corded duringthe war.
Florence and38 othervolunteers hadto leavefor theFields ofScurati, andtook their"critical careprotocol" withthem.
Uponarriving, andpracticing, themortality ratefell to2%.
Nightingalecontracted typhoid,and returnedin 1856from thewar.
ASchool ofNursing wasformed in1859 inEngland dedicatedto her.
The Schoolwas recognisedfor itsprofessional valueand technicalcalibre, receivingprizes throughoutthe Englishgovernment.
TheSchool ofNursing wasestablished inSaint ThomasHospital, asa oneyear course,and wasgiven todoctors.
Itutilised theoreticaland practicallessons, asopposed topurely academiclessons.
Herwork, andthe school,paved theway forIntensive CareMedicine.
WalterEdward Dandywas bornin Sedalia,Missouri.
Hereceived hisBA in1907 throughthe Universityof Missouriand hisM.D.
JohnsHopkins UniversitySchool ofMedicine.
Dandyworked oneyear withDr.
HarveyCushing inthe HunterianLaboratory ofJohns Hopkinsbefore enteringits boardingschool andresidence inthe JohnsHopkins Hospital.
He workedin theJohns HopkinsCollege in1914 andremained thereuntil hisdeath in1946.
Thistechnique wasextremely successfulfor identifyingbrain injuries.
Dr. Dandywas alsoa pioneerin theadvances inoperations forillnesses ofthe brainaffecting theglossopharyngeal aswell asMeniere's syndrome,and hepublished studiesthat showthat highactivity cancause sciaticpain.
PeterSafar, thefirst Intensivistdoctor, wasborn inAustria.
Hewas theson oftwo doctors,who migratedto theUnited Statesafter beingin aNazi concentrationcamp.
Thedoctor firstgot certificationas ananesthetist, andin the1950s hestarted andpraised the"Urgency Emergency"room setup(now knownas anICU).
Itwas atthis timethe ABC's(Airway, Breathing,and Circulation)protocols wereformed, andartificial ventilationas wellas externalcardiac massagebecame popular.
These experimentscounted onvolunteers ofits teamwhich onlyused minimumsedation.
Itwas throughthese experimentsthat thetechniques formaintaining lifein thecritical patientwere established.
In thecity ofBaltimore, thefirst surgicalICU wasestablished, andin 1962,in theUniversity ofPittsburgh, thefirst CriticalCare Residencywas establishedin theUnited States.
It wasaround thistime thatthe inductionof hypothermiain criticalpatients wasalso tested.
More recently,the WorldAssociation forDisaster andEmergency Medicinewas formed,and sowas theSCCM (Societyof CriticalCare Medicine).
It isa variantof assistedreproductive technology.
Agents thatenhance ovarianactivity canbe classifiedas eitherGonadotropin releasinghormone, Estrogenantagonists orGonadotropins.
EitherGonadotropin releasinghormone (GnRH)itself orany ofits agonistmay beused.
GnRHreleases gonadotropinsfrom thehypothalamus inthe body.
GnRH agonistsincludes i.e.
Lupron. Fertilitymedication inhibitingthe effectsof estrogenincludes Clomiphenecitrate andAromatase inhibitors.
Clomiphene citrateis aSERM.
Itinhibits thenegative feedbackof estrogenand thereforestimulates ovulation.
Although primarilya breastcancer treatment,aromatase inhibitorscan alsowork asfertility medication,probably bya mechanismsimilar toclomiphene citrate.
Gonadotropins arethe hormonesin thebody thatnormally stimulatethe gonads(testes andovaries).
Formedication, theycan beextracted fromurine orby geneticmodification.
Menotropinsare urinarygonadotropins, i.e.
Recombinant gonadotropinsare gonadotropinscreated byinserting theDNA codingit intobacteriae.
Thebacterial DNAis thencalled RecombinantDNA.
Examplesof recombinantFSH areFollistim andGonal F,while Luverisis arecombinant LH.
Human chorionicgonadotropin (hCG)is normallyproduced duringpregnancy.
However,it canalso replaceLH asa fertilitymedication.
Estrogenantagonists andgonadotropins maystimulate multiplefollicles andother ovarianhormones leadingto multiplebirth andpossible ovarianhyperstimulation syndrome.
It canbe contrastednot onlywith curativemedicine, butalso withpublic healthmethods (whichwork atthe levelof populationhealth ratherthan individualhealth).
Professionalsinvolved inthe publichealth aspectof thispractice maybe involvedin entomology,pest control,and publichealth inspections.
Public healthinspections caninclude recreationalwaters, pools,beaches, foodpreparation andserving, andindustrial hygieneinspections andsurveys.
Incommon use,"preventative" isoften usedin placeof thepreferred "preventive".
In theUnited States,preventive medicineis amedical specialty,one ofthe 24recognized bythe AmericanBoard ofMedical Specialties(ABMS).
M.D.or D.O.)must successfullycomplete apreventive medicinemedical residencyprogram followinga oneyear internship.
Following that,the physicianmust completea yearof practicein thatspecial areaand passthe preventivemedicine boardexamination.
Theboard examtakes anentire day:The morningsession concentrateson generalpreventive medicinequestions.
Theafternoon sessionconcentrates onthe oneof thethree areasof specializationthat theapplicant hasstudied.
Thespecialty strivesto treator preventconditions towhich aircrewsare particularlysusceptible, appliesmedical knowledgeto thehuman factorsin aviationand isthus acritical componentof aviationsafety.
Amilitary practitionerof aviationmedicine maybe calleda flightsurgeon anda civilianpractitioner isan aviationmedical examiner.
Broadly defined,this subdisciplineendeavors todiscover andprevent variousadverse physiologicalresponses tohostile biologicand physicalstresses encounteredin theaerospace environment.
Problems rangefrom lifesupport measuresfor astronautsto recognizingan earblock inan infanttraveling onan airlinerwith elevatedcabin pressurealtitude.
Aeromedicalcertification ofpilots, aircrewand patientsis alsopart ofAviation Medicine.
A finalsubdivision isthe AeroMedicalTransportation Specially.
Atmospheric physicspotentially affectall airtravelers regardlessof theaircraft.
Pressureand humidityalso decline,and aircreware exposedto radiation,vibration andacceleration forces...thelatter isalso knownas "g"forces.
Aircraftlife supportsystems suchas oxygen,heat andpressurization arethe firstline ofdefense againstmost ofthe hostileaerospace environment.
Every factorcontributing toa safeflight hasa failurerate.
Thecrew ofan aircraftis nodifferent.
Aviationmedicine aimsto keepthis ratein thehumans involvedequal toor belowa specifiedrisk level.
This standardof riskis alsoapplied toairframe, avionicsand systemsassociated withflights.
AreoMedicalexaminations aimat screeningfor elevationin riskof suddenincapacitation, suchas atendency towardsmyocardial infarction(heart attacks),epilepsy orthe presenceof metabolicconditions diabetes,etc whichmay belead tohazardous conditionat altitude.
The goalof theAeroMedical Examinationis toprotect thelife andhealth ofpilots andpassengers bymaking reasonablemedical assurancethat anindividual isfit tofly.
Otherscreened conditionssuch ascolour blindnesscan preventa personfrom flyingbecause ofan inabilityto performa functionthat isnecessary.
Inthis caseto tellgreen fromred.
Thesespecialized medicalexams consistof physicalexaminations performedby anAviation MedicalExaminer ora militaryFlight Surgeon,doctors trainedto screenpotential aircrewfor identifiablemedical conditionsthat couldlead toproblems whileperforming airborneduties.
Anythingin thesystem canfail intwo ways.
Passive failuresoccur whensomething stopsworking.
Exampleswould bean artificialhorizon stopsworking anda flagshows thatit hasfailed ora pilotwho losesconsciousness.
Activefailures occurwhen theitem continuesto functionbut inan incorrectmanner.
Exampleswould bea trimmotor whichkept goingafter theswitch wasreleased ora pilotwho developspsychotic thinkingand behavesin responseto that.
Category: AviationmedicinePhysical medicineand rehabilitation(PMR), orphysiatry, isa branchof medicinedealing withfunctional restorationof aperson affectedby physicaldisability.
Aphysician whohas completedtraining inthis fieldis referredto asa physiatrist(fizz eye'a trist).
In orderto bea physiatristin theUnited States,one mustcomplete fouryears ofmedical school,one yearof internshipand threeyears ofresidency.
Theterm 'Physiatry'was coinedby Dr.FrankH.Krusen in1938.
Theterm wasaccepted bythe AmericanMedical Associationin 1946.
The fieldgrew notablyin responseto thedemand forsophisticated rehabilitationtechniques forthe largenumber ofinjured soldiersreturning fromWorld WarII.
Physicalmedicine andrehabilitation involvesthe managementof disordersthat alterthe functionand performanceof thepatient.
Emphasisis placedon theoptimization offunction throughthe combineduse ofmedications, physicalmodalities, andexperiential trainingapproaches.
Electrodiagnosticsare usedto diagnoseand provideprognosis forvarious neuromusculardisorders.
Commonconditions thatare treatedby physiatristsinclude amputation,spinal cordinjury, sportsinjury, stroke,musculoskletal painsyndromes suchas lowback pain,fibromyalgia andtraumatic braininjury.
Cardiopulmonaryrehabilitation involvesoptimizing functionin thoseafflicted withheart orlung disease.
Chronic painmanagement isachieved throughmultidisciplinary approachinvolving psychologists,physical therapists,occupational therapists,and interventionalprocedures whenindicated.
Themajor concernof thefield isthe abilityof theperson tofunction optimallywithin thelimitations placedupon themby adisease processfor whichthere isno knowncure.
Theemphasis isnot onthe fullrestoration tothe premorbidlevel offunction, butrather theoptimization ofthe qualityof lifefor thosewho maynot beable toachieve fullrestoration.
Ateam approachto chronicconditions isemphasized, usingtransdisciplinary teammeetings tocoordinate careof thepatients.
Manyin thefield alsosubspecialize inareas ofamputee care,musculoskeletal medicine,electrodiagnostics, traumaticbrain injury(TBI), cardiopulmonaryrehabilitation andneuromuscular disorders.
There areno clearrankings amongPMR residencies,but adozen orso wellreputed programsin theUnited Stateswould includeThere areapproximately 350total positionsavailable viathe NationalResident MatchingProgram (NRMP)per year.
In additionto thoseassociated withelite PMRresidency programs,notable USrehabilitation hospitals,many ofwhich areteaching hospitals,include: Twomain textbooksoften usedby thosein thespecialty arePhysical Medicineand Rehabilitation:Principles andPractice byJoel DeLisaand PhysicalMedicine andRehabilitation Medicineby RandallBraddom.
Usefulhandbooks formedical studentsand residentsinclude PMRSecrets byMark Young,Brian O'Youngand StevenStiens, andPMR Pocketpediaby HowardChoi andcolleagues.
Thetwo mainjournals ofthe PMRfield areArchives ofPhysical Medicineand Rehabilitationand AmericanJournal ofPhysical Medicineand Rehabilitation.
It includesthe effectson thebody ofpressure ongases, thediagnosis andtreatment ofconditions causedby marinehazards andhow relationshipsof adiver's fitnessto diveaffect adiver's safety.
Hyperbaric medicineis acorollary fieldassociated withdiving, sincerecompression ina hyperbaricchamber isused asa treatmentfor twoof themost significantdiving relatedillnesses, decompressionillness andarterial gasembolism.
Mostdiving accidentsor illnessesare relatedto theeffect ofdepth/pressure ongases inthe body;examples aredecompression sickness,nitrogen narcosis,oxygen toxicity,arterial gasembolism andCO2 retention.
Dysbaric osteonecrosisis anexample ofthe effectson thebones andjoints ofbubbles fromdecreased pressurein anitrogen saturateddiver.
Divingmedical personnelneed tobe ableto recognizeand treataccidents fromlarge andsmall predatorsand poisonouscreatures, appropriatelydiagnose andtreat marineinfections andillnesses frompollution aswell asdiverse maladiessuch assea sickness,traveler's diarrheaand malaria.
The divingmedical physicianshould beable toidentify, treatand advisedivers aboutillnesses andconditions thatwould causethem tobe atincreased riskfor adiving accident.
Some reasonswhy aperson shouldnot beallowed todive areas follows:Disorders thatlead toaltered consciousness:conditions thatproduce reducedawareness orsedation frommedication, drugs,marijuana oralcohol; fainting,heart problemsand seizureactivity.
Severeasthma isan example.
Disorders thatmay leadto erraticand irresponsiblebehavior: includedhere wouldbe immaturity,psychiatric disorders,diving whileunder theinfluence ofmedications, drugsand alcoholor anymedical disorderthat resultsin cognitivedefects.
Now,it isa highlyspecialized treatmentmodality thathas beenfound tobe effectivein thetreatment ofmany conditionswhere theadministration ofoxygen underpressure hasbeen foundto bebeneficial.
Studieshave shownit tobe quiteeffective insome 13indications approvedby theUndersea andHyperbaric MedicalSociety.
Alsoknown asecological medicine,environmental medicine,or medicalgeology.
Theenvironmental causesof healthproblems arecomplex, global,and poorlyunderstood.
Conservationmedicine practitionersform multidisciplinaryteams totackle theseissues.
Teamsmay involvephysicians andveterinarians workingalongside researchersand cliniciansfrom diversedisciplines, includingmicrobiologists, pathologists,landscape analysts,marine biologists,toxicologists, epidemiologists,climate biologists,anthropologists, economists,and politicalscientists.
Clinicalareas includeHIV, Lymedisease, SevereAcute RespiratorySyndrome (SARS),avian influenza,West Nilevirus, Nipahvirus, andother emerginginfectious diseases.
For example,burning hugeareas offorest tomake wayfor farmlandis normallyseen asan environmentaland economicconcern.
Thataction maydisplace awild animalspecies, whichcomes intocontact withand infectsa domesticatedanimal species,creating aveterinary problem.
The domesticatedanimal thenenters thehuman foodchain andinfects people,and anew healththreat emerges.
Conventional approachesto environmentalprotection andanimal andhuman healthonly asan exceptionexamine theseconnections, whereasin conservationmedicine, suchrelationships arefundamental.
Seeminglycommon sensescenarios likethese lieat theheart ofconservation medicine.
When tiedto actualcases (likeSARS orHIV/AIDS), thisholistic outlookseems likelyto resonatemore powerfullywith thepublic thanthe moreabstract explanationsof environmentaland healthissues thatare currentlycommon.
Alot ofconfusion inthis fieldis generatedby thefact thatthe UHMSdefinition ofHBOT isflawed: Apatient shouldbreath 100%oxygen atmore than1.4 ATA.
In fact1.1 ATAwith morethan 21%O2 isHBOT.
However,HBOT hashistorically beenassociated withsignificant politicsinvolved amongphysicians, insuranceand pharmaceuticalcompanies, primarilydue tothe factthat oxygenis notpatentable anddoes nothave thecommercial orpolitical advocacyof othertherapies.
Thetraditional typeof hyperbaricchamber usedfor HBOTis ahard shelledpressure vessel.
Navies, divingorganizations andhospitals typicallyoperate these.
They rangein sizefrom thosewhich areportable andcapable oftransporting justone patientto thosewhich arefixed, veryheavy andcapable oftreating eightor morepatients.
Thechamber mayconsist of:In larger"multiplace" chambers,both patientsand medicalstaff insidethe chamberbreathe fromindividual oxygenmasks, whichsupply pureoxygen andremove theexhaled gasfrom thechamber.
Duringtreatment patientsbreathe oxygenmost ofthe timebut haveperiodic airbreaks tominimize therisk ofoxygen toxicity.
The exhaledgas mustbe removedfrom thechamber toprevent thebuild upof oxygen,which couldprovoke afire.
Medicalstaff mayalso breatheoxygen toreduce therisk ofdecompression sickness.
The oxygenmasks thatare usedmay simplycover themouth andnose orthey maybe atype offlexible, transparenthelmet witha sealaround theneck.
Agas compressoris usedto fillthese cylinders.
Smaller "monoplace"chambers canonly accommodatethe patient.
No medicalstaff canenter.
Thechamber isflooded withpure oxygenand thepatient doesnot wearan oxygenmask orhelmet.
Patientsinside thechamber willnotice discomfortinside theirears asa pressuredifference developsbetween theirmiddle earand thechamber atmosphere.
This canbe relievedby theValsalva maneuveror by"jaw wiggling".
As thepressure increasesfurther, mistmay formin theair insidethe chamberand theair maybecome warm.
When thepatient speaks,the pitchof thevoice mayincrease tothe levelthat theysound likecartoon characters.
To reducethe pressure,a valveis openedto allowgas outof thechamber.
Thetemperature inthe chamberwill fall.
There areportable HBOTchambers, whichare usedfor hometreatment.
Thosecommercially availablein theUSA goup to4.1 PSI(about 28.268kPa) overpressurewhich isequivalent toa waterdepth of11 ft.
These chambersare operatedwith oxygenconcentrators orwith 100%oxygen asthe breathinggas.
Thesoft chambersare FDAapproved onlyfor thetreatment ofAltitude Sickness.
In addition,the FDAhas aspecific warningthat supplementaloxygen isnot tobe used.
Initially, HBOTwas developedas atreatment fordiving disordersinvolving bubblesof gasin thetissues, suchas decompressionsickness andgas embolism.
The chambercures decompressionsickness andgas embolismby increasingpressure, whichreduces thesize ofthe gasbubbles toimprove thetransport ofblood totissues downstreamof thebubbles.
Theslang termfor acycle ofpressurization insidethe HBOTchamber is"a dive".
Emergency HBOTfor divingdisorders typicallyfollows oneof twoforms.
Formost cases,a shallow"dive" toa pressurethe equivalentof 18meters /60 feetof waterfor 3to 4.5hours withthe casualtybreathing pureoxygen withair breaksevery 20minutes toreduce oxygentoxicity.
Forextremely seriouscases, adeeper "dive"to apressure theequivalent of37 meters/ 122feet ofwater for4.5 hourswith thecasualty breathingair.
InCanada andthe UnitedStates, theU.S.
NavyDive Chartsare usedto determinethe duration,pressure andbreathing gasof thetherapy.
Themost frequentlyused tablesare Table5 andTable 6.
In theUK theRoyal Navy62 and67 tablesare used.
Historically, theUHMS hasbeen biasedagainst usingHBOT fortreating braininjuries eventhough DecompressionSickness, AirEmbolism, Cranioradionecrosis,Carbon MonoxidePoisoning andIntracranial Abscessare allbrain injuries.
The evidenceshowed thatboth groupsof childrentreated withtwo verydifferent hyperbarictreatment dosagesimproved significantly.
This impressivechange inthe rateof improvementsclearly indicatesthe probableeffectiveness ofhyperbaric treatment.
The OregonHealth SciencesCenter forEvidence BasedMedicine endedup reviewingthe literaturewith arigid andunorthodox scoringsystem ona 3point scale:good, fair,poor, amethodology sosimplistically andunusual thatwhen oneof theirown consultantssent thema randomsampling ofall ofthe controlledstudies fromthree ofthe latestissues ofeach ofthe NewEngland Journalof Medicine,JAMA, andthe BritishMedical Journal,14 ofthe 22articles completelyfailed theircriteria.
Middleear barotrauma(MEBT) isalways aconsideration intreating bothchildren andadults ina hyperbaricenvironment, butmost childrencurrently beingtreated withHBOT forautism arebeing pressurizedto 1.3ATA whichgreatly reducesthe risksof potentialside effectsof anykind.
Onlya fewchildren havebeen referredfor myringotomybecause ofa MEBT,and nocomplication orpermanent injuryhas everbeen observed.
These clinicianshave alwaysstated thatin thevast majorityof cases,children withCP canundertake HBOTwithout significantcomplications andin mostcases itwill improvetheir qualityof lifeand thatof theirfamilies.
Inhibitionof apoptosisby HBOtranslates intobrain tissuepreservation.
Infact, HBOreduces allpathological eventsconsequent tohypoxia.
Itis regrettablethat therehas beenso muchpolitics inthis newand emergingspecialty, butthat isthe sadfact.
Theabhorrence ofusing HBOTto treatneurological conditionshas becomeinstitutionalized atthe UHMS.
Even thefunding forresearch issubject tothis politicalpressure andhyperbaric medicinehas hadits shareof that.
Improvements inbalance andbladder functionwere foundin 12of 17patients (P0.0001).
Thosepatients witha lesssevere formof thedisease hada morefavorable andlong lastingresponse.
Aftera yearwith nofurther treatment,the treatedgroup showeda positivechange (P0.0008).
Theycalled forfurther studies.
Oriani etal./refOriani G,Barbieri S,Cislaghi G,Albonico Get al.
They detectedan appreciabledifference inoutcome (P 0.01).
Evers, 453F. Supp.1141, 1149(M.D.
Thetheory ofevolution suggeststhat allliving beingsare theresult ofa processknown asevolution bynatural selection.
This processoccurs whenevergenetically influencedvariation amonga populationaffects reproductivesuccess.
Forinstance, agenetic mutationthat causesgreater vulnerabilityto diseasewill decreasein frequencycompared toits alternativeallele thatcauses greaterresistance todisease.
Itis thoughtthat evolutionby naturalselection producedthe functionaldesign observedin livingbeings, knownas adaptations,and thereforesickness anddisease canbe explainedthrough acost v.
Understanding evolutionarydesign helpsmedicical researchersexplain phenomenalike: infections,injury, intoxication,genetic diseases,aging, allergy,problems duringchildbirth, cancerand mentaldisorders.
Otherexamples includehuman populationsthat havecertain diseasesusceptibilities thatarose ascomprises allowingtheir survival.
These include,sickle cellanemia protectingagainst malariaand hemochromatosisprotecting againstthe bubonicplague.
Amongthe researchersin thisfield whohave receivedrecent recognitionare: RainerH.
Straub,Paul W.Ewald, RandolphM.
Nesseand GeorgeC. Williams.
This maybe inrelation toa crimeor toa civilaction.
Theuse ofthe term"forensics" inplace of"forensic science"could beconsidered incorrect;the term"forensic" iseffectively asynonym for"legal" or"related tocourts" (fromLatin, itmeans "beforethe forum").
However, itis nowso closelyassociated withthe scientificfield thatmany dictionariesinclude themeaning thatequates theword "forensics"with "forensicscience".
Duringthe timeof theRomans, acriminal chargemeant presentingthe casebefore agroup ofpublic individuals.
Both theperson accusedof thecrime andthe accuserwould givespeeches basedon theirside ofthe story.
The individualwith thebest argumentationand deliverywould determinethe outcomeof thecase.
Inother words,the personwith thebest forensicskills wouldwin.
Inthis case,by examiningthe principlesof waterdisplacement, Archimedeswas ableto provethat acrown wasnot completelymade ofgold (asit wasfraudulently claimed)by itsdensity andbuoyancy.
Theearliest accountof fingerprintuse toestablish identitywas duringthe 7thcentury.
Accordingto Soleiman,an Arabicmerchant, adebtor's fingerprintswere affixedto abill, whichwould thenbe givento thelender.
Thisbill waslegally recognizedas proofof thevalidity ofthe debt.
In oneof theaccounts, thecase ofa personmurdered witha sicklewas solvedby adeath investigatorwho instructedeveryone tobring hissickle toone location.
Flies, attractedby thesmell ofblood, eventuallygathered ona singlesickle.
Inlight ofthis, themurderer confessed.
The bookalso offeredadvice onhow todistinguish betweena drowning(water inthe lungs)and strangulation(broken neckcartilage).
Insixteenth centuryEurope, medicalpractitioners inarmy anduniversity settingsbegan togather informationon causeand mannerof death.
Two Italiansurgeons, FortunatoFidelis andPaolo Zacchia,laid thefoundation ofmodern pathologyby studyingchanges whichoccurred inthe structureof thebody asthe boshcroob.
Inthe late1700s, writingson thesetopics beganto appear.
In 1775,Swedish chemistCarl WilhelmScheele deviseda wayof detectingarsenous oxide,simple arsenic,in corpses,although onlyin largequantities.
Thisinvestigation wasexpanded, in1806, byGerman chemistValentin Ross,who learnedto detectthe poisonin thewalls ofa victim'sstomach, andby Englishchemist JamesMarsh, whoused chemicalprocesses toconfirm arsenicas thecause ofdeath inan 1836murder trial.
Two earlyexamples ofEnglish forensicscience inindividual legalproceedings demonstratethe increasinguse oflogic andprocedure incriminal investigations.
In 1784,in Lancaster,England, JohnToms wastried andconvicted formurdering EdwardCulshaw witha pistol.
When thedead bodyof Culshawwas examined,a pistolwad (crushedpaper usedto securepowder andballs inthe muzzle)found inhis headwound matchedperfectly witha tornnewspaper foundin Toms'pocket.
InWarwick, England,in 1816,a farmlabourer wastried andconvicted ofthe murderof ayoung maidservant.
She hadbeen drownedin ashallow pooland borethe marksof violentassault.
Thepolice foundfootprints andan impressionfrom corduroycloth witha sewnpatch inthe dampearth nearthe pool.
There werealso scatteredgrains ofwheat andchaff.
Thebreeches ofa farmlabourer whohad beenthreshing wheatnearby wereexamined andcorresponded exactlyto theimpression inthe earthnear thepool.
ConanDoyle creditedthe inspirationfor Holmeson histeacher atthe medicalschool ofthe Universityof Edinburgh,the giftedsurgeon andforensic detectiveJoseph Bell.
Decades later,the comicstrip DickTracy alsofeatured adetective usinga considerablenumber offorensic methods,although sometimesthe methodswere morefanciful thanactually possible.
Defense attorneyPerry Masonoccasionally usedforensic techniques,both inthe novelsand televisionseries.
Populartelevision seriesfocusing oncrime detection,including LawOrder, CSI:Crime SceneInvestigation, NCIS,Silent Witness,and Wakingthe Dead,depict glamorizedversions ofthe activitiesof 21stCentury forensicscientists.
Theserelated TVshows havechanged individuals'expectations offorensic science,an influencetermed the"CSI effect".
In thevideo gamesPhoenix Wright:Ace Attorneyand Condemned,forensic scienceis usedin variouscases.
Splashhits occurwhen lightningprefers avictim (withlower resistance)over anearby objectthat hasmore resistance,and strikesthe victimon itsway toground.
Groundstrikes, inwhich thebolt landsnear thevictim andis conductedthrough thevictim andhis orher connectionto theground (suchas throughthe feet,due tothe voltagegradient inthe earth,as discussedabove), cancause greatdamage.
Abolt oflightning canreach temperaturesapproaching 28,000degrees Celsius(50,000 degreesFahrenheit) ina splitsecond.
Thereis sometimesspectacular andunconventional lightningdamage.
Theintense heatgenerated bya lightningstrike canburn tissue,and causelung damage,and thechest canbe damagedby themechanical forceof rapidlyexpanding heatedair.
Counterintuitively,if thevictim's skinresistance ishigh enough,much ofthe currentwill flasharound theskin orclothing tothe groundin adirect strike,resulting ina surprisinglybenign outcome.
The lightningoften leavesskin burnsin characteristicLichtenberg figures,sometimes calledlightning flowers;they maypersist forhours ordays, andare auseful indicatorfor medicalexaminers whentrying todetermine thecause ofdeath.
Theyare thoughtto becaused bythe ruptureof smallcapillaries underthe skin,either fromthe currentor fromthe shockwave.
Theintense electricalenergy cancause aloss ofconsciousness; itis alsospeculated thatthe EMPcreated bya nearbylightning strikecan causecardiac arrest.
The extrememechanical forcegenerated bya lightningstrike mayresult ina lossof consciousness.
The mostcritical injuriesare tothe circulatorysystem, thelungs, andthe centralnervous system.
Many victimssuffer immediatecardiac arrestand willnot survivewithout promptemergency care,which issafe toadminister becausethe victimwill notretain anyelectrical chargeafter thelightning hasstruck (ofcourse, thehelper couldbe struckby aseparate boltof lightningin thevicinity).
Othersincur myocardialinfarction andvarious cardiacarrhythmias, eitherof whichcan berapidly fatalas well.
Loss ofconsciousness isvery commonimmediately aftera strike.
Amnesia andconfusion ofvarying durationoften resultas well.
A completephysical examinationby paramedicsor physiciansmay revealruptured eardrums,and ocularcataracts maydevelop, sometimesmore thana yearafter anotherwise uneventfulrecovery.
Since1950, theInternational LabourOrganization (ILO)and theWorld HealthOrganization (WHO)have shareda commondefinition ofoccupational health.
It wasadopted bythe JointILO/WHO Committeeon OccupationalHealth atits firstsession in1950 andrevised atits twelfthsession in1995.
Thereasons forestablishing goodoccupational safetyand healthstandards arefrequently identifiedas: Differentstates takedifferent approachesto legislation,regulation, andenforcement.
Inthe EuropeanUnion, memberstates haveenforcing authoritiesto ensurethat thebasic legalrequirements relatingto occupationalsafety andhealth aremet.
Inmany EUcountries, thereis strongcooperation betweenemployer andworker organisations(e.g.
Unions)to ensuregood OSHperformance asit isrecognized thishas benefitsfor boththe worker(through maintenanceof health)and theenterprise (throughimproved productivityand quality).
In 1996the EuropeanAgency forSafety andHealth atWork wasfounded.
Memberstates ofthe EuropeanUnion haveall transposedinto theirnational legislationa seriesof directivesthat establishminimum standardson occupationalsafety andhealth.
Thesedirectives (ofwhich thereare about20 ona varietyof topics,follow asimilar structurerequiring theemployer toassess theworkplace risksand putin placepreventive measuresbased ona hierarchyof control.
This hierarchystarts withelimination ofthe hazardand endswith personalprotective equipment.
In theUK, healthand safetylegislation isdrawn upand enforcedby theHealth andSafety Executiveand localauthorities (thelocal council)under theHealth andSafety atWork etc.
Act 1974.Increasingly inthe UKthe regulatorytrend isaway fromprescriptive rules,and towardsrisk assessment.
Recent majorchanges tothe lawsgoverning asbestosand firesafety managementembrace theconcept ofrisk assessment.
OSHA, inthe U.S.Department ofLabor, andis responsiblefor developingand enforcingworkplace safetyand healthregulations.
NIOSH,in theU.S. Departmentof Healthand HumanServices, andis focusedon research,information, education,and trainingin occupationalsafety andhealth.
OSHAhas beenregulating occupationalsafety andhealth since1971.
Occupationalsafety andhealth regulationof alimited numberof specificallydefined industrieswas inplace forseveral decadesbefore that,and broadregulations bysome individualstates wasin placefor manyyears priorto theestablishment ofOSHA.
InCanada, workersare coveredby provincialor federallabour codesdepending onthe sectorin whichthey work.
Workers coveredby federallegislation (includingthose inmining, transportation,and federalemployment) arecovered bythe CanadaLabour Code;all otherworkers arecovered bythe healthand safetylegislation ofthe provincethey workin.
TheCanadian Centrefor OccupationalHealth andSafety (CCOHS),an agencyof theGovernment ofCanada, wascreated in1978 byan Actof Parliament.
The actwas basedon thebelief thatall Canadianshad "...afundamental rightto ahealthy andsafe workingenvironment."
In Malaysia,the Departmentof OccupationalSafety andHealth (DOSH)under theMinistry ofHuman Resourceis responsibleto ensurethat thesafety, healthand welfareof workersin boththe publicand privatesector isupheld.
DOSHis responsibleto enforcethe Factoryand MachineryAct 1969and theOccupational Safetyand HealthAct 1994.
Occupational safetyand healthmay involveinteraction amongmany cognatedisciplines, includingoccupational medicine,occupational (orindustrial) hygiene,public health,safety engineering,health physics,ergonomics, toxicology,epidemiology, industrialrelations, publicpolicy, sociology,and psychology.
For example,repetitively carryingout manualhandling ofheavy objectsis ahazard.
Theoutcome wouldbe amusculoskeletal disorder(MSD).
Therisk canbe expressednumerically, (e.g.
Modern occupationalsafety andhealth legislationusually demandsthat arisk assessmentbe carriedout priorto makingan intervention.
This assessmentshould: Thecalculation ofrisk isbased onthe likelihoodor probabilityof theharm beingrealised andthe severityof theconsequences.
Thiscan beexpressed mathematicallyas aquantitative assessment(by assigninglow, mediumand highlikelihood andseverity withintegers andmultiplying themto givea riskfactor), oras adescription ofthe circumstancesby whichthe harmcould arisei.e.
Theassessment shouldbe recordedand reviewedperiodically andwhenever thereis asignificant changeto workpractices.
Theassessment shouldinclude practicalrecommendations tocontrol therisk.
Generallyspeaking, newlyintroduced controlsshould lowerrisk byone level,i.e, fromhigh tomedium orfrom mediumto lowThe precautionaryprinciple isan increasinglyused methodfor reducingpotential chemicalor biologicalOSH risks.
Workplace hazardsare oftengrouped intophysical hazards,physical agents,chemical agents,biological agents,and psychosocialissues.
Physicalhazards include:Physical agentsinclude: Chemicalagents, includePsychosocial issuesinclude: Otherissues include:Prevention offire oftencomes withinthe remitof healthand safetyprofessionals aswell.
Newtechnologies, manufacturingprocesses, anddisassembly techniquesoften bringwith themnewly emergingoccupational safetyand healthconcerns.
Recentexamples includeworkplace useand productionof geneticallymodified organismsand nanotechnology.
There isgrowing concernabout exposureto varioustoxins inthe disassemblyof electronicwaste aswell.
AlternativeMedical Systems2.
BiologicallyBased Therapy4.
EnergyTherapy Naturopathicmedicine (alsoknown asnaturopathy) isa schoolof medicalphilosophy andpractice thatseeks toimprove healthand treatdisease chieflyby assistingthe body'sinnate capacityto recoverfrom illnessand injury.
Naturopathic practicemay includea broadarray ofdifferent modalities,including manualtherapy, hydrotherapy,herbalism, acupuncture,counseling, environmentalmedicine, aromatherapy,nutritional counseling,homeopathy, andso on.
Practitioners tendto emphasizea holisticapproach topatient care.
Naturopathy hasits originsin avariety ofworld medicinepractices, includingthe Ayurvedaof Indiaand NatureCure ofEurope.
Itis todaypracticed inmany countriesaround theworld inone formor another,where itis subjectto differentstandards ofregulation andlevels ofacceptance.
Naturopathicpractitioners prefernot touse invasivesurgery, ormost syntheticdrugs, preferring"natural" remedies,for instancerelatively unprocessedor wholemedications, suchas herbsand foods.
Practitioners fromaccredited schoolsare trainedto usediagnostic testssuch asimaging andblood testsbefore decidingupon thefull courseof treatment.
If thepatient doesnot respondto thesetreatments, theyare oftenreferred tophysicians whoutilize standardmedical careto treatthe underlyingdisease orcondition.
Withonly afew exceptions,most naturopathictreatments havenot beentested forsafety andefficacy utilizingscientific studiesor clinicaltrials.
Lusthad beenschooled inhydrotherapy andother naturalhealth practicesin Germanyby FatherSebastian Kneipp,who sentLust tothe UnitedStates tobring themKneipp's methods.
In 1905,Lust foundedthe AmericanSchool ofNaturopathy inNew York,the firstnaturopathic collegein theUnited Statesbut "accordingto theNew YorkDepartment ofState, andthe FloridaReport toGovernor LeroyCollins, itappears thatthis naturopathicschool wasnever anythingbut adiploma mill".
Lust tookgreat stridesin promotingthe profession,culminating inpassage oflicensing lawsin severalstates priorto 1935,including Arizona,California, Connecticut,Hawaii, Oregon,and Washingtonand thefounding ofseveral naturopathiccolleges.
Naturopathicmedicine wentinto decline,along withmost othernatural healthprofessions, afterthe 1930s,with thediscovery ofpenicillin andadvent ofsynthetic drugssuch asantibiotics andcorticosteroids.
Itcaused manysuch programsto shutdown andcontributed tothe popularityof conventionalmedicine.
Oneof themost visiblesteps towardsthe profession'smodern renewalwas theopening in1956 ofthe NationalCollege ofNaturopathic Medicinein Portland,Oregon.
Naturopathyis verypopular inIndia, andthere arenumerous naturopathichospitals inthe country.
The termwhen originallycoined byJohn Scheel,and popularizedby Dr.
Benedict Lustwas toapply tothose receivingan educationin thebasic medicalsciences withan emphasison naturaltherapies.
Thisusage bestdescribes modernday naturopathicphysicians.
Naturopathicphysicians inNorth Americaare primarycare providerstrained inconventional medicalsciences, diagnosisand treatment,and areexperts innatural therapeutics.
Licensing andtraining requirementsvary fromstate tostate, butat least14 states,the Districtof Columbia,and fourCanadian provinceshave formallicensing andeducational requirements.
Some mayvoluntarily joina professionalorganization, butthese organizationsdo notacredit educationalprograms inany meaningfulway orlicense practitionersper se.
The trainingprograms fortraditional naturopathscan varygreatly, areless rigorousand donot providethe samebasic andclinical scienceeducation asnaturopathic medicalschools do.
The professionalorganizations formedby traditionalnaturopaths arenot recognizedby theU.S.
Governmentor anyU.S.
Stateor Territory.In somejurisdictions thepractice ofnaturopathic medicineis unregulatedand sothe titleslike "naturopath","naturopathic doctor",and "doctorof naturalmedicine" arenot protectedby law.
This maylead todifficulty inensuring thata practitioneris trainedto aparticular standardor hasadequate liabilityinsurance.
Thereis currentlyno statelicensure inAustralia, ratherthe industryis selfregulated.
Thereis noprotection oftitle, meaningthat technicallyanyone canpractise asa naturopath.
The onlyway toobtain insurancefor professionalindemnity orpublic liabilityis byjoining aprofessional association,which canonly beachieved havingcompleted anaccredited courseand gainingprofessional certification.
Currently onlya fewinstitutions fulfilthese requirements,including HealthSchools Australiathe AustralianCollege ofNatural Medicine'sdegree course,Southern CrossUniversity Bachelordegree, andthe Universityof WesternSydney's combinedBachelor ofApplied Science(Naturopathic Studies)and GraduateDiploma inNaturopathy.
Asthe naturopathicprofession hasdeveloped alongdifferent linesin theUK, naturopathsdo notperform minorsurgery orhave prescribingrights.
Somemodalities usedin naturopathyare controversial.
Some medicaldoctors havecited thelarge differencesamong naturopathicpractitioners andthe lackof scientificdocumentation ofthe safetyand efficacyof theirpractices inorder tojustify limitingnaturopathic scope.
Proponents claimthat thisis slowlychanging asnaturopathic physiciansdevelop researchprograms tohelp buildup afoundation forevidence basedtreatment.
Conventionalmedicine isrequired toundergo rigorousscientific testing;drug trialsoften lastfor adecade.
Acriticism ofalternative therapiesis thatthey arenot subjectto detailedsafety assessment.
Advocates ofnaturopathy respondthat manyof theirtherapeutic interventionshave beensafely usedfor hundredsand insome casesthousands ofyears, claimingwhat islost informal studydesign ismore thanmade upfor bythe breadthand depthof humanexperience withthe interventionsin question.
Also ofconcern isthe ambiguityof theword "natural"and pooragreement asto itsmeaning; 'natural'does notnecessarily meanbeneficial, oreven benign.
See Naturalisticfallacy.) Naturopathicmodalities maybe controversial(e.g.
Ifa moreappropriate WikiProjector portalexists, pleaseadjust thistemplate accordingly.
Sports medicineor sportmedicine isan interdisciplinarysubspecialty ofmedicine thatdeals withthe treatmentand preventivecare ofathletes, bothamateur andprofessional.
Thesports medicine"team" includesspecialty physiciansand surgeons,athletic trainers,physical therapists,coaches, otherpersonnel, and,of course,the athlete.
Sports medicinehas alwaysbeen difficultto definebecause itis nota singlespecialty, butan areathat involveshealth careprofessionals, researchersand educatorsfrom awide varietyof disciplines.
Its functionis notonly curativeand rehabilitative,but especiallypreventive.
Thereis muchmore tosports medicinethan justmusculoskeletal diagnosisand treatment.
Consequently, sportsmedicine canencompass anarray ofspecialties, includingcardiology, pulmonology,orthopaedic surgery,exercise physiology,biomechanics, andtraumatology.
Forexample, heat,cold oraltitude duringtraining andcompetition canalter performanceor mayeven belife threatening.
The femaletriad ofdisordered eating,menstrual disturbances,and bonedensity problems,and theproblems ofpregnant oraging athletesdemand knowledgefrom manydiverse fields.
Further uniqueproblems areassociated withinternational sportingevents, suchas theeffects oftravel andacclimatization, andthe attemptto balancean athlete'sparticipation withhis orher health.
Much ofthis drawson newfields ofstudy, inwhich extensiveclinical andbasic scienceresearch isburgeoning.
Doctorswishing tospecialize startwith aprimary residencyprogram infamily practice,internal medicine,emergency medicine,pediatrics, orphysical medicineand rehabilitation,and thengenerally obtainone totwo yearsof additionaltraining throughaccredited fellowship(subspecialty) programsin sportsmedicine.
Physicianswho areboard certifiedin familypractice, internalmedicine, emergencymedicine, orpediatrics arethen eligibleto takea subspecialtyqualification examinationin sportsmedicine.
Additionalforums, whichadd tothe expertiseof aSports MedicineSpecialist, includecontinuing educationin sportsmedicine, andmembership andparticipation insports medicinesocieties.
Sportsmedicine hasbeen arecognized subspecialtyof theAmerican Boardof MedicalSpecialties since1989.
Currentlythere aremore than70 sportsmedicine fellowshipsand approximatelyone thousandcertified SportsMedicine Specialistsin theUnited States.
However, itwas notuntil in1928 atthe Olympicsin St.
Moritz, whena committeecame togetherto planthe FirstInternational Congressof SportsMedicine, thatthe termitself wascoined.
Inthe 5thcentury, however,the careof athleteswas primarilythe responsibilityof specialists.
The firstuse oftherapeutic exerciseis creditedto Herodicus,who isthought tohave beenone ofHippocrates' teachers.
Until the2nd centuryAD, whenthe first"team doctor",Galen, wasappointed tothe gladiators,the physicianonly becameinvolved ifthere wasan injury.
What isclear, however,is thatfrom itsbeginnings, sportsmedicine hasbeen multidisciplinary,and chargedwith theobligation notonly totreat injuriesbut alsoto helpprevent them,and toinstruct andprepare athletesfor competition.
This linkwith physicaleducation hasremained inplace throughoutits evolution.
While watchinghis daughterLouise swimat the1968 SummerOlympics inMexico City,Dr.
J.C. Kennedy,a doctorbased inLondon, Ontario,Canada concludedfor avariety ofreasons thatcompeting athleticteams fromCanada shouldbe accompaniedby aqualified andwell organizedmedical team.
This beliefled himto bea foundingfather ofthe CanadianAcademy ofSport Medicine.
One ofthe primarymandates ofthis societywas toprovide expertcare toCanadian athletes,and in1972 Dr.
Kennedy wasappointed chiefmedical officerof thefirst "true"medical team,at the1972 SummerOlympics inMunich, Germany.
Other countriessoon followedthis exampleand assignedmedical teamsto theirown Olympicathletes.
Dr.Kennedy's visionwas notlimited totraveling Canadianathletes.
Ata timewhen sportmedicine clinicswere unheardof inCanada, heconvinced hisuniversity's administrationto converta formerwrestling roominto TheAthletic InjuriesClinic thatofficially openedin 1972.
The firstNautilus equipmentin Canadawas purchasedfrom fundsraised tooutfit thisclinic.
Dr.Kennedy inspiredand fosteredan interestin researchin sportmedicine, forwhich theUniversity ofWestern Ontario(UWO) andLondon, Ontariohave becomeknown.
Manybelieve thatsports medicinewill makeits mostsignificant futurecontributions inthe areaof prevention.
According toDr. DavidJanda, orthopedicsurgeon anddirector ofThe Institutefor PreventativeMedicine inMichigan, preventionis sportsmedicine's finalfrontier.
Therisk ofinjury willnever beentirely eliminated,but modificationsin trainingtechniques, equipment,sports venuesand rules,based onoutcomes ofmeaningful researchhave shownthat itcan belowered.
Onerapidly advancingfield withgreat potentialfor applicationsin preventionis thestudy ofthe body'sneuromuscular adaptations.
A studyof specificpreseason neuromusculartraining forsoccer playersdemonstrated asignificant decreasein theincidence ofanterior cruciateligament tears.
In anotherinvestigation byJanda etal., seriousinjuries inrecreational softballwere reducedby 98%when breakawaybases wereused.
Participationin allforms ofphysical activityat alllevels isa hugepart ofeveryday life,and itsbenefits tohealth andquality oflife areclear.
Sportsmedicine's continuedgrowth anddevelopment mayhelp thebenefits ofphysical activityto befully andsafely realized.
Globalization facilitatesthe spreadof diseaseand increasesthe numberof travelerswho willbe exposedto adifferent healthenvironment.
Thefield oftravel medicineencompasses awide varietyof disciplinesincluding epidemiology,infectious disease,public health,tropical medicine,high altitudephysiology, travelrelated obstetrics,psychiatry, occupationalmedicine, militaryand migrationmedicine, andenvironmental health.
Special itinerariesand activitiesinclude cruiseship travel,diving, massgatherings (e.g.
Hajj), andwilderness/remote regionstravel.
Basically,the travelmedicine candivide into4 maintopics: theprevention (vaccinationand traveladvice), theassistance medicine(dealing withrepatriation andmedical treatmentof travelers),the wildernessmedicine (e.g.
The CDCsite delineatesthe riskareas andprovides informationabout vaccinationand preventivesteps.
Meningococcalmeningitis isendemic inthe tropicalmeningococcal beltof Africa.
Vaccination isrequired forpilgrims goingto Mecca.
Detailed informationis availableon theCDC site.
In additionchemoprophylaxis isstarted beforethe travel,during thetime ofpotential exposure,and for4 weeks(chloroquine, doxycycline,or mefloquine)or 7days (atovaquone/proguanilor primaquine)after leavingthe riskarea.
Basedon circumstancesit shouldinclude alsomalaria prophylaxis,condoms, andmedication tocombat traveler'sdiarrhea.
Inaddition, abasic firstaid kitcan beof use.
MD, fromthe LatinMedicinae Doctormeaning "Teacherof Medicine,")is anacademic degreefor medicaldoctors.
TheM.B. orBachelor ofMedicine wasthe firstmedical degreesto begranted inthe UnitedStates andCanada.
Thefirst medicalschools thatgranted theM.B.
UPenn,Harvard, Toronto,Maryland, andColumbia.
Thisdegree isthe oldestand mosttraditional degreeheld byphysicians andsurgeons.
NorthAmerican Medicalschools howeverstarted grantingthe M.D.
M.B. Sometimes,holders ofthe M.D.
Students earningan M.D.
Association ofAmerican MedicalColleges andthe LiaisonCommittee onMedical Education,both independentboards ofthe AmericanMedical Association,the AMA.
Admissions tomedical schoolsin theUnited Statesis competitive,with lessthan onehalf ofthe approximately35,000 applicantsmatriculating toa medicalschool.
Beforegraduating froma medicalschool andachieving thedegree ofMedical Doctor,students haveto passthe UnitedStates MedicalLicensing Examination(USMLE) Step1 andboth theClinical Knowledgeand ClinicalSkills partsof Step2.
TheM.D. degreeis typicallyearned infour years.
Most, inorder toreceive BoardEligible orBoard Accreditedstatus ina specialtyof medicinesuch asgeneral surgeryor internalmedicine, thenundergo additionalspecialized trainingin theform ofa residency.
Those whowish tofurther specializein areassuch ascardiology orinterventional radiologythen completea fellowship.
Depending uponthe physician'schosen field,residencies andfellowships involvean additionalthree toeight yearsof trainingafter obtainingthe M.D.
This canbe lengthenedwith additionalresearch years,which canlast one,two, ormore years.
In Canada,the M.D.is thebasic medicaldegree requiredto practicemedicine.
AtMcGill Universityin Montreal,M.D.C.M.
MedicinaeDoctorem etChirurgiae Magistrum)degrees areawarded.
Thoughthe M.D.degree isa professionaldoctorate, andnot aresearch doctorate,many holdersof theM.D.
SomeM.D.s choosea researchcareer andreceive fundingfrom theNIH aswell asother sourcessuch asthe HowardHughes MedicalInstitute.
US,being putafter thename asa title;however, itis alsoused onits ownin informalwriting, asan abbreviationfor "medicaldoctor."
It isone ofthe mostrecognized degreesin thegeneral publicand themedia, andsometimes incorporatedinto thetitles oftelevision showssuch asHouse MD,or DoogieHowser, M.D..
The MBBSor MBChB degreesare also"allopathic" medicalqualifications equivalentto theMD degree.
In all50 ofthe UnitedStates, andsome Canadianprovinces, theDoctor ofOsteopathic medicine(D.O.) degreeis virtuallyidentical tothe trainingrequirements andpractice rightsof theM.D.
Inthe EuropeanUnion, theM.D.
AnM.D. typicallyinvolves eithera numberof publicationsor athesis.
AnM.D. typicallyinvolves eithera numberof publicationsor athesis.
Givengood progress,and byadding afurther year,students canconvert toa Ph.D.
Alternately, theM.D. maybe adegree grantedto medicalgraduates ofthe sameinstitution aftera bodyof previouslypublished researchis submitted.
This maybe consideredequivalent toa Ph.D.
Some universitieswill grantan M.D.
M.A. (inthe caseof Oxfordor Cambridge),an MScor aPh.D.
M.B.,Ch.B.), earnedwith typicallyfour tosix yearsof studiesand trainingat university.
There isalso asimilar advancedprofessional degree,the Masterof Surgery(usually Ch.M.
M.S., butM.Ch. inIreland, Walesand Oxfordand M.Chir.
Cambridge), whichis obtainedafter anM.B., Ch.B.
DO) isan academicdegree offeredin theUnited States.
Holders ofthe D.O.degree areknown asosteopathic physicians,while holdersof thesimilar, butmore commonM.D.
Osteopathicmedicine isa diagnosticand therapeuticsystem basedon thepremise thatthe primaryrole ofthe physicianis tofacilitate thebody's inherentability toheal itself.
D.O.'s maybe foundwithin anymedical specialtybut amajority ofthem workwithin primarycare medicalfields: internalmedicine, pediatrics,obstetrics, andfamily practice.
Although U.S. osteopathicmedical physicianscurrently mayobtain licensurein 47countries, osteopathiccurricula incountries otherthan theUnited Statesdiffers.
D.O.soutside theU. S.
In additionto theHippocratic oath,Osteopathic medicalstudents takean oathto maintainand upholdthe "coreprinciples" ofosteopathic medicalphilosophy.
Revisedin 1953,and againin 2002,the coreprinciples are:There aredifferent opinionson thesignificance ofthese principles.
Upon graduation,osteopathic medicalphysicians mayopt topursue residencytraining programs.
Osteopathic physiciansmay applyto residencyprograms accreditedby eitherthe AOAor theAccreditation Councilfor GraduateMedical Education(ACGME).
Osteopathywas foundedby AndrewTaylor Still,M.D.
Earlyin thetwentieth century,the Americanosteopathic professionadopted theuse ofmedicine andsurgery.
Asbiomedical sciencedeveloped, osteopathicmedicine graduallyincorporated allits proventheories andpractices.
D.O.'shave beenadmitted tofull activemembership inthe AmericanMedical Associationsince 1969.
California D.O.swere offeredthe M.D.
The CaliforniaMedical Associationmay havebeen attemptingto eliminateosteopathic competitionby aprocess ofamalgamation byconverting thousandsof D.O.sto M.D.s.
The Collegeof OsteopathicPhysicians andSurgeons becamethe Universityof California,Irvine Schoolof Medicine.
However, thedecision provedto becontroversial.
In1974, afterprotest andlobbying byinfluential andprominent D.O.s,the CaliforniaSupreme Courtruled thatlicensing ofD.O.s inthat statemust beresumed.
Thisdecision bythe CaliforniaMedical Associationin the1960s togrant D.O.
M.D. licensewas oneof twoturning pointsfor D.O.sin theirearly strugglefor parity;the otherbeing theU.S.
Army'sdecision toallow D.O.sto enterthe militaryas physicians.
These twoturning pointsprovided theosteopathic communitywith thestamp ofequivalency theydesired.
Today,except fora strongerprimary careemphasis inmost osteopathicmedical schoolsand additionaleducation inmusculoskeletal diagnosisand treatment,the trainingand scopeof osteopathicmedicine practicedby D.O.'
UnitedStates isidentical tothat oftheir allopathiccounterparts, thosewho holdthe M.D.
While thereare approximately55,000 D.O.spracticing withinthe UnitedStates, thisnumber representsonly 6%of allpracticing physicians.
D.O.'s mayobtain licensurein anyof thefifty statesand practicein allmedical specialtiesincluding, butnot limitedto, familymedicine, internalmedicine, emergencymedicine, dermatology,surgery, andradiology.
TheD.O. degreeis thelegal andprofessional equivalentof theM.D.
Withinthe osteopathicmedical curriculum,manipulative treatmentis taughtas anadjunctive measureto otherbiomedical interventionsfor anumber ofdisorders anddiseases.
However,a 2001survey ofosteopathic physiciansfound thatmore than50% ofthe respondentsused OMTon lessthan 5%of theirpatients.
However,the numberof D.O.swho reportconsistently prescribingand performingmanipulative treatmenthas beenfalling steadily.
One survey,published inthe Journalof ContinuingMedical Education,found thata majorityof physicians(81%) andpatients (76%)felt thatmanual manipulation(MM) wassafe, andover half(56% ofphysicians and59% ofpatients) feltthat manipulationshould beavailable inthe primarycare setting.
Allopathic physicians."
Thefollowing tablelists thepractice rightsof U.S.
D.O.s inselected countries.
Some questionthe therapeuticutility ofosteopathic manipulativetreatment modalities.
A Harvardmedical schoolreviewed websitesite citesnumerous studiesdemonstrating thatthere aresome ailmentsfor whichthe benefitof manipulativetherapy has"firmly established"scientific support.
While frequentlyassociated withalternative medicine,it isalso increasinglyused inmainstream medicalpractice aspart ofa broadview ofpatient care.
Holism asa healthconcept hasexisted forages outsideof academiccircles, butonly relativelyrecently hasthe modernmedical establishmentbegun tointegrate itinto themainstream healthcare system.
In theUnited States,the firstNational Conferenceon HolisticHealth washeld withthe Universityof California,San DiegoSchool ofMedicine inJune 1975.
Holism refersto theidea thatan entityis greaterthan thesum ofits parts.
In thecase ofhealth, theentity inquestion isthe humanbody.
Thegoal isa wellnessthat encompassesthe entireperson, ratherthan justthe lackof physicalpain ordisease.
Holistichealth isnot itselfa methodof treatment,but insteadan approachto howtreatment shouldbe applied.
Traditional medicalphilosophy approachedpatient careas simplyattempting tocorrect physicalsymptoms, usingstandardized methodssuch asthe prescriptionof drugsor theundertaking ofsurgery, whilethe patientis onlypassively involved.
In contrast,holistic approachesto healthare wideand varied.
When theconcepts ofholistic healthare putinto practicewithin thehealth caresystem, theapproach totherapy takeson anew dimension;traditional medicalcare isexpanded toencompass abroad spectrumof therapiescoordinated tomeet thetotality ofa particularindividual.
Thefocus isno longeron justthe disease,but thewhole person.
The roleof thepatient alsochanges inlearning howchoices, actionsand attitudesaffect thepresent condition,and howone canbe anactive participantin thehealing process.
Some holistichealth advocatessubscribe toalternative medicalpractices whichconventional medicinedoes notsupport.
Studentsof thehistory ofmedicine knowhim forhis attemptsto introducesystematic experimentationand quantificationinto thestudy ofphysiology".
Someexamples include:nurses, laboratoryscientists, pharmacists,physiotherapists, speechtherapists, occupationaltherapists, dietitiansand bioengineers.
The scopeand sciencesunderpinning humanmedicine overlapmany otherfields.
Dentistryand psychology,while separatedisciplines frommedicine, aresometimes alsoconsidered medicalfields.
Physicianassistants, nursepractitioners andmidwives treatpatients andprescribe medicationin manylegal jurisdictions.
Veterinary medicineapplies similartechniques tothe careof animals.
Medical doctorshave manyspecializations andsubspecializations whichare listedbelow.
Thereare variationsfrom countryto countryregarding whichspecialities certainsubspecialities arein.
AlternativeMedical Systems2.
BiologicallyBased Therapy4.
Ifan alternativemedical approach,initially regardedas untested,is subsequentlyshown tobe safeand effective,it maythen beadopted byconventional practitionersand nolonger considered"alternative".
Alternativemedicine iscommonly categorisedtogether withcomplementary medicineunder theumbrella term'complementary andalternative medicine'(CAM forshort).
Somescientists rejectthis andthe aboveclassifications andto varyingdegrees rejectthe term"alternative medicine"itself.
Thefollowing threecommentators arguefor classifyingtreatments basedon theobjectively verifiablecriteria ofthe scientificmethod, notbased onthe changingcurricula ofvarious medicalschools orsocial sphereof usage.
According tothem itis possiblefor amethod tochange categories(proven vs.
In article34 (Specificlegal obligations)of theGeneral CommentNo.
Theyclaim thatthis impedesthose seekingto bringuseful andeffective treatmentsand approachesto thepublic, andprotest thattheir contributionsand discoveriesare unfairlydismissed, overlookedor suppressed.
Alternative medicineproviders oftenargue thathealth fraudshould bedealt withappropriately whenit occurs.
In India,which isthe homeof severalalternative systemsof medicines,Ayurveda, Siddha,Unani, andHomeopathy arelicenced bythe government,despite lackof reputablescientific evidence.
Naturopathy willalso belicensed soonbecause severalUniversities nowoffer bachelorsdegrees init.
Otheractivities connectedwith AM/CM,such asPanchakarma andmassage therapyrelated toAyurveda arealso licencedby thegovernment now.
However, studiesindicate thata majorityof peopleuse alternativeapproaches inconjunction withconventional medicine.
Edzard Ernstwrote inthe MedicalJournal ofAustralia that"about halfthe generalpopulation indeveloped countriesuse complementaryand alternativemedicine (CAM)."
Increasingnumbers ofmedical collegeshave begunoffering coursesin alternativemedicine.
Forexample, theUniversity ofArizona Collegeof Medicineoffers aprogram inIntegrative Medicineunder theleadership ofDr.
AndrewWeil whichtrains physiciansin variousbranches ofalternative medicinewhich "...neitherrejects conventionalmedicine, norembraces alternativepractices uncritically."
SeeNaturopathic medicine.
In Britain,no conventionalmedical schoolsoffer coursesthat teachthe clinicalpractice ofalternative medicine.
However, alternativemedicine istaught inseveral unconventionalschools aspart oftheir curriculum.
Teaching isbased mostlyon theoryand understandingof alternativemedicine, withemphasis onbeing ableto communicatewith alternativemedicine specialists.
To obtaincompetence inpracticing clinicalalternative medicine,qualifications mustbe obtainedfrom individualmedical societies.
The studentmust havegraduated andbe aqualified doctor.
The BritishMedical AcupunctureSociety, whichoffers medicalacupuncture certificatesto doctors,is onesuch example,as isthe Collegeof NaturopathicMedicine UKand Ireland.
The NCCAMsurveyed theAmerican publicon complementaryand alternativemedicine usein 2002.
Prof. EdzardErnst isa notableproponent ofapplying EBMto CAM.
Although advocatesof alternativemedicine acknowledgethat theplacebo effectmay playa rolein thebenefits thatsome receivefrom alternativetherapies, theypoint outthat thisdoes notdiminish theirvalidity.
Researcherswho judgetreatments usingthe scientificmethod areconcerned bythis viewpoint,since itfails toaddress thepossible inefficacyof alternativetreatments.
Amajor objectionto alternativemedicine isthat itis donein placeof conventionalmedical treatments.
The issueof alternativemedicine interferingwith conventionalmedical practicesis minimizedwhen itis turnedto onlyafter conventionaltreatments havebeen exhausted.
Many patientsfeel thatalternative medicinemay helpin copingwith chronicillnesses forwhich conventionalmedicine offersno cure,only management.
Over time,it hasbecome morecommon fora patient'sown MDto suggestalternatives whenthey cannotoffer effectivetreatment.
Seealso Listof branchesof alternativemedicine forspecific criticismsof differenttypes ofCAM Dueto thewide rangeof therapiesthat areconsidered tobe "alternativemedicine" fewcriticisms applyacross theboard, exceptpossibly thatof notbeing scientificallysupported oreven testable.
But plausibility,not proof,should besufficient toinitiate theprocess.
Inother words,proponents ofCAMs arguethat skeptics,in sayingthat theoriesor anecdotaland preclinicaldata donot constituteproof, merelystate theobvious butdo notactually engagein theevaluation ofCAMs.
Criticismsdirected atspecific branchesof alternativemedicine rangefrom thefairly minor(conventional treatmentis believedto bemore effectivein aparticular area)to incompatibilitywith theknown lawsof physics(for example,in homeopathy).
Critics arguethat alternativemedicine practitionersmay nothave anaccredited medicaldegree orbe licensedphysicians orgeneral practitionersand makesweeping claimswithout demonstratedexpertise.
Thiscannot alwaysbe considereda seriouscriticism, becauseunless anew systemof medicinebecomes established,it doesnot receiveaccreditation ofany kind,except byits ownprofessional organizations.
This isthe routehomeopathy, ayurveda,siddha, unani,and naturopathyhad tofollow inthose countrieswhere itis nowoffered byaccredited institutions.
Refutations ofcriticism sometimestake theform ofan appealto nature.
Some arguethat lessresearch iscarried outon alternativemedicine becausemany alternativemedicine techniquescannot bepatented, andhence thereis littlefinancial incentiveto studythem.
Drugresearch, bycontrast, canbe verylucrative, whichhas resultedin fundingof trialsby pharmaceuticalcompanies.
Tothis, CAMcritics pointout thatthis doesnot accountfor conventionalmedical successin doubleblind clinicaltrials.
CAMproponents, however,don't typicallyquestion conventionalmedical successesrevealed indouble blindclinical trials.
Critics contendthat somepeople havebeen hurtor killeddirectly fromthe variouspractices orindirectly byfailed diagnosesor thesubsequent avoidanceof conventionalmedicine whichthey believeis redundant.
Alternative medicinecritics agreewith itsproponents thatpeople shouldbe freeto choosewhatever methodof healthcarethey want,but stipulatethat peoplemust beinformed asto thesafety andefficacy ofwhatever methodthey choose.
People whochoose alternativemedicine maythink theyare choosinga safe,effective medicine,while theymay onlybe gettingquack remedies.
For thisreason, criticscontend thattherapies thatrely onthe placeboeffect todefine successare verydangerous.
ANorwegian multicentrestudy examinedthe associationbetween theuse ofalternative medicineand cancersurvival.
Thestudy revealedthat deathrates were30% higherin alternativemedicine usersthan inthose whodid notuse alternativemedicine (AM):"The useof AMseems topredict ashorter survivalfrom cancer."
AssociateProfessor AlastairMacLennan ofthe Departmentof Obstetricsand Gynaecologyin AdelaideUniversity, Australiareports thata patientof hisalmost bledto deathon theoperating table.
Nevertheless, attemptsto refutethis factwith regardto alternativetreatments sometimesuse theappeal tonature fallacy,i.e.
Homeopathy,however, isregarded asbeing safein termsof suchside effectssince, accordingto knownphysics andchemistry, itcannot possiblyhave moreeffect onthe patientthan simplewater does.
For example,an alternativemedicine mayinstantly makesymptoms better,but actuallyworsen problemsin thelong run.
Critics contendthat somebranches ofalternative medicineare oftennot properlyregulated insome countriesto identifywho practicesor knowwhat trainingor expertisethey maypossess.
Criticsargue thatthe governmentalregulation ofany particularalternative therapydoes necessitatethat thetherapy iseffective.
Themost sensiblecourse insuch acase couldbe tosimply ensurethat thesold treatmentis notdangerous, butthe problemwould thenremain toknow ifit doeswhat itsproponents sayit does.
The mainproponent ofintegrative medicineis AndrewT.
WeilM.D., whofounded theProgram inIntegrative Medicineat theUniversity ofArizona in1994 basedon aphrase coinedby ElsonHaas, MD.
Alternative MedicalSystems 2.
Biologically BasedTherapy 4.
If analternative medicalapproach, initiallyregarded asuntested, issubsequently shownto besafe andeffective, itmay thenbe adoptedby conventionalpractitioners andno longerconsidered "alternative".
Alternative medicineis commonlycategorised togetherwith complementarymedicine underthe umbrellaterm 'complementaryand alternativemedicine' (CAMfor short).
Some scientistsreject thisand theabove classificationsand tovarying degreesreject theterm "alternativemedicine" itself.
The followingthree commentatorsargue forclassifying treatmentsbased onthe objectivelyverifiable criteriaof thescientific method,not basedon thechanging curriculaof variousmedical schoolsor socialsphere ofusage.
Accordingto themit ispossible fora methodto changecategories (provenvs.
Inarticle 34(Specific legalobligations) ofthe GeneralComment No.
They claimthat thisimpedes thoseseeking tobring usefuland effectivetreatments andapproaches tothe public,and protestthat theircontributions anddiscoveries areunfairly dismissed,overlooked orsuppressed.
Alternativemedicine providersoften arguethat healthfraud shouldbe dealtwith appropriatelywhen itoccurs.
InIndia, whichis thehome ofseveral alternativesystems ofmedicines, Ayurveda,Siddha, Unani,and Homeopathyare licencedby thegovernment, despitelack ofreputable scientificevidence.
Naturopathywill alsobe licensedsoon becauseseveral Universitiesnow offerbachelors degreesin it.
Other activitiesconnected withAM/CM, suchas Panchakarmaand massagetherapy relatedto Ayurvedaare alsolicenced bythe governmentnow.
However,studies indicatethat amajority ofpeople usealternative approachesin conjunctionwith conventionalmedicine.
EdzardErnst wrotein theMedical Journalof Australiathat "abouthalf thegeneral populationin developedcountries usecomplementary andalternative medicine(CAM)."
Increasing numbersof medicalcolleges havebegun offeringcourses inalternative medicine.
For example,the Universityof ArizonaCollege ofMedicine offersa programin IntegrativeMedicine underthe leadershipof Dr.
Andrew Weilwhich trainsphysicians invarious branchesof alternativemedicine which"...neither rejectsconventional medicine,nor embracesalternative practicesuncritically."
See Naturopathicmedicine.
InBritain, noconventional medicalschools offercourses thatteach theclinical practiceof alternativemedicine.
However,alternative medicineis taughtin severalunconventional schoolsas partof theircurriculum.
Teachingis basedmostly ontheory andunderstanding ofalternative medicine,with emphasison beingable tocommunicate withalternative medicinespecialists.
Toobtain competencein practicingclinical alternativemedicine, qualificationsmust beobtained fromindividual medicalsocieties.
Thestudent musthave graduatedand bea qualifieddoctor.
TheBritish MedicalAcupuncture Society,which offersmedical acupuncturecertificates todoctors, isone suchexample, asis theCollege ofNaturopathic MedicineUK andIreland.
TheNCCAM surveyedthe Americanpublic oncomplementary andalternative medicineuse in2002.
Prof.Edzard Ernstis anotable proponentof applyingEBM toCAM.
Althoughadvocates ofalternative medicineacknowledge thatthe placeboeffect mayplay arole inthe benefitsthat somereceive fromalternative therapies,they pointout thatthis doesnot diminishtheir validity.
Researchers whojudge treatmentsusing thescientific methodare concernedby thisviewpoint, sinceit failsto addressthe possibleinefficacy ofalternative treatments.
A majorobjection toalternative medicineis thatit isdone inplace ofconventional medicaltreatments.
Theissue ofalternative medicineinterfering withconventional medicalpractices isminimized whenit isturned toonly afterconventional treatmentshave beenexhausted.
Manypatients feelthat alternativemedicine mayhelp incoping withchronic illnessesfor whichconventional medicineoffers nocure, onlymanagement.
Overtime, ithas becomemore commonfor apatient's ownMD tosuggest alternativeswhen theycannot offereffective treatment.
See alsoList ofbranches ofalternative medicinefor specificcriticisms ofdifferent typesof CAMDue tothe widerange oftherapies thatare consideredto be"alternative medicine"few criticismsapply acrossthe board,except possiblythat ofnot beingscientifically supportedor eventestable.
Butplausibility, notproof, shouldbe sufficientto initiatethe process.
In otherwords, proponentsof CAMsargue thatskeptics, insaying thattheories oranecdotal andpreclinical datado notconstitute proof,merely statethe obviousbut donot actuallyengage inthe evaluationof CAMs.
Criticisms directedat specificbranches ofalternative medicinerange fromthe fairlyminor (conventionaltreatment isbelieved tobe moreeffective ina particulararea) toincompatibility withthe knownlaws ofphysics (forexample, inhomeopathy).
Criticsargue thatalternative medicinepractitioners maynot havean accreditedmedical degreeor belicensed physiciansor generalpractitioners andmake sweepingclaims withoutdemonstrated expertise.
This cannotalways beconsidered aserious criticism,because unlessa newsystem ofmedicine becomesestablished, itdoes notreceive accreditationof anykind, exceptby itsown professionalorganizations.
Thisis theroute homeopathy,ayurveda, siddha,unani, andnaturopathy hadto followin thosecountries whereit isnow offeredby accreditedinstitutions.
Refutationsof criticismsometimes takethe formof anappeal tonature.
Someargue thatless researchis carriedout onalternative medicinebecause manyalternative medicinetechniques cannotbe patented,and hencethere islittle financialincentive tostudy them.
Drug research,by contrast,can bevery lucrative,which hasresulted infunding oftrials bypharmaceutical companies.
To this,CAM criticspoint outthat thisdoes notaccount forconventional medicalsuccess indouble blindclinical trials.
CAM proponents,however, don'ttypically questionconventional medicalsuccesses revealedin doubleblind clinicaltrials.
Criticscontend thatsome peoplehave beenhurt orkilled directlyfrom thevarious practicesor indirectlyby faileddiagnoses orthe subsequentavoidance ofconventional medicinewhich theybelieve isredundant.
Alternativemedicine criticsagree withits proponentsthat peopleshould befree tochoose whatevermethod ofhealthcare theywant, butstipulate thatpeople mustbe informedas tothe safetyand efficacyof whatevermethod theychoose.
Peoplewho choosealternative medicinemay thinkthey arechoosing asafe, effectivemedicine, whilethey mayonly begetting quackremedies.
Forthis reason,critics contendthat therapiesthat relyon theplacebo effectto definesuccess arevery dangerous.
A Norwegianmulticentre studyexamined theassociation betweenthe useof alternativemedicine andcancer survival.
The studyrevealed thatdeath rateswere 30%higher inalternative medicineusers thanin thosewho didnot usealternative medicine(AM): "Theuse ofAM seemsto predicta shortersurvival fromcancer."
Associate ProfessorAlastair MacLennanof theDepartment ofObstetrics andGynaecology inAdelaide University,Australia reportsthat apatient ofhis almostbled todeath onthe operatingtable.
Nevertheless,attempts torefute thisfact withregard toalternative treatmentssometimes usethe appealto naturefallacy, i.e.
Homeopathy, however,is regardedas beingsafe interms ofsuch sideeffects since,according toknown physicsand chemistry,it cannotpossibly havemore effecton thepatient thansimple waterdoes.
Forexample, analternative medicinemay instantlymake symptomsbetter, butactually worsenproblems inthe longrun.
Criticscontend thatsome branchesof alternativemedicine areoften notproperly regulatedin somecountries toidentify whopractices orknow whattraining orexpertise theymay possess.
Critics arguethat thegovernmental regulationof anyparticular alternativetherapy doesnecessitate thatthe therapyis effective.
The mostsensible coursein sucha casecould beto simplyensure thatthe soldtreatment isnot dangerous,but theproblem wouldthen remainto knowif itdoes whatits proponentssay itdoes.
Themain proponentof integrativemedicine isAndrew T.
Weil M.D.,who foundedthe Programin IntegrativeMedicine atthe Universityof Arizonain 1994based ona phrasecoined byElson Haas,MD.
Since1879, theNLM haspublished theIndex Medicus,a monthlyguide toarticles innearly fivethousand selectedjournals.
Thelast issueof IndexMedicus wasprinted inDecember 2004,but thisinformation isoffered inthe freelyaccessible PubMedamongst themore thanfifteen millionMEDLINE journalarticle referencesand abstractsgoing backto the1960s and1.5 millionreferences goingback tothe 1950s.
The NLMalso runsthe NationalCenter forBiotechnology Information(NCBI) whichhouses biologicaldatabases freelyaccessible overthe Internetthrough theEntrez searchengine andPubMed.
Theseresources areaccessible withoutcharge onthe Web.
The ExtramuralPrograms Divisionprovides grantsto supportresearch inmedical informationscience andto supportplanning anddevelopment ofcomputer andcommunications systemsin medicalinstitutions.
Researchand publicationsin thehistory ofmedicine andthe lifesciences arealso supported.
The precursorof theNLM, establishedin 1836,was theLibrary ofthe SurgeonGeneral's Office,a partof theoffice ofthe U.S.
Army SurgeonGeneral. TheArmed ForcesInstitute ofPathology andits MedicalMuseum werefounded in1862 asthe ArmyMedical Museum.
Throughout theirhistory theArmy MedicalLibrary andthe ArmyMedical Museumoften sharedquarters.
From1866 to1887, theywere housedin Ford'sTheatre afterproduction therewas stoppedafter theassassination ofPresident AbrahamLincoln.
In1956, theLibrary collectionwas transferredfrom thecontrol ofthe U.S.
Department ofDefense tothe PublicHealth Serviceof theDepartment ofHealth, Educationand Welfareand renamedthe NationalLibrary ofMedicine.
TheLibrary movedto itscurrent quartersin Bethesda,Maryland, onthe campusof theNational Institutesof Healthin 1962.
Alternative MedicalSystems 2.
Biologically BasedTherapy 4.
Energy TherapyNaturopathic medicine(also knownas naturopathy)is aschool ofmedical philosophyand practicethat seeksto improvehealth andtreat diseasechiefly byassisting thebody's innatecapacity torecover fromillness andinjury.
Naturopathicpractice mayinclude abroad arrayof differentmodalities, includingmanual therapy,hydrotherapy, herbalism,acupuncture, counseling,environmental medicine,aromatherapy, nutritionalcounseling, homeopathy,and soon.
Practitionerstend toemphasize aholistic approachto patientcare.
Naturopathyhas itsorigins ina varietyof worldmedicine practices,including theAyurveda ofIndia andNature Cureof Europe.
It istoday practicedin manycountries aroundthe worldin oneform oranother, whereit issubject todifferent standardsof regulationand levelsof acceptance.
Naturopathic practitionersprefer notto useinvasive surgery,or mostsynthetic drugs,preferring "natural"remedies, forinstance relativelyunprocessed orwhole medications,such asherbs andfoods.
Practitionersfrom accreditedschools aretrained touse diagnostictests suchas imagingand bloodtests beforedeciding uponthe fullcourse oftreatment.
Ifthe patientdoes notrespond tothese treatments,they areoften referredto physicianswho utilizestandard medicalcare totreat theunderlying diseaseor condition.
With onlya fewexceptions, mostnaturopathic treatmentshave notbeen testedfor safetyand efficacyutilizing scientificstudies orclinical trials.
Lust hadbeen schooledin hydrotherapyand othernatural healthpractices inGermany byFather SebastianKneipp, whosent Lustto theUnited Statesto bringthem Kneipp'smethods.
In1905, Lustfounded theAmerican Schoolof Naturopathyin NewYork, thefirst naturopathiccollege inthe UnitedStates but"according tothe NewYork Departmentof State,and theFlorida Reportto GovernorLeroy Collins,it appearsthat thisnaturopathic schoolwas neveranything buta diplomamill".
Lusttook greatstrides inpromoting theprofession, culminatingin passageof licensinglaws inseveral statesprior to1935, includingArizona, California,Connecticut, Hawaii,Oregon, andWashington andthe foundingof severalnaturopathic colleges.
Naturopathic medicinewent intodecline, alongwith mostother naturalhealth professions,after the1930s, withthe discoveryof penicillinand adventof syntheticdrugs suchas antibioticsand corticosteroids.
It causedmany suchprograms toshut downand contributedto thepopularity ofconventional medicine.
One ofthe mostvisible stepstowards theprofession's modernrenewal wasthe openingin 1956of theNational Collegeof NaturopathicMedicine inPortland, Oregon.
Naturopathy isvery popularin India,and thereare numerousnaturopathic hospitalsin thecountry.
Theterm whenoriginally coinedby JohnScheel, andpopularized byDr.
BenedictLust wasto applyto thosereceiving aneducation inthe basicmedical scienceswith anemphasis onnatural therapies.
This usagebest describesmodern daynaturopathic physicians.
Naturopathic physiciansin NorthAmerica areprimary careproviders trainedin conventionalmedical sciences,diagnosis andtreatment, andare expertsin naturaltherapeutics.
Licensingand trainingrequirements varyfrom stateto state,but atleast 14states, theDistrict ofColumbia, andfour Canadianprovinces haveformal licensingand educationalrequirements.
Somemay voluntarilyjoin aprofessional organization,but theseorganizations donot acrediteducational programsin anymeaningful wayor licensepractitioners perse.
Thetraining programsfor traditionalnaturopaths canvary greatly,are lessrigorous anddo notprovide thesame basicand clinicalscience educationas naturopathicmedical schoolsdo.
Theprofessional organizationsformed bytraditional naturopathsare notrecognized bythe U.S.
Government orany U.S.
State orTerritory. Insome jurisdictionsthe practiceof naturopathicmedicine isunregulated andso thetitles like"naturopath", "naturopathicdoctor", and"doctor ofnatural medicine"are notprotected bylaw.
Thismay leadto difficultyin ensuringthat apractitioner istrained toa particularstandard orhas adequateliability insurance.
There iscurrently nostate licensurein Australia,rather theindustry isself regulated.
There isno protectionof title,meaning thattechnically anyonecan practiseas anaturopath.
Theonly wayto obtaininsurance forprofessional indemnityor publicliability isby joininga professionalassociation, whichcan onlybe achievedhaving completedan accreditedcourse andgaining professionalcertification.
Currentlyonly afew institutionsfulfil theserequirements, includingHealth SchoolsAustralia theAustralian Collegeof NaturalMedicine's degreecourse, SouthernCross UniversityBachelor degree,and theUniversity ofWestern Sydney'scombined Bachelorof AppliedScience (NaturopathicStudies) andGraduate Diplomain Naturopathy.
As thenaturopathic professionhas developedalong differentlines inthe UK,naturopaths donot performminor surgeryor haveprescribing rights.
Some modalitiesused innaturopathy arecontroversial.
Somemedical doctorshave citedthe largedifferences amongnaturopathic practitionersand thelack ofscientific documentationof thesafety andefficacy oftheir practicesin orderto justifylimiting naturopathicscope.
Proponentsclaim thatthis isslowly changingas naturopathicphysicians developresearch programsto helpbuild upa foundationfor evidencebased treatment.
Conventional medicineis requiredto undergorigorous scientifictesting; drugtrials oftenlast fora decade.
A criticismof alternativetherapies isthat theyare notsubject todetailed safetyassessment.
Advocatesof naturopathyrespond thatmany oftheir therapeuticinterventions havebeen safelyused forhundreds andin somecases thousandsof years,claiming whatis lostin formalstudy designis morethan madeup forby thebreadth anddepth ofhuman experiencewith theinterventions inquestion.
Alsoof concernis theambiguity ofthe word"natural" andpoor agreementas toits meaning;'natural' doesnot necessarilymean beneficial,or evenbenign.
SeeNaturalistic fallacy.)Naturopathic modalitiesmay becontroversial (e.g.
Biomedicine isusually notconcerned withthe practiceof medicineas muchas itis withthe theory,knowledge andresearch ofit; itsresults renderpossible newdrugs anda deeper,molecular understandingof themechanisms underlyingdecease, andthus laysthe foundationof allmedical application,diagnosis andtreatment.
Category:Medicine stubs1.
Alternative MedicalSystems 2.
Biologically BasedTherapy 4.
Chiropractic wasfounded in1895 byD.
Eventually,these ledto thescientific investigationof chiropractic,and anantitrust suitagainst theAmerican MedicalAssociation.
Chiropractictreatments varydepending onthe patient'scondition andthe typeof approachtaken bythe particularchiropractor.
Theycommonly includespinal adjustments,although otherinterventions maybe usedas well.
Differences arebased onthe philosophyfor adjusting,claims madeabout theeffects ofthose adjustments,and variousadditional treatmentsprovided alongwith theadjustment.
Chiropracticwas foundedin 1895by DanielDavid Palmer,based onhis assertionthat 95%of allhealth problemscould beprevented ortreated usingadjustments ofthe spine(spinal adjustments),and 5%by adjustmentsof otherjoints, tocorrect whathe termedvertebral subluxations.
He, andlater hisson B.J.
Palmer, proposedthat subluxationswere misalignedvertebrae whichcaused nervecompression thatinterfered withthe transmissionof whathe namedInnate Intelligence.
This interferenceinterrupted theproper flowof InnateIntelligence from"above, down,inside, andout" (ADIO)to theorgan towhich ittraveled.
Palmerrelated thisconcept assimilar toapplying pressureto ahose thatsupplies agarden; relievethe pressureand thegarden flourishes.
A modernchiropractor mayspecialize inspinal manipulationsonly, ormay usea widerange ofmethods intendedto addressan arrayof neuromusculoskeletaland generalhealth issues.
Examples includemassage, strengthtraining, dryneedling (similarto acupuncture),functional electricalstimulation, traction,and nutritionalrecommendations.
Somechiropractors specializein chiropracticsports medicine,which includesmanipulation ofthe extremities,and exercisesto increasespinal strength.
Chiropractors mayalso useother complementaryalternative methodsas partof aholistic treatmentapproach.
Chiropractorsgenerally cannotwrite medicalprescriptions.
Giventhe possibilityof adverseeffects, thisreview doesnot suggestthat spinalmanipulation isa recommendabletreatment."
There havebeen controlledtrials whichgive weightto Chiropractorsclaim thatvertebral alignment,by influencingthe nervoussystem, canhave effectson othersystems ofthe body.
He heldthat amalposition ofspinal bones,which protectthe spinalcord andnerve roots,interfered withthe transmissionof nerveimpulses.
Becausehalf ofthe nervoussystem issensory andthe otherhalf motor(control), hepostulated thatliving thingshad anInnate intelligence,a kindof "spiritualenergy" orlife forcethat receivedthe sensoryinformation fromthe variousparts ofthe bodyand madea decisionas towhat themotor nervesshould convey.
The vitalisticconcepts impliedan intelligentgoverning entitythat wasreadily perceivedas spiritualconstructs bymany bothinside andoutside theprofession.
Itremains untestableand unverifiableand hasan unacceptablyhigh penalty/benefitratio forthe chiropracticprofession.
Thechiropractic conceptof InnateIntelligence isan anachronisticholdover froma timewhen insufficientscientific understandingexisted toexplain humanphysiological processes.
It isclearly religiousin natureand mustbe consideredharmful tonormal scientificactivity."
Meridel I.Gatterman DC,educator andwriter observed:Debate aboutthe needto removethe conceptof subluxationfrom thechiropractic paradigmhas beenongoing sincethe mid1960s.
Whilestraights holdfirmly tothe termand itsvitalistic construct,reformers suggestthat themechanistic modelwill allowchiropractic tobetter integrateinto mainstreammedicine withoutmaking claimsinherent inthe term.
Anthony RosnerPhD, directorof educationand researchat theFoundation forChiropractic Educationand Research(FCER) consideredsubluxation andthe conceptof Occam'srazor.
Hesuggests "thereis noobvious reasonto discardthe conceptof subluxation,while atthe sametime maintainingthat itis nota rigidentity, butrather animportant modeland concept;a workin progressthat undoubtedlywill undergoextensive modificationas ourconcepts oflight orpsychoanalysis haveevolved overhalf acentury."
Despite theterm's vitalisticroots, chiropractictoday maystill usethe termInnate Intelligence;however, ithas takenon aless metaphysicalmeaning.
ReedPhillips D.C.,Ph.D., althoughchiropractic hasmuch incommon withother healthprofessions, itsphilosophical approachdistinguishes itfrom modernmedicine.
Bycontrast, thenaturopathic approachconsiders thatlowered "hostresistance" isnecessary fordisease tooccur, sothe appropriatesolution isto directtreatment tostrengthen thehost, regardlessof theenvironment.
TheChiropractic approachto healthcarestresses theimportance ofprevention.
Departmentof Labor'sOccupational OutlookHandbook said:Most DCsare inprivate practiceor workin smallgroups, employingchiropractic assistantsas officestaff andto performtherapeutic activities.
They mayalso employmassage andphysiotherapists asadjuncts tochiropractic care.
Samuel Weedsuggested combiningthe wordscheiros andpraktikos (meaning"done byhand") todescribe Palmer'streatment method,creating theterm "chiropractic."
In1896, DDadded aschool tohis magnetichealing infirmary,and beganto teachothers hismethod.
Itwould becomeknown asPalmer Schoolof Chiropractic(now PalmerCollege ofChiropractic), locatedin Davenport,Iowa.
InSeptember 1899,a medicaldoctor inDavenport, IA,named HeinrichMatthey starteda campaignagainst druglesshealers inIowa.
DDPalmer, whoseschool hadjust graduatedits 7thstudent, insistedthat histechniques didnot needthe samecourses orlicense asmedical doctors,as hisgraduates didnot prescribedrugs orevaluate bloodor urine.
However, in1906, Palmerwas convictedfor practicingmedicine withouta license.
He choseto turnover hisinterests inthe PSCto hisson, BJand wife,Mabel.
Morikubowas freedusing thedefense thatchiropractic philosophywas differentfrom osteopathicphilosophy.
Thevictory reshapedthe developmentof thechiropractic profession,which thenmarketed itselfas ascience, anart anda philosophy,and BJPalmer becamethe "Philosopherof Chiropractic".
Medical ExaminingBoards workedto keepall healthcarepractices undertheir legalcontrol, butan internalstruggle amongDCs onhow tostructure thelaws significantlycomplicated theprocess.
Initially,the UCA,led byBJ Palmerand armedwith hisphilosophy, opposedstate licensurealtogether.
Mixerscampaigned toalter educationstandards towardthose ofmedical schoolsand consistentwith thetenets ofthe medicalprofession whilePalmer resistedany alterationin standardsaway fromhis conceptualizationof thechiropractic profession.
In 1975,the NationalInstitutes ofHealth broughtchiropractors, osteopaths,medical doctorsand Ph.D.
DeBoer, thenan instructorin basicscience atPalmer Collegein Iowa,revealed thepower ofa scholarlyjournal (JMPT)to empowerfaculty atthe chiropracticschools.
DeBoer'sopinion piecedemonstrated thefaculty's authorityto challengethe statusquo, topublicly addressrelevant, albeitsensitive, issuesrelated toresearch, trainingand skepticismat chiropracticcolleges, andto produce"cultural change"within thechiropractic schoolsso asto increaseresearch andprofessional standards.
Principle 3of theAMA Principlesof MedicalEthics stated:A Chicagochiropractor, ChesterA.
Thecourt recognizedthat theAMA hadto showits concernfor patients,but wasnot persuadedthat thiscould nothave beenachieved ina mannerless restrictiveof competition,for instanceby publiceducation campaigns.
She saidno "welldesigned, controlled,scientific study"had beendone, andconcluded "Idecline topronounce chiropracticvalid orinvalid onanecdotal evidence,even though"the anecdotalevidence inthe recordfavors chiropractors."
Source:Phillips RB,Mootz RD.
Contemporary chiropracticphilosophy.
InHaldeman S(ed). Principlesand Practiceof Chiropractic,2nd Ed.
Norwalk, CT:Appleton Lange,1992.
Chartreprinted fromKeating J(1995), D.D.
They concludethat chiropractichas bothmaterialistic qualitiesthat lendthemselves toscientific investigationand vitalisticqualities thatdo not(Table 1).
With relativelylittle federalfunding, academicresearch inchiropractic hasonly recentlybecome establishedin theUSA.
However,of these,only JMPTis includedin IndexMedicus.
Theseare designedso thatneither thepatient northe doctorknows whetherthey areusing theactual treatmentor aplacebo (or"sham") treatment.
However, chiropractictreatment involvesa manipulation;"sham" procedurescannot beeasily devisedfor this,and evenif thepatient isunaware whetherthe treatmentis areal orsham procedure,the doctorcannot beunaware.
Similarly,it isoften difficultto devisea shamprocedure forsurgical procedures,but itis notimpossible.
Itis alsoa problemin evaluatingtreatments; evenwhen thereare objectiveoutcome measures,the placeboeffect canbe verysubstantial.
Thus,DCs havehistorically reliedmostly ontheir ownclinical experienceand theshared experienceof theircolleagues, asreported incase studies,to directtheir treatmentmethods.
Inthis, theyare notdifferent tothe practicein muchof conventionalmedicine.
SociologistLeslie Biggsinterviewed 600Canadian DCsin 1997:while 86%felt thatchiropractic methodsneeded tobe validated,74% didnot believethat controlledclinical trialswere thebest wayto evaluatechiropractic.
Thereis wideagreement that,where applicable,an evidencebased medicineframework shouldbe usedto assesshealth outcomes,and thatsystematic reviewswith strictprotocols areimportant forobjectively evaluatingtreatments.
Whereevidence fromsuch reviewsis lacking,this doesnot necessarilymean thatthe treatmentis ineffective,only thatthe casefor abenefit oftreatment maynot havebeen rigorouslyestablished.
A2005 editorialin JMPT,"The CochraneCollaboration: isit relevantfor doctorsof chiropractic?"
Cochranecollaboration wouldbe away forchiropractic togain greateracceptance withinmedicine.
Thecollaboration has11,500 contributorsfrom morethan 90countries organizedin 50review groups.
For chiropractic,relevant reviewgroups includethe BackGroup; theBone, Joint,and MuscleTrauma Group;the MusculoskeletalGroup; andthe NeuromuscularDisease Group.
The editorialstates that,for example,"a chiropractormay provideconservative caresupported bya Cochranereview toa patientwith carpaltunnel syndrome.
If thepatient's symptomsbecome progressive,the doctormay considerreferring thepatient forsurgery usinga recentCochrane reviewthat examinednew surgicaltechniques comparedwith traditionalopen surgery..."
TheCochrane Collaborationdid notfind enoughevidence tosupport orrefute theclaim thatmanual therapy(including, butnot limitedto, chiropractic)is beneficialfor asthma.
Bandolier foundlimited evidencethat spinalmanipulative therapy(including, butnot limitedto, chiropractic)might reducethe frequencyand intensityof migraineattacks, butthe evidencethat spinalmanipulation isbetter thanamitriptyline, oradds tothe effectsof amitriptyline,is insubstantialfor thetreatment ofmigraine, although"spinal manipulativetherapy mightbe worthtrying forsome patientswith migraineor tensionheadaches."
The beneficialeffect ofchiropractic onpain wasparticularly clear."
A1994 studyby theU.S.
Agencyfor HealthCare Policyand Research(AHCPR) andthe U.S.
Department ofHealth andHuman Servicesendorses spinalmanipulation foracute lowback painin adultsin itsClinical PracticeGuideline.
Thefirst significantrecognition ofthe appropriatenessof spinalmanipulation forlow backpain wasperformed bythe RANDCorporation.
Somechiropractors claimedthese resultsas proofof chiropractichypotheses, butRAND's studieswere aboutspinal manipulation,not chiropracticspecifically, anddealt withappropriateness, whichis ameasure ofnet benefitand harms;the efficacyof chiropracticand othertreatments werenot explicitlycompared.
Forinstance, manyDCs claimto treatinfantile colic.
The reportstates that"The literatureclearly andconsistently showsthat themajor savingsfrom chiropracticmanagement comefrom fewerand lowercosts ofauxiliary services,fewer hospitalizations,and ahighly significantreduction inchronic problems,as wellas inlevels andduration ofdisability."
In 1998,a studyof 10,652Florida workers'compensation caseswas conductedby SteveWolk.
Thestudy comparedbenefits andthe costof carefrom MDs,DCs andDOs, focusingon individualswho hadmissed daysof workand whohad receivedcompensation fortheir injuries.
Washington werethree timesas likelyto reportsatisfaction withcare fromDCs asthey werewith carefrom otherphysicians.
TheWorld HealthOrganization statesthat when"employed skilfullyand appropriately,chiropractic careis safeand effectivefor theprevention andmanagement ofa numberof healthproblems."
According toHarrison's, theseinclude vertebrobasilaraccidents (VBA),strokes, spinaldisc herniation,vertebral fracture,and caudaequina syndrome.
A 1996Danish chiropracticstudy confirmedthe riskof stroketo below, anddetermined thatthe greatestrisk iswith manipulationof thefirst twovertebrae ofthe cervicalspine, particularlypassive rotationof theneck, knownas the"master cervical"or "rotarybreak."
Estimates ofserious complicationsrange from1 in400,000 manipulationsto 0in 5million manipulations.
While individualchiropractors mayshare theviewpoints ofone ormore organizations,most chiropractorsare notmembers ofany nationalorganization.
TraditionalStraight chiropractorsare theoldest movement.
They adhereto thephilosophical principlesset forthby DDand BJPalmer; thatvertebral subluxationleads tointerference ofthe humannervous systemand isa primaryunderlying riskfactor foralmost anydisease.
Straightsadhere tothe chiropracticdiagnosis ofsubluxations, andview themedical diagnosisof patientcomplaints (whichthey considerto bethe "secondaryeffects" ofsubluxations) tobe unnecessaryfor treatment.
Instead, patientsare typicallyscreened for"red flags"of seriousdisease, andtreated basedon apractitioner's preferredchiropractic technique.
This stanceagainst medicaldiagnosing hasbeen asource ofcontention betweenmixers andstraights, becauseaccreditation standardsmandate thatdifferential diagnosisbe taughtin allchiropractic programsso thatpatient careis safeand relevantto theircomplaints.
Additionally,several statechiropractic licensingboards mandatethat patientcomplaints bediagnosed beforereceiving care.
Traditional straightstend toshare theviewpoints foundin theInternational ChiropractorsAssociation (ICA),as wellas theFederation ofStraight Chiropractorsand Organizations(FSCO) andthe WorldChiropractic Alliance(WCA).
Mixerchiropractors arean earlyoffshoot ofthe straightmovement.
Theyeventually splitfrom thetraditional straightgroup andformed variousother chiropracticschools includingthe NationalCollege ofChiropractic.
Theirtreatments mayinclude naturopathicremedies, physicaltherapy devices,or otherComplementary andalternative medicine(CAM) methods.
While stillsubluxation based,mixers alsotreat problemsassociated withboth thespine andextremities, includingmusculoskeletal issuessuch aspain anddecreased rangeof motion.
Mixers describevertebral subluxationsas aform ofjoint dysfunctionor osteoarthritis.
Diagnosis ismade afterruling outother knowndisorders andnoting generalsigns ofmechanical dysfunctionin thespine.
Thisgroup isdifferentiated fromtraditional straightsmainly bythe claimsmade.
Whiletraditional straightsclaimed thatchiropractic adjustmentsare aplausible treatmentfor awide rangeof diseases,objective straightsonly focuson thecorrection ofchiropractic vertebralsubluxations.
Liketraditional straights,objective straightstypically donot diagnosepatient complaints.
Their guidingprinciples aresummed upas: "Wedo notwant todiagnose andtreat diseases,even diseasesof thespine."
We donot wantchiropractic tobe practicedas analternative tomedicine."
They alsodon't referto otherprofessionals, butdo encouragetheir patients"to seea medicalphysician ifthey indicatethat theywant tobe treatedfor thesymptoms theyare experiencingor ifthey wouldlike amedical diagnosisto determinethe causeof theirsymptoms."
Most objectivestraights limittreatment tospinal adjustments.
Objective straightstend toshare theviewpoints foundin theFoundation forthe Advancementof ChiropracticEducation (F.A.C.E.).
Reform chiropractorsare aminority groupwho advocatethe useof palpationand manipulationto identifyand treatosteoarthritis, painfuljoints, andother musculoskeletalproblems.
Theydo notsubscribe tothe Palmerphilosophy ofInnate Intelligenceand vertebralsubluxations, donot believethat spinaljoint dysfunctioncauses organicor systemicdisease, andtend notto usealternative medicinemethods.
Theyprefer toalign themselvesmore withmedical andosteopathic physiciansin theirviews ofdisease causes,processes andresponses tomanipulative therapy.
This procedureis usedin thehospital settingfor patientswhose conditionis unresponsiveto otherforms oftreatment.
Today,there are17 accreditedchiropractic collegesin theUSA andtwo inCanada, andan estimated70,000 chiropractorsin theUSA, 5000in Canada,2500 inAustralia, 2,381in theUK, andsmaller numbersin about50 othercountries.
Inthe USAand Canada,licensed individualswho practicechiropractic arecommonly referredto aschiropractors, doctorsof chiropractic(DC), orchiropractic physicians.
MD, fromthe LatinMedicinae Doctormeaning "Teacherof Medicine,")is anacademic degreefor medicaldoctors.
TheM.B. orBachelor ofMedicine wasthe firstmedical degreesto begranted inthe UnitedStates andCanada.
Thefirst medicalschools thatgranted theM.B.
UPenn,Harvard, Toronto,Maryland, andColumbia.
Thisdegree isthe oldestand mosttraditional degreeheld byphysicians andsurgeons.
NorthAmerican Medicalschools howeverstarted grantingthe M.D.
M.B. Sometimes,holders ofthe M.D.
Students earningan M.D.
Association ofAmerican MedicalColleges andthe LiaisonCommittee onMedical Education,both independentboards ofthe AmericanMedical Association,the AMA.
Admissions tomedical schoolsin theUnited Statesis competitive,with lessthan onehalf ofthe approximately35,000 applicantsmatriculating toa medicalschool.
Beforegraduating froma medicalschool andachieving thedegree ofMedical Doctor,students haveto passthe UnitedStates MedicalLicensing Examination(USMLE) Step1 andboth theClinical Knowledgeand ClinicalSkills partsof Step2.
TheM.D. degreeis typicallyearned infour years.
Most, inorder toreceive BoardEligible orBoard Accreditedstatus ina specialtyof medicinesuch asgeneral surgeryor internalmedicine, thenundergo additionalspecialized trainingin theform ofa residency.
Those whowish tofurther specializein areassuch ascardiology orinterventional radiologythen completea fellowship.
Depending uponthe physician'schosen field,residencies andfellowships involvean additionalthree toeight yearsof trainingafter obtainingthe M.D.
This canbe lengthenedwith additionalresearch years,which canlast one,two, ormore years.
In Canada,the M.D.is thebasic medicaldegree requiredto practicemedicine.
AtMcGill Universityin Montreal,M.D.C.M.
MedicinaeDoctorem etChirurgiae Magistrum)degrees areawarded.
Thoughthe M.D.degree isa professionaldoctorate, andnot aresearch doctorate,many holdersof theM.D.
SomeM.D.s choosea researchcareer andreceive fundingfrom theNIH aswell asother sourcessuch asthe HowardHughes MedicalInstitute.
US,being putafter thename asa title;however, itis alsoused onits ownin informalwriting, asan abbreviationfor "medicaldoctor."
It isone ofthe mostrecognized degreesin thegeneral publicand themedia, andsometimes incorporatedinto thetitles oftelevision showssuch asHouse MD,or DoogieHowser, M.D..
The MBBSor MBChB degreesare also"allopathic" medicalqualifications equivalentto theMD degree.
In all50 ofthe UnitedStates, andsome Canadianprovinces, theDoctor ofOsteopathic medicine(D.O.) degreeis virtuallyidentical tothe trainingrequirements andpractice rightsof theM.D.
Inthe EuropeanUnion, theM.D.
AnM.D. typicallyinvolves eithera numberof publicationsor athesis.
AnM.D. typicallyinvolves eithera numberof publicationsor athesis.
Givengood progress,and byadding afurther year,students canconvert toa Ph.D.
Alternately, theM.D. maybe adegree grantedto medicalgraduates ofthe sameinstitution aftera bodyof previouslypublished researchis submitted.
This maybe consideredequivalent toa Ph.D.
Some universitieswill grantan M.D.
M.A. (inthe caseof Oxfordor Cambridge),an MScor aPh.D.
M.B.,Ch.B.), earnedwith typicallyfour tosix yearsof studiesand trainingat university.
There isalso asimilar advancedprofessional degree,the Masterof Surgery(usually Ch.M.
M.S., butM.Ch. inIreland, Walesand Oxfordand M.Chir.
Cambridge), whichis obtainedafter anM.B., Ch.B.
DO) isan academicdegree offeredin theUnited States.
Holders ofthe D.O.degree areknown asosteopathic physicians,while holdersof thesimilar, butmore commonM.D.
Osteopathicmedicine isa diagnosticand therapeuticsystem basedon thepremise thatthe primaryrole ofthe physicianis tofacilitate thebody's inherentability toheal itself.
D.O.'s maybe foundwithin anymedical specialtybut amajority ofthem workwithin primarycare medicalfields: internalmedicine, pediatrics,obstetrics, andfamily practice.
Although U.S. osteopathicmedical physicianscurrently mayobtain licensurein 47countries, osteopathiccurricula incountries otherthan theUnited Statesdiffers.
D.O.soutside theU. S.
In additionto theHippocratic oath,Osteopathic medicalstudents takean oathto maintainand upholdthe "coreprinciples" ofosteopathic medicalphilosophy.
Revisedin 1953,and againin 2002,the coreprinciples are:There aredifferent opinionson thesignificance ofthese principles.
Upon graduation,osteopathic medicalphysicians mayopt topursue residencytraining programs.
Osteopathic physiciansmay applyto residencyprograms accreditedby eitherthe AOAor theAccreditation Councilfor GraduateMedical Education(ACGME).
Osteopathywas foundedby AndrewTaylor Still,M.D.
Earlyin thetwentieth century,the Americanosteopathic professionadopted theuse ofmedicine andsurgery.
Asbiomedical sciencedeveloped, osteopathicmedicine graduallyincorporated allits proventheories andpractices.
D.O.'shave beenadmitted tofull activemembership inthe AmericanMedical Associationsince 1969.
California D.O.swere offeredthe M.D.
The CaliforniaMedical Associationmay havebeen attemptingto eliminateosteopathic competitionby aprocess ofamalgamation byconverting thousandsof D.O.sto M.D.s.
The Collegeof OsteopathicPhysicians andSurgeons becamethe Universityof California,Irvine Schoolof Medicine.
However, thedecision provedto becontroversial.
In1974, afterprotest andlobbying byinfluential andprominent D.O.s,the CaliforniaSupreme Courtruled thatlicensing ofD.O.s inthat statemust beresumed.
Thisdecision bythe CaliforniaMedical Associationin the1960s togrant D.O.
M.D. licensewas oneof twoturning pointsfor D.O.sin theirearly strugglefor parity;the otherbeing theU.S.
Army'sdecision toallow D.O.sto enterthe militaryas physicians.
These twoturning pointsprovided theosteopathic communitywith thestamp ofequivalency theydesired.
Today,except fora strongerprimary careemphasis inmost osteopathicmedical schoolsand additionaleducation inmusculoskeletal diagnosisand treatment,the trainingand scopeof osteopathicmedicine practicedby D.O.'
UnitedStates isidentical tothat oftheir allopathiccounterparts, thosewho holdthe M.D.
While thereare approximately55,000 D.O.spracticing withinthe UnitedStates, thisnumber representsonly 6%of allpracticing physicians.
D.O.'s mayobtain licensurein anyof thefifty statesand practicein allmedical specialtiesincluding, butnot limitedto, familymedicine, internalmedicine, emergencymedicine, dermatology,surgery, andradiology.
TheD.O. degreeis thelegal andprofessional equivalentof theM.D.
Withinthe osteopathicmedical curriculum,manipulative treatmentis taughtas anadjunctive measureto otherbiomedical interventionsfor anumber ofdisorders anddiseases.
However,a 2001survey ofosteopathic physiciansfound thatmore than50% ofthe respondentsused OMTon lessthan 5%of theirpatients.
However,the numberof D.O.swho reportconsistently prescribingand performingmanipulative treatmenthas beenfalling steadily.
One survey,published inthe Journalof ContinuingMedical Education,found thata majorityof physicians(81%) andpatients (76%)felt thatmanual manipulation(MM) wassafe, andover half(56% ofphysicians and59% ofpatients) feltthat manipulationshould beavailable inthe primarycare setting.
Allopathic physicians."
Thefollowing tablelists thepractice rightsof U.S.
D.O.s inselected countries.
Some questionthe therapeuticutility ofosteopathic manipulativetreatment modalities.
A Harvardmedical schoolreviewed websitesite citesnumerous studiesdemonstrating thatthere aresome ailmentsfor whichthe benefitof manipulativetherapy has"firmly established"scientific support.
Just asclinicians operateby immediacyrules underlarge emergencysystems, emergencyphysicians andother alliedhealth careworkers inthe emergencydepartment basetheir practiceon atriage system.
Emergency medicinefocuses ondiagnosis andtreatment ofacute illnessesand injuriesthat requireimmediate medicalattention.
UrgentCare Centersare oftenstaffed byphysicians, nursesand nursepractitioners whomay ormay notbe formallytrained inemergency medicine.
They offerprimary caretreatment topatients whodesire orrequire immediatecare, butwho donot reachthe acuitythat requirescare inan emergencydepartment.
Theemergency physicianrequires abroad fieldof knowledgeand advancedprocedural skillsoften includingsurgical procedures,trauma resuscitation,advanced cardiaclife supportand advancedairway management.
International Federationfor EmergencyMedicine 1991During theFrench Revolution,after seeingthe speedwith whichthe carriagesof theFrench flyingartillery maneuveredacross thebattlefields, Frenchmilitary surgeonDominique JeanLarrey appliedthe ideaof FlyingAmbulances forrapid transportof woundedsoldiers toa centralplace wheremedical carewas moreaccessible andeffective.
DominiqueJean Larreyis sometimescalled thefather ofEmergency Medicinefor hisstrategies duringthe Frenchwars.
EmergencyMedicine (EM)as amedical specialtyis relativelyyoung.
Priorto the1960's and70's, hospital"emergency rooms"were generallystaffed byphysicians onstaff atthe hospitalon arotating basis,among themgeneral surgeons,internists, psychiatrists,and dermatologists.
Physicians intraining (internsand residents),foreign medicalgraduates andsometimes nursesalso staffedthe ED.
EM wasborn asa specialtyin orderto fillthe timecommitment requiredby physicianson staffto workin thegrowingly chaoticemergency departments(EDs) ofthe time.
During thisperiod, groupsof physiciansbegan toemerge whohad lefttheir respectivepractices inorder todevote theirwork completelyto theED.
Soon,the problemof the"ER", propagatedby publishedreports andmedia coverageof thepoor stateof affairsfor emergencymedical carehad culminatedwith theestablishment ofthe firstemergency medicinetraining programat CincinnatiGeneral Hospital,with BruceJaniak, M.D.
During the1970's, severalother residencyprograms developedthroughout thecountry.
Atthis time,EM wasnot yeta recognizedspecialty andhence hadno primaryboard certificationexam.
Itwas notuntil theestablishment ofACEP, therecognition ofemergency medicinetraining programsby theAMA andthe AOA,and in1979 ahistorical voteby theAmerican Boardof MedicalSpecialties thatEM becamea recognizedmedical specialty.
In theUnited States,the AmericanCollege ofEmergency Physicians(ACEP) ispresently thelargest memberorganization ofemergency physicians(EPs), andActive membershipis opento bothallopathic (M.D.)and osteopathic(D.O.) legacyphysicians (physiciansengaged inthe practiceof emergencymedicine priorto 2000)and thosephysicians whohave completedan emergencymedicine residencyapproved bythe AccreditationCouncil onGraduate MedicalEducation (ACGME),the AmericanOsteopathic Association(AOA), orare certifiedby anemergency medicinecertifying bodyrecognized byACEP.
Originallyfounded in1968, itwas thefirst EmergencyMedicine societyformed inthe UnitedStates.
Fellowsuse thedesignation FACEP.
Membership census:unknown (2006)The AmericanCollege ofOsteopathic EmergencyPhysicians (ACOEP)was foundedseven yearslater in1975.
Activemembership isopen toosteopathic (D.O.)physicians whohave practicedemergency medicinefor thepast threeyears and/orhave completedan emergencymedicine residencyapproved bythe AOAor ACGME.
Fellows usethe designationFACOEP.
Membershipcensus: 2,300(2006) Foundedin 1991,the Associationof EmergencyPhysicians (AEP),distinguishes itselfby offeringmembership toany practicingemergency physicianregardless oftraining.
Byso doing,the AEPacknowledges thatmore thanhalf ofpracticing emergencyphysicians inthe UnitedStates, muchlike theircolleagues inother countries,completed residenciesin otherrelated specialtieswhich includedtraining inthe practiceof emergencymedicine.
TheAmerican Academyof EmergencyMedicine (AAEM)was formedin 1993and hasbeen thesubject ofsome controversydue toits traditionalposition statementsconcerning boardcertification, resident"moonlighting", andthe practiceof "corporatemedicine".
Nevertheless,AAEM hasworked cooperativelyalongside theACEP andthe ACOEPwhen theinterests ofemergency medicinehave calledfor aunited front.
Active membershipis opento bothallopathic (M.D.)and osteopathic(D.O.) physicianswho havecompleted anemergency medicineresidency approvedby ACGMEor theAOA.
Fellowsuse thedesignation FAAEM.
Membership census:5,000 members(2007) TheAmerican Boardof EmergencyMedicine (ABEM)provides boardcertification toallopathic (M.D.)or osteopathic(D.O.) emergencyphysicians.
LikeABEM, theAOBEM atone timeoffered certificationeligibility viaa practicetrack, allowingtraining inanother specialty,practicing emergencymedicine, andthen passingthe AOBEMcertification exam.
The Boardof Certificationin EmergencyMedicine (BCEM)provides boardcertification toboth allopathicand osteopathicphysicians thathave completedan emergencymedicine orprimary careresidency andperformed 5years ofemergency medicinepractice, followedby awritten andoral examinationprocess.
Manyof theabove mentionedlegacy physiciansare certifiedvia thispathway.
TheBritish Associationfor EmergencyMedicine isthe memberorganization inthe UK.
In 2005, thetwo organizationsinitiated stepsto mergeas theCollege ofEmergency Medicine.
In Australiaand NewZealand, advancedtraining inEmergency Medicineis overseenby theAustralasian Collegefor EmergencyMedicine (ACEM).
In Canada,there aretwo routesto practiceemergency medicine.
More thantwo thirdsof physicianscurrently practicingemergency medicineacross theCanadian nationhave nospecific emergencymedicine residencytraining.
Physicianspracticing inmajor urban/tertiarycare hospitalswill oftenpursue a5 yearspecialist residencyin EmergencyMedicine, certifiedby theRoyal Collegeof Physiciansand Surgeonsof Canada.
These memberstypically spenda greatdeal oftime inacademic andleadership roleswithin emergencymedicine, EMS,research, andother avenues.
There isno significantdifference inremuneration orclinical practicetype betweenphysicians certifiedvia eitherroute.
Seemedical emergencyfor specificlists ofmedical emergenciesand howbest torespond.
Inthe US,Emergency Medicineis amoderately competitivespecialty formedical graduatesto enter,ranking 7of 16specialties interms ofpercentage ofU.S.
However,over 90%of applicantsfrom USmedical schoolsto USEmergency Medicineresidencies aresuccessful.
Inaddition tothe didacticexposure, muchof anemergency medicineresidency involvesrotating throughother specialtieswith amajority ofsuch rotationsthrough theemergency departmentitself.
Bythe endof theirtraining, emergencyphysicians areexpected tohandle avast fieldof medical,surgical, andpsychiatric emergencies,and areconsidered specialistsin thestabilization andtreatment ofemergent condition.
A numberof fellowshipsare availablefor emergencymedicine graduatesincluding toxicology,sports medicine,ultrasound, andpediatric emergencymedicine.
Theemployment arrangementof emergencyphysician practicesare eitherprivate (ademocratic groupof EPsstaff anED undercontract), institutional(EPs withan independentcontractor relationshipwith thehospital), corporate(EPs withan independentcontractor relationshipwith athird partystaffing companythat servicesmultiple emergencydepartments) orgovernmental (employedby theUS armedforces, theUS publichealth service,the Veteran'sAdministration orother governmentagency).
Mostemergency physiciansstaff hospitalemergency departmentsin shifts,a jobstructure necessitatedby the24/7 natureof theemergency department.
Doctors ofinternal medicine,also called"internists", arerequired tohave includedin theirmedical schoolingand postgraduatetraining atleast threeyears dedicatedto learninghow toprevent, diagnose,and treatdiseases thataffect adults.
Internists aresometimes referredto asthe "doctor'sdoctor," becausethey areoften calledupon toact asconsultants toother physiciansto helpsolve puzzlingdiagnostic problems.
While thename "internalmedicine" maylead oneto believethat internistsonly treat"internal" problems,this isnot thecase.
Doctorsof internalmedicine treatthe wholeperson, notjust internalorgans.
Internistshold eitheran M.D.
Medical Doctor),D.O. (Doctorof OsteopathicMedicine) ora Biomedicalscience degreeas BiomedicalDoctors.
Theyare notto beconfused with"Medical Interns,"who arephysicians intheir firstyear ofresidency training.
Although Internistsmay actas primarycare physicians,they arenot "familyphysicians," "familypractitioners," or"general practitioners"(whose trainingin certaincountries includesthe medicalcare ofchildren, andmay includesurgery, obstetricsand pediatrics).
General Internistspractice medicinefrom aprimary careperspective butthey cantreat andmanage manyailments andare usuallythe mostadept attreating abroad rangeof diseasesaffecting adults.
The primarycare ofadolescents isprovided byfamily practice,internists andpediatricians.
Theprimary careof childrenand infantsis providedby FamilyPractice orPediatricians.
Thus,there isoverlap.
Internistsare trainedto solvepuzzling diagnosticproblems andhandle severechronic illnessesand situationswhere severaldifferent illnessesmay strikeat thesame time.
They alsobring topatients anunderstanding ofpreventative medicine,men's andwomen's health,substance abuse,mental health,as wellas effectivetreatment ofcommon problemsof theeyes, ears,skin, nervoussystem andreproductive organs.
Most olderadults inthe UnitedStates seean internistas theirprimary physician.
Internists canchoose tofocus theirpractice ongeneral internalmedicine, ormay takeadditional trainingto "subspecialize"in oneof 13areas ofinternal medicine,generally organizedby organsystem.
Cardiologists,for example,are doctorsof internalmedicine whosubspecialize indiseases ofthe heart.
The trainingan internistreceives tosubspecialize ina particularmedical areais bothbroad anddeep.
Subspecialtytraining (oftencalled a"fellowship") usuallyrequires anadditional oneto threeyears beyondthe standardthree yeargeneral internalmedicine residency.
Residencies comeafter astudent hasgraduated frommedical school.)In theUnited States,there aretwo organizationsresponsible forcertification ofsubspecialists withinthe field,the AmericanBoard ofInternal Medicine,and theAmerican OsteopathicBoard ofInternal Medicine.
The ABIMalso recognizesadditional qualificationsin thefollowing areasInternists mayalso specializein allergyand immunology.
The AmericanBoard ofAllergy, Asthma,and Immunologyis aconjoint boardbetween internalmedicine andpediatrics.
Subtledescriptions ofdisease (e.g.
In themedical history,the "Reviewof Systems"serves topick upsymptoms ofdisease thata patientmight notnormally havementioned, andthe physicalexamination typicallyfollows astructured fashion.
At thisstage, adoctor isgenerally ableto generatea differentialdiagnosis, ora listof possiblediagnoses thatcan explainthe constellationof signsand symptoms.
Occam's razordictates that,when possible,all symptomsshould bepresumed tobe manifestationsof thesame diseaseprocess, butoften multipleproblems areidentified.
Inorder to"narrow down"the differentialdiagnosis, bloodtests andmedical imagingare used.
They canalso servescreening purposes,e.g.
Atthis stage,the physicianwill oftenhave alreadyarrived ata diagnosis,or maximallya listof afew items.
Specific testsfor thepresumed diseaseare oftenrequired, suchas abiopsy forcancer, microbiologicalculture etc.
Medicine ismainly focusedon theart ofdiagnosis andtreatment withmedication, butmany subspecialtiesadminister surgicaltreatment: Contentbased onauthoritative informationfrom theWeb sitesof theAmerican Collegeof Physicians,ABIM, andACOI.
Itcan becontrasted notonly withcurative medicine,but alsowith publichealth methods(which workat thelevel ofpopulation healthrather thanindividual health).
Professionals involvedin thepublic healthaspect ofthis practicemay beinvolved inentomology, pestcontrol, andpublic healthinspections.
Publichealth inspectionscan includerecreational waters,pools, beaches,food preparationand serving,and industrialhygiene inspectionsand surveys.
In commonuse, "preventative"is oftenused inplace ofthe preferred"preventive".
Inthe UnitedStates, preventivemedicine isa medicalspecialty, oneof the24 recognizedby theAmerican Boardof MedicalSpecialties (ABMS).
M.D. orD.O.) mustsuccessfully completea preventivemedicine medicalresidency programfollowing aone yearinternship.
Followingthat, thephysician mustcomplete ayear ofpractice inthat specialarea andpass thepreventive medicineboard examination.
The boardexam takesan entireday: Themorning sessionconcentrates ongeneral preventivemedicine questions.
The afternoonsession concentrateson theone ofthe threeareas ofspecialization thatthe applicanthas studied.
Many proceduresin nuclearmedicine usepharmaceuticals thathave beenlabeled withradionuclides (radiopharmaceuticals).
In diagnosis,radioactive substancesare administeredto patientsand theradiation emittedis measured.
The majorityof thesediagnostic testsinvolve theformation ofan imageusing agamma camera.
Imaging mayalso bereferred toas radionuclideimaging ornuclear scintigraphy.
Other diagnostictests useprobes toacquire measurementsfrom partsof thebody, orcounters forthe measurementof samplestaken fromthe patient.
In therapy,radionuclides areadministered totreat diseaseor providepalliative painrelief.
Nuclearmedicine differsfrom mostother imagingmodalities inthat thetests primarilyshow thephysiological functionof thesystem beinginvestigated asopposed tothe anatomy.
In somecentres, thenuclear medicineimages canbe superimposedon imagesfrom modalitiessuch asCT orMRI tohighlight whichpart ofthe bodythe radiopharmaceuticalis concentratedin.
Nuclearmedicine diagnostictests areusually providedby adedicated departmentwithin ahospital andmay includefacilities forthe preparationof radiopharmaceuticals.
The specificname ofa departmentcan varyfrom hospitalto hospital,with themost commonnames beingthe nuclearmedicine departmentand theradioisotope department.
Diagnostic testsin nuclearmedicine exploitthe waythat thebody handlessubstances differentlywhen thereis diseaseor pathologypresent.
Theradionuclide introducedinto thebody isoften chemicallybound toa complexthat actscharacteristically withinthe body;this iscommonly knownas atracer.
Inthe presenceof disease,a tracerwill oftenbe distributedaround thebody and/orprocessed differently.
Any increasedphysiological function,such asdue toa fracturein thebone, willusually meanincreased concentrationof thetracer.
Manytracer complexeshave beendeveloped inorder toimage ortreat manydifferent organs,glands, andphysiological processes.
Some specialiststudies requirethe labelingof apatient's owncells witha radionuclide(leukocyte scintigraphyand redcell scintigraphy).
Molybdenum/Technetium orStrontium/Rubidium.
Themost commonlyused liquidradionuclides are:The mostcommonly usedgaseous/aerosol radionuclidesare: Theradiation emittedfrom theradionuclide insidethe bodyis usuallydetected usinga gammacamera.
Thatis, thepixel appearsbrighter asmore countsare detectedin thatposition.
Activitycloser tothe cameraface willproduce moreinformation inthe imagethan activitylocated deeperin thebody, however,because ofattenuation bytissues betweenthe radionuclideevent andthe cameraface.
Tomographicimaging appliessimilar principles,taking multipleplanar imagesfrom differentangles andthen refiningthem usinga processknown asfiltered backprojection generatingthree dimensionalviews oforgans orareas ofinterest.
Thisallows noisecaused byCompton scatteringto begated out.
The endresult ofthe nuclearmedicine imagingprocess isa "dataset"comprising oneor moreimages.
Thenuclear medicinecomputer mayrequire millionsof linesof sourcecode toprovide quantitativeanalysis packagesfor eachof thespecific imagingtechniques availablein nuclearmedicine, Apatient undergoinga nuclearmedicine procedurewill receivea radiationdose.
Underpresent internationalguidelines itis assumedthat anyradiation dose,however small,presents arisk.
Theradiation dosesdelivered toa patientin anuclear medicineinvestigation presenta verysmall riskof inducingcancer.
Theradiation dosefrom anuclear medicineinvestigation isexpressed asan effectivedose withunits ofsieverts (usuallygiven inmillisieverts, mSv).
The effectivedose resultingfrom aninvestigation isinfluenced bythe amountof radioactivityadministered inmegabecquerels (MBq),the physicalproperties ofthe radiopharmaceuticalused, itsdistribution inthe bodyand itsrate ofclearance fromthe body.
Notes forguidance onthe clinicaladministration ofradiopharmaceuticals anduse ofsealed radioactivesources.
Administrationof radioactivesubstances committeeUK 1998.
Since 1950,the InternationalLabour Organization(ILO) andthe WorldHealth Organization(WHO) haveshared acommon definitionof occupationalhealth.
Itwas adoptedby theJoint ILO/WHOCommittee onOccupational Healthat itsfirst sessionin 1950and revisedat itstwelfth sessionin 1995.
The reasonsfor establishinggood occupationalsafety andhealth standardsare frequentlyidentified as:Different statestake differentapproaches tolegislation, regulation,and enforcement.
In theEuropean Union,member stateshave enforcingauthorities toensure thatthe basiclegal requirementsrelating tooccupational safetyand healthare met.
In manyEU countries,there isstrong cooperationbetween employerand workerorganisations (e.g.
Unions) toensure goodOSH performanceas itis recognizedthis hasbenefits forboth theworker (throughmaintenance ofhealth) andthe enterprise(through improvedproductivity andquality).
In1996 theEuropean Agencyfor Safetyand Healthat Workwas founded.
Member statesof theEuropean Unionhave alltransposed intotheir nationallegislation aseries ofdirectives thatestablish minimumstandards onoccupational safetyand health.
These directives(of whichthere areabout 20on avariety oftopics, followa similarstructure requiringthe employerto assessthe workplacerisks andput inplace preventivemeasures basedon ahierarchy ofcontrol.
Thishierarchy startswith eliminationof thehazard andends withpersonal protectiveequipment.
Inthe UK,health andsafety legislationis drawnup andenforced bythe Healthand SafetyExecutive andlocal authorities(the localcouncil) underthe Healthand Safetyat Worketc.
Act1974. Increasinglyin theUK theregulatory trendis awayfrom prescriptiverules, andtowards riskassessment.
Recentmajor changesto thelaws governingasbestos andfire safetymanagement embracethe conceptof riskassessment.
OSHA,in theU.S. Departmentof Labor,and isresponsible fordeveloping andenforcing workplacesafety andhealth regulations.
NIOSH, inthe U.S.Department ofHealth andHuman Services,and isfocused onresearch, information,education, andtraining inoccupational safetyand health.
OSHA hasbeen regulatingoccupational safetyand healthsince 1971.
Occupational safetyand healthregulation ofa limitednumber ofspecifically definedindustries wasin placefor severaldecades beforethat, andbroad regulationsby someindividual stateswas inplace formany yearsprior tothe establishmentof OSHA.
In Canada,workers arecovered byprovincial orfederal labourcodes dependingon thesector inwhich theywork.
Workerscovered byfederal legislation(including thosein mining,transportation, andfederal employment)are coveredby theCanada LabourCode; allother workersare coveredby thehealth andsafety legislationof theprovince theywork in.
The CanadianCentre forOccupational Healthand Safety(CCOHS), anagency ofthe Governmentof Canada,was createdin 1978by anAct ofParliament.
Theact wasbased onthe beliefthat allCanadians had"...a fundamentalright toa healthyand safeworking environment."
InMalaysia, theDepartment ofOccupational Safetyand Health(DOSH) underthe Ministryof HumanResource isresponsible toensure thatthe safety,health andwelfare ofworkers inboth thepublic andprivate sectoris upheld.
DOSH isresponsible toenforce theFactory andMachinery Act1969 andthe OccupationalSafety andHealth Act1994.
Occupationalsafety andhealth mayinvolve interactionamong manycognate disciplines,including occupationalmedicine, occupational(or industrial)hygiene, publichealth, safetyengineering, healthphysics, ergonomics,toxicology, epidemiology,industrial relations,public policy,sociology, andpsychology.
Forexample, repetitivelycarrying outmanual handlingof heavyobjects isa hazard.
The outcomewould bea musculoskeletaldisorder (MSD).
The riskcan beexpressed numerically,(e.g.
Modernoccupational safetyand healthlegislation usuallydemands thata riskassessment becarried outprior tomaking anintervention.
Thisassessment should:The calculationof riskis basedon thelikelihood orprobability ofthe harmbeing realisedand theseverity ofthe consequences.
This canbe expressedmathematically asa quantitativeassessment (byassigning low,medium andhigh likelihoodand severitywith integersand multiplyingthem togive arisk factor),or asa descriptionof thecircumstances bywhich theharm couldarise i.e.
The assessmentshould berecorded andreviewed periodicallyand wheneverthere isa significantchange towork practices.
The assessmentshould includepractical recommendationsto controlthe risk.
Generally speaking,newly introducedcontrols shouldlower riskby onelevel, i.e,from highto mediumor frommedium tolow Theprecautionary principleis anincreasingly usedmethod forreducing potentialchemical orbiological OSHrisks.
Workplacehazards areoften groupedinto physicalhazards, physicalagents, chemicalagents, biologicalagents, andpsychosocial issues.
Physical hazardsinclude: Physicalagents include:Chemical agents,include Psychosocialissues include:Other issuesinclude: Preventionof fireoften comeswithin theremit ofhealth andsafety professionalsas well.
New technologies,manufacturing processes,and disassemblytechniques oftenbring withthem newlyemerging occupationalsafety andhealth concerns.
Recent examplesinclude workplaceuse andproduction ofgenetically modifiedorganisms andnanotechnology.
Thereis growingconcern aboutexposure tovarious toxinsin thedisassembly ofelectronic wasteas well.
A physicianwho hascompleted trainingin thisfield isreferred toas aphysiatrist (fizzeye' atrist).
Inorder tobe aphysiatrist inthe UnitedStates, onemust completefour yearsof medicalschool, oneyear ofinternship andthree yearsof residency.
The term'Physiatry' wascoined byDr.Frank H.Krusenin 1938.
The termwas acceptedby theAmerican MedicalAssociation in1946.
Thefield grewnotably inresponse tothe demandfor sophisticatedrehabilitation techniquesfor thelarge numberof injuredsoldiers returningfrom WorldWar II.
Physical medicineand rehabilitationinvolves themanagement ofdisorders thatalter thefunction andperformance ofthe patient.
Emphasis isplaced onthe optimizationof functionthrough thecombined useof medications,physical modalities,and experientialtraining approaches.
Electrodiagnostics areused todiagnose andprovide prognosisfor variousneuromuscular disorders.
Common conditionsthat aretreated byphysiatrists includeamputation, spinalcord injury,sports injury,stroke, musculoskletalpain syndromessuch aslow backpain, fibromyalgiaand traumaticbrain injury.
Cardiopulmonary rehabilitationinvolves optimizingfunction inthose afflictedwith heartor lungdisease.
Chronicpain managementis achievedthrough multidisciplinaryapproach involvingpsychologists, physicaltherapists, occupationaltherapists, andinterventional procedureswhen indicated.
The majorconcern ofthe fieldis theability ofthe personto functionoptimally withinthe limitationsplaced uponthem bya diseaseprocess forwhich thereis noknown cure.
The emphasisis noton thefull restorationto thepremorbid levelof function,but ratherthe optimizationof thequality oflife forthose whomay notbe ableto achievefull restoration.
A teamapproach tochronic conditionsis emphasized,using transdisciplinaryteam meetingsto coordinatecare ofthe patients.
Many inthe fieldalso subspecializein areasof amputeecare, musculoskeletalmedicine, electrodiagnostics,traumatic braininjury (TBI),cardiopulmonary rehabilitationand neuromusculardisorders.
Thereare noclear rankingsamong PMRresidencies, buta dozenor sowell reputedprograms inthe UnitedStates wouldinclude Thereare approximately350 totalpositions availablevia theNational ResidentMatching Program(NRMP) peryear.
Inaddition tothose associatedwith elitePMR residencyprograms, notableUS rehabilitationhospitals, manyof whichare teachinghospitals, include:Two maintextbooks oftenused bythose inthe specialtyare PhysicalMedicine andRehabilitation: Principlesand Practiceby JoelDeLisa andPhysical Medicineand RehabilitationMedicine byRandall Braddom.
Useful handbooksfor medicalstudents andresidents includePMR Secretsby MarkYoung, BrianO'Young andSteven Stiens,and PMRPocketpedia byHoward Choiand colleagues.
The twomain journalsof thePMR fieldare Archivesof PhysicalMedicine andRehabilitation andAmerican Journalof PhysicalMedicine andRehabilitation.
Patientsrequiring intensivecare usuallyrequire supportfor hemodynamicinstability (hypertension/hypotension),airway orrespiratory compromise(such asventilator support),acute renalfailure, potentiallylethal cardiacdysrhythmias, andfrequently thecumulative affectsof multipleorgan systemfailure.
Patientsadmitted tothe intensivecare unitnot requiringsupport forthe aboveare usuallyadmitted forintensive/invasive monitoring,such asthe crucialhours aftermajor surgerywhen deemedtoo unstableto transferto aless intensivelymonitored unit.
Since thecritically illare closeto dyingthe outcomeof thisintervention isdifficult topredict.
Manypatients thereforestill diein theIntensive CareUnit.
Thereforetreatment ismerely meantto wintime inwhich theacute afflictioncan beresolved.
Forexample, adjustedICU mortality(for apatient ataverage predictedrisk forICU death)was 21.2%in hospitalswith 87to 150mechanically ventilatedpatients annually,and 14.5%in hospitalswith 401to 617mechanically ventilatedpatients annually.
Hospitals withintermediate numbersof patientshad outcomesbetween theseextremes.
Itis generallythe mostexpensive, hightechnology andresource intensivearea ofmedical care.
Intensive careusually takesa systemby systemapproach totreatment, ratherthan theSOAP (subjective,objective, analysis,plan) approachof highdependency care.
As wellas thekey systemsIntensive caretreatment alsoraises otherissues includingpsychological health,pressure points,mobilisation andphysiotherapy, andsecondary infections.
The provisionof intensivecare isgenerally administeredin aspecialized unitof ahospital calledthe IntensiveCare Unit(ICU) orCritical CareUnit (CCU).
Many hospitalsalso havedesignated intensivecare areasfor certainspecialities ofmedicine, suchas theCoronary CareUnit (CCU)for heartdisease, MedicalIntensive CareUnit (MICU),Surgical IntensiveCare Unit(SICU), PediatricIntensive CareUnit (PICU),Neuroscience CriticalCare Unit(NCCU), OvernightIntensive Recovery(OIR), Shock/TraumaIntensive CareUnit (STICU),Neonatal IntensiveCare Unit(NICU), andother unitsas dictatedby theneeds andavailable resourcesof eachhospital.
Thenaming isnot rigidlystandardized.
Fora timein theearly 1960sit wasnot clearthat specializedintensive careunits wereneeded andintensive careresources (seebelow) werebrought tothe roomof thepatient whoneeded theadditional monitoring,care, andresources.
Itbecame rapidlyevident, though,that afixed locationwhere intensivecare resourcesand personnelwere availableprovided bettercare thanad hocprovision ofintensive careservices spreadthroughout ahospital.
Commonequipment inan intensivecare unit(ICU) includesmechanical ventilationto assistbreathing throughan endotrachealtube ora tracheotomy;hemofiltration equipmentfor acuterenal failure;monitoring equipment;intravenous linesfor druginfusions fluidsor totalparenteral nutrition,nasogastric tubes,suction pumps,drains andcatheters; anda widearray ofdrugs includinginotropes, sedatives,broad spectrumantibiotics andanalgesics.
Criticalcare medicineis arelatively newbut increasinglyimportant medicalspecialty.
Physicianswho havetraining incritical caremedicine arereferred toas intensivists.
The specialtyrequires additionalfellowship trainingfor physicianswho completetheir primaryresidency trainingin internalmedicine, anesthesiology,or surgery.
Board certificationin criticalcare medicineis availablethrough allthree specialtyboards.
Intensivistswith aprimary trainingin internalmedicine sometimespursue combinedfellowship trainingin anothersubspecialty suchas pulmonarymedicine, cardiology,infectious disease,or nephrology.
The Societyof CriticalCare Medicineis awell establishedmultiprofessional societyfor pracitionerswho workin theICU, includingintensivists.
Medicalresearch hasrepeatedly demonstratedthat ICUcare providedby intensivistsproduces betteroutcomes andmore costeffective care.
Unfortunately thereis acritical shortageof intensivistsin theUnited Statesand mosthospitals lackthis criticalphysician teammember.
Inveterinary medicine,critical caremedicine isrecognized asa specialtyand isclosely alliedwith emergencymedicine.
Patientmanagement inintensive carediffers significantlybetween countries.
In Australia,where IntensiveCare Medicineis awell establishedspeciality, ICUsare describedas 'closed'.
In aclosed unitthe intensivecare specialisttakes onthe seniorrole wherethe patient'sprimary doctornow actsas aconsultant.
Othercountries haveopen IntensiveCare Units,where theprimary doctorchooses toadmit andgenerally makesthe managementdecisions.
In1854 theCrimean War,in whichEngland, Franceand Turkeydeclared waron Russia,began.
Becauseof thelack ofcritical careand thehigh rateof infection,there wasa highmortality rateof hospitalisedsoldiers, reachingas highas 40%of thedeaths recordedduring thewar.
Florenceand 38other volunteershad toleave forthe Fieldsof Scurati,and tooktheir "criticalcare protocol"with them.
Upon arriving,and practicing,the mortalityrate fellto 2%.
Nightingale contractedtyphoid, andreturned in1856 fromthe war.
A Schoolof Nursingwas formedin 1859in Englanddedicated toher.
TheSchool wasrecognised forits professionalvalue andtechnical calibre,receiving prizesthroughout theEnglish government.
The Schoolof Nursingwas establishedin SaintThomas Hospital,as aone yearcourse, andwas givento doctors.
It utilisedtheoretical andpractical lessons,as opposedto purelyacademic lessons.
Her work,and theschool, pavedthe wayfor IntensiveCare Medicine.
Walter EdwardDandy wasborn inSedalia, Missouri.
He receivedhis BAin 1907through theUniversity ofMissouri andhis M.D.
Johns HopkinsUniversity Schoolof Medicine.
Dandy workedone yearwith Dr.
Harvey Cushingin theHunterian Laboratoryof JohnsHopkins beforeentering itsboarding schooland residencein theJohns HopkinsHospital.
Heworked inthe JohnsHopkins Collegein 1914and remainedthere untilhis deathin 1946.
This techniquewas extremelysuccessful foridentifying braininjuries.
Dr.Dandy wasalso apioneer inthe advancesin operationsfor illnessesof thebrain affectingthe glossopharyngealas wellas Meniere'ssyndrome, andhe publishedstudies thatshow thathigh activitycan causesciatic pain.
Peter Safar,the firstIntensivist doctor,was bornin Austria.
He wasthe sonof twodoctors, whomigrated tothe UnitedStates afterbeing ina Naziconcentration camp.
The doctorfirst gotcertification asan anesthetist,and inthe 1950she startedand praisedthe "UrgencyEmergency" roomsetup (nowknown asan ICU).
It wasat thistime theABC's (Airway,Breathing, andCirculation) protocolswere formed,and artificialventilation aswell asexternal cardiacmassage becamepopular.
Theseexperiments countedon volunteersof itsteam whichonly usedminimum sedation.
It wasthrough theseexperiments thatthe techniquesfor maintaininglife inthe criticalpatient wereestablished.
Inthe cityof Baltimore,the firstsurgical ICUwas established,and in1962, inthe Universityof Pittsburgh,the firstCritical CareResidency wasestablished inthe UnitedStates.
Itwas aroundthis timethat theinduction ofhypothermia incritical patientswas alsotested.
Morerecently, theWorld Associationfor Disasterand EmergencyMedicine wasformed, andso wasthe SCCM(Society ofCritical CareMedicine).
Medicineis directlyconnected tothe healthsciences andbiomedicine.
Broadlyspeaking, theterm 'Medicine'today refersto thefields ofclinical medicine,medical researchand surgery,thereby coveringthe challengesof diseaseand injury.
Since the19th century,only thosewith amedical degreehave beenconsidered worthyto practicemedicine.
Clinicians(licensed professionalswho dealwith patients)can bephysicians, physicaltherapists, physicianassistants, nursesor others.
The medicalprofession isthe socialand occupationalstructure ofthe groupof peopleformally trainedand authorizedto applymedical knowledge.
Many countriesand legaljurisdictions havelegal limitationson whomay practicemedicine.
Humansocieties havehad variousdifferent systemsof healthcare practicesince atleast thebeginning ofrecorded history.
Medicine, inthe modernperiod, isthe mainstreamscientific traditionwhich developedin theWestern worldsince theearly Renaissance(around 1450).
Many othertraditions ofhealth careare stillpracticed throughoutthe world;most ofthese areseparate fromWestern medicine,which isalso calledbiomedicine, allopathicmedicine orthe Hippocratictradition.
Themost highlydeveloped ofthese aretraditional Chinesemedicine, TraditionalTibetan medicineand theAyurvedic traditionsof Indiaand SriLanka.
Thesesystems aresometimes consideredcompanions toHippocratic medicine,and sometimesare seenas competitionto theWestern tradition.
Few ofthem haveany scientificconfirmation oftheir tenets,because ifthey didthey wouldbe broughtinto thefold ofWestern medicine.
Medicine" isalso oftenused amongstmedical professionalsas shorthandfor inter