As everyone in medicine knows, a crisis is affecting all areas of the field. In an attempt to control the spiraling costs of health care, multiple regulatory interventions have been undertaken, all of which have led to continuing problems. Such experiments as professional standards review organizations (PSROs), certificates of need (CONs), diagnostic-related groups (DRGs), the Health Professions Educational Assistance Act, expanding medical schools and faculty, managed care, and the Balanced Budget Act of 1997 have created a tragedy that may well be irreversible.
We have assembled a group of knowledgeable representatives from many areas of surgery to discuss the issues affecting their respective domains: the academic health center as viewed by an established overseer, an academic health center from the perspective of a surgeon-dean, a program director's view of threats to the surgical residency system, continuing surgical research by a top-notch investigator-chairman, the view from the American College of Surgeons' executive director, ideas from the chief executive officer of our largest managed care organization, reflections of a surgical chairman as he looks back on his career and ponders the problems and solutions facing a new chair, thoughts on issues affecting community hospitals by an able leader of a surgical department, and a Canadian physician's perspective as one who has participated in this system for many years.
The problems are elaborated in detail. The solutions are more difficult to define and will depend on the political climate of our country.
See Crisis in Health Care and the following 9 articles.Article
In an analysis of almost 200 consecutive patients, these investigators concluded that 87% were free of recurrent reflux 5 years or more following Nissen fundoplication. All complications were noted and reviewed by an independent investigator. The conversion rate to an open procedure was 12% including the early learning curve experience. Thus, it is their belief that laparoscopic Nissen fundoplication is comparable with open fundoplication and should be used as the gold standard.
In a case-control study, 42 patients were examined to determine the effects of pelvic irradiation and chemotherapy after proctectomy with coloanal anastomosis for low- and mid-rectal lesions. Eight to 12 weeks after the surgical procedure, a 24% decrease was noted in the resting pressure in the surgery-only group, whereas a 51% decrease ensued when radiation was added. (Resting pressure reflects internal sphincter dysfunction.) The effects of chemotherapy were variable but generally toxic. It was concluded that protection for low-lying lesions should be afforded, when possible, by shielding prior to irradiation.
The size of a breast mass can be repeatedly measured to an absolute error of 13% by using pressure sensors stroked over the mass prior to surgical intervention (as opposed to a 46% error with physical examination and 34% with ultrasonography). This capability can enhance cancer surveillance for patients with benign masses and aid in clinical staging for breast cancer patients.
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