, law, and medical ethics. Emergency physicians treat a variety of patients to whom confidentiality is of vital importance: employees, celebrities, victims of violence or disaster, minors, students, criminals, drug abusers, and patients with STDs. EDs should develop methods of ensuring confidentiality for all patients. Although confidentiality is an important principle that should be respected and guarded, it is not absolute. Various laws mandate disclosure of certain patient information; in addition, an overriding moral duty may occasionally require a breach of confidentiality. As Beauchamp and Childress noted, "the therapeutic role may sometimes have to yield to one's role as citizen and as protector of the interests of others." In general, however, circumstances requiring a breach of confidentiality are rare.     

Double type III epiphyseal separation of distal ulna associated with ulnar nerve palsy

The Boston Electronic Medical Record Collaborative is working to develop a system that will use the World Wide Web to transfer computer-based patient information to clinicians in emergency departments. Maintaining adequate confidentiality of these records while still facilitating patient care is paramount to this effort. This paper describes an explicit protocol that would make it possible to electronically identify patients and providers, secure permission for release of records, and track information that is transmitted. It is hoped that other, similar efforts now underway will be able to use and build on this model. Comment on this proposal is invited from all parties with an interest in confidentiality. The system will be used only with "scrubbed" data-data from which all identifiers have been removed-until it is generally agreed that the confidentiality methods proposed here are appropriate and sufficient.     

New antiepileptic drugs for the treatment of childhood epilepsies

The Council on Scientific Affairs of the California Medical Association presents the following epitomes of progress in pediatrics. Each item, in the judgment of a panel of knowledgeable physicians, has recently become reasonably firmly established, both as to scientific fact and clinical importance. The items are presented in simple epitome, and an authoritative reference, both to the item itself and to the subject as a whole, is generally given for those who may be unfamiliar with a particular item. The purpose is to assist busy practitioners, students, researchers, and scholars to stay abreast of progress in medicine, whether in their own field of special interest or another. The epitomes included here were selected by the Advisory Panel to the Section on Pediatrics of the California Medical Association, and the summaries were prepared under the direction of Susan B. Conley, MD, and the panel.     

Panel discussion: problems of the specialist's duty to inform the patient (author's transl)

The obligation of the physician to inform the patient--which he has to prove in case of a suit--is based on the patient's right of self-determination. This self-decision information was subject of the panel discussion. Not discussed in detail were the information concerning diagnosis and prognosis, and the instruction of the patient regarding his conduct postoperatively and during medical treatment. Not considered was the so-called malpractice and negligence respectively. Medical liability suits are increasing for various reasons and are frequently directed at a failure to inform the patient becuase the patient is often unable to prove a negligence of the physician ("surrogate liability"). The dimension of the duty of disclosure (complete information--no information at all) is discussed in general and with special regard to the Ear-Nose- and Throat field. Special questions are answered regarding otoplasty, middle ear surgery, transplantations, extension of laryngeal surgery without prior informed consent, paranasal sinus and rhino-basis operations as well as surgery in minors and foreigners. In cases of non-vital indication and particularly in plastic-cosmetic procedures and outsider methods the requirements for informed consent are particularly important. The so-called rate of complications has perhaps a relative, but never an absolute meaning, and even this only in connection with the other circumstances of an individual case. The evidence of an adequate informed consent which must be included in a physician--patient-dialogue is most convincing by means of a written consent and the additional signature of a witness, perhaps also of the patient. The value, the problems and even the risks of an information based only on forms or brochures is discussed in detail. The panel discussion from the four points of view of the organizers should be no means confuse the otorhinolaryngologist. It should inform him about the medicolegal aspects of his activity and protect him from avoidable burdens.