In 1987 the Office of Technology Assessment (OTA), a late research arm of Congress, set to work on a report about cancer treatments that lie outside standard care. The OTA mulled over a number of terms for these treatments, none of which satisfied proponents and critics of non-standard approaches.

When the OTA published this report in 1990, under the title Unconventional Cancer Treatments, the introduction recalled efforts to come up with a single descriptor for the wide variety of therapeutic approaches surveyed.

“Unconventional’ is just one of the many terms, all imperfect descriptors, that were considered,” the Introduction said. It went on: “Other terms used by proponents to describe all or some of these treatments include: alternative, complementary, non-toxic, holistic, natural, noninvasive. Those used by the sharpest of critics include: unproven, questionable, dubious, quackery, and fraudulent.”

Sensitized by the bitter protests from proponents and critics over terms, the OTA noted: “We intend no implicit message in the use of the word ‘unconventional’; it was chosen with the hope that debate engendered by this report could center not on that word, but on the issues themselves.”

Like size, terminology matters at times–instrumentally. The terms in common use for therapeutic approaches developing beyond the domains of established institutions have long hampered unbiased evaluation and acceptance of outlier treatment. For instance:

Mainstream grants for research hardly ever go to “unorthodox” clinicians. Medical centers that have recently added integrative programs virtually exclude “alternative” therapy. Insurers routinely turn thumbs down on reimbursement for “unproven” treatment. The FDA continues to require developers of pharmaceuticals, fitting any of the terms just cited, to jump through more than the normal number of evidentiary hoops for marketing approval. Most state boards that discipline physicians for unprofessional conduct reflexively grab a noose when “unconventional” doctors fall into their hands. The media, covering doctors charged with departing from community practice (i.e., venturing beyond standard care), seldom bother to distinguish “bad” deviants (real quacks) from the “good” (whose treatments show effectiveness); they indiscriminately lump the latter under one of the above terms.

Decades from today, medical historians may view publication of the OTA report as a watershed event, not only for non-standard cancer therapy but for all forms of health care that depart from the entrenched approaches.

Government attacks against a broad range of “unconventional” therapies marked the 1980’s. Speaking solely about cancer, in the mid-80’s the Bahamian government, the FDA, and the state medical board in New York, the Office of Professional Medical Conduct (OPMC), acted respectively against three prominent “unconventional” therapists: Lawrence Burton, PhD; Stanislaw Burzynski, MD, PhD; and Emanuel Revici, MD.

All three therapists had pioneered treatments the mainstream oncology community regarded as unproven, despite publications of their scientific findings in peer-reviewed journals and extraordinary numbers of patients reporting improvement. Burton had developed a therapy for tumors utilizing immunological factors from blood. Burzynski had extracted peptides from urine, calling them “antineoplastons,” which produce beneficial results in human patients with negligible toxicity. Revici had discovered lipidic substances active against cancer generally, among them omega 3 fatty acids derived from fish oil and selenium compounds that can be given in high doses with little toxicity. Crucially, independent confirmation of the efficacy of the treatments originated by all three “unconventional” therapists had begun to filter into the research literature.

Robert G. Houston offers a reliable account of the early course of these actions in Repression and Reform in the Evaluation of Alternative Cancer Therapies, a monograph in support of non-standard treatment, published in 1987 and updated in 1989. Houston is a research specialist whose articles and letters on alternative medicine have appeared in leading journals and the popular press over the past 35 years.

Because the details he presents are too numerous for this column, I’ll summarize the actions and outcomes here. As liaison for Revici and his patients during their OTA project, an official reviewer of its report, the lay authority on Revici’s life and medical breakthroughs, and a privileged observer of pivotal developments in alternative and mainstream medicine from 1984 to the present, I’m well acquainted with the complete record of attacks on “unconventional” oncologists.

The OPMC initiated proceedings to revoke Dr. Revici’s medical license in January 1984, charging him in three cases with fraud, gross negligence, and gross incompetence (among other charges). The final determination in this proceeding, in July 1988, revoked his license but stayed the penalty, placing him on probation for 5 years.

Clinical Quiz questions are based on selected articles in this issue. Answers appear in this issue.

American Family Physician has been approved by the American Academy of Family Physicians as having educational content acceptable for Prescribed credit hours. Term of approval covers issues published within one year from the beginning distribution date of December 2001. This issue has been approved for up to 3 Prescribed credit hours. Credit may be claimed for one year from the date of this issue.

The American Academy of Family Physicians is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The AAFP designates this educational activity for a maximum of 3 hours in Category 1 credit toward the American Medical Association Physician’s Recognition Award. Each physician should claim only those hours of credit that he or she actually spent in the educational activity.

AAFP Credit

Each copy of AFP contains a Clinical Quiz answer card. AAFP members may use this card to obtain the designated number of Prescribed credit hours for the year in which the card is postmarked.

AMA/PRA Category 1 Credit

AAFP members who satisfy the Academy’s continuing medical education requirements are automatically eligible for the AMA/PRA.

Physicians who are not members of the AAFP are eligible to receive the designated number of credit hours in Category 1 of the AMA/PRA on completion and return of the Clinical Quiz answer card. AFP keeps a record of AMA/PRA Category 1 credit hours for nonmember physicians. This record will be provided on request; however, nonmembers are responsible for reporting their own Category 1 CME credits when applying for the AMA/PRA or other certificates or credentials.

For health care professionals who are not physicians and are AFP subscribers, a record of CME credit is kept by AAFP and will be provided to you on written request. You are responsible for reporting CME hours to your professional organization.

NOTE: The full text of AFP is available online (http://www.aafp.org/afp), including each issue’s Clinical Quiz. The table of contents for each online issue will link you to the Clinical Quiz. Just follow the online directions to take the quiz and, if you’re an AAFP member, you can submit your answers for CME credit.

Instructions

(1) Read each article, answer all questions on the quiz pages and transfer your answers to the Clinical Quiz answer card (bound into your copy of AFP). This will help you avoid errors and permit you to check your answers against the correct answers.

(2) Mail the Clinical Quiz answer card within one year (by December 31, 2002). The bar code on the answer card contains your identification for CME credit hours.

Before beginning the test, please note:

Each Clinical Quiz includes two types of questions: Type A and Type X.

Type A questions have only one correct answer and may have four or five choices. Here is a typical Type A question:

Q1. Most allergic reactions to foods are:

[ ] A. Due to IgA deficiency.
[ ] B. Due to IgG and IgM antibodies.
[check] C. IgE-mediated.
[ ] D. Due to enzyme deficiencies.
[ ] E. Due to toxins.

Type X questions may have one or more correct answers. They are multiple true-false questions with four options. Here is a typical Type X question:

Q2. Causes of varicosities in pregnancy
include:
[check] A. Hormonal changes.
[check] B. Venous compression.
[check] C.  Familial tendency.
[check] D. Prolonged sitting and standing.

Clinical Quiz questions are written by the associate and assistant editors of AFP.

ATLA’s Professional Negligence Law Reporter includes a broad range of medical negligence cases. Here are examples of the kinds of cases appearing in each issue of PNLR.

New Jersey consumer fraud statute inapplicable to learned professionals

The New Jersey Supreme Court held that the state’s Consumer Fraud Act (CFA), N.J. Stat. Ann. §§ 56:8-1 et seq., does not apply to the actions of learned professionalssuch as doctors and lawyers-acting in their professional capacities.

Verdict for a man who has numbness below the knees in both legs, necessitating that he use a wheelchair, after undergoing surgery to remove a cyst on his spine. He and his wife sued the osteopath who performed the surgery, alleging that plaintiff’s true condition-peripheral neuropathy-had not warranted the surgery. Plaintiffs also contended that defendant had negligently performed the procedure by piercing plaintiff’s dura with a surgical instrument. * Wil H. Florin and “Thomas D. Roebig Jr., both of Palm Harbor, Fla., represented plaintiffs.

Vann v. Webb, Fla., Pinellas-Pasco County Cir. Ct., No. 01-008 711CI-015, Feb. 6, 2004.

Failure to perform proper vascular surgery

Verdict for a woman who suffered paraplegia and later required amputation of her right leg after undergoing emergency surgery to restore blood flow to her legs following an aortic dissection. She and her husband sued a vascular surgeon, alleging he had (1) not performed the surgery that had been consented to and (2) failed to ensure that blood flow had been restored to the woman’s legs after the procedure. “Stephen Schaefer, Southfield, Mich., represented plaintiffs.

Miller v. Berg, Mich., Wayne County Cir. Ct., No. 02214453NH, Feb. 5, 2004.

Failure to diagnose tonsil cancer

Verdict for the estate of a man who died after being diagnosed as having Stage IV tonsil cancer. His estate filed suit against several internists, alleging failure to timely diagnose the cancer or refer the man to a specialist despite suspicious symptoms that included one swollen tonsil and lymph node. * Jorden Pederson, Hoboken, N.J., represented plaintiff in this case.

Rivera, v. Shah, N.J., Hudson County Super. Ct., No. HUD-L-1329-01, Oct. 1, 2003.

Failure to diagnose, treat preterm labor

Verdict for the parents of a child who died after being delivered during the 30th gestational week. The parents sued an obstetrician, alleging failure to diagnose and treat preterm labor and order a timely cesarean section. Steven T. Horton, Oklahoma City, Okla., represented plaintiffs in this case.

Davis v. Sanger, Okla., Oklahoma County Dist. Ct., No. CJ-2001-1395-63, Oct. 2, 2003.

Comment: For another case involving failure to diagnose preterm labor, see Karney v. Arnot-Ogden Mem’l Hosp., 40 ATLA L. Rep. 140 (May 1997). * David S. Pollack, Garden City, N. Y., represented plaintiff in this case. Documents in this case are available through the Court Document Sets section in the back of this issue, courtesy of Mr. Pollack.

Use of unsterilized surgical instruments during face lift

Verdict for a woman who suffered cosmetic deformity and required additional surgeries after undergoing a face lift performed by a plastic surgeon. The woman and her husband sued the surgeon, alleging he had used unsterilized instruments during the surgery and had an insufficient protocol for sterilizing tools. * Frank D. Allen, Haddonfield, N.J., represented plaintiffs.

Hayes v. Cha, U.S. Dist. Ct., D.N.J., No. 00-CV-1101, Dec. 8, 2003.

Wrongful cancer diagnosis

Verdict for a man who suffered incontinence and erectile dysfunction after undergoing treatment for aggressive prostate cancer. After learning the diagnosis had been a mistake, he and his wife sued a pathologist and a laboratory for the negligence of its histologist. The couple claimed that the wrongful diagnosis resulted from the misplacement of another patient’s biopsy tissue onto the man’s slide, and that the pathologist had failed to compare the tissue on the slide with a written description of the man’s tissue.

The Boston Home–a historic residence in Dorchester, Massachusetts, that sits high on a hill among the neighboring triple-decker houses–is a not-for-profit long-term nursing care facility that is home to adults with multiple sclerosis and other progressive neurologic diseases. Dorchester is a part of Boston with a history as old as America, and The Boston Home is part of the fabric of that community. It was the founders’ mission that our residents would maintain an active role in the community and not be shut off from the outside world. We strive to meet this goal by hosting events that welcome neighbors into our home and encouraging volunteers to spend time with our residents.

Our service model includes exceptional clinical care, as well as services that address the physical, psychosocial, recreational, and spiritual needs of our residents. As the only facility of its kind in New England and one of only a few in the country, The Boston Home has created a “home healthcare” model in which our nursing staff helps residents to maintain independence.

In all of this, and more, assistive technology plays a key role. The Boston Home has been a pioneer in assistive technology, and we were eager to adopt these advanced systems to raise the bar in boosting residents’ comfort, convenience, and control.

Celebrating Advanced Technology

Recently, we invited the community to help us celebrate a major building renovation and expansion that integrated technology into our residential community. Our upgrades include wireless elevator and door access*, which give residents hands-free control of their environment. The renovation also added overhead lifts* to each room to efficiently transport residents, freeing staff to spend more time providing care. We added new patient rooms, as well as new and expanded areas for group activities.

[FIGURE 1 OMITTED]

Our renovation plan was the result of an initiative of our board of trustees’ Strategic Planning Committee, whose objective is to establish The Boston Home as a center for excellence in clinical and residential services. Committee members met with trustees, staff, and building experts during an 18-month planning period. In addition to adhering to a tight budget, the most important challenge members faced was to maintain the same level of resident care throughout the two-year building process. To ensure that resident care wasn’t disrupted, the committee set up meetings between the build-out team and resident representatives to address concerns and update residents as the project progressed.

When reviewing the budget, we determined which new technology applications would help to maximize our residents’ comfort and control in their wheelchairs. We use terms like “functionality” and “mobility” when discussing assistive technology, but we consider technologies that help nurture the mind and spirit, as well. We embrace a philosophy that looks at the “bigger reality” for people who must deal with chronic disabilities. We put much thought and energy into finding technologies that would positively affect our residents’ well-being.

Promoting Independence

Our wireless elevator and door access system allows residents to travel independently from floor to floor. The elevator uses radio frequency identification (RFID) technology–a tag attached to the wheelchair enables the unit to receive and respond to radiofrequency queries from a transceiver. The long-range RFID reader is capable of reading tags from a distance of 9 to 11 feet. The tag automatically sends a signal to call the elevator when the resident approaches. Our residents have hands-free freedom to attend classes, socialize in the Cyber Cafe (figure 1), and visit other residents without staff assistance. The tag also opens our facility’s back door, which leads to a serene garden area complete with a goldfish pond (figure 2).

[FIGURE 2 OMITTED]

We use an overhead lift system consisting of a mechanism and a sling that descends from a ceiling track, ready to raise, lower, and move the resident to and from bed, wheelchair, physical therapy mat, and shower chair (figure 3). In addition, residents are transferred in a sitting position, which means that less physical maneuvering is required, saving time and reducing the risk of injury to both residents and staff. Because of the efficiency of this overhead lift, aides can spend more time providing care, an important consideration since many residents have complex medical conditions, and aides need every moment to attend to them. This creates a more rewarding environment for our nursing staff, leading to high retention rates.

Our facility is also home to a host of hands-free equipment in addition to wheelchairs, including computers and environmental controls for beds, nurse call devices, phones, and TVs. According to Don Fredette, our assistive technology specialist, also known as “the wheelchair doctor” at The Boston Home, “These systems make a resident’s wish technology’s command.”

A recent voluntary survey of 410 personnel from the U.S. Armed Forces Medical Departments and the Public Health Service indicated that humanitarian service experience has positive effects on recruitment and retention: 48% of respondents indicated that the opportunity to provide humanitarian service was a factor in their decision to join a uniformed service and 62% indicated that humanitarian service opportunities positively influenced their decision to remain in uniform. Humanitarian service requirements were a disincentive to remain in uniform for 25%. Pending further study, these preliminary implications can be applied to personnel policies and programs to recruit and retain uniformed health care professionals.

Although the original project did not include recruitment and retention aspects, information from humanitarian after action reports and interviews suggested that humanitarian experiences profoundly affected some personnel, prompting the survey.1

Study Design

Uniformed health care personnel of many specialties voluntarily completed anonymous, short surveys about whether humanitarian service opportunity influenced their joining or remaining in uniform (i.e., recruitment and retention). Surveys were circulated in the fall of 2001 via personal contact and e-mail to individuals, at professional conferences, in newsletters, on the internet, and to units, including the medical student body of the Uniformed Services University of Health Sciences. A variant of the questionnaire also asked about the effect of humanitarian service on professional development, morale, and esprit de corps. Responses, collected through late winter of 2002, included 158 Navy, 105 Army, 64 Air Force, 79 Public Health Service, and 4 unspecified persons, 410 people in all. Respondents ranged from junior personnel on initial tours to senior officers who had led humanitarian missions. Two hundred thirty-one cited previous humanitarian experience(s).

Respondents included officer and enlisted health care and other professionals, including nearly 100 physicians and 79 Uniformed Services University of Health Sciences (USUHS) medical students. Respondents also included nurses, veterinarians, environmental health officers, dentists, laboratory technicians, radiation health officers, entomologists, epidemiologists, pharmacists, health care administrators, and other health care specialties. Veterinarians, ophthalmologists, and Navy family practice physicians were strongly represented, likely because of their frequent humanitarian deployment and/or the varying coverage of survey distribution.

Surveys elicited positive, negative, or no effect replies, as well as free-text comments. Because of the small, nonrandom sample, service comparisons are not made: humanitarian service seemingly similarly affects recruitment and retention across services, specialties, and ranks, although further study is needed. Study limits include the small sample size, retrospective nonrandom survey, and possible selection bias, as humanitarian participants (231) may have been more inclined to respond than those without humanitarian experience (179).

Results and Discussion

Recruitment

Among 410 Army, Navy, Air Force, and Public Health Service health care personnel, 198 or 48% reported being influenced to join, in part, by humanitarian service opportunity (Table I). This estimate is perhaps conservative, as respondents included comments such as, “DoD didn’t do ‘humanitarian assistance’ when I joined 17 years ago.” In this small survey, the recruitment effect was pronounced among USUHS students; 67 of 79 (85%) indicated humanitarian service opportunity influenced them to join. Other USUHS responses included seven “no effect” responses and four negative responses, the latter citing lengthy family separations.

Retention

Providing humanitarian care can positively or negatively affect retention of uniformed health care professionals (Table II). Overall, 254 (62%) of 410 cited humanitarian service as positively influencing their decision to remain in uniform. Negative retention effects were reported by 98 and 58 replied “no effect” or no answer.

Professional Development and Espirit de Corps

Some questionnaires (241 of 410) also inquired about other aspects of humanitarian service. Reportedly, 44% of respondents sought additional assignments or opportunities in humanitarian relief; 48% felt that humanitarian service had changed or expanded their professional and military interests; 56% cited positive effects on morale, “Esprit de corps,” or attitude; and 61% affirmed humanitarian service as a positive experience. As in recruitment and retention, the potential for humanitarian service to influence professional development warrants further study.

Humanitarian Experience

As a result of the small nonrandom sample, it is not known whether the high rate of humanitarian service experience (231 of 410) is representative. According to the survey, 39% of USUHS respondents had previous humanitarian experience, either from previous military service or with civilian organizations, including faith-based, private volunteer, or international organizations such as the World Health Organization, Amnesty International, and Doctors Without Borders. Some respondents expressed strong interest in humanitarian service, using the survey to volunteer for humanitarian missions “anytime, anywhere,” often expressing, “This is why I joined.”

Food and exercise are powerful tools in diabetes control. Before the discovery of insulin, nutrition therapy was the treatment for diabetes. Medical nutrition therapy (MNT) continues as the foundation of management even as more insulin and medication options become available for diabetes (Pastors, Warshaw, DaIy, Franz, Kulkarni, 2002). Consulting a registered dietitian, with the certified diabetes educator (CDE) credential if possible, provides the assessment, education and lifestyle recommendations that are necessary to manage diabetes on a daily basis. Patient education to understand the effects of food, exercise, medication, stress, illness and diabetes complications is provided by Diabetes Self-Management Education (DSME)

The American Diabetes Association has published clinical nutrition recommendations as follows (ADA nutrition principles, 2004):

“Goals of Medical Nutrition Therapy for Diabetes”

1. Attain and maintain optimal metabolic outcomes including:

* Blood glucose levels in the normal range or as close to normal as is safely possible to prevent or reduce the risk for complications of diabetes.

* A lipid and lipoprotein profile that reduces the risk for macrovascular disease.

* Blood pressure levels that reduce the risk for vascular dis ease.

2. Prevent and treat the chronic complication of diabetes. Modify nutrient intake and lifestyle as appropriate for the prevention and treatment of obesity, dyslipidemia, cardiovascular dis ease, hypertension and nephropathy.

3. Improve health through healthy food choices and physical activity.

4. Address individual nutritional needs taking into consideration personal and cultural preferences and lifestyle while respecting the individual ’s wishes and willingness to change.

The ADA nutrition principles (2004) indicate that there is no standard diet or ADA diet because there are many methods of meal planning. A plan may be exchanges, calorie points, carbohydrate counting, menus or guidelines. Some people with diabetes want a meal plan to follow every day to match the medication and blood glucose goals. Others prefer to learn to adjust insulin to the amount of food they choose to eat. A dietitian can calculate calorie needs based on a person’s height, weight, age, gender and activity. The body mass index (BMI) is calculated to determine the goals of the patient to gain, lose, or maintain weight. A person with a BMI over 25 would benefit from a plan for weight loss. All diabetes meal plans should be individualized according to food preferences, calorie needs and lifestyle. Adjustments must be made according to blood glucose level, weight and client satisfaction with the plan (Pastors et al, 2002).

Meal plans are based on the fact that all food raises blood glucose and insulin lowers blood glucose. The goal then is to match the amount of food with insulin or diabetes pills to meet blood glucose goals. Too much food or too little diabetes medication will cause high blood glucose. Too little food or too much diabetes medication will cause low blood glucose. The blood glucose result two hours after the meal is the best check to know whether the diabetes medication and food at that meal are in the right amount.

The amount of the foods may be prescribed, usually by a dietitian, using calories, calorie points, exchanges, carbohydrate choices or grams. The client is given a list of food with the carbohydrate, calorie or calorie point content. The client will also be given the amount of calorie points, calories or carbohydrate for each meal and snack or a ratio of insulin/carbohydrate or calories or points. Most people eat better, feel better and have more energy if they eat regular meals and distribute food throughout the day. The food guide pyramid is one guideline for choosing what to eat (United States Department of Agriculture, 1992). The food pyramid emphasizes healthy carbohydrates such as whole grains, fruit, beans, milk and vegetables. Other good choices on the pyramid are lean meat, low fat dairy products such as cheese and yogurt, nuts and seeds. Desserts and fats (especially the unsaturated fats such as olive, peanut and canola oil) can be included in the context of a healthy diet and within the calories to maintain a healthy weight. When implementing a meal plan, the portion size is more important than the specific food a person eats. There are not lists of do and don’t eat foods because a combination of any foods can make a healthy menu.

Snacks depend on the diabetes medications. Snacks might include vegetables, vegetable juice, milk, crackers, yogurt or fruit. These are healthier choices than fried foods, sweets and sugarsweetened drinks such as soda pop, sports drinks and fruit drinks. If a person is on Lantus (glargine) and a rapid-acting insulin such as Novolog (aspart) or Humalog (lispro), they may need an insulin injection to prevent high blood glucose if they eat more than 120 calories (1 ½ calorie points) in a snack (Guthrie, Childs & Guthrie, 2003). Therefore, snacks are often not recommended for persons taking Lantus and rapid-acting insulin except in children or with exercise.

Northbrook, IL - Critical care professional societies in the United States are urging the federal government to address the impending critical care workforce shortage and other deficiencies in critical care medicine before the nation enters into a full-scale critical care crisis. The Critical Care Workforce Partnership, comprised of the American College of Chest Physicians (ACCP), American Association of Critical-Care Nurses (AACN), American Thoracic Society (ATS), and the Society of Critical Care Medicine (SCCM), has issued a report outlining the state of critical care medicine in the United States and strategies to prevent a crisis in the delivery of critical care services. The Partnership’s findings are presented in a special report and corresponding white paper in the April issue of CHEST, the peer-reviewed journal of the ACCP.

“Critical care professional societies and their members have felt the tremendous strain caused by the depletion of critical care resources and the increased patient demand for critical care services. These trends have forced critical care in the United States to enter into an extremely vulnerable state, leaving our critical care professionals and their patients equally as vulnerable,” said report co-author Mark A. Kelley, MD, FCCP, Henry Ford Hospital, Detroit, MI. “The Critical Care Workforce Partnership is appealing to both the medical profession and public policy makers to take action against these alarming trends in critical care before the consequences become insurmountable.”

In 2000, the Committee on Manpower for Pulmonary and Critical Care Services (COMPACCS), including members of the ACCP, ATS, and SCCM, published a study predicting that critical care specialists would not be able to meet the demands of the aging population in the United States and that the effects of the manpower shortage would reach crisis proportions in 2007. To address this imminent critical care issue, the three medical societies and the AACN formed the Critical Care Workforce Partnership and a supporting task force on Framing Options for Critical Care in the United States (FOCCUS). In the current report, the Partnership and FOCCUS task force expand on the COMPACCS prediction, citing that waning interest in the critical care profession will greatly reduce the future number of critical care providers, making it difficult to meet the overwhelming patient demand for critical care services.

To overcome these challenges, the FOCCUS task force offers the following recommendations for the critical care medical profession: adopt common standards for critical care to ensure uniformity, promote quality, and rationalize resources; use information technology to promote standardization and improve efficiency in critical care; advise policymakers to develop incentives to attract health-care professionals to critical care; and encourage policymakers to sponsor research that defines the optimal role of a critical care specialist in the delivery of critical care.

In their accompanying white paper, the four critical care professional societies urge public policy makers to assist in the implementation of the FOCCUS recommendations in order to improve the efficiency and number of critical care providers and manage the demand for critical care services. To improve efficiency, policy makers are encouraged to redistribute the current critical care workforce, explore ways to relieve the burden on the current workforce, and simplify medical reimbursement for critical care services. To increase the number of critical care providers, policy makers are asked to support graduate medical education initiatives, permitting more medical students to train in critical care programs, and to expand the J-1 visa waiver program, allowing foreign physicians to extend their critical care practice in the United States.

Additionally, policy makers are advised to address patient demand by expanding research on the delivery critical care services for the elderly and Medicare beneficiaries and educating Americans on the benefits and limitations of critical care medicine.

“The limited number of physician residency and fellowship trainee opportunities combined with increasing medical school costs and decreasing Federal funds for physician training, will have a severe impact on the future number of critical care physicians,” said Richard. S. Irwin, MD, FCCP, President of the American College of Chest Physicians. “Although the United States government has acknowledged the impending shortage of critical care providers, policy makers must begin public discussions on this issue and support the redesign of critical care practice and improve the supply of its professionals.”

CHEST is a peer-reviewed journal published by the ACCP. It is available online each month at www.chestjournal.org. ACCP represents more than 15,700 members who provide clinical respiratory, critical care, and cardiothoracic patient care in the United States and throughout the world. ACCP’s mission is to promote the prevention and treatment of diseases of the chest through leadership, education, research, and communication.

Research is integral to the delivery of best practice diabetes education, care and management and a core component of the diabetes educator (DE) role. However, previous studies and anecdotal evidence suggest that although DEs are ideally placed to undertake research, the majority do not participate in research activities. This article describes a study designed to explore the experiences, skills and attitudes of Australian DEs towards research, and to identify the barriers to, and facilitators of, research.

Research is a challenge for all nurses, including diabetes educators (DEs), and their interest in research activities varies. Although the DE role is primarily clinical, research is a core component and a requirement for the Australian Diabetes Educators Association (ADEA; 2001) and the credentialing programme (ADEA, 2000). In Australia, the term ‘diabetes educator’ describes a number of health professional disciplines. Although the majority are nurses, other health professionals such as dietitians and podiatrists also undertake the role to varying degrees within the scope of their primary discipline.

There is an expectation that nurses will provide clinical leadership, especially in advanced nursing roles such as the DE. Clinical leadership includes a range of research activities, such as being aware of the importance of research to clinical practice, using research findings to provide evidence-based diabetes care, as well as collaborating in and undertaking research. Translating research into clinically usable forms is part of a cycle of knowledge transformation that includes developing policies and guidelines and monitoring outcomes to achieve best practice.Research can therefore be a change agent.

The research–practice gap between undertaking research and incorporating research findings into nursing practice (research utilisation) is well described in the literature (Roycroft-Malone, 2004). Professional nursing bodies such as the International Council of Nurses (ICN) have developed policies and task forces to formulate a worldwide research agenda for nursing (ICN, 1990) but the impact of this initiative is unknown.

Anecdotal comments during research education sessions for DEs suggested that the method of educating nurses about research could be either a barrier to, or facilitator of research utilisation. Most undergraduate nursing courses incorporate research to some degree (Olade, 2004). However, education alone does not encourage nurses to use or participate in research (Dunning, 2004; Jordan, 2004). Active support from employers, research mentors and role models plays a major role (Byrne and Keefe, 2002; Dunning, 2004).

People with diabetes have a right to expect evidence-based care. Jordan (2004) suggested that consumers will have an increasing influence on, and a role in, research utilisation, and therefore the provision of evidence-based practice. Likewise, a survey of people with diabetes on the Australian National Diabetes Services Scheme (NDSS) register, a Government-sponsored scheme to subsidise the cost of blood glucose test strips, insulin syringes and needles and some insulin pump consumables, found that people were interested in hearing about research findings, receiving research updates and information about research projects that they could be eligible to participate in (Diabetes Australia [DA], 2004).

Consumer involvement in clinical decision-making is already occurring, e.g. consumers are being included on policy-making and guideline development committees and research fundraising committees. In addition, consumers are expected to actively participate in their care, especially when they have a chronic disease such as diabetes. Being informed about relevant research findings enables people to participate in management decisions more effectively and to make relevant, informed self-care decisions (Heater et al, 1988).

Research utilisation

Research utilisation is a complex process: clinicians need to possess strong research knowledge and skills, including the ability to critically analyse and understand published research, in order to be able to apply the findings generally in their particular practice context and to individual patients.

A number of factors affect nurses’ ability to utilise research besides their knowledge and skills; these include the social and historical context in which they work, their own and colleagues’ beliefs and attitudes about research, and the philosophy of the employing organisation (Roycroft-Malone, 2004).

Furthermore, everybody concerned needs to understand and value the contribution that the different research paradigms make to patient care. Controlled trials provide evidence of safety and benefit (the science of care) and qualitative studies provide important information about the social and human aspects that affect whether and how research will be utilised (the art of care). Together they constitute the yin and yang of research. Evaluation studies provide information about the outcomes of using research to guide practice. Considered together, the research paradigms provide a holistic picture of research development and utilisation.

MAQUET, a leading provider of medical equipment, has leased 14,230 square feet for its North American headquarters at Centerpointe IV, 1140 Route 22 East in Bridgewater, New Jersey, announced Jeremy Neuer of Cushman & Wakefield of New Jersey, Inc.

MAQUET GmbH & Co. KG is a member of the publicly listed GETINGE AB group of companies based in Sweden.

Headquartered in Germany, MAQUET is a leading global provider of equipment for operating rooms and intensive care units.

The company employs some 2,900 staff and is represented worldwide through 22 of its own sales and service companies and through more than 200 specialist dealers and partner companies. “New Jersey, and especially the Somerset County area, is an ideal place for MAQUET to establish its U.S. base,” Neuer said.

“The region’s strong pharmaceutical and life sciences presence provides an ideal environment for the company’s expansion here.”

Neuer, Joseph Sarno and Jon Marks of Cushman & Wakefield’s Iselin, New Jersey, office represented MAQUET in negotiating the long-term lease.

Susan Mason, Bob Ryan and Kevin Welsh of CB Richard Ellis represented Glenborough Property Trust, which owns Centerpointe IV.

Possibly more than other nursing colleagues we (diabetes specialist nurses and nurse consultants in diabetes) have long been aware of the need to prove our worth to both our patients and our employers. So the current emphasis on value for money is not new to our world.

However, what is possibly new is the overwhelming emphasis on successful financial management at whatever cost (or so it appears), as well as the reality of hospital closures and service reductions. There are many methods currently in use which seek to control and manage financial flows and expenditure, one of which is payment by results (PbR).

PbR is a way to reward hospitals for providing high-quality services at better than average costs. It is said to be key to patient choice (by, for example, Sigsworth, 2006) but in reality the ‘cost’ of this system on primary care trusts and local commissioners may reduce patients’ access to specialist secondary care services. Conversely, acute trusts may seek to encourage outpatient appointments and, in particular, new appointments which attract a greater fee. All procedures will probably have a fixed fee and time limit, so again it is in the acute trusts’ financial interest to reduce patients’ length of stay, as increased throughput will increase bed usage and, therefore, increase funding. (Believe me, patients do appear on the bottom line somewhere, trust me!)

So where do diabetes services feature in all this? Consider practice-based commissioning: Farooqi (2006) recommends active management of both commissioning risks and fragmentation of services. Now is the time to really talk to your commissioners, GPs and service users in terms of what they believe to be good within current resources. I also recommend talking to secondary care managers who you may be employed by but who may not necessarily appreciate what you do with respect to care of the person with diabetes or your corporate contribution. Failure of such discussions could lead to cherry-picking by independent service providers leading to ‘incalculable damage to coherent long-term care for people with diabetes’ (Farooqi, 2006). Many of us have worked long and hard with primary and secondary care colleagues to join up services and improve patient outcomes and that clearly is at risk.

The concepts and drivers in the two articles within this supplement are products of this financial debate, and as one is based in an acute trust and the other in a primary care trust, reflect issues in both areas of diabetes management and services.

In the first article, Julie May focuses on leading service redesign within an acute trust, whose purpose was to avoid automatic admission the night before minor surgery due to diabetes. Her work on protocols to manage diabetes peri-operatively, and collaboration with all staff involved is enlightening, and has principles which could be applied elsewhere regarding length of stay and inpatient care.

The second article, by Debbie Hicks and Kit McAuley, describes the ‘repatriation’ of patients seen in secondary care into primary care. They also discuss the need for reducing the number of referrals to secondary care in the first place and the cost savings and other benefits achieved.

Underpinning both articles is financial review and improved management, and most importantly, although perhaps featuring less in the current climate, patient benefit. Both provide ideas and solutions and perhaps I could add one of my own–put on your Abba Gold CD and dream of a rich man’s world, it always works for me!