Fourth-year medical student rotations and the "pre-residency syndrome"

To assist medical students who wish to pursue a residency training program in obstetrics and gynecology in planning senior-year rotations, a questionnaire was sent to university Department Chairs. Each Chair was asked to construct a curriculum consisting of ten 4-week rotations. The respondents described a balanced general medical education consisting primarily of internal medicine, surgery, and pediatrics. Thirty percent of respondents believed these students should not take any rotations in obstetrics and gynecology, and 47% felt that one rotation in obstetrics and gynecology was sufficient. A "pre-residency syndrome" has been described in the literature, wherein fourth-year medical students take multiple rotations in the specialty in which they are seeking residency training. The majority of university Department Chairs supported a balanced general medical education during the fourth year of medical school rather than a narrow curriculum in which students take multiple electives in obstetrics and gynecology.     

Time-Line in HFEA Developments and Regulatory Challenges: 20 Years of Overseeing Fertility Practices and Research in the UK

In the wake of political upheaval, the Human Fertilisation and Embryo Authority (HFEA) has faced increasing insecurity over its future as a pivotal regulatory body of fertility practices in the UK. HFEA regulates activities by means of licensing, audit, and inspection of fertility centers and maintaining the Code of Practice, which ensures the optimum undertaking of licensed activities by fertility centers. In 2009, amendments to the 1990 Act came into force representing an amalgamation of cumulative proposals, debates, and changes in legislation, which have shaped the world of reproductive medicine. The medical world has, in many cases, adapted to righteous political and social demands, and continues to evolve at a rapid rate. The HFEA has faced many regulatory challenges and changes, and through this study, we aim to provide an overview of some of these changes, particularly those during the last 10 years and the implications that they may have had to fertility practices.     

Developmental trends in reproduction medicine

In the last few years reproductive medicine has developed into a medical research field of its own. It deals with the theoretical and practical problems of human reproduction and is characterized by close cooperation between medical and scientific specialists both clinically and in research. Far-reaching social effects arise from the application of hitherto unknown research and treatment methods. The results of research in reproductive medicine led, due to the development of effective contraceptives, to a reduced connection between sexual intercourse and reproduction, and have made possible reproduction even without sexual intercourse, by means of artificial insemination and in-vitro fertilization. These latest and most exciting developments in reproductive medicine are based on and justified by the right of every couple to a child of their own. In-vitro fertilization and related treatments, eg. gamete intrafallopian transfer, are expected to dominate the treatment of the sterile couple in future. The social effects of the new techniques in reproductive medicine nessecitate the development of ethical standpoints, in which human welfare must predominate. In the GDR, in accordance with the recommendations of the "Ethics in medicine" working group, in-vitro fertilization using gametes of the same couple is ethically accepted, as is also oocyte and embryo donation, provided they aim to fulfil a couple's wish for a child. Surrogate mothers are rejected, however. The combination of in-vitro fertilization and genetic engineering could potentially be used in the treatment of certain types of hereditary disease, but there is also the possibility of misuse.(ABSTRACT TRUNCATED AT 250 WORDS)     

Evidence-based medicine and medical databases in obstetrics and gynecology

Evidence-based medicine is a new trend in both teaching medicine and supporting the clinical decisive process, answering the clinical questions. The basis of the evidence-based medicine comprises of analysing and interpreting current and reliable medical publications concerning certain subject. The important condition, which has to be fulfilled is a possibility of an easy access to current medical information--via internet, medical publications' databases and publications themselves. It is crucial to use the proper hardware system (local net) and proper software system--tools for using evidence-based medicine. Regarding the medical research, nowadays, database systems became unavoidable. By using such a programs process of data collection, control and analysis became both easier and more reliable thanks to eliminating many "human based" errors. In following paper own experience in introducing evidence-based medicine and medical databases in the field of obstetrics and gynaecology will be presented.     

Whose child is it anyway? Resolving parent-physician conflict in the NICU setting

Much has been written on parental involvement in decision making when dealing with critically ill children, but few articles have touched upon parental refusal of treatment in noncritically ill children. What steps should be taken when a parent refuses what is generally considered "standard of care" medicine for their hospitalized child? Does medical advice outweigh parental views or wishes, and what does one do when our role as physician turns from medical expert into one of medical negotiator? The following case and discussion deal with parental refusal of conventional medical care, and how one may find peaceful resolutions to challenging situations for the ultimate good of the child.     

Work disability and invalidism of women following surgically treated genital cancer

An expert assessment of the fitness for work and vigour of women after gynaecological cancer operations has to be made by an experienced medical specialist who is well acquainted with the problem. The role of individual decisions on the basis of secure scientific knowledge gets more and more dominating with emphasis placed on the assessment of functional achievements. -Important assessment criteria are the following: stage of tumour, histology, degree of differentiation, type of therapy and possible consequences of therapy as well as psycho-social factors and elements of working medicine. In any case the consideration of individual consequences of illness and medical treatment remains the decisive criterion at the time of evaluation. -This paper should serve as guidance for the assessment of disablement/disability of women after gynaecological cancer operations in the framework of a graduated therapy concept.     

Medical tourism and reproductive outsourcing: the dawning of a new paradigm for healthcare

Medical tourism, a term that also can be used to describe medical outsourcing, is characterized by travel away from one's home region to procure treatment in another. It may take one of two forms: obligatory or elective. The former occurs when necessary treatments are unavailable or illegal in the place of origin. The latter includes elective and medically indicated procedures that, although available at the place of origin, may be delivered more quickly or in a more cost-effective manner in another location. Reproductive outsourcing is a special form of medical tourism that has quickly become an important area of present-day medicine because the changes of the last four decades have left all but the most advanced fertility centers breathless as they try to adjust their treatment protocols in effective and ethical manners. Legal and policy limitations have created a global environment where, in a rising number of instances, individuals and couples must travel elsewhere to procure fertility procedures that are unavailable back home. With low cost airfares to and from America, a growing number of "medical cartographers" have set out to map which places are the "best" (in terms of cost, effectiveness and timeliness), for what procedures, and for whom. On the other hand, physicians, legal experts and policy makers have only begun to shape how government and health care agencies should formally guide or regulate medical tourism. In doing so, a number of factors may challenge the limits of ethics, policy and legality in this most important trend in modern medicine.     

Proposal of practicing Japanese Kampo in menopausal medicine

Traditional Chinese Medicine (TCM) is now called "Kampo Medicine" in Japan. What is really needed for the treatment of human sickness and what is really wanted by sick people is medical care tailored to the particular patient, which respects the individual characteristics and personality of the patient. In Kampo medicine, therapeutic policy is determined on the basis of the physical constitution and condition of individual patients. For this reason, Kampo medicine is called "tailor-made medicine." One characteristic of Kampo medicine is that it is aimed at treating conditions preceding disease. The diagnosis system of Kampo medicine therefore includes identification of the personality of each patient and correction of its distortion, if any. Women with undefined complaints in the climacteric period often have multiple symptoms. To identify the characteristics of each patient and to provide treatment tailored to each patient, SHO diagnosis is needed. This diagnostic process is unique to Kampo medicine and is not included in modern Western medicine. Making full use of the traditional diagnostic approach of Kampo medicine, SHO is determined and the patient's condition is understood from the standpoint of Kampo medicine. Optimum treatment is then provided on the basis of such understanding of the patient and his or her illness. Kampo medicine is established as a science with art. Practicing Kampo medicine involves dealing with patients using a science with art and thus providing humane medical care to patients. Kampo medicine is thus of use to all the world.     

Complementary medicine: knowledge, use and attitudes of doctors

The recent growth in interest in the use of complementary medicine by the general public has been well reported. Health professionals, particularly nurses and midwives, are incorporating the use of complementary therapies into their practice. The medical profession is involved in the political processes affecting legislation governing complementary medicine and it is therefore important to determine the views of doctors when considering the use of complementary therapies by nurses within the health-care system. A critical review of published research studies which consider the knowledge, use and attitudes of doctors to complementary medicine is presented. These studies suggest doctors' interest in complementary medicine but they also raise a number of concerns including lack of evidence to demonstrate effectiveness, possible harmful effects, inadequate knowledge of doctors and lack of statutory regulation for most therapies. Recommendations of recent reports are outlined which attempt to address these and other issues.     

Vaginal ecosystem

The vagina is original biotype with its own ecosystem, according to medical ecology science. This ecosystem has dynamic, but very unstable equilibrium. Disturb equilibrium is known as a disbiosys. It was discussed different components of this ecosystem: morphology of vaginal walls, vaginal liquidity, lacto-acid and residental flora, "invader" microorganisms, vaginal acidity, immune processes. It was shared our own experience with medicine Polygynax, remedy of Laboratoire Innotech International (Paris, France). Polygynax has such an advantage - rapidly restore disturbed ecological equlibrium in case of bacterial vulvovaginitis, caused mainly of intestine pathogenic flora.     

Medical deresponsibilization

The medical profession is facing a serious challenge. The increase of technology, risks, and costs of modern medicine leads to the intervention of third parties within the medical decision-making process. This is particularly true in reproductive medicine, where a large part of medical activities are not curative, not linked with actual abnormalities, but preventive, and frequently oriented more to desire and convenience than to needs. These third parties belong to the fields of economics, administration, law, public opinion, mediatic power. This trend is universal, with some specific characteristics varying by country. The increased risk of litigation leads to an increase of all aspects of defensive medicine, with obvious medical, practical, economic deleterious consequences.This paper has been written according to the chapter entitled The Malpractice Crisis. A Sociologic Choice, C. Sureau, pages 289–301 in The Newborn Infant. One Brain for Life, from C. Amiel Tison, Ann Stewart Edit. Les Editions INSERM, Publ. Paris 1994. 307 pages and to the presentation given by C. Sureau in 1993 to the Committee on Ethical Aspects of Human Reproduction of the International Federation of Gynecology and Obstetrics.     

Zur Situation des 3-Säulen-Prinzipes in der Frauenheilkunde

The conclusion to be drawn from the evolution of the field of “reproductive medicine and gynaecological endocrinology” in the last 30 years in Switzerland is a positive one: within the Swiss Medical Faculties, the “principle of the three pillars” gynaecology/obstetrics/reproductive medicine and gynaecological endocrinology has been introduced with success and has proved itself. With the acceptance of the new guidelines of the postgraduate education of gynaecologists and obstetricians, including the subspecialty reproductive medicine and gynaecological endocrinology, and with the firm establishment of this subspecialty in all university clinics, this “principle of the three pillars” can be considered to definitely accepted. Today, all medical faculties possess a division (or clinic) of reproductive medicine and gynaecological endocrinology. All these divisions have their own budgets and their own research programme. The main remaining problem is the insufficient number of young specialists. However, in Switzerland, this problem is common to all fields within medicine. It is the consequence of a planning error made by the Swiss State. The main reasons for this difficult situation are: (1) an unnecessary numerus clausus for the admission to the medical schools, (2) the (in itself justified) reduction of the maximal working hours for hospital doctors without sufficient compensation by the creation of new jobs and (3) an increased demand for part-time jobs, linked to an increased attraction of our speciality for female doctors.     

The law and congenital malformations

In 1967, I indicated that the number of lawsuits involving malformed infants seemed to be increasing, not realizing that the increase was foretelling an epidemic. The reasons for this epidemic are described in this paper and are due to attitudes and happenings in the medical, legal, and lay sectors of our society. Case histories have been used to demonstrate that the litigation process can produce pain and suffering. The case histories also indicate that, when the members of family become orchestrated by a lawyer into the position of devoting a great deal of their energy to litigation, many high priority family responsibilities are ignored and important ethical standards are distorted. To win at all costs may be good for a football team, but it is obviously bad for a family. We must take drastic changes in the method of supporting the victims of disease and injury so that litigation is no longer necessary to compensate and support patients and families, whether negligence is or is not a factor. Recommendations for diminishing the malpractice crises include: education of the patient about the consequences of the litigation process--that only a small portion of the malpractice premium dollar ever reaches the patient and that most human malformations are not produced by medical negligence, altering the deteriorating image of the physician, reversing the increase in irresponsible medical expert testimony and changing the laws pertaining to medical licensure and loss of medical licensure, improving the health care system, making the awards more realistic by taking into consideration community and insurance resources of the patient and by eliminating lump sum awards and "punitive" awards, decreasing lawyer representation in legislative bodies so that legal reforms will become a possibility, and eliminating the contingency fee system by replacing it either with legal insurance so that the attorney is working for the patient or by adopting no-fault malpractice insurance with binding arbitration so that the negligently injured patient is compensated properly. The process of litigation rarely solves the patient's problems and frequently develops into a disease all its own.     

Codes of perinatal ethics: an international perspective

The research on different aspects of perinatal medicine offers valuable avenues into developmental biology and medicine that could markedly improve therapy of the pregnant patient and premature and newborn babies. Research with all sources of human cell stems should be supported to provide new therapeutic modalities. This research should be regulated, peer reviewed, and ethically controlled. The range of ethical questions raised by new scientific achievements in the life science, and methods of taking care of women's health especially, have been debated by international political and professional bodies. Biomedical ethical issues, guidelines, principles, and regulations cut across national boundaries and often have universal implications. Although cultures differ, certain values are common to all. In this context, the most important value is respect for human dignity, and this should not be negotiable. The establishment of international and interdisciplinary forums in which scientists and lay people can exchange views on topics of immediate concern, unhampered by administrative, political, or other considerations, was needed. They are intended especially for the discussion of the scientific and technical bases of advances in biology and medicine and other related areas and their social, economic, ethical, administrative, and legal implications. Commissions appointed by institutions, governments, and international bodies serve to alleviate the medical profession from making ethical decisions and to protect human subjects from any harm. The deliberations of these committees are usually followed by guidelines of operation, which in many cases have become abiding law. For these committees to be of full advantage, they must convene promptly as issues arise so as not to delay medical advances from being implemented.     

Thomas Mann's last novella "The Black Swan": the tragic story of a post-menopausal woman

In this work, Mann describes the tragic story of a post-menopausal woman who notices signs of rejuvenation in herself and what she takes to be menstruation, and thus believes that her much mourned lost youth has returned, whereas in fact the changes she has so welcomed are due to the hormonal effects of an advanced estrogen-producing granulosa cell tumor of the ovary, to which she rapidly succumbs. Mann was fascinated by the cruelty of the "deadly hoax" played by nature in such cases. The article outlines the story and medical background, and describes Mann's preparatory research and his comments on the subject matter.     

Highlights from the history of sexual medicine

IntroductionToday, we have a clear concept of sexual medicine and how to define this medical discipline. But historically, the unification of sexuality and medicine was not a given condition. Medicine was mainly focused on human reproduction and how to prevent and treat sexually transmitted diseases. Hardly any other aspect would have met the interest of medical doctors for centuries.MethodsHistorical review that can only highlight developments and milestones of sexual medicine and is not intended to be encyclopedic.ResultsPerhaps, the first true medicalization of sexuality was the dreadful anti-masturbation campaign led by doctors, beginning with Tissot, since the middle of the 18th century. In the 2nd half of the 19th century, first pioneers like the physician Paolo Mantagazza were systematically addressing issues related to human sexuality. This highly developing scientific field and medical community were destroyed after 1933 by the political influence of the national socialists in Europe. After World War II, a new era started with the works of Alfred Kinsey and other sexologists mainly in the United States of America.ConclusionsThe term sexual medicine was established around 1970, most likely in Europe, and subsequently resulted in a new worldwide academic and clinical speciality. Schultheiss D, and Glina S. Highlights from the history of sexual medicine.     

Awareness of the effects of postponing motherhood among hospital gynecologists: is their knowledge sufficient to offer appropriate help to patients?

Purpose

The aim of this study is to ascertain the awareness of hospital gynecologists about the effects of woman’s age on spontaneous fecundity and on the efficacy of assisted reproduction techniques (ARTs).

Methods

One hundred fifty-six gynecologists working in public or private Italian hospitals, without specific experience in reproductive medicine and ART, were administered a multiple-choice answer questionnaire addressing (a) the effect of age on woman’s spontaneous fecundity, (b) the tools to estimate the ovarian follicular reserve, and (c) the outcome of ART in women above 40 years.

Results

Approximately half of the interviewed gynecologists indicated the woman’s age limit for successful reproduction between 44 and 50 years; fertility lifespan was believed to be prolonged by oral contraception, pro-fertility medical treatments, or ART. The correct meaning of serum FSH measurement was known by approximately one third of the interviewed doctors. The effectiveness of ART for women of advanced age was overestimated by half of the gynecologists, especially in case of patients having regular cycles and/or small follicles at ultrasound.

Conclusions

Overall, the survey clearly showed that the knowledge of hospital gynecologists about the effects of age on woman’s fertility and ART effectiveness is largely insufficient to offer scientifically correct, helpful information to patients. Properly targeted corrections to academic and periodical educational programs for Ob/Gyn specialists are warranted.

     

Risikomanagement in der Geburtshilfe – Zertifizieren reicht nicht

The book To Err is Human in 1999 changed the world of risk management in medicine forever. After Brennan and Leape’s Harvard medical practice study in 1991 (the first major publication where all aspects of preventable adverse events in medicine were discussed in detail), preventable errors in medicine started to become a focus of interest. It is common knowledge today that human error caused by precipitating environmental factors is involved in about 70% of all accidents in all industries, including health care. Helmreich, a psychologist and pioneer in error management, wrote in one of his papers:“Error results from physiological and psychological limitations of humans. Causes of error include fatigue, workload, and fear as well as cognitive overload, poor interpersonal communications, imperfect information processing, and flawed decision making”. Effective error management is based on understanding the nature and extent of human error. However, it is still the case that the consequences of errors in medicine often trigger the“shame and blame” reaction towards the individuals involved in the case. The nurse or doctor at the end of the chain of events is found guilty for committing the error and for the adverse clinical outcome. While medical skills are the basis of medical success, the NOTECHS (non-technical skills) are mandatory in preventing catastrophic events due to the“human factor”. This article highlights risk management strategies that must be implemented and trained in education and practice of all personnel in the labour ward if we would like to reduce patient harm effectively.     

Medical Education in the New Millennium. Medical Informatics,Evidence-based Medicine,Self-directed Learning and the K.O.A.L.A.© Programme

Medical education has changed drastically in recent years in response to political, social and economical pressures. The information age, increasing accountability and fiscal restraint are causing physicians and medical educators to re-examine the way they practise and teach medicine.No longer is a core curriculum of basic and clinical sciences sufficient to produce physicians competent to practise in contemporary society. Additional skills are required for the new millennium. These skills broach the fields of medical informatics, evidence-based medicine and self-directed teaming. The challenge for medical education, in these times of shrinking financial and human resources, is how to incorporate these new skilk into the culture of resident training programmes.The Computerized Obstetrics and Gynaecology Automated learning Analysis (K.O.A.L.A.©) programme, a computerized, Internet-based, teaming portfolio, allows residents to document cases/patient encounters and critical incidents of teaming. Through the identification of these incidents and access to immediate on-line resources, this unique teaming tool encourages residents to be learners for life, to apply the rules of evidence to medical practice, and it also cultivates computer literacy, promoting essential skills for the new millennium.