An ethical justification and policy for making commitments during computerized residency application processes: The US matching program as a laboratory for needed reform.

The US National Residency Matching Program (NRMP) is a computerized, national system for matching residency applicants to programs. Similar systems exist in Canada, Australia, and New Zealand, and the need for such a program will probably make itself felt in the European Union soon. NRMP is an important laboratory for the ethical challenges that computerized matching programs create, especially its current prohibition of making commitments by both applicants and residency programs. Nonetheless, it would be denial to suppose that commitments are not being made and that there is no dishonesty when commitments are made. We analyze the current NRMP no-commitment policy by reference to Plato's retelling of the myth of the Ring of Gyges, which makes its wearer physically invisible and therefore ethically unaccountable. Because applicants and programs complete their preference-lists in secret, the matching process inadvertently slips a Ring of Gyges on the fingers of both parties. As a result, making false commitments promotes the rational self-interest of both parties. To strengthen the professional integrity of the matching process, we argue that NRMP should abandon its no-commitment policy and adopt a new paradigm: sanctioning honest, non-contingent, accountable, one-party, and documented commitments. Computerized residency matching systems in other countries should consider the NRMP a laboratory and develop policies about making commitments that promote professionalism in the residency application process.

Fetal extrasystole may predict poor neonatal outcome.

Extrasystoles particularly premature atrial contractions noted during labour on the fetal heart rate monitoring strip are usually thought to be benign. In pregnancies complicated by fetal infection and/or the fetal inflammatory response syndrome, there are some data that extrasystoles noted during the intrapartum period may be related to neonatal sepsis and eventual poor neonatal outcome including death or neonatal encephalopathy. Additional observations are needed to substantiate this hypothesis.

Where is the "W"oman in MCH?

Scientific evidence indicates that improving a woman's health before pregnancy will improve pregnancy outcomes. However, for many years, our efforts have focused primarily on prenatal care and on caring for infants after birth. The concept of preconception care has been identified repeatedly as a priority for improving maternal and infant health. Preconception care is not something new that is being added to the already overburdened healthcare provider, but it is a part of routine primary care for women of reproductive age. Many opportunities exist for preconception intervention, and much of preconception care involves merely the provider reframing his or her thinking, counseling, and decisions in light of the reproductive plans and sexual and contraceptive practices of the patient. With existing scientific evidence that improving the health of "W"omen will improve the health of mothers and children, we must focus on improving the health of "W"omen before pregnancy and put the "W" in Maternal and Child Health.

The clinical content of preconception care: immunizations as part of preconception care.

Many vaccine-preventable diseases have serious consequences for the pregnant mother, the fetus, and the neonate. This article reviews the rationale and impact of including vaccinations as part of preconception care and provides recommendations for clinical care. Vaccinations that are recommended highly in preconception care include the hepatitis B and the measles, mumps, and rubella vaccines. The role of human papillomavirus, varicella, diphtheria, tetanus, and pertussis vaccinations as part of preconception care is also discussed.

The clinical content of preconception care: infectious diseases in preconception care.

A number of infectious diseases should be considered for inclusion as part of clinical preconception care. Those infections strongly recommended for health promotion messages and risk assessment or for the initiation of interventions include Chlamydia infection, syphilis, and HIV. For selected populations, the inclusion of interventions for tuberculosis, gonorrheal infection, and herpes simplex virus are recommended. No clear evidence exists for the specific inclusion in preconception care of hepatitis C, toxoplasmosis, cytomegalovirus, listeriosis, malaria, periodontal disease, and bacterial vaginosis (in those with a previous preterm birth). Some infections that have important consequences during pregnancy, such as bacterial vaginosis (in those with no history of preterm birth), asymptomatic bacteriuria, parvovirus, and group B streptococcus infection, most likely would not be improved through intervention in the preconception time frame.

The clinical content of preconception care: alcohol, tobacco, and illicit drug exposures.

Substance abuse poses significant health risks to childbearing-aged women in the United States and, for those who become pregnant, to their children. Alcohol is the most prevalent substance consumed by childbearing-aged women, followed by tobacco, and a variety of illicit drugs. Substance use in the preconception period predicts substance use during the prenatal period. Evidence-based methods for screening and intervening on harmful consumption patterns of these substances have been developed and are recommended for use in primary care settings for women who are pregnant, planning a pregnancy, or at risk for becoming pregnant. This report describes the scope of substance abuse in the target population and provides recommendations from the Clinical Working Group of the Select Panel on Preconception Care, Centers for Disease Control and Prevention, for addressing alcohol, tobacco, and illicit drug use among childbearing-aged women.

Hospital primary cesarean delivery rates and the risk of poor neonatal outcomes.

OBJECTIVE: The purpose of this study was to determine whether risk-adjusted hospital primary cesarean delivery rates are associated with poor neonatal outcomes. STUDY DESIGN: The Washington State Birth Events Records for 1995 and 1996 were used. Predicted primary cesarean delivery rates were calculated for each hospital. Women were divided by whether the hospital had an actual primary cesarean delivery rate below, within, or greater than the predicted CI. Asphyxia (a lack of oxygen that leads to organ damage) was used as a marker of poor neonatal outcome. Risk of neonatal asphyxia was compared for each of the 3 cesarean rating groups. RESULTS: The risk for asphyxia among infants who were born to women who delivered at hospitals that had more, within, or fewer cesarean deliveries than predicted were 0.58%, 0.17%, and 0.33%, respectively (P <.0001). CONCLUSION: Infants born to women who delivered at hospitals that had more than or fewer than the predicted number of primary cesarean deliveries experienced a greater risk of neonatal asphyxia.

Career transitions:planning for alternative futures.

Transition to retirement is a necessary step for all physicians because of the physical and emotional changes that occur with the aging process, the physician's ethical responsibilities to patients, and at times, because there is a desire to pursue different goals. It is important to begin to plan for this transition early in one's career so that some planning for postretirement vocation and avocation can be made and financial concerns can be addressed. A recent ACOG survey of 1000 Fellows ages 40-60 demonstrates that this planning is not occurring universally and the assistance of Fellows in preparation for this transition is now becoming an ACOG initiative.