Accessibility in health professions education: The Flexner Report and barriers to diversity in American physical therapy.

Health professionals do not reflect the broader racial/ethnic diversity of the United States. Historical barriers to accessing health professions education have played a major role in initiating and perpetuating these disparities. Sociologists of professions have highlighted the role of educational reform in professions' efforts to enhance their status, but have overlooked the central role of government bodies in facilitating or impeding these strategies. The Flexner Report (1910) enhanced the status of medicine, but only after state medical boards adopted its recommendations, leading to the closure of half of the nation's medical schools and limiting opportunities for marginalized populations to enter the medical profession. Physical therapy leaders have espoused Flexner's precepts in seeking to advance their field's professionalization. In doing so, they consistently overlooked the more insidious impacts of Flexnerian approaches on student and practitioner diversity. This article examines how physical therapy's Flexnerian ambitions disrupted its parallel efforts to increase the field's racial/ethnic diversity. I argue that physical therapy leaders' focus on enhancing their profession's status and indifference toward facilitating educational access and mobility played a significant role in the field's racial/ethnic homogeneity. To increase practitioner diversity in the future, especially following the 2023 US Supreme Court decision (600 U.S. 181) restricting race conscious affirmative action, health professions must do more to address barriers to student access. This will involve moving away from the Flexnerian model and pursuing approaches that have helped more diverse and inclusive health professions, like nursing, to achieve greater educational opportunity and mobility.

Underrepresented Minority Recruitment: Manpower as Motivator in Late Twentieth-Century Occupational Therapy and Physical Therapy.

This article offers a historical perspective on diversity, equity, and inclusion initiatives in health professions. Historians have highlighted how workforce shortages have facilitated increased gender diversity in male-dominated scientific and clinical occupations. Less attention has been given to manpower as a motivator for enhancing racial/ethnic diversity. I explore the history of minority recruitment, retention, and inclusion initiatives in occupational therapy and physical therapy after 1970 and examine the evolving ways in which the longstanding underrepresentation of racial/ethnic minority health professions students and practitioners was recognized, mobilized, and instrumentalized in each field. I argue that broad-based manpower concerns, though often compelling initial motivators for action, were insufficient for sustaining successful and long-term minority initiatives, due to constant shifts in job market demand. Instead, this article shows that annual and institutionalized minority-specific awards and fundraisers were the most effective strategies for maintaining minority recruitment initiatives over multiple decades.

Hemodialysis Arteriovenous Access Cosmesis Scale (AVACS): A new measure for vascular access.

RATIONALE AND OBJECTIVE: This study aimed to develop a cosmesis scale to evaluate the cosmetic appearance of hemodialysis (HD) arteriovenous (AV) accesses from the perspective of the patient and clinician, which could be incorporated into clinical trials. STUDY DESIGN: Using a modified Delphi process, two AV access cosmesis scale (AVACS) components were developed in a four-round Delphi panel consisting of two surveys and two consensus meetings with two rounds of patient consultation. SETTING AND PARTICIPANTS: The Delphi panel consisted of 15 voting members including five interventional or general nephrologists, five vascular surgeons, three interventional radiologists, and two vascular access nurse coordinators. Four patients experienced with vascular access were involved in patient question development. ANALYTICAL APPROACH: For a component to be included in the AVACS, it had to meet the prespecified panel consensus agreement of ⩾70%. RESULTS: The clinician component of the AVACS includes nine questions on the following AV access features: scarring, skin discoloration, aneurysm/pseudoaneurysms and megafistula appearance. The patient component includes six questions about future vascular access decisions, interference with work or leisure activities, clothing choices, self-consciousness or attractiveness, emotional impact, and overall appearance. LIMITATIONS: Delphi panel methods are subjective by design, but with expert clinical opinion are used to develop classification systems and outcome measures. The developed scale requires further validation testing but is available for clinical trial use. CONCLUSIONS: While safety and efficacy are the primary concerns when evaluating AV access for HD, cosmesis is an important component of the ESKD patient experience. The AVACS has been designed to assess this important domain; it can be used to facilitate patient care and education about vascular access choice and maintenance. AVACS can also be used to inform future research on developing new techniques for AV access creation and maintenance, particularly as relates to AV access cosmesis.

Moving Away from the "Medical Model": The Development and Revision of the World Health Organization's Classification of Disability.

Recently, there has been a prominent call in the history of medicine for greater engagement with disability perspectives. In this article, I suggest that critiques of the so-called medical model have been an important vehicle by which alternative narratives of disability entered the clinical arena. Historians of medicine have rarely engaged with the medical model beyond descriptive accounts of it. I argue that to more adequately address disability perspectives, historians of medicine must better historicize the medical model concept and critique, which has been drawn upon by physicians, activists, and others to advance particular perspectives on disability. My present contribution describes two distinct formulations of critique that originated in differing interest groups and characterized the medical model alternatively as insufficient and oppressive. I examine the World Health Organization's efforts to incorporate these distinctive medical model critiques during the development and revision of its International Classification of Impairments, Disabilities, and Handicaps.

From Precaution to Peril: Public Relations Across Forty Years of Genetic Engineering.

The Asilomar conference on genetic engineering in 1975 has long been pointed to by scientists as a model for internal regulation and public engagement. In 2015, the organizers of the International Summit on Human Gene Editing in Washington, DC looked to Asilomar as they sought to address the implications of the new CRISPR gene editing technique. Like at Asilomar, the conveners chose to limit the discussion to a narrow set of potential CRISPR applications, involving inheritable human genome editing. The adoption by scientists in 2015 of an Asilomar-like script for discussing genetic engineering offers historians the opportunity to analyze the adjustments that have been made since 1975, and to identify the blind spots that remain in public engagement. Scientists did take important lessons from the fallout of their limited engagement with public concerns at Asilomar. Nonetheless, the scientific community has continued to overlook some of the longstanding public concerns about genetic engineering, in particular the broad and often covert genetic modification of food products.

Making the most of uncertainty: Treasuring exceptions in prenatal diagnosis.

Throughout the 20th century, human genetics research was driven by the identification of new variants. As pioneering geneticist William Bateson put it, novel variants were "exceptions" to "treasure". With the rise of human chromosomal analysis in the postwar period, the identification of genetic variants became increasingly significant to clinical and prenatal diagnosis. Human geneticists had long sought a broader sampling of human genetic variation, from a largely "normal" population. The expansion of prenatal diagnosis in the late 20th century offered a new resource for identifying novel genetic variants. In the prenatal diagnostic setting however, many of the exceptions to be treasured were of uncertain clinical significance, which raised anxiety among parents. In the early 1990s, providers reported that specific uncertain results from chorionic villus sampling (CVS) facilitated prenatal diagnoses that were not previously possible. Based on this, some prenatal diagnostic providers began to embrace uncertainty, when properly managed to reduce anxiety, rather than prevent it. The potential to produce uncertainty in prenatal diagnosis grew with whole genome microarray in the 2000s. Rather than outcomes to avoid, or accept as inevitable, providers presented uncertain results as starting points for research to improve the scope prenatal diagnosis, and bring future certainty.

Role of PBPD1 in stimulation of Listeria monocytogenes biofilm formation by subminimal inhibitory ß-lactam concentrations.

Disinfectant-tolerant Listeria monocytogenes biofilms can colonize surfaces that come into contact with food, leading to contamination and, potentially, food-borne illnesses. To better understand the process of L. monocytogenes biofilm formation and dispersal, we screened 1,120 off-patent FDA-approved drugs and identified several that modulate Listeria biofilm development. Among the hits were more than 30 ß-lactam antibiotics, with effects ranging from inhibiting (≤50%) to stimulating (≥200%) biofilm formation compared to control. Most ß-lactams also dispersed a substantial proportion of established biofilms. This phenotype did not necessarily involve killing, as >50% dispersal could be achieved with concentrations as low as 1/20 of the MIC of some cephalosporins. Penicillin-binding protein (PBP) profiling using a fluorescent penicillin analogue showed similar inhibition patterns for most ß-lactams, except that biofilm-stimulatory drugs did not bind PBPD1, a low-molecular-weight d,d-carboxypeptidase. Compared to the wild type, a pbpD1 mutant had an attenuated biofilm response to stimulatory ß-lactams. The cephalosporin-responsive CesRK two-component regulatory system, whose regulon includes PBPs, was not required for the response. The requirement for PBPD1 activity for ß-lactam stimulation of L. monocytogenes biofilms shows that the specific set of PBPs that are inactivated by a particular drug dictates whether a protective biofilm response is provoked.

The 'morbid anatomy' of the human genome: tracing the observational and representational approaches of postwar genetics and biomedicine the William Bynum Prize Essay.

This paper explores evolving conceptions and depictions of the human genome among human and medical geneticists during the postwar period. Historians of science and medicine have shown significant interest in the use of informational approaches in postwar genetics, which treat the genome as an expansive digital data set composed of three billion DNA nucleotides. Since the 1950s, however, geneticists have largely interacted with the human genome at the microscopically visible level of chromosomes. Mindful of this, I examine the observational and representational approaches of postwar human and medical genetics. During the 1970s and 1980s, the genome increasingly came to be understood as, at once, a discrete part of the human anatomy and a standardised scientific object. This paper explores the role of influential medical geneticists in recasting the human genome as being a visible, tangible, and legible entity, which was highly relevant to traditional medical thinking and practice. I demonstrate how the human genome was established as an object amenable to laboratory and clinical research, and argue that the observational and representational approaches of postwar medical genetics reflect, more broadly, the interdisciplinary efforts underlying the development of contemporary biomedicine.

Visualizing carrier status: fragile X syndrome and genetic diagnosis since the 1940s.

What does it look like to be the carrier of a genetic disease? Carrier status may be determined through the visual analysis of both genotypic and phenotypic evidence. Over the past 70 years, clinical geneticists have depended upon multiple strategies for identifying disease carriers within a family. This has included pedigree analysis, which was based upon clinical observations of individual family members and, in recent decades, cytogenetic and molecular methods. Newer techniques have offered novel opportunities to actually see the suspected etiological markers of certain genetic diseases, such as Fragile X syndrome. The visualization of these markers has both clarified and confused previously observed inheritance patterns, in some cases leading to the development of newly distinct diagnostic categories. As a result, what it means to be affected by, or the carrier of, a genetic disease has continuously evolved.

The combined use of simulation and navigation to demonstrate hip kinematics.

Computer navigation of total hip arthroplasty and computer simulation of hip motions based on collision detection were both introduced more than ten years ago. Neither of these promising technologies has achieved its full potential to improve patient outcomes. Combining these two technologies allows the individual strengths of each to more easily demonstrate hip kinematics in a clinically useful way. All normal and pathologic combined hip motions must be clearly and accurately reported to fully evaluate the kinematics involved in total hip arthroplasty, femoroacetabular impingement syndrome, and other hip disorders. The use of three-dimensional data graphs allows for a rapid and thorough evaluation of the very large data sets that are required for the purpose of making a complete report of all combined hip motions. Data can be obtained from simulations made with use of high-resolution computed tomographic scans and computer-aided implant-design files or from clinically obtained motion analysis on fresh cadavers or normal subjects. The use of these methods and graphics allows for the thorough evaluation of the geometries of current implant designs and will help improve future implant designs. The pathologic structures in hips with femoroacetabular impingement can be modeled in three dimensions, and surgical treatment plans can be developed to provide impingement-free normal hip motion without excessive osseous resection. The combination of these technologies provides hope for the improved surgical placement of total hip implants by providing the basis for a kinematic, impingement-based total hip navigation system.