We read with great interest the recent article by Carey and colleagues on the role of estrogen receptors in airway responsiveness (1). This study deals with an important area that has potential clinical significance. However, in the analysis of airway responsiveness, it is unfortunate that the authors chose to rely so heavily on a misrepresentation of the variable Penh. In an earlier letter published in the AJRCMB, this variable was explicitly criticized by leaders in the field of respiratory mechanics, stating that, “however tempting is the ease of using the unrestrained plethysmography, Penh is not a measure of airway mechanics” (2). Although Carey and coworkers did cite this reference, they nevertheless repeatedly referred to Penh as airway responsiveness in the title, text, and legends. In fact, the irony in their present use of Penh is that, although respiratory impedance was also measured in an attempt to provide validation for the Penh measurements, this validation failed!

Rn is the parameter that has been shown to best reflect airway resistance in vivo in several species, including mice (3), but in Carey and coworkers’ study this measurement clearly showed that there was in fact no change in the airway responsiveness in the ?ERKO females (Figure 2), or with ovariectomy or exogenous estradiol (Figure 4). Since the defect in asthma is with airway narrowing, why the authors chose to rely so heavily on a measurement that relates more to ventilatory control, and not one that is known to directly reflect airway size, is a mystery. Furthermore, their results actually show that the estrogen receptor is more closely related to the tissue viscoelasticity than the airway size, but this finding is not addressed.

On a related matter, since the authors tacitly assume that Penh is a measure of the airway resistance based on compression-expansion of alveolar gas, this raises questions about the reliability of their measurement of ventilation with unrestrained plethysmography in these same animals (4). This could perhaps account for the abnormally high respiratory rate and minute ventilation reported in Table 1, which are more than double what is normally observed in quietly resting, conscious mice (5, 6). Finally, perhaps the most interesting question that arises from this study is why the increased responsiveness observed in vitro in the ?ERKO does not manifest itself in vivo. There must be compensatory regulation in vivo that overcomes the intrinsic increased sensitivity to cholinergic stimulation sufficiently to allow the responsiveness of airways to remain similar to that in the wild type controls.

Conflict of Interest Statement : None of the authors has a financial relationship with a commercial entity that has an interest in the subject of this manuscript.

When a drug has been adequately tested and has been found to have the effect claimed for it, this claim should be permitted even though there may be preponderant evidence to the contrary based upon equally reliable studies. There may also be a situation in which a new drug has been studied and its effectiveness established only to the satisfaction of a few investigators qualified to use it [emphasis added]. There may be many physicians who would deny the effectiveness simply on the basis of a disbelief growing out of their past experience with other drugs or with the diseases involved…. What the committee intends is…that safe new drugs become available for use by the medical profession so long as they are supported by a responsible body of opinion and scientific fact.

–Report, 1962 amendments of the Food, Drug, and cosmetic Act, US Senate (quoted in the Final Report, 8/15/90, of the National committee to Review current Procedures for Approval of New Drugs for cancer and AIDS.

This is the fifth in a series of articles about medical boards authorized in every state to discipline physicians for professional misconduct. Unlike medical societies and specialty certifying boards, which may oust or decertify members but not bar them from practice, these government agencies can revoke the licenses of doctors — a power which gives them considerable influence over both the quality and accessibility of health care.

All articles in this series have taken New York State’s board, the Office of Professional Medical Conduct (OPMC), as a case study. The Empire State has roughly 60,000 MDs, one of every ten physicians licensed in the US. (About 3/4 of the New York doctors actually practice. The rest conduct lab research, hold administrative positions, etc.)

In addition, New York has numerous hospital complexes, some world-renowned for specializing in certain diseases and/ or prominent as institutions at the frontiers of medical science. Therefore, New York’s physician population covers the gamut of standard and experimental health care. And thus most types of professional misconduct pass before he OPMC’s eye.

Prospects for OPMC Reform Concerning Due Process. Sniping at the OPMC for the manner in which it polices physicians started soon after transfer of the disciplinary process for MDs from the Education Department to the Health Department (1975). Critics of various stripes have been sniping at New York’s medical cops ever since.

Most of the criticism has centered on delays in processing complaints and for lenient penalties in instances of alleged flagrant incompetence, negligence, or unethical behavior by mainstream physicians.

Over the years, the majority of OPMC reforms have addressed the agency’s failure to meet expectations by expanding its reach, funds, and personnel. Recent dissatisfaction with the OPMC has again included questions about inconsistent rulings and puzzling recommendations for penalties. Now, though, much of the discontent springs from concern over alleged violations of due process by the agency.

In January 2002, the New York Assembly conducted an all-day hearing into complaints about these process violations. Then in June, the Assembly passed a bill meant to strengthen essential administrative trial protections for physicians. But the New York Senate, supported by long established public interest/consumer protection groups (and spurred perhaps by the insurance industry behind the scenes), refused to pass a companion bill. (The opponents felt the Assembly bill protected physicians far more than it did patients.)

Since Democrats have controlled the Assembly and Republicans the Senate for decades, and are likely to retain control of their respective chambers for the foreseeable future, chances of the two parties agreeing on a reform package that would minimize due process violations by the OPMC appear slight.

Rationale for the Proposed OPMC Reforms. Partly because of the aforementioned political impasse, the reforms proposed here bypass due process issues. Instead, they target a burgeoning tendency of the OPMC to investigate and prosecute MDs for treatment regarded by the agency as inappropriate or unnecessary. This tendency has the potential to disadvantage physicians — and, more important, patients — in a broader way than any OPMC failure to observe due process can do.

To understand why, one must realize that when the OPMC frames charges against doctors in these cases it often employs the terms “improper,” “incompetent,” or “negligent.” Such terminology fuzzes crucial distinctions between ineptly done procedures and incorrectly interpreted diagnostic tests that harm or may harm patients, and approaches to treatment that simply depart from community norms, causing negligible harm and sometimes providing benefits not obtainable under standard therapy.

One must also note that in the year the Legislature established the OPMC in the Health Department (1975), the legislators probably expected the agency to concentrate on incompetent, negligent, or otherwise unacceptable conduct by MDs (e.g., botched surgeries, misdiagnoses, mental or physical impairment, sexual abuse of patients).

I wish to commend Dr. Faith Fitzgerald for pointing out the absurdity of the medicalization of social issues (”Unhealthy News,” Guest Editorial, June 15, 2000, p. 9).

Like her, I refuse to refer to some of those issues as health problems. Some of them, such as gun control, are nothing but political issues advanced by an elitist liberal minority that is determined to use any means possible to destroy our God-given right to bear arms. That principle was considered such a fundamental right by our founding fathers that they saw fit to specifically include it in the Bill of Rights.

Dr. Fitzgerald has shown great insight by dearly and without apology pointing out how the medicalization of these issues relieves those truly at fault of responsibility for their actions. These attempts place physicians in positions as experts in fields in which most have no legitimate qualification and drastically escalate health costs by falsely including these social issues under the umbrella of health care.

Our duty is to care for individual patients. We are not nannies who supervise all the multiple choices in life that people in a free country are entitled to make.

Cleaning, disinfection, and sterilization are infection control’s Three Musketeers, snuggling to thwart the evil cross-infection before it has an opportunity to overtake weakened patients. A special report by William A. Rutala, Ph.D., and David J. Weber, M.D., published in the Centers for Disease Control and Prevention’s journal “Emerging Infectious Diseases “points to the importance of vigilance and diligence in the battle against cross-infection: “The need for appropriate disinfection procedures is highlighted by the multitude of outbreaks resulting from improperly decontaminated patient-care items.” (1)

No way can it be emphasized too much that the most important step in disinfection and sterilization is the first step: Cleaning. If items aren’t cleaned adequately, no state-of-the-art equipment or top–of-the-line products can disinfect or sterilize them. When bioburden is not removed, it gets baked on during the disinfection cycle, making it impossible for the disinfectant or sterilant to reach the item’s surface, setting the scene for cross-infection.

What’s the difference?

The difference between high-level disinfection (HLD) and sterilization is sometimes misunderstood by healthcare personnel, and that can result in disastrous consequences for patients. Arthur Trapotsis, vice-president, research and development, Consolidated Stills and Sterilizers, Boston, and chief technology officer, William Barnstead Engineering Corp, Boston, finds confusion between the two terms alarming: “I often hear the terms disinfection and sterilization used interchangeably. This is incorrect and very misleading. It scares me when I hear healthcare professionals mixing up the terminology. In basic terms, sterilization is the destruction of all microorganisms, including spores, and HLD could be anything less than that.”

Besides HLD, there are two other categories of disinfection. Chuck Fishelson, vice president, Alfa Medical Equipment Inc, Hempstead, NY, described them: “There are three levels of disinfection: High, intermediate, and low. High-level disinfection kills all organisms, except high levels of bacterial spores, and is effected with a chemical germicide cleared for marketing as a sterilant by the Food and Drug Administration. Intermediate-level disinfection kills mycobacteria, most viruses, and bacteria with a chemical germicide registered as a tuberculocide by the Environmental Protection Agency (EPA). Low-level disinfection kills some viruses and bacteria with a chemical germicide registered as a hospital disinfectant by the EPA.”

Todd Nielsen, national director of sales and marketing, infection control, Getinge USA, Rochester, NY, illustrated the difference between disinfection and sterilization: The levels of disinfection and sterilization are points along the same continuum of risk. HLD is at a point on the continuum indicating a greater risk of contamination than sterilization. Sterilization is the terminus of the continuum where risk is, effectively, reduced to the lowest practical point. As an alternative to the continuum construct, think in terms of concentric circles: Low-level disinfection is a sub-set of high-level disinfection, which in turn is a sub-set of sterilization.”

Basically, the difference between HLD and sterilization is that only sterilization can kill high numbers of bacterial spores. However, in recent years, a new challenge to sterilization has stolen some of spores’ significant thunder. Fishelson indicated that prions are now at the top of the microbial totem pole, requiring even more sterilization exposure time than highly resistant bacterial endospores.

The threat of infection by spores or prions doesn’t exist in all circumstances so sterilization of all items used on or by patients is unnecessary. Rutala and Weber noted, “Because sterilizing all such items is unnecessary, hospital policies need to identify whether cleaning, disinfection, or sterilization is indicated based primarily on an item’s intended use but considering other factors including cost.” (1)

Spaulding classification of medical devices

The system used to determine whether items should be cleaned, disinfected, or sterilized was in 1968 by Earl Spaulding. (3-8) Cynthia Spry, RN, MSN, CNOR, international clinical consultant for Advanced Sterilization Products (a Johnson & Johnson company), Irvine, CA, told Healthcare Purchasing News, “The classification of a device provides guidance as to how a device should be processed. If the person responsible for instrument processing knows how the device is used or classified, then it is possible to determine whether sterilization is required or whether HLD is appropriate.”

Spaulding’s classification of medical devices divides items into three categories–critical, semicritical, and noncritical–based on how the object is intended to be used. (2-8) Rutala and Weber explained how the system works in their special report for “Emerging Infectious Diseases”.

AT A TIME when the church had grown too cozy with the ruling authorities, when faith had become a means to power and influence, some Christians who sought to live out an authentically biblical faith headed for desolate places. They pooled their resources and dedicated themselves to a life of asceticism and prayer. Most outsiders thought they were crazy. They saw themselves as being on the narrow and difficult path of salvation, with a call to prick the conscience of the wider church about its compromises with the “world.”

I’m describing not fourth-century monks, but present-day communities of Christians who think the church in the United States has too easily accommodated itself to the consumerist and imperialist values of the culture. Living in the corners of the American empire, they hope to be a harbinger of a new and radically different form of Christian practice.

These “new monastics” pursue the ancient triumvirate of poverty, chastity and obedience, but with a twist. Their communities include married people whose pledge to chastity is understood as a commitment to marital fidelity. Poverty means eschewing typical middle-class economic climbing but not total indigence–some economic resources are necessary for building this desert kingdom. Obedience means accountability not to an abbot but to Jesus and to the community.

The description new monasticism comes from the theologian Jonathan Wilson. In Living Faithfully in a Fragmented World: Lessons for the Church from MacIntyre’s “After Virtue” (1998), Wilson responds to moral philosopher Alasdair MacIntyre, who concludes his celebrated 1991 critique of modernity by calling for “the construction of local forms of community within which civility and the intellectual and moral life can be sustained through the new dark ages which are already upon us…. We are waiting for another–doubtless very different–St. Benedict.” Wilson agrees, and as an Anabaptist theologian he recognizes the resources in his church to create precisely the sort of new monasticism for which MacIntyre calls.

Be careful what you write. Wilson’s daughter is now a founding member of one such new community, the Rutba House in Durham, North Carolina. Rutba got its start and its name from the experience of a Christian Peacemaker Team that was in Iraq at the start of the war. Leah Wilson-Hartgrove and her husband, Jonathan, were trained in CPT’s tactics of nonviolent conflict resolution and of “getting in the way” of those who would do violence. Their group had a car accident in which a member was seriously hurt. They took him to Rutba, the nearest town with a hospital. The Iraqi doctor treated the injured American for no fee, but asked the group to promise to tell others what had happened to them in Rutba–that while their country was dropping bombs on his, he offered healing and peace. (Jonathan Wilson-Hartgrove tells this story in To Baghdad and Beyond: How I Got Born Again in Babylon [Cascade].)

The Wilson-Hartgroves returned to the United States and started the Christian community in Durham, where Jonathan began study at Duke Divinity School. It’s based in a sprawling old house with creaky hardwood floors in a largely black section of the city called Walltown; drug problems and civic neglect give the neighborhood a reputation as a dangerous place. Jonathan Wilson-Hartgrove describes Rutba’s mission there as one of “hospitality, peacemaking and discipleship.” He contrasts the community’s vision with that of the rural Southern Baptists among whom he grew up: “Jesus doesn’t just forgive my sins, he gives a whole new way of life–the best way to live.”

THE COMMUNITY shares meals and daily prayers from the Book of Common Prayer. Its members do not have a common treasury in the strict sense. They tend their own finances, but they do keep a common purse that members are encouraged to give to or take from as they have ability or need.

Their theological commitments are visible in the pictures on the living room walls: one is of Martin Luther King Jr., the other of Dorothy Day, cofounder of the Catholic Worker movement. Rutba’s members are committed to being in Walltown. When other Duke students travel home for holidays, Rutba is their home. A bit worried that the Rutba members may be perceived as white do-gooders who intend to “save” the housing projects, Jonathan can only counter that they are committed to being a presence in Walltown–”unless the area gentrifies completely.”

Wilson-Hartgrove heard a call to this sort of life while at Eastern College outside Philadelphia, where he studied with Tony Campolo. “A lot of Tony’s students took his ideas more seriously than even he was ready for,” he said. A number of Christian communities that include Campolo’s students have cropped up in blight ed neighborhoods in and around Philadelphia.

The Rutba community has only five members. In addition to the Wilson-Hartgroves, it includes another divinity school student, a 40-year-old man and a high school student whom the community has taken in as a foster child. When I asked whether the neighbors think Rutba is weird, Jonathan said, “You should hear [the high school student] tell his friends where he lives. ‘Well, I live in this house, they’re Christians, white and black, who aren’t really kin to me, but as Christians sort of are …”

How will medical students assess a standardized whiplash patient? Will they order a cervical radiographie study based on the history provided? Will they change their minds about ordering radiographs after reading an abstract from a peer-reviewed medical journal recommending against them on the basis of some criteria? How will their opinions change based on a) the relative sensitivity and specificity of the findings of that study; and b) the class of evidence (i.e., prospective cohort design vs. retrospective chart reviews)? Finding the answers to these questions was the object of a recent study.1

The Medical Students

Fourth-year medical students from the University of Chicago were presented with a standardized whiplash patient to test their clinical perspicacity. he was a 21-year-old male who gave a history of being a passenger in a car that was struck from the rear at a speed of 25 mph. Shortly after the crash, he began to experience neck pain and was transported by ambulance to the ER. Students were asked whether they would order radiographs of his neck, and for their level of confidence in their decision. They were then presented with a variable of the abstract from a recent paper by Stiell, et al.,2 in which the authors developed a radiography algorithm. (I will discuss that paper next.)

After reviewing the abstract, the students were allowed to reaffirm their decision to order plain films, or to change it, and were asked to once again rank their level of confidence. Most of the 165 students did endorse the idea of ordering radiographs initially. Many apparently changed their minds after being exposed to the abstract informing them that radiographs were unnecessary under the circumstances. Of those initially reject- ing the idea of radiographs, their confidence in that decision was strengthened by the abstract.

These medical students correctly assigned the proper weight in accordance with the relative reported sensitivity vs. specificity (i.e., high sensitivity and low specificity would be preferable to low sensitivity and high specificity). However, the results showed that the students did not consider the prospective cohort design more persuasive than the weaker case review design. Of course, other factors could have influenced their decisions.

The standardized patient completed a questionnaire for each medical student, reporting the depth of the exam. Sixty-seven percent correctly inquired as to whether the patient had numbness and tingling in the upper extremities. However, only 21% palpated the posterior neck, and only 17% asked the patient to turn his head from side to side. A scant 11% did all three. This is disturbing, but perhaps not surprising, in light of another recent study, which reported a surprisingly low level of knowledge of musculoskeletal disorders among a group of medical residents.

One wonders what might be the basis for the seemingly absurd recommendation to forego radiographs in a 25 mph rear-impact motor vehicle crash. Carle Ward has reported that spinal fractures, dislocations, and spinal cord injuries are not uncommon in rearimpact crashes in which delta Vs are often only in the 15-20 mph range,3 as represented below.

While at least one study has shown that police officers are able to gauge collision velocity from damage severity with some accuracy, my experience is that real-world subjects nearly always overestimate crash speed. I suspect there are a number of explanations for this observation, including the volume of the resulting crash noise and the subjective violence of the collision. Patients may also be concerned that physicians will not take them seriously if the physicians perceive the crash to be trivial. Meanwhile, it is not clear from reading the present paper how the Canadian authors arrived at the 25 mph threshold for safety, or whether other occupant risk factors were considered, such as the nature of presenting symptoms, the patient’s age, spinal condition, etc. However, it seems unwise to base a criteria for radiography on a crash metric that has been shown to be a) not strongly correlated with injury risk; b) unlikely to be accurately estimated by vehicle occupants; and c) only somewhat better gauged by police.

In general, the authors of this paper endorsed the Canadian guidelines and anticipated that the medical students would either forego the radiographs initially or decide against them after reviewing the abstract of the Canadian paper. Interestingly, students who were more “in tune” with the epidemiological and clinical literature, vis-a-vis c-spine trauma and MVC, unequivocally chose to examine the c-spine radiographically, including the use of flexion and extension views, as recommended by some radiologists.4

The Canadian C-Spine Rule Study

So, what is this Canadian c-spine “rule” and how was this research conducted? Perhaps a better question might be, “Why should we be concerned?” The results of the study were reproduced in JAMA, one of the most influential of the American medical journals. It is likely that it will not escape the attention of those interested in medical cost containment. It could become transmogri-fied into public policy in Canada, in a way similar to that of the British Columbia Whiplash Initiative, which used the Quebec Task Force on Whiplash Associated Disorders’ (QTF-WAD) dubious guidelines to influence medical decision-making by practitioners there. That project, of course, was put together by the Insurance Corporation of British Columbia, the chief insurer for the province. (The QTF-WAD was also financed by the insurance industry.) This c-spine rule study was funded, at least in part, by the Ontario Ministry of Health Emergency Health Services Committee. One of the authors of the present paper, incidentally, has also been active in the development of a decision rule for whiplash.5

Somatropin, commonly referred to as human growth hormone (HGH), is currently one of the most popular drugs on the market. Because of this, many companies would like to make a profit from its popularity. Unfortunately, companies that sell HGH drugs are not always legitimate, and there are many forms of human growth hormone that are simply ineffective or, even worse, dangerous.

HGH’s popularity stems from its wide-ranging effects on the human body. HGH is a hormone that is naturally produced in the human body, and the drug form of HGH is an exact replica of natural human growth hormone. In the medical industry, HGH is used to treat short stature in children caused by both growth hormone deficiency and certain diseases, including Turner’s, Prader-Willi, and short bowel syndromes, renal disease, and a genetic condition known as X-Linked Hypophosphatemia (XLH). Additionally, it’s used to treat muscle wasting in AIDS and cachexia patients, and short stature in children with an undetermined cause.

However, much of human growth hormone’s popularity stems from its cosmetic effects; it is most widely used as a bodybuilding and physical enhancement drug. As an intravenous drug, HGH can promote lean muscle growth and weight loss, increase energy, shorten recovery time between workouts, heal damaged tissue, and strengthen joints and ligaments. HGH is also commonly used as an anti-aging drug to prevent and repair the damage responsible for wrinkled skin, osteoporosis, and memory loss.

In an attempt to prevent HGH scams, several HGH manufacturers (GeneScience Pharmaceuticals, Neogenica BioScience, AnkeBio, etc.) have developed a web site–www.somatropin.net–devoted entirely to somatropin. Covering the basic facts on the drug, the web site defines growth hormone terminology, presents a basic history on the development of the recombinant HGH drug, and explains in detail how HGH works as both a medical and cosmetic drug.

The web site is innovative in its attempt to prevent HGH scams. Information on the site explains some of the ineffective methods of HGH administration widely available on the market, and also explains certain methods of HGH manufacturing that are impure and can cause damage.

The web site lists the companies that sell HGH, the type of HGH they manufacture, and their contact information. When questioned about their intentions for this web site, a representative from Neogenica BioScience explained, “We basically want to stop HGH scams, prevent abuse, and educate people on what HGH can and cannot do for them.” For more information, please visit www.somatropin.net.

When FAIM and coalition supporters passed the New York health freedom law in 1994 [L.1994,C.558], permitting “non-conventional” methods, we knew that eventually the Office of Professional Medical Conduct, OPMC, would test and try to overturn our law. That time is before us now — in spades.

The vehicle for challenge to our law by OPMC is the treacherously flawed system of professional discipline, which is sorely lacking the due process that the constitution affords those who are accused of crimes. Having had the opportunity to research and compare New York’s administrative process to that of 16 other states, I assure Townsend readers that while many states fail in some aspect of due process or another, New York is uniquely awful — which is strange since it is one of the few states which still embraces “peer review.” In most other states, the facts are tried before administrative law judges who make the determinations of guilt or innocence, which are then confirmed by the medical board. In New York, the administrative law judge is present but only to rule on process; the testimony is heard and the facts are determined by a panel of three, including two doctors. It is becoming apparent that peer review can enforce bias, that is, depending upon whose peers are sitting in review and depending as w ell, on what evidence is allowed into their view.

Further, it is our observation that the staff of the OPMC have gained much too much leeway in the prosecution of cases. They have driven the agenda away from the control of the BPMC, the Board for Professional Medical Conduct, which is supposed to be the governing body of physicians and laypersons who hear and try the cases.

Lastly, it is clear that the failures of due process and the hubris of OPMC staff are being used by insurers to wage a war on patients; to deprive them of the physicians who advocate for their care against the denial of benefits, and to stifle the science that would promote treatments insurers simply don’t want to pay for. While advocating for Lyme patients in New York, FAIM has become witness not only to the insurance lobby’s declarations of their support for OPMC actions against innovative Lyme doctors, but as well, OPMC staff have acceded to lawmakers that they rely on insurers’ ability to audit patient’s charts and generate complaints.

Legislation is being drafted at this time by a team of bill drafters from the three legislative committees who have jurisdiction over the law. FAIM’s concern begins, of course, with protecting patient access to CAM physicians. But all patients and all physicians who think progressively and who innovate in order to individualize care, are at risk.

These concepts are being developed into balanced legislation that will reform the physician discipline process to protect patient privacy and choice as well as patient safety from harm. A public legislative hearing on OPMC reform is scheduled by the Assembly Health Committee for January 31, 2002 in Manhattan.

The following are reforms of OPMC due process being promoted by FAIM:

1) Before an investigative interview, the OPMC should provide fort the licensee to review the Department expert’s investigative report.

Currently, the licensee does not know in advance of his or her interview just what the concerns are, and therefore cannot prepare to offer a resolution. Currently, the interview does give opportunity for further discovery by OPMC, but not serve at a11 as an opportunity for mediation.

2) Before the investigative interview, the licensee should be advised that their statements may be used against them in a subsequent disciplinary hearing.

3) When the subject of investigation involves in any way, the use of a non-conventional or individualized therapy, an expert who practices similarly should be consulted who can attest to the appropriateness or not of the care in question.

Despite assurances by the Department at the passage of L.1994,C.558, that specific assignment would be logical and was not necessary to place into law, OPMC has failed to avail itself of the expertise of any non-conventional physicians in current investigations of non-conventional practice. Consequently, OPMC faultily prosecutes scientific disputes.

4) The name, address, and qualifications (including past/present employers and affiliations and consultant-ships), of any expert relied upon or to be used at trial, as well as of BPMC committee members, shall be provided to the licensee under investigation, and any amendments to the expert or committee lists should be provided “promptly” to the licensee.

Currently, the only experts who will testify at trial are disclosed shortly before trial, with no accompanying disclosure for examination for conflict of interest.

5) Orders for a “comprehensive review” of patient records in a medical office should be made only upon a majority vote by an investigative committee of the BPMC after having heard a rebuttal by the licensee to the investigator’s report.

When conventional and Complementary and Alternative Medicine (CAM) educators gathered at Georgetown University in June 2005 for The National Education Dialogue to Advance Integrated Health Care (NED), they were looking for ways to create common ground in the education of health care professionals. Since creating major change is never easy, they took time to reflect on the basic principles underlying change.

Dale W. Lick, PhD, the facilitator of the NED meeting, was selected in part due to his experience working with leaders of diverse institutions to create common ground for change. Lick, a professor in the Learning Systems Institute at Florida State University, told NED participants, “even the word ‘change’ scares people and makes them feel uncomfortable. When you’re seeking change, learning must precede change. If you’re thinking about a really major change, you need a lot of learning first.” Traditionally, Lick said, you work to change people’s behavior, so that eventually you’ll change their beliefs and assumptions. But when you’re seeking major organizational changes, you often need to start by looking at, and changing, basic assumptions. Then it becomes possible to change beliefs and behaviors, and that leads to sustainable change. Transformational leaders must create a shared, inspiring vision that provides direction, motivation, and commitment to your desired long-range future, Lick said. “In change efforts, vision is the essential direction-setter, people-aligner, and emotion-grabber!”

Lick invited NED participants to think about key roles they can play as part of any change process:

* A change sponsor has the power to sanction or legitimize change–it might be the organization’s board, or a president, division director, or department head.

* A change agent is an individual or group responsible for implementing the desired change.

* A change target is an individual or group that must change as a result of the change process.

* A change advocate is someone who desires change but doesn’t have the authority or power to sanction it; they can recommend actions to those who do have the authority to legitimize change.

“The key thing is, if you don’t have strong sponsorship, your project, is almost certain to fail,” Lick said. “If your sponsorship isn’t strong enough, first work to strengthen it.” Change advocates should find ways to help people change appropriate assumptions and increase learning among potential sponsors and others, he advised.

Innovative Curriculum at Georgetown University School of Medicine

Faculty at the Georgetown University School of Medicine have been working to develop an improved curriculum in ways that exemplify the principles put forth by Dr. Lick. Their primary goal is to train better physicians. One step in that process, they find, is to train physicians who are familiar with CAM.

“Mind-body approaches are particularly important … by their very nature they put high value on and teach the power of self-awareness and self-care,” says the Georgetown website. “In so doing, they help shape the new integrative model of healthcare–one in which treatment is balanced with teaching; in which prevention and self-care are given as much respect as procedures and pharmacological interventions.”

If you go to that website today, you’ll see that information on CAM is integrated throughout Georgetown’s curriculum. For example, the anatomy course looks at the anatomy of acupuncture; physiology includes biofeedback and neuromuscular manipulation; while human endocrinology discusses stress hormone modulation through the relaxation response, meditation, imagery, and breathing. Georgetown also offers a master’s level course in CAM (within the physiology department) and a five-year program combining that course of study with an MD degree.

In part, this wealth of information and options is due to a five-year, $1.7 million grant from the National Institutes of Health (NIH) that supported the planning phase to incorporate CAM into the curriculum. Even more, this integration is due to a step-wise strategy that started on a small scale and gradually gained support from many levels of the organization. For example, a course for first-year medical students on “Mind-Body Medicine: An Experiential and Didactic Introduction” started as a pilot program. The course is held two hours a week for eleven weeks and includes approaches such as relaxation, meditation, guided imagery, biofeedback, writing exercises, movement, music. and art. It’s designed to help students become self-aware and foster self-care strategies that should help them in their own lives (this is particularly important for stressed-out medical students.) It also gives them a clear sense of how helpful these skills can be for their future patients.

“Initially we planned to get a pilot started, look at outcomes, gauge student reactions, and see how it went,” says Aviad Haramati, PhD, professor of physiology, biophysics, and medicine. “Based on that, we’d make modifications. As the program improved, we’d scale it up.” Haramati’s research interests for 20 years focused on regulation of renal and electrolyte physiology during growth, and cardiovascular-renal-endocrine regulation of volume homeostasis in heart failure–not exactly CAM-centered. However, he is keenly interested in improving the training of physicians and other health professionals and, over the years, has helped develop major curricular initiatives at Georgetown. His solid professional background (and numerous teaching awards) give him additional credibility when he talks about the ways mind-body training will benefit medical students.

The term epidemic (from the Greek epi [on] plus demos [people]), first used by Homer, took its medical meaning when Hippocrates used it as the title of one of his famous treatises. At that time, epidemic was the name given to a collection of clinical syndromes, such as coughs or diarrheas, occurring and propagating in a given period at a given location. Over centuries, the form and meaning of the term have changed. Successive epidemics of plague in the Middle Ages contributed to the definition of an epidemic as the propagation of a single, well-defined disease. The meaning of the term continued to evolve in the 19th-century era of microbiology. Its most recent semantic evolution dates from the last quarter of the 20th century, and this evolution is likely to continue in the future.

At the start of the 21st century, epidemics of infectious diseases continue to be a threat to humanity. Severe acute respiratory syndrome, avian influenza, and HIV/AIDS have, in recent years, supported the reality of this threat. Civil wars and natural catastrophes are sometimes followed by epidemics. Climate change, tourism, the concentration of populations in refugee camps, the emergence of new human pathogens, and ecologic changes, which often accompany economic development, contribute to the emergence of infectious diseases and epidemics (1). Epidemics, however, have occurred throughout human history and have influenced that history. The term epidemic is [approximately equal to] 2,500 years old, but where does it come from?

Before Hippocrates

When works that put forward new ideas are translated, determining the original terminology (in Ancient Greek in this case) is not easy. In 430 BC, when Hippocrates was collecting the clinical observations he would publish in Epidemics, his treatise that forms the foundation of modern medicine, at least 3 terms were used in Ancient Greece to describe situations that resembled those described by Hippocrates: nosos, phtoros, and loimos (2).

Nosos, meaning disease, was used by Plato in the 4th century BC and clearly had the same meaning 2 centuries earlier in the works of Homer and Aeschylus. Nosos encompasses disease of the mind, body, and soul: physical, including epilepsy, and moral (i.e., psychological and psychiatric). Phtoros or phthoros means ruin, destruction, deterioration, damage, unhappiness, and loss, after war for example. The word was frequently used by Aeschylus and Aristophanes, was known in the 8th century BC, and was later used by Plato and Thucydides. Its meaning has remained general. Bailly translates loimos as plague or contagious scourge. Used by Esiodus in the 7th century BC and later by Sophocles and Herodotus, this term is ancient. Its translation as plague should be interpreted in the sense of a scourge rather than as the disease plague. In the Septuagint, a translation of the Old Testament into Greek by 70 Greek Jews from Alexandria, this word is used in the book of Kings to describe the 10 plagues of Egypt.

But the term epidemic already existed in 430 BC. The Greek word epidemios is constructed by combining the preposition epi (on) with the noun demos (people), but demos originally meant “the country” (inhabited by its people) before taking the connotation “the people” in classical Greek. Indeed, the word epidemios was used by Homer, 2 centuries before Hippocrates, in the Odyssey (canto I, verses 194 and 230), where it was used to mean “who is back home” and “who is in his country” in contrast to a voyager who is not: [TEXT NOT REPRODUCIBLE IN ASCII.], “because someone said that your father was back (home)” (canto I, verse 194). In this context, epidemios means indigenous or endemic. In the Iliad, Homer confirmed this meaning (canto XXIV, verse 262), by using also polemos epidemios to mean civil war:, “this one who [TEXT NOT REPRODUCIBLE IN ASCII.] liked passionately the frightening civil war” (canto IX, verse 64). Later, Plato and Xenophon (400 BC) used the word to describe a stay in a country or the arrival of a person: [TEXT NOT REPRODUCIBLE IN ASCII.], “a Parian who, I learned, was in town” (Plato, Apology, chapter I, paragraph 38). The verb epidemeo was used by Thucydides (460 BC-395 BC) to mean “to stay in one’s own country,” in contrast to apodemeo, “to be absent from one’s country, to travel.” For Plato, epidemeo meant “to return home after a voyage, to be in town.” Later, the orators Demosthenes (384 BC-322 BC) and Eschines (390 BC-314 BC) used this word to refer to a stranger who came to a town with the intention of living there, and the verb epidemeo was used to mean “to reside.” Typical of Greek semantics, epidemeo takes its meaning from the result of the action, rather than from the action itself. It relates to something that has already happened, with the implication that it had previously happened elsewhere. Authors before Hippocrates used epidemios for almost everything (persons, rain, rumors, war), except diseases. Hippocrates was the first to adapt this word as a medical term.