Search

While malpractice claims alleging lack of informed consent are proliferating, the courts are requiring more detailed information regarding the risks of proposed treatment. Increased use of consent forms and brochures designed to provide comprehensive, objective information for specific procedures could help physicians avoid most of these types of claims.

Economic pressures, awareness that physicians can be sued, improved medical care, and increased patient expectations have led to the skyrocketing liability insurance costs physicians face today. In the early days when the doctor could offer hope but little medicine, patients were not inclined to sue for medical "failures." But with the Great Depression, World War II, more recent medical advances changed the patient-physician relationship. Patients had gained the expertise of specialists, but often lost the personal relationship they once shared with their primary physician. Thus, when treatments were unsuccessful, the patient often-times blamed the physician. Insurance premiums (and patient costs) increased, while patients became even more aware that physicians were covered by insurance. This article reviews key economic, medical, and social events that led to the present medical liability insurance crisis.

Advertising is nothing new to the medical profession, although for many years reputable doctors did not advertise their skills. In 1975, the Federal Trade Commission (FTC) successfully argued in a case that was appealed to the Supreme Court that the AMA had unlawfully restricted medical advertising. While the FTC usurped the job of policing medical advertising, it seems to regard medical adverstising as a local problem not worthy of FTC attention. It has avoided setting standards for medical advertising and has failed to initiate significant enforcement against deceptive medical advertising. This article briefly reviews the historical role of advertising in modern American medicine and discusses advertising in relation to risk management.

This article describes the activities of physicians who offer their services for hire as witnesses and consultants to attorneys in malpractice litigation. Cases illustrating the extent of the problem are discussed along with legal and ethical restrictions on witnesses and contingent-fee payment of medicolegal consultants. A common belief is that the ever-present threat of malpractice litigation, which hangs over the heads of physicians like the sword of Damocles, is due to avaricious lawyers, unrealistic expectations of patients, and the reckless generosity of juries with other people's money. But physicians also have exacerbated a troublesome situation. Gone is the universal reluctance of doctors to testify against other doctors.

The transplacental effects of 1,25(OH)2D3 and of 24,25(OH)2D3 on bone formation in rat fetuses and pups have been investigated. Pregnant rats treated with 1,25(OH)2D3 or with 1,25(OH)2D3 and 24,25(OH)2D3 showed hypercalcemia, while those treated with 24,25(OH)2D3 did not. Fetal weight was markedly reduced by treatment with 1,25(OH)2D3 and not with 24,25(OH)2D3 or with a combination of both metabolites. Microscopical examination of fetal long bones showed after treatment with 1,25(OH)2D3 a marked reduction in diaphysial length. Diaphyseal trabeculae were thin and disorganized. The epiphysis had a thinner layer of hypertrophic and calcified cartilage. The numbers of osteoclasts in the diaphysis and metaphysis were the same as in controls. Treatment with 24,25(OH)2D3 did not affect fetal bone length; many bone trabeculae were found in the diaphyseal cavity leaving small bone marrow spaces; the number of osteoclasts in the metaphysis and in the diaphysis was increased. All changes in the skeleton disappeared during the first week after birth. It can be suggested that high doses of 1,25(OH)2D3 inhibit bone formation and maturation of cartilage. The addition of 24,25(OH)2D3 to 1,25(OH)2D3 seemed to reduce the toxic effects of the latter on the fetal skeleton. These results point to a definite difference between the action of high doses of 1,25(OH)2D3 and 24,25(OH)2D3 on fetal bone.

Table 8 lists the patterns of the five discrete tissue reaction patterns of granulomatous inflammation and relates them to the predominant microscopic tissue reaction as well as to the dominant cell type present in the infiltrate. The possibility of a sixth group, granulation tissue, was also considered for this classification schema. The term "granulation tissue" was used by Virchow to define granulomatous inflammation. He probably used this term in a broader context than our present definition of granulation tissue (ie, fibrocapillary proliferation). Using the more narrow and perhaps more precise definition, we think that granulation tissue does not constitute a form of granulomatous inflammation.

Granular cell tumor usually presents as an asymptomatic mass in the skin or subcutaneous tissue, yet it is rarely considered in the clinician's differential diagnosis of such masses. We present a case of granular cell tumor located on an extremity and discuss its characteristic histopathologic findings and aspects of its origin and management.

A case of Flavobacterium meningosepticum bacteremia complicating the course of a patient with leukemia is described. The patient was treated successfully when rifampin was added to the antibiotic therapy. Unusual organisms should be considered as agents of infection in immunocompromised hosts and susceptibility testing with drugs not commonly employed for gram-negative rods should be performed in complicated cases.

Public policy dictates that physicians maintain confidentiality of their interchanges with their patients and of their records. Though few instances of litigation regarding breach of such confidence are recorded, physicians are well advised not to divulge information or acknowledge the doctor-patient relationship without a patient's consent. Under special circumstances where harm to the patient or the public may be inferred, the physician may have special obligations to contact and/or divulge information to appropriate parties. The special circumstances of AIDS and mental illness merit individual consideration.