Being white, female, an academic high achiever, and singleminded can have its drawbacks, but when it comes to selection for United Kingdom medical schools, no one’s better placed. At least that’s the message from the analysis by McManus of the anonymised data on selection released this week (p 1111).[1] The key findings show, surprisingly, that women are more likely to gain entry to medical schools, but candidates from ethnic minorities remain disadvantaged. Concerns about the selection procedure have long inspired calls for a code of practice.[2]

Differences exist between ethnic minority groups. Caribbeans are less disadvantaged than Africans. Indians are less disadvantaged than Bangladeshis or Pakistanis. While wide confidence intervals hint that some of these differences may not be real, it is undeniable–and suspicions are confirmed–that overall ethnic minorities are disadvantaged. Sceptics will argue that this analysis by McManus doesn’t take into account data on predicted A level grades (which were not made available to him but which selectors rely on heavily), but previous work suggests that even when academic achievement is taken into account ethnic minority candidates are less likely to be accepted, probably on the basis of their surname.[3] This adds to mounting evidence of disadvantage at all stages in the careers of ethnic minority doctors.[4-6]

McManus also finds more Subtle disadvantages. Applicants not wholly committed to medicine on their application forms, those choosing a gap year, and those from colleges of further and higher education and sixth form colleges may be less likely to gain admission to some medical schools. Older applicants and those from lower socioeconomic groups are also disadvantaged. One myth that is not substantiated, however, is that applicants from independent (private) schools are advantaged in terms of selection.

McManus points out that the new evidence raises the possibility of legal action against medical schools under section 17 of the 1976 Race Relations Act. But whether it proves racial discrimination is open to debate. Disadvantage does not necessarily equal discrimination. Legally, direct and indirect discrimination are separate concepts, with direct discrimination hinging solely on an individual’s race, while indirect discrimination arises from some hurdle in the selection procedure that is more difficult for ethnic minority candidates to clear. These data appear to raise issues of indirect discrimination, which may be difficult to prove in court (p 1117).

In the United Kingdom ethnic minorities as a whole are overrepresented in the medical profession. This is explained by the high proportion of applicants of Asian origin to medical schools as well as being a legacy of the days when overseas doctors were more welcome in the National Health Service. Even though they are disadvantaged in terms of selection, enough Asian students apply to ensure that they make up a larger proportion of the medical work force than they do of the population of the United Kingdom. Around 6% of the United Kingdom population are Asian, but they constitute 28% of medical school applicants and 21.7% of those receiving offers of a medical school place. AfroCaribbeans, meanwhile, constitute 2% of the UK population and 3.79% of medical school applicants but receive only 1.72% of offers. By contrast, 64.9% of applicants are white but they receive 74% of offers (IC McManus, personal communication).

Disadvantage, however, can be turned to advantage, as in the case of women applicants–although positive effects on career progression are yet to be seen. By contrast, medical schools in general appear unable to redress the inequalities faced by ethnic minority candidates, despite repeated focus on this issue in recent years.[7 8]

McManus confirms that some medical schools manage not to disadvantage women and ethnic minorities[3] Perhaps the answer is to learn from their admissions procedures. Alternatively, more aggressive policies may be needed; there is, for example, evidence that raising awareness of ethnic minority issues can increase recruitment.[9] Moreover, experience from the University of Arkansas has shown that lowering entry requirements for African-American applicants need not reduce standards: those same students have gone on to score above average marks in medical exams.[10]

The Council of Heads of Medical Schools is to be commended for making these data available; other selection bodies such as the police and the legal profession are much less open about their procedures, and what the deans have done should serve as a model to other professions. The council has also worked with the Commission for Racial Equality to produce an eight point list of “guiding principles” for selecting of students which will be adopted by all UK medical schools. The schools promise to review the criteria for medical student selection, both academic and non-academic; ensure that all medical schools publish and monitor equal opportunities action plans; and monitor and publish the annual figures on applications. Other proposals include further research looking into why certain applicants are disadvantaged, bringing forward the deadline for medical school applications, and reducing the number of choices available on the university application form. The Commission for Racial Equality has threatened to conduct formal investigations into medical schools that fall short.

Lawsuit protection, customer satisfaction coverage, preserving the company’s assets insurance-all could be appropriate names for commercial general liability coverage. The liability exposure is the unknown risk every business faces. Since accidents can and do happen, even the best run business can face bankruptcy every time a customer walks through its door. People walk, children climb, teenagers eat-any activity can result in an accident, and how and where that accident occurs can determine the financial health of a business. Liability insurance is designed to allow the owners of a commercial enterprise to continue concentrating on their business plan, knowing that they have insurance to protect against the unforeseeable.

The CGL can be offered either on an occurrence basis or a claims made basis. It can be written either as a monoline policy or in connection with one or more other lines of insurance to form a commercial package policy. Instead of having to select specific areas of coverage (which may result in gaps in an insurance program), the insured enjoys fairly comprehensive liability coverage. The basic exposures covered by the CGL include:

* Ownership or use of the premises by the insured

* The insured’s operations

* Contractual agreements entered into by the insured

* Products the insured makes, sells or distributes

* Operations the insured has completed

* Personal and advertising injury caused by the insured

* Medical payments coverage on the insured’s premises or jobsite without regard to fault

Section I of the form provides three distinct coverages:

* Coverage A - Bodily Injury and Property Damage

* Coverage B - Personal and Advertising Injury

* Coverage C - Medical Payments

Each coverage is described in section I of the policy with an insuring agreement, exclusions and supplementary payment information.

The following sections apply to all three of the coverages named above:

* Section II describes who is an insured. A number of individuals are covered as insureds but only with respect to the named insured’s business.

* Section III explains the application of the various limits of insurance and how they work together.

* Section IV describes the conditions that are specific to general liability coverage. Many of these conditions explain the responsibilities of the insured after a loss. If the insured violates these conditions, coverage can be voided, so careful attention to this area is warranted.

* Section V covers definitions for certain words and phrases used in the coverage part. These definitions are not the same as the ones found in a dictionary. The important part of every definition section is the coverage that is provided and the coverage that is excluded by a definition.

The CGL coverage form has many endorsements available to tailor the coverage for a particular exposure situation. Some of the endorsements are mandatory for specific classifications while others are optional. The optional endorsements allow the insured to sculpt coverage to fit an individual need. This flexibility allows a standard form to become custom-made coverage.

The CGL has no limitations on the types of risks that can be written on a monoline policy or a commercial package program. Certain types of risks or classifications, however, may not be combinable with other coverage lines and therefore would not qualify for a commercial package policy discount. These include personal liability and farm liability risks. Also, some specific property programs cannot be combined with any other line for a package policy discount. These include highly protected risks (HPR), petroleum properties, petrochemical plants, electric generating stations and natural gas pumping stations.

Underwriting and rating commercial general liability coverages must start with thorough exposure identification. Since coverage follows the named insured operations on and off premises, underwriting efforts must concentrate on defining who is/are the named insured(s) is and what the named insured(s) do/does. All rating and underwriting decisions flow from the answers developed in this exploration effort.

Please note that this is only an overview of this coverage. A thorough discussion of this coverage form may be found in the PF&M Analysis from The Rough Notes Company.

Agency OnLine subscribers, please refer to PF&M Section 270.4-2 - Commercial General Liability Coverage Form Analysis for a more in-depth discussion of this coverage part.

Traditional herbal strategies for treating lung disease are founded on supporting and tonifying the innate protective resources. This is one area where the divide between traditional and modern approaches is particularly great. There are very few modern endorsements of early treatment strategies. Modern medical science, which at first embraced such agents in the earlier part of this century, now sees no role for their use. For example, modern editions of Martindale’s Extra Pharmacopoeia claim that: “There is little evidence to show that expectorants are effective.” Some modern drugs may have expectorant activity, such as bromhexine, but they are usually referred to as ‘mucolytic’. The impact of traditional remedies on the respiratory system is relatively poorly researched. Reliable external measures of change in mucosal functions are elusive; many respiratory diseases are either self-limiting or are among some of the most persistent conditions in the clinic. (1)

However, while the traditional herbal approach is somewhat lacking in scientific support, it is not without a rational basis. This article will examine some important herbal concepts involved in supporting the innate defenses of the lungs during infection. The key concept of expectorants will be discussed in detail, with a focus on the classification of expectorants and the scientific investigations into their effects.

Part of the problem with expectorants probably arises from confusion over their definition. Another aspect of the dismissal of expectorants stems from the difficulties involved with measuring their efficacy.

The four definitions of expectorants given below highlight the difficulties. The dictionary meaning is only concerned with the actual oral production of phlegm or sputum. Since the majority of mucus produced from the lungs is swallowed, this definition is clearly unsatisfactory. Definitions from the pharmacologists Boyd and Lewis are more useful but probably the best definition comes from Brunton, a 19th century pharmacologist.

Oxford Dictionary “Promoting the ejection of phlegm by coughing or spitting.”

Boyd (1954) “An expectorant may be pharmacologically defined as a substance which increases the output of demulcent respiratory tract fluid.”

Lewis (1960) “Expectorants increase the secretions of the respiratory tract and so reduce the viscosity of the mucus which can then act as a demulcent. By virtue of the presence of increased quantities of fluid mucus, expectorants produce a “productive cough” which is less exhausting and less painful to the patient.”

Brunton (1885) “Remedies which facilitate the removal of secretions from the air passages. The secretion may be rendered more easy of removal by an alteration in its character or by increased activity of the expulsive mechanism.”

Why Expectorants?

Many respiratory conditions are characterized by abnormal mucus (catarrh) which can narrow airways. This abnormal mucus may be thick and tenacious and hence very difficult to clear from the airways. If expectorants can render this catarrh more fluid and/or assist in its expulsion, then a clinical benefit should be achieved.

Expectorants can help to relieve debilitating cough. The presence of an irritation in the airways (such as tenacious abnormal mucus) invokes the cough reflex. (The cough reflex is most sensitive in the trachea and larger airways. The sensitivity progressively decreases in the finer airways and in the very fine airways there is no reflex at all. So in alveolitis, there is little stimulation of the cough reflex, whereas for tracheitis the stimulus is strong). By clearing abnormal mucus or by changing its character and making it more demulcent, expectorants can allay cough and are therefore antitussive.

Classification of Expectorants (after Gunn, 1927)

The classification of expectorants by their mode of action is extremely valuable in understanding their appropriate use. In 1927 Gunn proposed four classes of expectorants. (2) A fifth class was suggested by the Russian scientist Gordonoff. (3)

1. Reflex expectorants

These are emetics which cause an increased secretion of respiratory tract fluid when given orally in subemetic doses. Act by reflex from the upper GIT mediated by the vagus nerve eg saponin herbs, Lobelia, Ipecac

2. Central expectorants

Act on the CNS. Possibly Ipecac

3. Parasympaticomimetics

Stimulate the vagus nerve eg Pilocarpus. Also capsaicin (in Capsicum) stimulates bronchial C-fibres

4. Stimulants of secretory cells

Act directly on goblet cells, eg essential oils

5. Secretomotorics (after Gordonoff 1938)

Stimulate mucociliary transport, eg camphor, thyme

From the herbal perspective the two most important classes are the reflex expectorants and the stimulants of secretory cells. The use of the terms stimulating or relaxing expectorants is no longer valuable, as the following quotation illustrates.

The Nevada Nurses Association invites you to celebrate nursing in this regular feature, which looks at the actions and words of nurses who made a difference. This issue addresses the need to protect the word “nurse,” the image of nursing, and the early days of state registration for nursing.

In these days of casual dress and sometimes insufficient identification, the patient has to wonder which of the persons in the health care setting is the professional nurse. Worse yet, the consumer may be even more vulnerable at the doctor’s office, when an efficient young person wearing a scrub suit, with a stethoscope around her neck calls you into the room and says,: “I’m Patsy, the nurse.” An astute consumer, noting this person’s response (or lack of) to some real medical concerns might ask Patsy about her nursing background, and learn that she is “really a medical assistant.”

The need to protect the term “nurse” seems like a new problem. Yet, it is long standing, and we must be continually willing to address it. Here is an example from American Nursing A History: (book review, this issue)

So many Society girls had romantic notions about nursing, after the United States entered what became World War I in 1917, that Clara Noyes, Director of the Red Cross Bureau of Nursing, was flooded with applications. She wrote to her friend Adelaid Nutting in desperation:

Surely we need your prayers. There are moments when I wonder whether we can stem the tide and control the hysterical desire on the part of thousands, literally thousands, to get into nursing or get their hands upon it.

Tell Annie [Goodrich] of Albany that if I were not convinced before, I should be now that the most vital thing in the life of our profession is the protection of the word nurse.

Everyone seems to have gone mad. I talk until I am hoarse,, dictating letters to doctors and [to] women who want to be Red Cross nurses in a few minutes, not knowing the meaning of the word nurse and what a Red Cross nurse is. (p.199).

After the war, Clara Noyes assigned qualified Red Cross nurses to help develop nursing programs in recovering European countries and acquired Red Cross funds to build a nursing school in Bordeaux, “France. During America’s economic depression in America she designed programs for qualified Red Cross nurses to meet people’s health needs.

Noyes was firm about the need for nurses to stay current, to take ongoing coursework, and to be involved in their professional organization. She promoted postgraduate study and often contrasted the active interest of older physicians in continuing education with the indifference of older nurse graduates.

If we are a profession, then surely there is an absolute necessity for advanced study. If we wish to see this profession placed on a strong basis, then we must be strong as a body in the fundamental principles underlying our work. If we attempt to take a position in the front ranks of the progressive movements of the age and, what is more important, stay there, we must as individuals be thoroughly prepared, and this can only be done by courses of study which have been organized on a permanent educational basis. (1905)

It comes as no surprise to any perioperative nurse that the lay public has an incomplete and sometimes erroneous perception of what perioperative nurses know and do. When a question about the adequacy of a perioperative nurse’s actions or competency is brought to the legal system, however, lay judges, juries, attorneys, or administrative law judges must make decisions as if they understood perioperative practice. To make these decisions, they cannot rely on their own knowledge; they must be assisted by documentary and testimonial evidence. More often than not, they require the assistance of an expert nurse witness. This column briefly defines the role of an expert witness, traces the evolution of the need for expert nurse witness testimony, and describes the consultative services a nurse expert can provide.

DEFINITIONS

According to Black’s Law Dictionary, an expert is

a person who, through education or
experience, has developed skill or
knowledge in a particular subject so
that he or she may form an opinion
that will assist the fact finder. (1(p619))

An expert witness is a person

qualified by knowledge, experience,
training, or education to provide a
scientific, technical, or other specialized
opinion about the evidence or a
fact issue. (1(pl633))

An expert witness differs from a material or lay witness in two respects: the expert usually has no first-hand knowledge of what led to the case and unlike material witnesses who are limited in their testimony to providing objective descriptions of what they observed or did, an expert witness is allowed to give his or her professional opinion and draw conclusions.

THE NEED FOR NURSE EXPERTS

Expert nurse witnesses typically are needed whenever the adequacy of another nurse’s actions are in question. Usually, this occurs in disciplinary proceedings against a nurse licensee before an administrative law judge or in malpractice cases where the actions of the nurse are alleged to have contributed to a patient’s injury.

For decades, most courts accepted that physicians had the necessary expertise to explain standards of nursing. More recently, it has been recognized that testimony about what a nurse should have done best comes from another nurse. For example, in 1958, a California court allowed a physician to testify about what nurses should have done saying, “Surely a qualified doctor would know what was standard procedure of nurses to follow” (Goff v Doctor’s Hospital, 166 CalApp2d 314, 319 [1958]). Fourteen years later, a Pennsylvania court recognized that a physician might not be the best expert on nursing standards, but it still allowed physicians’ testimony to be admitted because, “all areas of medical expertise within the knowledge of nurses are also within the knowledge of medical doctors” (Taylor v Spencer Hospital, 292 A2d 449, 452 [Pa Super 1972]). Finally, in 2004, an Illinois court explicitly held that a physician was not qualified to testify as to the standard of care for the nursing profession under the laws of the state of Illinois (Sullivan v Edward Hospital, 806 NE2d 645 [Ill 2004]). Along with this increasing judicial recognition of the unique body of nursing knowledge comes an increased responsibility for nurses to be willing to share their expertise with lay legal decision makers; however, they must do so within the context of the unfamiliar, adversarial legal system.

FINDING A NURSE EXPERT

Identifying a possible perioperative nurse expert is more art than science. Attorneys may conduct online searches for persons who have spoken or written on issues relevant to the case, or they may conduct a search of nursing and health care literature online or in hard copy indices. They may ask attorney colleagues for referrals or contacts. Sometimes, they contact nursing schools or professional nursing associations.

Nurses interested in offering services as consultants or witnesses can place their contact information in classified advertisements in legal journals. Some attorneys may not consult classified advertisements, however, because of concern about the credibility of the nurse expert; some states require that experts earn most of their income from the practice of the profession, not from testifying or consulting in legal cases. (2-4)

NEGOTIATING A CONTRACT

A nurse who is asked to consult or testify must approach the agreement with the retaining attorney as he or she would any other contract. The nurse expert has absolutely no duty to consult and cannot be subpoenaed to testify unless he or she consents to do so. This is a main point that should be negotiated up front. After the nurse agrees to provide a service, the nurse is legally bound by contract to do so; thus, there must be a clear expectation of services, timelines, and remuneration for time and expenses.

* Does the service consist of reviewing medical records and providing an opinion to the retaining attorney?

* Is this opinion to be an oral or written report?

Traditional herbal strategies for treating lung disease are founded on supporting and tonifying the innate protective resources. This is one area where the divide between traditional and modern approaches is particularly great. There are very few modern endorsements of early treatment strategies. Modern medical science, which at first embraced such agents in the earlier part of this century, now sees no role for their use. For example, modern editions of Martindale’s Extra Pharmacopoeia claim that: “There is little evidence to show that expectorants are effective.” Some modern drugs may have expectorant activity, such as bromhexine, but they are usually referred to as ‘mucolytic’. The impact of traditional remedies on the respiratory system is relatively poorly researched. Reliable external measures of change in mucosal functions are elusive; many respiratory diseases are either self-limiting or are among some of the most persistent conditions in the clinic. (1)

However, while the traditional herbal approach is somewhat lacking in scientific support, it is not without a rational basis. This article will examine some important herbal concepts involved in supporting the innate defenses of the lungs during infection. The key concept of expectorants will be discussed in detail, with a focus on the classification of expectorants and the scientific investigations into their effects.

Part of the problem with expectorants probably arises from confusion over their definition. Another aspect of the dismissal of expectorants stems from the difficulties involved with measuring their efficacy.

The four definitions of expectorants given below highlight the difficulties. The dictionary meaning is only concerned with the actual oral production of phlegm or sputum. Since the majority of mucus produced from the lungs is swallowed, this definition is clearly unsatisfactory. Definitions from the pharmacologists Boyd and Lewis are more useful but probably the best definition comes from Brunton, a 19th century pharmacologist.

Oxford Dictionary “Promoting the ejection of phlegm by coughing or spitting.”

Boyd (1954) “An expectorant may be pharmacologically defined as a substance which increases the output of demulcent respiratory tract fluid.”

Lewis (1960) “Expectorants increase the secretions of the respiratory tract and so reduce the viscosity of the mucus which can then act as a demulcent. By virtue of the presence of increased quantities of fluid mucus, expectorants produce a “productive cough” which is less exhausting and less painful to the patient.”

Brunton (1885) “Remedies which facilitate the removal of secretions from the air passages. The secretion may be rendered more easy of removal by an alteration in its character or by increased activity of the expulsive mechanism.”

Why Expectorants?

Many respiratory conditions are characterized by abnormal mucus (catarrh) which can narrow airways. This abnormal mucus may be thick and tenacious and hence very difficult to clear from the airways. If expectorants can render this catarrh more fluid and/or assist in its expulsion, then a clinical benefit should be achieved.

Expectorants can help to relieve debilitating cough. The presence of an irritation in the airways (such as tenacious abnormal mucus) invokes the cough reflex. (The cough reflex is most sensitive in the trachea and larger airways. The sensitivity progressively decreases in the finer airways and in the very fine airways there is no reflex at all. So in alveolitis, there is little stimulation of the cough reflex, whereas for tracheitis the stimulus is strong). By clearing abnormal mucus or by changing its character and making it more demulcent, expectorants can allay cough and are therefore antitussive.

Classification of Expectorants (after Gunn, 1927)

The classification of expectorants by their mode of action is extremely valuable in understanding their appropriate use. In 1927 Gunn proposed four classes of expectorants. (2) A fifth class was suggested by the Russian scientist Gordonoff. (3)

1. Reflex expectorants

These are emetics which cause an increased secretion of respiratory tract fluid when given orally in subemetic doses. Act by reflex from the upper GIT mediated by the vagus nerve eg saponin herbs, Lobelia, Ipecac

2. Central expectorants

Act on the CNS. Possibly Ipecac

3. Parasympaticomimetics

Stimulate the vagus nerve eg Pilocarpus. Also capsaicin (in Capsicum) stimulates bronchial C-fibres

4. Stimulants of secretory cells

Act directly on goblet cells, eg essential oils

5. Secretomotorics (after Gordonoff 1938)

Stimulate mucociliary transport, eg camphor, thyme

From the herbal perspective the two most important classes are the reflex expectorants and the stimulants of secretory cells. The use of the terms stimulating or relaxing expectorants is no longer valuable, as the following quotation illustrates.

The Nevada Nurses Association invites you to celebrate nursing in this regular feature, which looks at the actions and words of nurses who made a difference. This issue addresses the need to protect the word “nurse,” the image of nursing, and the early days of state registration for nursing.

In these days of casual dress and sometimes insufficient identification, the patient has to wonder which of the persons in the health care setting is the professional nurse. Worse yet, the consumer may be even more vulnerable at the doctor’s office, when an efficient young person wearing a scrub suit, with a stethoscope around her neck calls you into the room and says,: “I’m Patsy, the nurse.” An astute consumer, noting this person’s response (or lack of) to some real medical concerns might ask Patsy about her nursing background, and learn that she is “really a medical assistant.”

The need to protect the term “nurse” seems like a new problem. Yet, it is long standing, and we must be continually willing to address it. Here is an example from American Nursing A History: (book review, this issue)

So many Society girls had romantic notions about nursing, after the United States entered what became World War I in 1917, that Clara Noyes, Director of the Red Cross Bureau of Nursing, was flooded with applications. She wrote to her friend Adelaid Nutting in desperation:

Surely we need your prayers. There are moments when I wonder whether we can stem the tide and control the hysterical desire on the part of thousands, literally thousands, to get into nursing or get their hands upon it.

Tell Annie [Goodrich] of Albany that if I were not convinced before, I should be now that the most vital thing in the life of our profession is the protection of the word nurse.

Everyone seems to have gone mad. I talk until I am hoarse,, dictating letters to doctors and [to] women who want to be Red Cross nurses in a few minutes, not knowing the meaning of the word nurse and what a Red Cross nurse is. (p.199).

After the war, Clara Noyes assigned qualified Red Cross nurses to help develop nursing programs in recovering European countries and acquired Red Cross funds to build a nursing school in Bordeaux, “France. During America’s economic depression in America she designed programs for qualified Red Cross nurses to meet people’s health needs.

Noyes was firm about the need for nurses to stay current, to take ongoing coursework, and to be involved in their professional organization. She promoted postgraduate study and often contrasted the active interest of older physicians in continuing education with the indifference of older nurse graduates.

If we are a profession, then surely there is an absolute necessity for advanced study. If we wish to see this profession placed on a strong basis, then we must be strong as a body in the fundamental principles underlying our work. If we attempt to take a position in the front ranks of the progressive movements of the age and, what is more important, stay there, we must as individuals be thoroughly prepared, and this can only be done by courses of study which have been organized on a permanent educational basis. (1905)

It comes as no surprise to any perioperative nurse that the lay public has an incomplete and sometimes erroneous perception of what perioperative nurses know and do. When a question about the adequacy of a perioperative nurse’s actions or competency is brought to the legal system, however, lay judges, juries, attorneys, or administrative law judges must make decisions as if they understood perioperative practice. To make these decisions, they cannot rely on their own knowledge; they must be assisted by documentary and testimonial evidence. More often than not, they require the assistance of an expert nurse witness. This column briefly defines the role of an expert witness, traces the evolution of the need for expert nurse witness testimony, and describes the consultative services a nurse expert can provide.

DEFINITIONS

According to Black’s Law Dictionary, an expert is

a person who, through education or
experience, has developed skill or
knowledge in a particular subject so
that he or she may form an opinion
that will assist the fact finder. (1(p619))

An expert witness is a person

qualified by knowledge, experience,
training, or education to provide a
scientific, technical, or other specialized
opinion about the evidence or a
fact issue. (1(pl633))

An expert witness differs from a material or lay witness in two respects: the expert usually has no first-hand knowledge of what led to the case and unlike material witnesses who are limited in their testimony to providing objective descriptions of what they observed or did, an expert witness is allowed to give his or her professional opinion and draw conclusions.

THE NEED FOR NURSE EXPERTS

Expert nurse witnesses typically are needed whenever the adequacy of another nurse’s actions are in question. Usually, this occurs in disciplinary proceedings against a nurse licensee before an administrative law judge or in malpractice cases where the actions of the nurse are alleged to have contributed to a patient’s injury.

For decades, most courts accepted that physicians had the necessary expertise to explain standards of nursing. More recently, it has been recognized that testimony about what a nurse should have done best comes from another nurse. For example, in 1958, a California court allowed a physician to testify about what nurses should have done saying, “Surely a qualified doctor would know what was standard procedure of nurses to follow” (Goff v Doctor’s Hospital, 166 CalApp2d 314, 319 [1958]). Fourteen years later, a Pennsylvania court recognized that a physician might not be the best expert on nursing standards, but it still allowed physicians’ testimony to be admitted because, “all areas of medical expertise within the knowledge of nurses are also within the knowledge of medical doctors” (Taylor v Spencer Hospital, 292 A2d 449, 452 [Pa Super 1972]). Finally, in 2004, an Illinois court explicitly held that a physician was not qualified to testify as to the standard of care for the nursing profession under the laws of the state of Illinois (Sullivan v Edward Hospital, 806 NE2d 645 [Ill 2004]). Along with this increasing judicial recognition of the unique body of nursing knowledge comes an increased responsibility for nurses to be willing to share their expertise with lay legal decision makers; however, they must do so within the context of the unfamiliar, adversarial legal system.

FINDING A NURSE EXPERT

Identifying a possible perioperative nurse expert is more art than science. Attorneys may conduct online searches for persons who have spoken or written on issues relevant to the case, or they may conduct a search of nursing and health care literature online or in hard copy indices. They may ask attorney colleagues for referrals or contacts. Sometimes, they contact nursing schools or professional nursing associations.

Nurses interested in offering services as consultants or witnesses can place their contact information in classified advertisements in legal journals. Some attorneys may not consult classified advertisements, however, because of concern about the credibility of the nurse expert; some states require that experts earn most of their income from the practice of the profession, not from testifying or consulting in legal cases. (2-4)

NEGOTIATING A CONTRACT

A nurse who is asked to consult or testify must approach the agreement with the retaining attorney as he or she would any other contract. The nurse expert has absolutely no duty to consult and cannot be subpoenaed to testify unless he or she consents to do so. This is a main point that should be negotiated up front. After the nurse agrees to provide a service, the nurse is legally bound by contract to do so; thus, there must be a clear expectation of services, timelines, and remuneration for time and expenses.

* Does the service consist of reviewing medical records and providing an opinion to the retaining attorney?

* Is this opinion to be an oral or written report?

Being white, female, an academic high achiever, and singleminded can have its drawbacks, but when it comes to selection for United Kingdom medical schools, no one’s better placed. At least that’s the message from the analysis by McManus of the anonymised data on selection released this week (p 1111).[1] The key findings show, surprisingly, that women are more likely to gain entry to medical schools, but candidates from ethnic minorities remain disadvantaged. Concerns about the selection procedure have long inspired calls for a code of practice.[2]

Differences exist between ethnic minority groups. Caribbeans are less disadvantaged than Africans. Indians are less disadvantaged than Bangladeshis or Pakistanis. While wide confidence intervals hint that some of these differences may not be real, it is undeniable–and suspicions are confirmed–that overall ethnic minorities are disadvantaged. Sceptics will argue that this analysis by McManus doesn’t take into account data on predicted A level grades (which were not made available to him but which selectors rely on heavily), but previous work suggests that even when academic achievement is taken into account ethnic minority candidates are less likely to be accepted, probably on the basis of their surname.[3] This adds to mounting evidence of disadvantage at all stages in the careers of ethnic minority doctors.[4-6]

McManus also finds more Subtle disadvantages. Applicants not wholly committed to medicine on their application forms, those choosing a gap year, and those from colleges of further and higher education and sixth form colleges may be less likely to gain admission to some medical schools. Older applicants and those from lower socioeconomic groups are also disadvantaged. One myth that is not substantiated, however, is that applicants from independent (private) schools are advantaged in terms of selection.

McManus points out that the new evidence raises the possibility of legal action against medical schools under section 17 of the 1976 Race Relations Act. But whether it proves racial discrimination is open to debate. Disadvantage does not necessarily equal discrimination. Legally, direct and indirect discrimination are separate concepts, with direct discrimination hinging solely on an individual’s race, while indirect discrimination arises from some hurdle in the selection procedure that is more difficult for ethnic minority candidates to clear. These data appear to raise issues of indirect discrimination, which may be difficult to prove in court (p 1117).

In the United Kingdom ethnic minorities as a whole are overrepresented in the medical profession. This is explained by the high proportion of applicants of Asian origin to medical schools as well as being a legacy of the days when overseas doctors were more welcome in the National Health Service. Even though they are disadvantaged in terms of selection, enough Asian students apply to ensure that they make up a larger proportion of the medical work force than they do of the population of the United Kingdom. Around 6% of the United Kingdom population are Asian, but they constitute 28% of medical school applicants and 21.7% of those receiving offers of a medical school place. AfroCaribbeans, meanwhile, constitute 2% of the UK population and 3.79% of medical school applicants but receive only 1.72% of offers. By contrast, 64.9% of applicants are white but they receive 74% of offers (IC McManus, personal communication).

Disadvantage, however, can be turned to advantage, as in the case of women applicants–although positive effects on career progression are yet to be seen. By contrast, medical schools in general appear unable to redress the inequalities faced by ethnic minority candidates, despite repeated focus on this issue in recent years.[7 8]

McManus confirms that some medical schools manage not to disadvantage women and ethnic minorities[3] Perhaps the answer is to learn from their admissions procedures. Alternatively, more aggressive policies may be needed; there is, for example, evidence that raising awareness of ethnic minority issues can increase recruitment.[9] Moreover, experience from the University of Arkansas has shown that lowering entry requirements for African-American applicants need not reduce standards: those same students have gone on to score above average marks in medical exams.[10]

The Council of Heads of Medical Schools is to be commended for making these data available; other selection bodies such as the police and the legal profession are much less open about their procedures, and what the deans have done should serve as a model to other professions. The council has also worked with the Commission for Racial Equality to produce an eight point list of “guiding principles” for selecting of students which will be adopted by all UK medical schools. The schools promise to review the criteria for medical student selection, both academic and non-academic; ensure that all medical schools publish and monitor equal opportunities action plans; and monitor and publish the annual figures on applications. Other proposals include further research looking into why certain applicants are disadvantaged, bringing forward the deadline for medical school applications, and reducing the number of choices available on the university application form. The Commission for Racial Equality has threatened to conduct formal investigations into medical schools that fall short.

For those of us who don’t recognize many health care abbreviations beyond DC, NCTMB means Nationally Certified in Therapeutic Massage and Bodywork. But to call The Trigger Point Therapy Workbook a discussion of massage would be akin to referring to a Monet as graffiti.

Trigger-point therapy is not new, but Janet Travell, MD, who happened to be JFK and LBJ’s White House physician, popularized it among the medical people. She was over 90 when she released the second volume of her magnum opus and close to 100 when she died. David Simons, MD, was her coauthor, aerospace physician and the former holder of the altitude record in a balloon, as well as a researcher of some note.

Together, Travell and Simons wrote the equivalent of Gray’s Anatomy of trigger points. Unfortunately, it takes a huge investment to get much from the original work. It cost over $100 and is a most technical and difficult read. It took this reviewer over six months to read both volumes from cover to cover and I still refer to it constantly. Only my medical dictionary gets more use.

So, what is the average chiropractor to do if they want to know trigger points (TPs) but don’t have the time or inclination to study Travell and Simons directly? Reading and studying The Trigger Point Therapy Workbook, by Clair Davies, which costs $19.95 and can be read in less than a week and then kept as a quick study reference, is good way to go. There are other options out there, but Davies’ work provides a quicker and cheaper introduction. There is one caveat though: The material is meant to be self-administered, but in the penultimate chapter, treatment to others is addressed.

In the chiropractic community, many of us had the pleasure of studying with Dr. Raymond Nimmo. He was this little guy from Texas with a friendly drawl, a 10-gallon hat and a knack for finding and breaking up trigger points that would just make you want to cry. Dr. Nimmo has passed on and much of his work is no longer in vogue. Dr. Cyriax, the British physician, did some brilliant work that was picked up and expanded by Dr. Warren Hammer in his treatise on soft-tissue work. Recently, Dr. Michael Leahy developed a form of dynamic palpation of muscle that is effective in stretching chronically contracted muscles, freeing traction neurodesis (a nerve that has been entrapped in muscle or other soft tissue), or just plain releasing stuck trigger points. All these other approaches require a much larger investment in time and money to get started. The Trigger Point Therapy Workbook is a tremendous bargain.

This book is a great introduction and gives the practitioner a solid place to begin examining TPs. There are interesting correlations symptomatically: dyspareunia or pain after intercourse with the abductor magnus; pseudo-anginal pain with the scalene muscles; a persistent, dry cough or pain in the top, front or sides of the head with the sternal division of the SCM (sternocleidomastoid); and dizziness, prone to lurching or falling unexpectedly, and even reversible hearing loss, with the clavicular division of the SCM.

Davies also uses the original Travell and Simons algorithm of working backward from painful areas to the list of offending muscles. Then each muscle has the likely TPs mapped out which are confirmed by palpation. Finally, if the TPs are obliterated by needling or rubbing out, there should be symptomatic improvement.

In this second edition, there are two new chapters. The first is by Amber Davies, Glair’s daughter, and in it there are illustrations and text describing massage techniques for alleviating trigger points in others. The second new chapter gets into some of the socio-psycho-physiological aspects of muscle tension. It includes some family dynamics, systemic desensitization, a subtle form of contract relax, passive flooding (giving yourself permission to be tense so you have awareness without resistance) and finally, paradoxical intention, a technique in which one confronts their fears.*

In the 323-plus pages (plus a great index), you can start using one of the most powerful, well-documented approaches in all of physical medicine. This book rates a 10 as an introduction to trigger-point work. The only practitioners this book is not recommended for are those who already have and use Travell and Simons’ trigger-point manual. Good luck and happy hunting for those pesky trigger points!