The emerging medical/industrial complex. The industrialization of medicine

Until recently, the traditional practice of medicine has been thought of as a cottage industry practiced by individuals or small partnership groups. The transition of practice settings to large groups, multi-specialty groups, and corporations has paved the way to industrialization, with even larger health care organizations primarily managed by non-physicians. The similarities of these events to the industrial revolution and its impact on crafts guilds are striking. In order to understand this point of view, this article explores the function and influence of crafts guilds during stages of industrial development and the dynamics of the changes of employment needs and employability in an industrial environment as a comparison to what is happening in the health care field.

Methodologic and compliance issues in postcoronary bypass surgery subjects

Persons who engage in preventive health behaviors may reduce the progression of coronary artery disease. The immediate objective of this pilot study was to assess adherence to behavioral lifestyle changes in patients after coronary artery bypass graft surgery by analyzing self-reported responses using objective measures. Data on adherence to diet, exercise, and smoking were collected from questionnaires completed by each subject. Carbon monoxide index, serum cholesterol, pre- and postambulatory pulse rates, and pre- and post-stair-climbing pulse rates were measured. All tests were conducted before discharge and at a one-month follow-up visit. Analysis of objective data showed a statistically significant reduction in total serum cholesterol, decreased smoking behavior, and increased ambulation from before discharge to one-month follow-up. Analyses showed that self reports of adherence to diet, activity, and smoking cessation were consistent with objective measures in at least 50% of subjects. Serial objective measures provide valuable indicators of patient adherence and assist staff in developing individually tailored patient education.

Cardiovascular, pulmonary, and cancer rehabilitation. 4. Cancer rehabilitation: principles and psychosocial aspects

This self-directed learning module highlights advances in alternative treatment settings, nutrition, and sexuality in cancer rehabilitation. It is part of the chapter on cardiovascular, pulmonary, and cancer rehabilitation for the Self-Directed Medical Knowledge Program Study Guide for practitioners and trainees in physical medicine and rehabilitation. This section discusses principles of clinical oncology for rehabilitation, and psychosocial aspects of cancer rehabilitation management.

Cardiovascular, pulmonary, and cancer rehabilitation. 5. Cancer rehabilitation: management of pain, neurologic and other clinical problems

This self-directed learning module highlights new approaches to pain management, postmastectomy treatment, and rehabilitation issues in cancers of specific organ systems. It is part of the chapter on cardiovascular, pulmonary, and cancer rehabilitation for the Self-Directed Medical Knowledge Program Study Guide for practitioners and trainees in physical medicine and rehabilitation. This section discusses management of pain, neuromusculoskeletal compromise, paraneoplastic syndromes, and other clinical problems.

Overwork weakness in rats with acrylamide neuropathy

Exercised rats have larger myelinated nerve fibers than sedentary rats and exercised rats with acrylamide neuropathy have smaller fibers than acrylamide-treated sedentary rats. These nerve fiber changes were the result of work hypertrophy and overwork atrophy, respectively. This study was designed to reassess morphologic changes in nerves after overwork was induced in rats with acrylamide neuropathy and to test the effects of rest before and after an overwork period in rats with acrylamide neuropathy. The 4-week-old rats divided into four groups of eight rats. Acrylamide was administered to three groups (Groups 2, 3, and 4) to induce subacute paralysis followed by gradual ameriolation. Group 3 was exercised for the first 5 weeks and was rested for the last 5 weeks. Group 4 was exercised for the last 5 weeks. The diameter distribution of myelinated fibers of the tibial and sural nerves was analyzed. The percentage of larger myelinated fibers was decreased in all acrylamide-treated groups. The average values of fiber diameters in Group 4 were significantly smaller than injected sedentary animals (Group 2) or those with rest (Group 3), whereas no significant difference was found between the latter groups. Axonal degeneration of teased fibers was assessed in the tibial and sural nerves. The percentage of axonal degenerated fibers in exercised animals (Group 4) was significantly higher than in the other acrylamide-injected groups (Groups 2 and 3). This study supports the concept that acrylamide neuropathy worsens with moderate intensity of running activities for a prolonged period and that recovery may occur if vigorous exercise is avoided.

An electrodiagnostic study in chronic alcoholic subjects

Electrodiagnostic tests were performed on 16 alcoholic subjects and 15 age-matched controls. The tests were done to determine whether nerve conduction parameters differentiate between healthy and alcoholic subjects, and if so, which of these are most useful. Significant differences between alcoholic subjects and controls were found in the following variables: median nerve motor velocity; median nerve sensory latency, amplitude and velocity; ulnar nerve motor amplitude and velocity; ulnar nerve sensory amplitude, latency and velocity; sural nerve sensory amplitude and velocity; and peroneal motor amplitude and velocity. The combination of ulnar and sural sensory conduction velocity tests identified 85% of the chronic alcoholic subjects by stepwise discriminant analysis. Tibial nerve H-reflex latencies were either absent or prolonged in 63% of the subjects. Bilateral facial nerve amplitudes and latencies were normal. The ulnar sensory amplitude and ulnar sensory velocity inversely correlated with the duration of excessive alcohol drinking.

Functional strapping for incomplete Erb palsy: case report

A simple harness device for the treatment of residual arm posturing in patients with brachial plexus palsy is described. The harness consists of six parts and is made of elastic and cotton webbing. The harness holds the arm in a functional range of movement and permits the patient's hand to be used in bimanual tasks and activities of daily living. The approximate cost of this device is +65, including labor.

Physical medicine in medical curricula: training primary care physicians and students

The demonstrated need for the education of primary care physicians in the principles of Physical Medicine & Rehabilitation (PM&R) is not matched by the curricula of medical schools and primary care residency programs. This anomaly of medical education is discussed from the standpoint of the hindrances inherent in the medical professional as a whole and more specifically in PM&R itself. Several concepts are suggested to stimulate thought about how PM&R may change perceptions of the specialty. Increased general medical knowledge is an important element of the PM&R learning experience. The emphasis of medical education should be on the students' needs rather than those of the specialty.

Musculoskeletal and neurologic conditions in rural family practice: implications for physical medicine curriculums

To help determine the educational needs of both students and practitioners, an inventory of musculoskeletal and neurologic disorders was made of eight rural family practices for one year. Data on 54,043 patients representing 152,482 visits was put into an automated information system at the time care was received and coded by diagnosis. Computer listings provided the frequency of 372 diagnoses, the age distribution for diagnoses and the percent of total patients for each diagnosis. Physical medicine and rehabilitation (PM&R) conditions accounted for a minimum of 6.9% of the total visits and 11.7% of conditions that occurred individually in small numbers. PM&R conditions were fairly evenly distributed throughout all age ranges, indicating a need for education in both pediatric and adult areas. The breakdown of PM&R conditions by category provides valuable insight for future curriculum development.

Postural drainage: variability of patients' responses

Assessing the benefit of postural drainage (PD) by pulmonary function (PF) tests is complicated by variable responses of patients. Examples of subjects with chronic obstructive pulmonary disease are presented to emphasize: (1) the need for knowing whether a patient is already receiving PD treatment prior to pulmonary function testing (PFT), (2) measuring PF for several days concurrently with PD, and (3) the pitfalls of conclusions reached with a single-day assessment of PF before and after PD. Patients requiring substantially higher doses of medication were also those whose PF deteriorated with PD. Serial opinions of patients as to whether PD affected their ease of breathing proved a valuable indicator of actual PF changes. However, single-day determinations may give spuriously positive results.

Postural drainage effect after bronchodilator inhalation in patients with chronic airway obstruction

To determine the effect of postural drainage (PD) on pulmonary functions and sputum volume in patients with partially reversible chronic obstructive pulmonary disease, comparisons were made between days with and without PD in 13 such patients. Pulmonary function tests were done 3 times a day over a 12-day period. Medications remained unchanged during this time. PD had no significant effect on either individual pulmonary function tests or 24-hour spectrum volumes. The function tests done at 9:30 AM showed some improvement over those obtained at 8:00 AM without regard to PD, indicating the beneficial effects of bronchodilators inhaled 15 to 20 minutes before PD. Patients were classified as PD responders, nonresponders and negative responders on the basis of concurrent consideration of forced expiratory volume in 1 second, mid-forced expiratory flow and airway resistance. Although the 24-hour sputum volumes did not change, the amount associated with PD was greater. It is suggested that PD is helpful for some patients but detrimental to others. Single pulmonary function tests and single day measurements are insufficient to determine the effects of PD.

A simplified mercury switch head-control biofeedback device

A simplified mercury switch head-control device is reported. It is easily duplicated and amenable to quantitation. Advantages include simplicity and easy use at home, in school, or during therapy. Directionality of the feedback signal and visual feedback do not seem necessary to produce benefit. The results in six patients and two controls are consistent with other studies. This is the second study using mercury switches for feedback.

Pulmonary function in quadriplegia: effects of a corset

Fifteen quadriplegic patients underwent multiple pulmonary function studies performed in 2 positions, sitting and supine, and in both positions under 2 circumstances, wearing and not wearing a corset. Analysis of variance showed that 3 volumes were significantly improved (p less than 0.05) supine, especially without the corset: vital capacity (C), inspiratory capacity (IC) and tidal volume (Vt). Although most pulmonary function tests were improved when the patients were supine the trends when sitting were for improvement when wearing a corset. Most of these patients were studied at least 1 year postinjury and results are not substantially different from those 6 months postinjury. Corsets do not have an untoward effect on pulmonary function tests.

Use of the Goal Attainment Scale in the treatment and ongoing evaluation of neurologically handicapped children

Six children with multiple handicaps were treated as a pilot group by a physical therapist, occupational therapist, and a speech/language pathologist. Baseline evaluations were obtained through a compilation of traditional developmental tests. A Goal Attainment Scale technique was introduced to facilitate reevaluation of the children. The advantages of the scale were to facilitate ongoing feedback for both the professionals and the parents as well as to update specific, individualized goals in each therapeutic area. This information was also helpful to third-party payers of service. Results showed that, after an initial period of familiarization, therapists became more accurate in their expectations of progress in treatment. Therapy time spent with each child was also increased without increasing costs or preparation time for each therapist. Specifically, re-evaluation scores obtained on the Goal Attainment Scales approached a normal, expected distribution of values. The potential value of extending the system to more objectively, efficiently, and concisely display treatment results is discussed.