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It is obvious that we cannot change anything if we are not honest about what needs to be changed. We are fully aware of what stands in the way of change: powerful pharmaceutical and medical technology companies, along with other powerful groups with enormous vested interests in the business of medicine. They fund medical research, support medical schools and hospitals, and advertise in medical journals. Such funding can sway the balance of opinion from professional caution to uncritical acceptance of new therapies and drugs. You have only to look at the people who make up the hospital, medical, and government health advisory boards to see conflicts of interest. Erik Campbell, the lead author, said, "Our previous research with faculty has shown us that ties to industry can affect scientific behavior, leading to such things as trade secrecy and delays in publishing research. Marcia Angell struggled to bring greater attention to the problem of commercializing scientific research. In June 2002, the New England Journal of Medicine announced that it would accept journalists who accept money from drug companies because it was too difficult to find ones who have no ties. Jerome Kassirer, said that was not the case and that plenty of researchers are available who do not work for drug companies. Cynthia Crossen, a staffer for the Wall Street Journal, i n 1996 published Tainted Truth: the Manipulation of Fact in America, a book about the widespread practice of lying with statistics. In 1981 Steel reported that 36% of hospitalized patients experienced iatrogenesis with a 25% fatality rate, and adverse drug reactions were involved in 50% of the injuries. In 1991, Bedell reported that 64% of acute heart attacks in one hospital were preventable and were mostly due to adverse drug reactions. From the 98, 609 patients injured and the 14% fatality rate, he estimated that in the entire U. Why Leape chose to use the much lower figure of 4% injury for his analysis remains in question. Using instead the average of the rates found in the three studies he cites (36%, 20%, and 4%) would have produced a 20% medical error rate. The number of iatrogenic deaths using an average rate of injury and his 14% fatality rate would be 1, 189, 576. This may not seem like much, but Leape cited industry standards showing that in aviation, a 0. In trying to determine why there are so many medical errors, Leape acknowledged the lack of reporting of medical errors.
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The next day he moved about, listening carefully to talk of the re cently enacted 1973 Emergency Medical Services Systems Act. A half a billion dollars was the figure being bantered around with twenty million for New England alone. They had to be somewhat careful to dance on the edge of the rules, both written and unwritten. Lyle began to see the importance of this new organization with its original draftsmen in keeping information rationed and the rules unwritten. He noted the membership tables set up everywhere in the large hanger of the exhibit area extolling physicians to become members of the Academy. I think we should personally pay the annual dues of the physicians who work for us to belong to the Academy. Institutions are just the same everywhere, Boston politics, Tammany Hall, and now the party bosses of the American Academy of Emergency Physicians. The hospital admin istrators were perfect knockovers for the flimflam kitchen scheduling men eager for quick profits in this new specialty mushrooming over night. The kitchen schedulers were soon making so much money in their kitchens they would never pick up stethoscopes again. Several dropped out of lucrative ophthalmology and radiology practices just so they could make out schedules for emergency departments. Some maintained Ear, Nose and Throat practices while their wives made out the schedules on the side with their imprimatur on them. While it was true a physician could make a good living practicing medicine in an emergency room, the real bullion was in scheduling. The Rape of Emergency Medicine Page 43 Kitchen scheduling soon became the fastestgrowing specialty in medicine, a growth industry comparable to fast food or video rental stores, only the latter two had industry standards.
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In addition, many institutions promise scarce residency spots to their own medical students, who then rank the program #1 and receive that desired Match. As positions be come more competitive, this type of behavior undermines the integrity of the whole system. The two dermatology positions at a particular hospital, for example, may have already been promised to its own medical students and therefore be unavailable for the common applicant. The misleading numbers create uncer tainty and insecurity and make it very difficult for advisors to counsel their stu dents on how to obtain positions. With this greater emphasis on networking and contacts, the residency Match game has become more and more unfair. Medical students had to contact each in dividual program for a paper application, address envelopes for their letter writ ers, and drag out the old typewriter from the closet. The process was time consuming and tedious, especially for medical students applying to 20 or more programs in very competitive specialties. At first only obstetrics and gynecology par ticipated in the service, using a system based on diskettes sent in the mail. The webbased format is extremely user friendly, making it very easy to apply to multiple specialties, add or delete programs, or customize which supporting doc uments to send to each program. This ser vice is so easy to use that candidates can easily fiood the application pool with far too many unnecessary applications. Students should think carefully about limit ing the number of programs to which they eventually apply. With the click of a mouse, you can check a box and, on a whim, add more programs, particularly those you are not seriously considering. The excess applications cause the same students to receive most of the limited interview offers available for a given spe cialty, leaving others out in the cold. Realistically, very competitive specialties like orthopedic surgery and dermatology encourage students to apply to over 40 programs. Al though the process is relatively straightforward, always refer to the detailed in struction booklet provided with your token. Apply as early as possible, so you will never have to worry about individual program deadlines (which can vary). The entries can be changed at any time; an updated version is electronically sent to all programs. If you are applying to multiple specialties or preliminary programs, give it an easily recognizable title. To create multiple personal statements, just click on the New Personal Statement button.
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Review Test Directions: Each of the numbered items or incomplete statements in this section is followed by answers or by completions of the statement. While working with an international diagnosed with tuberculosis and has group ofphysicians to administer polio recently been started on a multidrug vaccines, a medical student sees several regimen that includes isoniazid. Which children with abdominal distention and of the following is the likely cause of her pale streaks in the hair and skin. In patients with chronic pancreatitis, Position and vibration sensation are deficiency of which of the followng markedly diminished, and hyperreflexia is vitamins is most likelyfi Laboratory studies, including (A) Folic acid examination of the bone marrow, reveal (B) Vitamin Bz (ribofavin) pancytopenia and other findings compatible (e) Vitamin B6 (pyridoxine) with a megaloblastic anemia. The physician should be on the (e) Homocysteine alert for which of the follOwing side effects (0) Niacin of this newly added medicationfi A 52yearold recentAsian immigrant bodies is brought to the emergency department (e) Highoutput heart failure after experiencing several convulsions. A woman from a rural Appalachian to being severely malnourished, the child community who had recently given birth is found to have bleeding gums and easy to a newborn boy at home with the aid bruisability, along with numerous poorly of a midwife now brings her infant to the healing skin ulcerations. Assuming that hospital because of continued bleeding and these findings resulted from vitamin C oozing from the umbilical stump. It is likely deficiency, what is the likely mechanism that the bleeding problem is secondary of these findingsfi A 4yearold Inuit child from northern Alaska is brought to the pediatrician because 10. An l8yearold young manwith known of concern about progressive bowing ofthe cystic fibrosis presents to the physician with legs and enlargement of the costochondral his third episode of kidney stones in the past junctions (rachitic rosary). In addition, he has begun to complain defect in this disorder is a defect in ofdifficulty seeing at night. Kwashiorkor should be distinguished from the relative deficiency of all calories, known as marasmus. Anorexia and bulimia are psychiatric eating disorders that are significantly more prevalent in developed countries. Deficiency of fatsoluble vitamins (vitamins A, D, E, and K) can occur in chronic pancreatitis due to loss of exocrine pancreas function. It should be noted that most patients with chronic pancreatitis also are alcoholics and that alcoholics often have multiple nutritional deficiencies, including lack ofwatersoluble vitamins.
