Band 94, Heft 9

The recruitment and retention of osteopathic medical students by osteopathic medical institutions is arguably the most important priority facing the profession today. Residencies accredited by the Accreditation Council on Graduate Medical Education are now the major competitors for osteopathic medical students; osteopathic residency graduates are readily accepted at most hospitals; and osteopathic medical faculty are regularly appointed to university and government positions. As a result, many osteopathic medical institutions are having difficulty in filling their training programs and recruiting faculty and medical staff physicians. These recruitment problems can be resolved by the development of graduate medical education (GME) programs that are competitive with their allopathic GME counterparts, but hospitals and colleges must do so by developing a new approach to osteopathic GME. Osteopathic GME must sell academic quality by developing a university-like environment in the hospitals conducting training programs. Osteopathic training hospitals should consider requiring their directors of medical education to develop strategic plans for GME which result in the development of competitive programs.

The development of clinical practice guidelines has spread from utilization review agencies to physician specialty societies, federal agencies, managed care organizations, and academic health centers as their usefulness in accomplishing the goals of healthcare reform become clear. The author reviews the mounting evidence that variation in the practice of medicine suggests that patients in some areas are not receiving all needed services, while others are receiving unnecessary services. He explores the implications of practice guidelines for improving the quality of care while controlling cost. Practice guidelines are defined and distinguished from medical review criteria. The author explores the challenges in governance, funding, and guideline development and communication that will have to be overcome to establish the credibility of practice guidelines. Finally, he addresses the opportunities for the osteopathic medical profession to establish its uniqueness in this setting.

A young woman did not seek emergency treatment after a minor automobile collision as she thought that she had been spared serious injury by the inflation of the driver's-side airbag. She had a benign-looking erythema on her neck which, over the next several days, became a second-degree chemical burn infected with Staphylococcus aureus. The burn and subsequent infection took several weeks to heal and the patient had to endure a prolonged course of antibiotics, nonsteroidal antiinflammatory drugs, and continued irrigation. This case exemplifies why alkali chemical burns from an automotive airbag should be treated aggressively, despite their benign appearance, as they may take several days to evolve. Physicians should be warned that careful follow-up examination of patients seen in the hospital emergency department or in the physician's office is necessary to abate any hidden sequelae. Of course, the opportunity to decrease morbidity is lost if the patient does not seek emergency treatment.

A 31-year-old man was seen with addisonian crisis, followed by the abrupt onset of spastic paraparesis and peripheral neuropathy. A workup revealed adrenal insufficiency, for which the patient was aggressively treated. The workup also revealed an increase in very-long-chain fatty acids consistent with the diagnosis of adrenomyeloneuropathy. Abnormal pituitary dysfunction improved with treatment of the Addison's disease. A review of the patient's pedigree revealed two family members in whom multiple sclerosis had been diagnosed but which, in retrospect, was thought to be adrenomyeloneuropathy. No other family member was found to have Addison's disease. A sibling died at age 8 of Schilder's disease, confirming the presence of adrenoleukodystrophy as well as adrenomyeloneuropathy within this family.