The moonlighting dilemma. Balancing education, service, and quality care while limiting risk exposure.

Moonlighting by medical residents is a highly controversial topic that has recently received new interest and concern as states are implementing legislative and regulatory efforts to limit residents' work hours and as teaching hospitals are increasingly concerned about liability exposure. Despite the potential problems, moonlighting, or outside employment, represents additional income to residents that enables repayment of massive student loans and/or improves their standard of living. It means additional clinical experience and responsibility, which many feel enhances their educational experience, and it permits essential night and weekend coverage for community hospital emergency departments and walk-in centers. Because of these important considerations for residents, community hospitals, and risk management, the University of Massachusetts Medical Center has developed a unique approach to the problems of moonlighting that addresses the concerns of all involved parties. The development of extended employment guidelines has also enabled the medical center to maintain a detailed database on the volume of such activity.

Competition and cost in graduate medical education. Should we train unsalaried residents and fellows?

In 1985, a total of 6,080 applicants to the National Resident Matching Program (Match) were unable to match with residency positions. The majority of unmatched applicants were graduates of foreign medical schools. In addition, many US and foreign medical graduate applicants did not find positions in their preferred choice of specialties. As a result, teaching hospitals are increasingly receiving offers from would-be residents who are willing to work without financial support to gain the experience and credentials required for medical licensure. Teaching hospitals that consider accepting unsalaried house staff must begin to develop policies and guidelines that ensure fair and equitable treatment of all residents and fellows and that standards of quality are not compromised.

CT sialography: utilising acinar filling.

The technique of computed tomographic sialography (CTS) has been demonstrated to be valuable in the diagnosis of masses of the major salivary glands. Forty-one CT sialograms were performed in 35 patients using acinar glandular filling with oily contrast material. Twenty-two mass lesions and seven cases of inflammatory disease were identified. There were two instances of mild parotitis following the procedure. CTS performed with this technique was found to be a safe, accurate method for evaluating salivary gland masses.

Glioblastoma of the cerebellum. Computed tomographic and pathologic considerations.

Cerebellar glioblastoma is a brain malignancy that is often difficult to distinguish from metastatic disease in the elderly before biopsy. The clinical course and computed tomographic appearance of four patients with multiform glioblastoma of the cerebellum are presented and correlated with other reports in the literature. The appearance of a cerebellar hemispheric lesion with little mass effect is described, and the pathology of the tumor is reviewed.

Prevention of visual anxiety and proficiency problems in the senior air transport pilot.

Several actual cases were presented to show the problems encountered with flight deck vision in the middle-age presbyopic pilot both in the simulator and in flight. We have gained useful knowledge in the proper flight-deck needs and optical corrections for these pilots, which should be passed on to aviation examiners, eye specialists, and pilots themselves. This would relieve a great deal of unnecessary lost time and anxiety which results when the pilot has a correction unsuited for the cockpit and encounters extreme difficulty in simulator work and in actual flight conditions which he does not understand and which can become very frustrating and a source of anxiety because his career is at stake. This anxiety may lead to other functional ocular problems, is unnecessary, and can be prevented.

Pseudo-internuclear oculomotor ophthalmoplegia secondary to Guillain-Barré polyneuronitis simulating myasthenia gravis in a air transport pilot.

A 32-year old experienced co-pilot was grounded because of handicapping and disabling doulbe vision and was off-flight from October, 1969, until January, 1972. He presented with a bilateral external ophthalmoplegia with alternate extreme divergent strabismus, and polyneuronitis. The clinical picture was confused by features resembling either a polyneuronitis of the Guillain-Barrè type, (confused by a false positive Tensilon test), myasthenia gravis, or a demyelinizing process. Because the prognosis for return to flight was so contradictory in these respective conditions, a long observative followup time was essential. The pilot recovered completely after 4 months. The long 2 year followup effectively ruled out the entity of myasthenia gravis as well as a progressive demyelinizing disease. The pilot was returned to full flight duties with no handicapping residuals. He has shown no evidence of recurrence to the date of this report (April, 1974). This case was reviewed and presented for its obvious aerospace implications.