JAMA. 2003;289:2709-2716.
Researchers, clinicians, and policy makers face 3 challenges in writing about race and ethnicity: accounting for the limitations of race/ethnicity data; distinguishing between race/ethnicity as a risk factor or as a risk marker; and finding a way to write about race/ethnicity that does not stigmatize and does not imply a we/they dichotomy between health professionals and populations of color. Josurnals play an important role in setting standards for research and policy literature. The authors outline guidelines that might be used when race and ethnicity are addressed in biomedical publications.
JAMA. 2005;293:1367-1373.
The discovery of RNA interference (RNAi), an endogenous cellular gene-silencing mechanism, has already provided a powerful tool for basic science researchers to study gene function. The subsequent finding that RNAi also operates in mammalian cells has generated excitement regarding potential therapeutic applications. In this article we discuss the basic mechanism of RNAi and the therapeutic opportunities and obstacles for harnessing RNAi for therapy of human disease.
JAMA. 2002;288:1097-1101.
Since family practice was first recognized as a specialty in the late 1960s, considerable intellectual and organizational change has occurred in medicine, especially during the 1990s. To reflect on and reconsider the role of family practice in US health care, this article reviews the development of family practice as a specialty, provides a current assessment of the status of family medicine in the United States, and comments on issues that are of ongoing importance to family practice.
JAMA. 2002;288:1775-1779.
The chronic care model is a guide to higher-quality chronic illness management within primary care. The model predicts that improvement in its 6 interrelated components—self-management support, clinical information systems, delivery system redesign, decision support, health care organization, and community resources—can produce system reform in which informed, activated patients interact with prepared, proactive practice teams. Case studies are provided describing how components of the chronic care model have been implemented in the primary care practices of 4 health care organizations.
JAMA. 2003;290:2470-2475.
Pain is a complex clinical problem. Assessment depends on verbal report, and the patient's physical perceptions may be modified by cognitive and affective factors. The salience of pain as a problem in its own right has grown since 1945 and new therapeutic alternatives have developed from research and from new theoretical perspectives. This short historical review of the highlights of the history of pain management gives particular emphasis to the 20th century and to chronic and cancer pain.
JAMA. 1998;279:864-869.
In July 1996, Tennessee initiated a managed mental health and substance abuse program called TennCare Partners. This publicly funded "carve-out" experiment started chaotically and soon deteriorated into a crisis. Many patients did not receive care or lost continuity of care, and the traditional "safety net" mental health system nearly disintegrated. This qualitative case study sought to ascertain the impact of the TennCare Partners program. It points out that the program's difficulties stemmed directly from a flawed design that spread funds previously earmarked for severely mentally ill patients across the entire Medicaid population. States contemplating similar reforms should strive to protect vulnerable patients by risk-adjusting capitation payments and by focusing resources on care for severely mentally ill persons. States should also minimize program complexity and ensure the accountability of managed care networks for their patients' behavioral health care needs.
JAMA. 2002;288:889-893.
This article—the first in a series on primary care—outlines the daunting challenges facing primary care today. Most people in the United States desire a primary care "home" to provide for and coordinate their health care needs. Yet primary care is endangered by physician stress, inadequate performance in managing chronic illness, and inability to provide prompt access and reliable continuity of care. Fundamental redesign is needed to improve access to and quality of care while easing physicians' workload without causing major increases in health care costs.
JAMA. 2005;294:2618-2622.
The National Institute for Health and Clinical Excellence (NICE) was established as a part of the British National Health Service in 1999 to set standards for the adoption of new health care technologies and the management of specific conditions. In doing so it was required explicitly to take into account both clinical effectiveness and cost-effectiveness. This article describes how NICE has responded to the challenge and considers whether its experience of balancing quality, innovation, and value for money holds policy lessons for the United States.
JAMA. 2002;287:2765-2767.
The aim of medical research is to advance scientific knowledge and hence—directly or indirectly—lead to improvements in the treatment and prevention of disease. Each research project should continue systematically from previous research and feed into future research. Each project should contribute beneficially to a slowly evolving body of research. A study should not mislead; otherwise it could adversely affect clinical practice and future research. In 1994 I observed that research papers commonly contain methodological errors, report results selectively, and draw unjustified conclusions. Here I revisit the topic and suggest how journal editors can help.
JAMA. 2005;294:1083-1087.
Because of the traditional subordination of education to service, graduate medical education (GME) in the United States has never realized its full educational potential. This article suggests 4 strategies for reasserting the primacy of education in GME: limit the number of patients house officers manage at one time, relieve the resident staff of noneducational chores, improve educational content, and ease emotional stresses. Achieving these goals will require regulatory reform, adequate funding, and institutional competency in the use of educational resources. Modern medicine grows ever more complex. The need to address the deficiencies of GME is urgent.
JAMA. 2000;284:1284-1289.
The growth of specialization in graduate medical education (GME) and physician practice continues at a rapid rate, generating increasing national attention. Although the major educational, accrediting, and certifying bodies have mechanisms for approving new areas of study and practice, the results of their efforts have not been consistently congruent. This article presents information about GME since the beginnings of its standardization and accreditation in the early 20th century, its growth during and following World War II, and the variations among accredited specialties and subspecialties, certificates, and self-designated practice areas that have resulted from this long period of unstructured growth.
JAMA. 2003;290:98-104.
Predicting survival and disclosing the prediction to patients with advanced disease, particularly cancer, is among the most difficult tasks that physicians face. With the de-emphasis of prognosis in favor of diagnosis and therapeutics in the medical literature, physicians may have difficulty finding the survival information they need to make appropriate estimates of survival for patients who develop cancer. Quite separate from the challenge of estimating survival accurately, physicians may also find the process of disclosing the prognosis to their patients difficult. Using the vignette of a real patient with advanced cancer who far outlived her physician's prognostic estimate, we discuss clinical issues related to the science of prognosis in advanced cancer and the art of its disclosure.
JAMA. 2005;294:1260-1267.
Tumor-induced osteomalacia (TIO) is a rare paraneoplastic form of renal phosphate wasting that results in severe hypophosphatemia, a defect in vitamin D metabolism, and osteomalacia. This debilitating disorder is illustrated by the clinical presentation of a 55-year-old woman with progressive fatigue, weakness, and muscle and bone pain with fractures. After a protracted clinical course and extensive laboratory evaluation, tumor-induced osteomalacia was identified as the basis of her clinical presentation. In this article, the distinctive clinical characteristics of this syndrome, the advances in diagnosis of TIO, and new insights into the pathophysiology of this disorder are discussed.
JAMA. 2004;292:1474-1479.
Many 21st-century observers explain international efforts to control infectious diseases as a function of globalization and recent transformations in international commerce, transportation, and human migration. However, these contemporary global health initiatives can be more fully understood by also exploring the origins of international health organizations and regulations, which were initially dedicated exclusively to stemming the tide of infectious epidemics. This article reviews 3 eras of international approaches to controlling infectious diseases (1851-1881, 1881-1945, and 1945 to the present) and concludes by assessing how nations have a strong fiscal and humanitarian incentive to invest in infectious disease control programs and infrastructures in and beyond their own borders.
JAMA. 2002;288:1909-1914.
This article reviews research evidence showing to what extent the chronic care model can improve the management of chronic conditions (using diabetes as an example) and reduce health care costs. Thirty-two of 39 studies found that interventions based on chronic care model components improved at least 1 process or outcome measure for diabetic patients. Regarding whether chronic care model interventions can reduce costs, 18 of 27 studies concerned with 3 examples of chronic conditions (congestive heart failure, asthma, and diabetes) demonstrated reduced health care costs or lower use of health care services. Even though the chronic care model has the potential to improve care and reduce costs, several obstacles hinder its widespread adoption.
JAMA. 2005;293:855-862.
Molecular imaging is an emerging field that aims to integrate patient-specific and disease-specific molecular information with traditional anatomical imaging readouts. The information provided by this field may ultimately allow for noninvasive or minimally invasive molecular diagnostic capabilities, better clinical risk stratification, more optimal selection of disease therapy, and improved assessment of treatment efficacy. In this update, we first provide an overview of clinically relevant molecular imaging technologies and imaging agents. Next, their applications to disease detection, drug discovery, and biomedical research are discussed. To specifically demonstrate the potential of molecular imaging, we highlight recent advances in clinical and preclinical molecular imaging of cancer and atherosclerosis.
JAMA. 2005;294:1380-1384.
Health-related research in the United States is funded by US citizens, either as taxpayers or as consumers. Public support is critical to the success of the research enterprise, and it is essential for stakeholders in research to pay attention to the public’s views about the investment level in research and the nature of its conduct, as well as to understand the public’s level of awareness and opinions about research to improve health. This article reviews key results from surveys concerning public attitudes and perceptions toward health-related research. Collectively, these data demonstrate that Americans rate research as a high national priority, and they strongly support greater investment by public and private funders.
JAMA. 2002;287:875-881.
Palliative care services provide secondary and tertiary levels of palliative care, the interdisciplinary care of patients in which the goal is comfort and quality of life. Primary palliative care refers to the basic skills and competencies required of all physicians and other health care professionals. Secondary palliative care refers to the specialist clinicians and organizations that provide consultation and specialty care. Tertiary palliative care refers to the academic medical centers where specialist knowledge for the most complex cases is practiced, researched, and taught. The case of Reverend J, a man with advanced cancer admitted to an acute palliative care unit in a teaching hospital, illustrates the use of secondary and tertiary clinical palliative care services in hospitals and health care systems.
JAMA. 1998;280:659-664.
The French health care system combines a strong tradition of autonomous private practice with nearly universal health care coverage through the social security system. The French state's responses to rising health care expenditures have included limitation of the number of medical students, control over physician fees, rules to prohibit certain clinical practices, experiments with generalist physicians coordinating care and access to specialists, and collective physician responsibility for expenditures beyond the health care budget. The failure of physicians' protests, including a strike of French residents and fellows in 1997, may signify the end of traditional private practice in the face of France's statist version of managed care.
JAMA. 2004;291:599-604.
The use of complementary and alternative medicine (CAM) has grown dramatically in recent years, as has research on the safety and efficacy of CAM treatments. Minimal attention, however, has been devoted to the ethical issues relating to research on CAM. We argue that public health and safety demand rigorous research evaluating CAM therapies, research on CAM should adhere to the same ethical requirements for all clinical research, and randomized, placebo-controlled clinical trials should be used for assessing the efficacy of CAM treatments whenever feasible and ethically justifiable. In addition, we explore the legitimacy of providing CAM and conventional therapies that have been demonstrated to be effective only by virtue of the placebo effect.