Philly physician executive combats big city blight.

Despite no money for college and little encouragement from his teachers, Eric Mitchell was determined to make something of himself. Ever since he got that plastic doctor kit when he was 7, he dreamed of becoming a physician. Learn how he achieved that goal--and so much more.

The ethics of the introduction of gene therapy into orthopaedic practice.

Gene therapy has the potential to transform musculoskeletal medicine. Orthopaedists have been ready to incorporate innovations in medicine and engineering into their surgical practice, frequently before having full information. There is no reason to doubt the rapid acceptance of gene therapy by the orthopaedic profession. Caution is needed in incorporating gene therapy into standard practice because of the lack of knowledge and risks that are greater than for previous innovations.

Moral decisions regarding innovation. The case method.

Little consideration has been given to the ethics of innovation in surgery despite the major role of innovation in orthopaedic practice. We propose that a series of cases of increasing ethical complexity may serve as a classification system and assist orthopaedists in thinking about the ethical dimensions of other cases.

Informed consent.

The origins of informed consent come from philosophy, medical experimentation, the law, and contemporary trends in doctor and patient relationships. Every surgical patient signs an informed consent form but the literature would suggest that many times there is incomplete information conveyed by the physicians or understood by the patient. Informed consent should be considered as an expression of respect for patient autonomy and the patient education necessary for a truly informed consent should be considered a surgical virtue.

Moral reasoning, professionalism, and the teaching of ethics to orthopaedic surgeons.

Moral reasoning is not the only component of moral behavior, but it is an important and measurable constituent. Eighty orthopaedists, who took a standardized test of moral reasoning, showed marked heterogeneity in scores, ranging from the level of junior high students to the level of moral philosophers. This variability poses difficulty for those who plan educational courses in ethics, but is not an insurmountable difficulty.

The virtuous orthopaedist has fewer malpractice suits.

It generally is believed that physicians who have poor relationships with their patients are more likely to be sued. We studied certain physician characteristics and related them to their number of malpractice suits and the amount paid to settle those claims. Physicians with better rapport with their patients, who took more time to explain, and who were available had fewer malpractice suits. The most significant correlation was found in time spent with the patient. As the time spent increased, the number of suits decreased.

Substance use by surgical residents and students entering surgery.

We studied the use of alcohol, tobacco, and nine unprescribed or illegal substances by surgical residents and medical students accepted into surgical programs. With the exception of alcohol, surgical residents had less lifetime experience and used less than other residents or nonmedical college graduates. Students entering surgery had used these substances more frequently and were more likely to be using them regularly than were residents. Residency directors need to be aware of the change in attitude and use patterns of present residents as compared with those of the past.

The "value" of functional independence measure scores.

Functional independence measure (FIM) scores are frequently used as if the various sections are of equal importance and as if the interval between each score is equal. We tested this hypothesis by using marketing research techniques to assess the value to rehabilitation nurses and therapists of four of the six sections. Communication was valued more highly than continence, mobility and self care in that order. The interval between the scores is not equal, with difference between a FIM 2 and 3 being greater than between a FIM 5 and 6. However, when the other difficulties such as interexaminer reliability are considered, these score differences are not great. We concluded that for practical purposes FIM scores may be used as if they were of equal interval spacing, and the scores of the various sections may be added together.

Scapulothoracic arthrodesis in facioscapulohumeral muscular dystrophy. Review of seventeen procedures with three to twenty-one-year follow-up.

The scapula was fixed to the ribs in twelve patients who had facioscapulohumeral muscular dystrophy, in order to provide stability for activities involving the upper limbs. The duration of follow-up ranged from three to twenty-one years. Abduction, in 30 degrees of flexion, improved an average of 60 degrees, and gains in strength for carrying and lifting were reported by the patients. Complications included a brachial plexus palsy, which resolved, and a frozen shoulder. All of the patients but one were pleased with the result.

The stresses of the surgical residency.

UNLABELLED: Concern over resident work hours prompted us to study the stress of surgical residencies and determine if the experience might be associated with an increased use of alcohol and drugs. Two hundred fifty-seven surgery residents were selected from a stratified, randomized sample of residents (n = 1728) from the AMA files and were given an eight-page self-administered questionnaire. RESULTS: Surgical residents reported very long hours and heavy duties and complained of loss of sleep and exhaustion, both of which correlated with nights on call. Despite the heavier work load, surgical residents showed no more emotional stress than other residents. Surgery residents were more likely to have used alcohol in the last month than other residents (P less than .05) but 70% had used it fewer than 10 times in the month. All surgical residents were less likely to have used marijuana, cocaine, or other drugs than were other residents. Surgical residents seem to cope well with the extreme stresses of surgery training programs; however, more research needs to be done if we are to fully understand the process for training surgeons.

Conversion reactions in pediatric athletes.

We report five children and adolescents who displayed a conversion reaction in response to stresses induced by athletic competition. Failure to make proper diagnosis led to additional physician referral, needless testing, rehabilitation, or orthotic management. Patients are characterized as high achievers who are frequently younger than peers in the sport. Conversation between child and physician identified the source of conflict in four patients. Physical therapy helps resolve symptoms associated with an acute episode and facilitates transition into psychotherapy. Psychotherapy is recommended only for patients with persistent maladaptive behavior.

The epidemiology of "schooliosis".

Questionnaires submitted to children subsequent to school screening for scoliosis reveal that 13% of respondents recall being referred to a physician. This rate is considerably higher than the 3% referral rate reported by school health officials. The discrepancy points to misperceptions by students and their parents as a likely cause of "schooliosis, " a condition which brings a flood of normal children into the offices of orthopaedists and pediatricians. Correcting possible communications problems, rather than blaming the screening program, should ease the over-referral phenomenon and allow screening to continue at its present efficient levels.

Factors influencing the penetration of wires into the neural canal during segmental wiring.

We evaluated the influence of the penetration of wires into the neural canal during segmental wiring in a three-part study. First we examined the anatomy of the thoracic spine, specifically the laminar and interlaminar dimensions, as well as the epidural space. In the second part, we evaluated the depth of penetration of wires into the spinal canal at the time of their passage during spinal segmental instrumentation, using direct laboratory measurements for three configurations of the wire: first with a straight wire, and then with two wires of varying curvature. The measurements were repeated after removal of a portion of the lamina. In the third and final part of the study, we assessed the relationship between the observed penetration of the wires and the depth of penetration as calculated using mathematical models for the three wire configurations. When a wire with the largest possible diameter of curvature was passed under the lamina, there was significantly less penetration using the curved-wire configuration. This was seen in calculated models, as well as in normal specimens of the thoracic spine that were obtained from cadavera. Little epidural space was found to be available for passage of the wire. In most instances, passage of the wire must result in contact with and displacement of the dural sac and its contents. To minimize the depth of penetration at any given spinal level, it is recommended that the wire be curved to the maximum degree that will allow it to pass under the lamina.(ABSTRACT TRUNCATED AT 250 WORDS)

What faculty members value in practice plans.

Faculty practice plans are under scrutiny at many academic medical centers as teaching hospitals seek ways to encourage their physicians to increase their clinical activities. Discussions with physicians at two medical schools yielded insights into the faculty members' perspective on faculty practice plans. Interviews disclosed that the physicians were satisfied with a practice plan if they felt their professional goals were in balance with the institution's goals. Changes in the plan can either sustain institutional values or introduce new priorities. In view of physicians' loyalty to a particular plan and their anxiety in the face of change, the authors suggest that it may be better to modify an established plan than to impose a new system. The physicians interviewed agreed that strong chairmen can work within any plan to reward faculty members for research, clinical, or administrative contributions and thus to determine a department's directions and character. In considering changes in a practice plan, chairmen, deans, and administrators need to weigh the faculty's values and commitments.

Progression of unsupported curves in adolescent idiopathic scoliosis.

Stability of three types of double scoliotic curves of 10-40 degrees was analyzed using a biomechanical model: double primary (Type I), primary thoracic with compensatory lumbar (Type II), and primary lumbar with compensatory thoracic (Type III). The load-carrying capacity of each curve was analyzed as a function of magnitude of the curve, its location and flexibility. Curve magnitude was found to be the most influential parameter governing the stability of a scoliotic curve up to 30 degrees. Results suggest that in evaluating curves of comparable magnitudes, Type I and II curves are more likely to progress and, therefore, should be braced at an earlier stage than Type III curves.