Estimating the impact of state manpower policy: a case study of reducing medical school enrollments

Perceptions of an impending oversupply of physicians have prompted proposals to reduce medical school enrollments in a number of states. Most of these states are also concerned with improving the specialty and geographic distribution of their medical manpower. The present study provides estimates of the effects of reduced numbers of in-state medical school graduates upon the future supply of physicians in Texas, and examines the medical school origin, medical specialty, and practice location of selected groups of Texas physicians. The results suggest that in Texas enrollment reductions would have no significant impact on physician supply over the next 15 years, and might actually prove counterproductive in altering physician distribution. The analysis of Texas data illuminates the unintended consequences likely to accompany a policy option that has been widely embraced by state officials largely on the basis of its intuitive appeal.     

当前医疗损害鉴定制度存在问题与对策

随着《侵权责任法》的实施,医疗纠纷司法鉴定将在医疗损害鉴定中起着越来越重要的作用。我国的医疗损害鉴定制度经历了一系列的制度变迁过程。但是,基于医疗的专业性、复杂性和技术性,医疗损害的鉴定不是一般法医能胜任的鉴定工作。医疗事故技术鉴定制度仍是一项可利用的制度资源。当前医疗损害鉴定制度的构建,应警惕形式意义上的鉴定公正带来实质意义上的鉴定不公正;警惕法律对患者的保护带来医疗对患者的伤害。建议对医疗事故技术鉴定制度进行改造,使之成为类似于美国的审前审查机制,或者采取医疗损害司法鉴定特别许可制度,以完善我国的医疗损害鉴定制度。     

Irrationality, evidence-based medicine and the standard of care

The determination of the legal standard of care in Australia for medical diagnosis and treatment has gone through three apparent phases in modern times: the Bolam era, the post-Rogers v Whitaker era, and the current Civil Liability Acts era. It is conventionally accepted that the two shifts linking these phases were a jettisoning of the Bolam principle in Rogers and a return to a modified Bolam principle in the Civil Liability legislation, with the post-Rogers interregnum being a time of a court-imposed standard. This story is somewhat inaccurate. The Bolam test relied more on practice accepted at the time as proper by a responsible body of medical opinion rather than the practice of a "responsible body of medical men". The ability of post-Rogers courts to override medical evidence was more a rhetorical power than an actual one. And the irrationality condition, which reserves the right to override medical opinion under the Civil Liability Acts, is more dependent on sound evidence than the terminology might suggest. It is not so much that the legal standard of care has changed in dramatic ways as that the content of competent professional opinion has evolved as medical research and practice have developed. There is greater continuity than is usually granted, throughout the three phases, of the standard's reliance on current best evidence and opinion. This is more easily seen with the advent of evidence-based medicine.     

医疗纠纷证据保全制度研究

医疗纠纷处理中有关证据真实性的问题越来越突出,证据保全是解决这一困境的较好办法。我国医疗事故处理条例规定了病历资料和可疑医疗物品的证据保全,但存在法律定位不清、具体操作性差等缺陷。对于条例规定的病历资料和可疑医疗物品的封存和管理,从法律性质上来说应属证据契约。当前我国证据保全制度在立法上存在诸多缺陷,长远来看有赖于我国证据保全制度在诉讼程序上的前移与适用范围的扩大,以及通过立法增强当事人的取证能力。在目前的法律体制下,只能通过引入第三方见证人和制作证据保全笔录来解燃眉之急。     

What the publisher can teach the patient: intellectual property and privacy in an era of trusted privication

This article begins with a premise that intellectual property and privacy have something significant and yet understated in common: both are about balancing a creator's desire to control a particular set of data with consumers' desires to access and redistribute that data. Both law and technology influence such balancing, making it more or less palatable to use data for particular purposes--whether one is an individual making a copy of a popular song for a friend, or a hospital selling a list of maternity ward patients to a day care service. In the shadow of the Internet's rapid development and concomitant easing of barriers to data sharing, holders of intellectual property are pairing increased legal protection with the technologies of "trusted systems." I describe how these technologies might allow more thorough mass distribution of data, while allowing publishers to retain unprecedented control over their wares. For instance, an e-Book seller might charge one price for a read-only copy that could not be printed or forwarded and charge an additional fee for each copy or printout made. Taking up the case of medical privacy, I then suggest that those who worry about the confidentiality of medical records, particularly as they are digitized by recent congressional mandate, might seek to augment comparatively paltry legal protections with trusted systems technologies. For instance, a trusted system could allow a patient to specify how and by whom her records could be used; within limits, she could allow full access to her primary care physician, while allowing only time-limited access to emergency care providers, non-personally identifiable access to medical researchers, and no access at all for marketing purposes. These technologies could allow for new kinds of privacy protection, without sacrificing the legitimate interests of the consumers of medical records.     

National health insurance and the new health occupations: nurse practitioners and physicians' assistants

This article considers a number of issues which might arise in formulating policy for new health occupations. Its particular focus is on nurse practitioners and physicians' assistants and their treatment under potential national health insurance arrangements. The development and expansion of these occupations are described, as is the evidence on their performance with respect to the quality of medical care provided, the impact on the cost of such care, and changes in access to care. We then discuss several issues which might arise in the context of national health insurance legislation, including reimbursement rates and methods, certification and licensure, training subsidies, deployment incentives, and compatibility with an increased supply of physicians.     

Justifications for Non-Consensual Medical Intervention: From Infectious Disease Control to Criminal Rehabilitation

A central tenet of medical ethics holds that it is permissible to perform a medical intervention on a competent individual only if that individual has given informed consent to the intervention. Yet it occasionally seems morally permissible to carry out non-consensual medical interventions on competent individuals for the purpose of infectious disease control (IDC). We describe two different moral frameworks that have been invoked in support of non-consensual IDC interventions and identify five desiderata that might be used to guide assessments of the moral permissibility of such interventions on either kind of fundamental justification. We then consider what these desiderata imply for the justifiability of carrying out non-consensual medical interventions that are designed to facilitate rehabilitation amongst serious criminal offenders. We argue that these desiderata suggest that a plausible case can be made in favor of such interventions.     

Patient Compensation Funds: legislative responses to the medical malpractice crisis

Fifteen states have created Patient Compensation Funds in response to the increased cost and reduced availability of medical malpractice insurance associated with the so-called "medical malpractice crisis." Patient Compensation Fund statutes limit health care providers' liability to a specified amount, and establish state-administered funds to compensate victorious malpractice plaintiffs for damage awards in excess of that amount. This Note examines the Patient Compensation Fund mechanism, evaluates its effectiveness as a compensation system for malpractice victims, and recommends particular provisions that might enhance its effectiveness. The Note concludes that the Patient Compensation Fund mechanism is an effective means of increasing the availability and of reducing the cost of medical malpractice insurance, and should be adopted by other states experiencing a "medical malpractice crisis."     

Caffeine fatalities--four case reports

Four cases of fatal intoxications with caffeine are described. Caffeine is widely available in beverages and in different OTC-products, in many of them in combinations with other drugs like ephedrine. Caffeine is not as harmless as one might believe. An overdose of caffeine alone, intentional or not, might be deadly. It seems to be warranted to include caffeine in the drug-screening of forensic autopsy cases. It is not motivated from a medical point of view to sell pure caffeine over the counter.     

Constitutional challenge to "medical inadmissibility" provisions in the Immigration Act

In a case with significant implications for people living with HIV/AIDS who wish to immigrate to Canada, in January 2002 a woman with multiple sclerosis launched a constitutional challenge to the "medical inadmissibility" provisions in the Immigration Act. The provisions state that any would-be immigrant may be denied permission to immigrate "if their admission would cause or might reasonably be expected to cause excessive demands on health or social services."     

The construction of socially remedial legislation in Australia: the strange case of hydrotherapy

The article examines the canons of construction of socially remedial statutes in Australia and the utility and acceptance of hydrotherapy as a means of medical treatment. It considers cases from various administrative bodies in Australia as they have applied to this mode of treatment and notes that the canons have not been applied uniformly. The results have sometimes been unhappy. The article suggests why that might be the case and argues that the process may have undermined the medical utility of the treatment.     

Limitation of medical research in German law.

In Germany, pharmaceutical trials and the testing of medical devices is regulated by statute. Any other kind of medical experimentation is handled according to the Declaration of Helsinki. Medical experimentation has to be reviewed by an ethics committee before the start and there has to be an elaborate research protocol, which provides for the protection of the experimental subject. In case of an accident, there is compulsory accident insurance as far as pharmaceutical trials and the testing of medical devices are concerned. The third party accident insurance just covers material loss, there is no provision paying and suffering. The sum paid by the insurance company is set off against damages for negligence. There is no strict liability for medical experimentation, but the German courts are expected to set very high standards for medical care in experimentation. The data protection and medical confidentiality have been lessened because of the European law that requires the experimental subject to give his consent to the inspection of the data or the file and if he takes part in the experimentation, that his data and some of his cells might be with the pharmaceutical company forever. In general, the German law seems to be adequate to the protection of experimental subjects.     

Exploring a Research Agenda of the Feminization of the Legal Profession: Theories of Gender and Social Change

This essay suggests that recent work in feminist theory should reorient the questions that are asked about the role of gender in the legal profession. Some use gender as a category of analysis to explore differences that reinforce conventional gendered stereotypes, such as the conceptualization of work and family in lawyering as a "women's issue." Others use conventional sociology of the professions analysis, such as stratification, to measure women's "success" and "satisfaction" in the context of the traditional law firm. By focusing on some recent historical and sociological research on women in the legal and medical professions, the author illustrates how we might ask different questions, not to reify gender differences but to more fully examine the role that gender difference, as socially constructed, might play in the transformation of law practice.     

医疗纠纷中病历存在瑕疵问题之研究

医患双方因医疗行为发生纠纷诉至人民法院后,对病历中存在改动、添加的痕迹,医方和患方会持截然相反的观点。医院认为这是正常的修改,对医疗行为的正确性没有影响。而患方会认为,这是医疗行为错误或违反卫生法律法规给患者带来损害后,医方为逃避承担责任,而采取的补救措施,是篡改病历,掩饰自己的过错。这样的证据摆在法官面前,无论法官作出怎样的内心确认,法院作出怎样的裁判,都可能使一方甚至双方内心永远留着痛。     

Teaching post-mortem external examination in undergraduate medical education--the formal and the informal curriculum

In undergraduate medical education, the training of post-mortem external examination on dead bodies might evoke strong emotional reactions in medical students that could counteract the intended learning goals. We evaluated student perception of a forensic medicine course, their perceived learning outcome (via self-assessment) and possible tutor-dependent influences on the overall evaluation of the course by a questionnaire-based survey among 150 medical students in Hamburg, Germany. The majority of students identified post-mortem external examination as an important learning objective in undergraduate medical education and did not feel that the dignity of the deceased was offended by the course procedures. After the course, more than 70% of the students felt able to perform an external examination and to fill in a death certificate. Respectful behavior of course tutors towards the deceased entailed better overall course ratings by students (p<0.001). Our findings highlight the importance of factors such as clearly defined learning goals and course standardization (formal curriculum) as well as tutor behavior (informal curriculum) in undergraduate education in forensic medicine. Furthermore, we suggest embedding teaching in forensic medicine in longitudinal curricula on death and dying and on the health consequences of interpersonal violence.     

Swollen Lips After a Night of Partying—An Allergic Reaction to Ecstasy?

Ecstasy (MDMA) is a mood‐lifting drug with numerous somatic side effects, for example, dehydration or continuous chewing and biting. We describe the case of a young woman who underwent a forensic medical examination for suspected sexual assault. She claimed to have suffered from a memory lapse, and she had a painful swelling of her lips with a plaque‐like coating on her lips and buccal mucosa. The attending physician suspected that these findings might have been caused by strong sucking pressure on her lips within the context of a sexual assault. A toxicological examination of a blood specimen verified that she had been under the influence of an extremely high dose of ecstasy (1.456 mg/L MDMA and 0.0213 mg/L MDA). Pursuant to the forensic medical assessment, the described findings on her lips, and buccal mucosa were interpreted as an allergic and mechanical reaction (through continuous chewing and biting) to ecstasy.     

The application of CT for 3D visualization of concealed bodies

In forensic radiology, computed tomography (CT) is often used as a medical imaging technique to identify the cause and manner of death of deceased victims of a possible crime. In this study, medical imaging is used to examine concealed bodies and packaging materials. Medical imaging techniques, mainly CT scan, were used to scan packaged or concealed bodies inside containers to identify clues and evidence indicating whether a crime might have been committed. Also, scene integrity and scene safety along with a systematic search for relevant evidentiary items value were considered.Eighteen concealed bodies that had been assessed using medical imaging techniques between 2010 and 2018 at the request of the Dutch National Police were selected. The file records of each case contained imaging data, a photographic record of the unpacking procedure, a list of all items and traces found in the package, and the forensic pathology report. The images were assessed with respect to the different aspects of the case and through a systematic approach.The packages included adult males, adult females, newborn infants, and animals. All human cases were related to criminal offences. In nine adult cases, evidence of a possible violent death could be determined using CT imaging. The cause of death in newborn infants, however, could not be determined. In cases of dismemberment, the completeness of the body could be determined by CT imaging, and the cutting surfaces of bones could be matched on CT images. Regarding scene safety and integrity, in this study all relevant macroscopic items were detected on the CT images.The CT-scans were supplemented with fiduciary markers to better map CT data with the real objects. This information in combination with 2D and 3D images provided the forensic investigator with information on how to unwrap the package layer by layer and help determine different types of packaging materials. Different textiles could not always be identified. The orientation of the body within the packages was provided in all cases, and advice could be given on the optimal approach to access the contents. The overall detection rate of items was 78%.This is one of the first studies to illustrate the contribution of medical imaging, specifically CT scan, to the analysis of concealed bodies and packaging materials prior to unpacking. This demonstrates its contribution to a systematic approach of the investigation by ensuring the safety and health of the investigator while documenting and maintaining the integrity of the crime scene. Imaging also provides information that can be helpful to determine whether a crime might have been committed and reducing the risk of damaging a concealed body. Medical imaging also provides the forensic investigator with information to draw up a workplan prior to unpacking, minimising loss of evidence and determining whether different forensic specialists (e.g., digital or DNA) are needed. It is therefore strongly recommended to use medical imaging, especially CT scanning, before opening a package containing a concealed body.     

Reframing the racial disparities issue for state governments

Although racial and ethnic disparities in health have been on the federal government's agenda since 1985, no policy reforms have significantly reduced disparities. The question arises whether states can effectively address this issue without waiting for solutions from the national government. The purpose of this article is to propose ways of reframing the disparities issue that might give state policy makers more leverage and might strengthen political will to address the issue. I suggest a moral frame based on a concept of distributive justice in which medical care must be distributed according to need. I explain the rationales for such a frame and consider its strategic advantages and disadvantages. In the last section, I suggest some policies based on this framing that are within the power of state legislatures.     

The ethical implications of prospective payment and corporate medical practice: A research agenda

The major trends in the growth of prospective payment and the corporatization of medical practice in the United States are examined. In particular, the ethical implications of these changes in the context of the multiple system goals of access, cost containment, and quality are considered. Considerable concern is being expressed that with the dominant emphasis on cost containment, the principles of access and quality might be compromised. This paper formulates a research agenda to address this question, based on a review and synthesis of empirical evidence and hypotheses about the probable or actual impact of these changes on the multiple health system goals. A basic premise is that ethical judgments should be grounded in empirical evidence about what actually is or will be.