The political and social context of silicone breast implant use in the United States.

Silicone breast implants have been used for breast enlargement and reconstruction after mastectomy since 1963. It is estimated that they have been implanted in over 2 million women in the U.S. The U.S. Food and Drug Administration (FDA) has required manufacturers of the implants to submit evidence of their safety and effectiveness. The implants have been shown to benefit women in psychological studies. Physical risks include capsular contracture (affecting up to half of wearers), impaired mammographic results, implant rupture, and possibly connective tissue disease. Human studies would benefit from improved research design, including controls and long-term follow-up. Professional societies of plastic surgeons, whose members benefit commercially from breast augmentation and reconstruction, have campaigned forcefully for the continued and increased use of breast implants by women.

Evolving residency requirements for ambulatory care training for five medical specialties, 1961 to 1989.

Recent changes in the patient population of teaching hospitals, spurred by technologic advances and economic forces, have jeopardized the traditional hospital-based model of residency training. In consequence, there has been increasing attention paid to the need for ambulatory care experience. A primary force in shaping the content of postgraduate medical education is "The Essentials of Accredited Residencies," published in the Directory of Graduate Medical Education Programs. We reviewed recommendations and requirements for ambulatory settings and outpatient experience as specified in the Directory during the years 1961 to 1988 and investigated pending changes in requirements for five major specialties: internal medicine, pediatrics, family practice, general surgery, and obstetrics and gynecology. Increases in the amount of time residents spend in ambulatory care training recently have been mandated in internal medicine and are under consideration in two other specialties, indicating probable major shifts in the locus of postgraduate medical training.

Academic medicine as a public trust.

Academic medicine is entrusted by society with the responsibility to undertake several important social missions toward improving the health of the public, including education, patient care, and research. This trust is given implicit authority by generous public funding and considerable autonomy. Medical academia can take pride in its successes, manifested by a premier scientific establishment, the development and use of sophisticated medical technologies and drugs, and the recent dramatic declines in death rates from heart disease and stroke. Academic medicine, however, has been relatively unresponsive to a number of vexing public problems, including skyrocketing expenditures for medical care, substandard indexes of population health, uneven quality of care, an unfavorable geographic and specialty mix of physicians, and widespread disability from long-term medical and psychiatric problems. Although there are many cogent reasons why academic medicine has chosen to define its task relatively narrowly (the nature of its funding successes, the intractability of the social problems, and the attractiveness of the biomedical model), the central issue is how well academic medicine is fulfilling its responsibilities to the public. To the degree that academic medicine defines its central mission narrowly, it may violate its implicit social contract and jeopardize its primary source of financial support. Alternatively, in recognition of its public responsibilities, academic medicine can choose to expand its current activities to be more responsive to the health concerns of the general population.