On-site Presence Research Articles

Telestroke in resource-poor developing country model.

Telemedicine is a major effort to tackle the uneven availability of facilities for thrombolysis in acute ischemic stroke. We present a telestroke model introduced in a small hilly state of Himachal Pradesh in India. To provide acute ischemic stroke treatment with tissue plasminogen activator in all district hospitals of Himachal Pradesh with computerized axial tomographic scan facility through Telemedicine. Smartphone-based hub and spoke telestroke model was used with two tertiary care hospitals (with neurologists) as hub and 17 district hospitals (without onsite neurologists) as spokes. The telestroke project was launched in the state of Himachal Pradesh in April 2014. Medical officers in district hospitals (Medicine graduates and Internal Medicine postgraduates) were trained in the treatment of stroke through workshops. Tissue plasminogen activator was made available at all these centers, free of cost through hospital pharmacies. Four neurologists at two tertiary care centers were made available for consultation on phone. Between June 2014 and May 2015, a total of 26 patients received thrombolysis under the telestroke project at nine district hospitals without onsite presence of a neurologist. Eight patients were females and 18 males. The age of patients ranged from 26 to 80 years. Only 2 patients developed an intracranial bleed following thrombolysis, and both were nonfatal. Smartphone-based telestroke services may be a much cheaper alternative to video-conferencing-based telestroke services and are more portable with less technical glitches. To the best of our knowledge, this is the first telestroke model being reported from India. It seems to be the way forward in providing timely treatment in acute ischemic stroke in underserved and resource poor settings.

Commentaries on health services research

Commentaries on health services research

CDC: Coordinated Strategy Will Curb Resistant Infections

CDC: Coordinated Strategy Will Curb Resistant Infections

Business knowledge requirements and onsite offshore work division in Indian software outsourcing projects

Purpose – The purpose of the paper is to find out the knowledge requirements and its effect on both onsite and offshore project work division for development, re-engineering and maintenance projects in Indian outsourcing software industry in different phases of software development. Design/methodology/approach – This study employs an expert interview approach in Indian software industry to find out knowledge requirement for project execution and division of work between onsite and offshore locations. The requisite data were collected through expert interviews and direct observations. Findings – The study found that the development projects require higher level of domain, strategic, business process and operation process knowledge in comparison to re-engineering and maintenance projects. So there is a need of higher onsite presence in development projects. The maintenance work is taken up at the offshore location in a phase-wise manner. Research limitations/implications – The implication of the study is in the development of a broad framework of knowledge requirements and work division in on-shore and offshore locations for Indian software outsourcing projects. As the study is based on expert opinion in the context of India, it cannot be generalized for outsourcing scenarios elsewhere. Practical implications – The software project manager can use the findings to get more insight into the project and divide the software team between onsite and offshore location. Originality/value – The study is novel, as there is little attempt at finding the knowledge requirement to execute various kinds of business software development in outsourcing environment in the context of India.

Engaging veterans with substance abuse disorders into a research trial: success with study branding, networking, and presence.

Recruiting and retaining clients in health interventions can be challenging especially when targeting multiple behavior change in high-risk populations. To inform the methods of trials working with similarly complex clinical populations, we describe multi-pronged efforts to recruit and retain a representative sample. In a two-group RCT, veterans were recruited from a Veteran Affairs Medical Center. The goal was to enroll 200 participants over a 25-month period, and to exceed 70% follow-up for all treatment arms. To meet these goals, a four-pronged strategy was developed: branding, outreach/networking, onsite presence, and incentives. In month 1, 32% of the proposed sample size was met (n = 64), and by month 2, 45% (n = 90); the recruitment goal (n = 200) was achieved 13 months ahead of schedule. Retention exceeds 90% at all time points out to 18months. The multipronged recruitment and retention plan was efficient, cost effective, and may generalize to other health promotion initiatives.

State Laws Governing Physician Assistant Practice in the United States and the Impact on Emergency Medicine

BackgroundMidlevel providers, including physician assistants (PA), have been recommended by some to fill the current inadequate supply of providers nationally, including in emergency medicine. ObjectivePA practice is governed by state law. We described the differences in qualifications, scope of practice, prescriptive authority, and physician supervision required by individual states for PA practice and describe the impact this may have on emergency medicine. MethodsA cross-sectional analysis of United States laws governing PA practice by abstraction from each state’s public website. State characteristics were collected from the American Academy of Physician Assistants and United States Census websites and dichotomized by median values. ResultsOnly six states (12%), all of which were larger-population states, required physician review of medical records within 1 week of a PA-only patient encounter. However, one state (Virginia) explicitly required onsite physician presence for PA practice in the emergency department. All states allowed PAs to assist in invasive procedures, but 13 (25%) restricted independent performance. Restriction of this practice was more likely in states with a higher population (38%), lower rural proportion (40%), and lower number of PAs per population (40%). Eleven (22%) states restricted performance of sedation or general anesthesia. An expanded scope of practice for disaster situations was allowed by 24 (47%) states and was more likely in larger population states (62%). All but two states (Florida and Kentucky) allowed PA prescribing of schedule III–V medications, and 37 (73%) allowed prescribing of schedule II medications. ConclusionsLaws governing PA practice in emergency departments differ by state, but generally allow for a broad scope of practice and limited direct supervision. Smaller, rural states were less likely to have tighter restrictions or oversight.

BOTH SIDES OF THE FENCE: METHODOLOGICAL CHALLENGES IN UNDERTAKING RESEARCH INTO END OF LIFE CARE FOR PRISONERS

IntroductionThe number of older prisoners in the UK has more than doubled in the last decade, with the greatest increases amongst those over 70. Around 40% of older prisoners are...

Groundwater source contamination mechanisms: Physicochemical profile clustering, risk factor analysis and multivariate modelling

An integrated domestic well sampling and "susceptibility assessment" programme was undertaken in the Republic of Ireland from April 2008 to November 2010. Overall, 211 domestic wells were sampled, assessed and collated with local climate data. Based upon groundwater physicochemical profile, three clusters have been identified and characterised by source type (borehole or hand-dug well) and local geological setting. Statistical analysis indicates that cluster membership is significantly associated with the prevalence of bacteria (p=0.001), with mean Escherichia coli presence within clusters ranging from 15.4% (Cluster-1) to 47.6% (Cluster-3). Bivariate risk factor analysis shows that on-site septic tank presence was the only risk factor significantly associated (p<0.05) with bacterial presence within all clusters. Point agriculture adjacency was significantly associated with both borehole-related clusters. Well design criteria were associated with hand-dug wells and boreholes in areas characterised by high permeability subsoils, while local geological setting was significant for hand-dug wells and boreholes in areas dominated by low/moderate permeability subsoils. Multivariate susceptibility models were developed for all clusters, with predictive accuracies of 84% (Cluster-1) to 91% (Cluster-2) achieved. Septic tank setback was a common variable within all multivariate models, while agricultural sources were also significant, albeit to a lesser degree. Furthermore, well liner clearance was a significant factor in all models, indicating that direct surface ingress is a significant well contamination mechanism. Identification and elucidation of cluster-specific contamination mechanisms may be used to develop improved overall risk management and wellhead protection strategies, while also informing future remediation and maintenance efforts.

Intussusception Revisited: Is Immediate On-Site Surgeon Availability at the Time of Reduction Necessary?

The American College of Radiology recommends that fluoroscopically guided intussusception reduction be performed with a surgeon readily available. At many institutions, this may not be feasible. The purpose of this study was to assess the utilization of immediate surgical services at the time of radiologic intussusception reduction. All radiologic intussusception reductions at a tertiary care children's hospital from November 2007 through August 2012 were reviewed to determine method, complications, clinical status of the child, and time between unsuccessful reduction and operative intervention. Among 433 patients with intussusception referred for fluoroscopic reduction, 86.1% (n = 373) had successful reductions, and 13.9% (n = 60) had unsuccessful reductions. Five perforations represented 8.3% (5/60) of the unsuccessful and 1.2% (5/433) of the total reduction attempts. Six patients' conditions became hemodynamically unstable during attempted reduction (four perforations, two unsuccessful reductions without perforation), representing 10% (6/60) of unsuccessful and 1.4% (6/433) of total reduction attempts. Percutaneous needle decompression and cardiopulmonary resuscitation restored hemodynamic stability in all cases. The mean time to surgery after perforation was 1.3 hours, after unsuccessful reduction complicated by hemodynamic instability was 2.2 hours, and after unsuccessful radiologic reduction without complication was 4.3 hours. In this series, complications requiring immediate medical or surgical attention were rare, occurring in 1.6% of cases (five bowel perforations, two cases of hemodynamic instability without perforation). On-site surgeon presence may not be necessary at the time of radiologically guided reduction attempts provided that the attending physician is facile with percutaneous needle decompression and management of hemodynamic instability and that ultimate surgical care can be arranged expeditiously.

Trade Fairs as an Export Marketing and Research Strategy: Results from a Study of Korean Advanced Machinery Firms

AbstractManufacturers pursuing information on potential customers in distant, dynamic markets confront myriad obstacles. To address this, many firms attend international trade fairs in order to market their products, to meet with prospective customers, and to tap into buzz related to potential international opportunities. In many ways, moreover, such exhibitions can serve as short‐term agglomerations of same‐industry activity, particularly important for producer–user interface geared towards innovation. The goal of this paper is to explore how Korean machine tool manufacturers utilise a major global trade show in Seoul to minimise the difficulties associated with accessing a global customer base, inclusive of their activity at this show geared towards innovation. Evidence from firm‐level surveys and interviews suggest that the amount of importance placed on trade fair attendance as part of a firm's internationalisation strategies is related to export growth. Additionally, a new insight generated is that firms that participate in trade shows as part of their innovation process also demonstrate higher rates of export intensity. Finally, we may be witnessing newly discovered, technology‐driven, symbiotic relationships between online portal sites, vendors, and potential customers at these trade fairs, where virtual services are nonetheless augmented by a need for a continued onsite presence at these exhibitions.

PL.68 When Should Twin Induction of Labour Start to Increase the Chances of Daytime Delivery?

BackgroundVaginal twin deliveries can be complicated and senior obstetrician presence may be advisable. Our unit has consultant on-site presence between 08:30 and 20:30, so we sought to determine when inductions...

Blood Glucose Monitoring and Underlying Question of Hypoglycemia Are Both Essential to Preventing Hypoglycemia in Nursing Home Residents

H ealth care providers are often faced with decisions about treatment options for diabetes that must take into consideration a patient's quality of life. One controversial area is whether finger-stick glucose monitoring is necessary once a patient becomes a nursing home resident because of the discomfort involved with fingersticks. This case will illustrate the benefit of glucose checking for all elderly patients who are prescribed medications that can cause hypoglycemia. It also offers strategies to minimize discomfort to such patients. At the Hurlbut Community Care skilled nursing facility in Rochester, N.Y., it has long been policy to check blood glucose at least before meals in patients who are on insulin or oral agents that carry a risk for hypoglycemia. With the help of Joslin Diabetes Center of Boston, Mass., the facility has established a three-pronged diabetes management program that includes staff and patient training in basic information about the disease and its treatment, the onsite presence of a diabetes care coordinator, and the involvement of an expert nurse practitioner who oversees residents' diabetes management. Mrs. J. is an 88-year-old African-American woman who was laterally transferred on 16 March 2011 from another skilled nursing facility where she had resided since 2007. She was moved to the Hurlbut facility to be closer to her family and to receive ongoing diabetes care. Mrs. J. is a poor self-historian because she has severe dementia. ### Medical History Her medical history includes dementia with psychosis/aggression, type 2 diabetes requiring insulin, hypoglycemia unawareness, hyperlipidemia, hypertension, degenerative joint disease, anemia, vitamin B12 deficiency, stage 3 chronic kidney disease, and hearing loss. Mrs. J. requires assistance with all activities of daily living. Before being transferred, she had frequent hyper- and hypoglycemia. In her previous facility, her glucose was monitored daily before breakfast only, and her results ranged from 41 to …

Student Satisfaction with Models of Field Placement Supervision

Field placements provide social work students with the opportunity to integrate their classroom learning with the knowledge and skills used in various human service programs. The supervision structure that has most commonly been used is the intensive one-to-one, clinical teaching model. However, this model is being challenged by significant changes in educational and industry sectors, which have led to an increased use of alternative fieldwork structures and supervision arrangements, including task supervision, group supervision, external supervision, and shared supervisory arrangements. This study focuses on identifying models of supervision and student satisfaction with their learning experiences and the supervision received on placement. The study analysed responses to a questionnaire administered to 263 undergraduate social work students enrolled in three different campuses in Australia after they had completed their first or final field placement. The study identified that just over half of the placements used the traditional one student to one social work supervisor model. A number of “emerging” models were also identified, where two or more social workers were involved in the professional supervision of the student. High levels of dissatisfaction were reported by those students who received external social work supervision. Results suggest that students are more satisfied across all aspects of the placement where there is a strong on-site social work presence.

ASHA Poll at AARP: Outreach Needed to Older Adults

You have accessThe ASHA LeaderASHA News1 Dec 2010ASHA Poll at AARP: Outreach Needed to Older Adults Greg Weimann Greg Weimann Google Scholar More articles by this author https://doi.org/10.1044/leader.AN2.15152010.27 SectionsAbout ToolsAdd to favorites ShareFacebookTwitterLinked In Audiologist Anne Hains Peters of Orlando, right, provides advice to one of many 2010 AARP [email protected]+ Convention participants who visited the ASHA booth. More than half (53%) of respondents to an ASHA poll believe they or their spouse have hearing loss, yet only a quarter have consulted an audiologist. Findings of the poll, conducted at the 2010 AARP [email protected]+ Convention in Orlando, combined with respondents’ lack of familiarity with audiology and speech-language pathology, suggest the need to reach out to older Americans about identification, prevention, and treatment of speech, language, and hearing disorders. The poll was completed by 484 respondents who stopped by the ASHA exhibit at the AARP convention from Sept. 30 through Oct. 2. The exhibit was staffed by Anne Hains Peters, an Orlando audiologist, and ASHA staff members. The poll explored respondents’ view of their own and their spouses’ hearing, what they value most from a health care provider, level of familiarity with audiologists and speech-language pathologists, and the most effective way to communicate to this population. AARP members’ responses to the poll also revealed: The vast majority (91%) do not own a hearing aid. Accuracy in diagnosis and treatment was the attribute most valued in a health care provider by the majority (74%) of respondents. Only about one-third of respondents reported visiting an audiologist in the last few years; 6% reported visiting an SLP. About a third (35%) of respondents reported no familiarity with audiologists; 43% indicated no familiarity with SLPs. Direct mail is the best way to communicate about hearing health for 39% of respondents. Maintaining a continued onsite presence and implementing marketing campaigns (commercials, brochures, etc.) were among the suggestions offered on how ASHA could raise consumer awareness of the professions at future AARP conventions. “We hope members find the results of this poll useful to their efforts to promote their services,” said ASHA President Tommie L. Robinson Jr. “The association also welcomes the opportunity to work with AARP in other ways that highlight how our members’ expertise can serve the communication health of older Americans.” For the complete report, contact [email protected]. Author Notes Greg Weimann, a public relations manager, can be reached a [email protected]. Advertising Disclaimer | Advertise With Us Advertising Disclaimer | Advertise With Us Additional Resources FiguresSourcesRelatedDetails Volume 15Issue 15December 2010 Get Permissions Add to your Mendeley library History Published in print: Dec 1, 2010 Metrics Downloaded 47 times Topicsasha-topicsleader_do_tagleader-topicsasha-article-typesCopyright & Permissions© 2010 American Speech-Language-Hearing AssociationLoading ...

Community-Driven Approaches for Reducing Health Disparities in Cancer

SINCE 1990, OVERALL CANCER MORTALITY RATES HAVE declined at a rate of approximately 1% per year, with mortality from breast, colorectal, prostate, and lung cancer declining at about 2% per year. These declines have largely been attributed to favorable trends in some risk factors for cancer, increased use of methods to detect cancer earlier, and more effective means to treat the disease. However, cancer-related mortality rates for African Americans continue to be considerably higher than those for non-Hispanic whites in the United States. Although the mortality gap has decreased somewhat, mostly secondary to tobacco-related cancers and reflecting declining tobacco use by African Americans, the mortality gap has not diminished for cancers with rates affected by early detection or effective treatment. Differences in mortality and prevalence of risk factors are related to social class as defined by level of educational achievement. The decline in cancer mortality is greater for college graduates than for high school graduates, and no decline has occurred among those with less than a high school education. Other causes of cancer health disparities involve limited access to care, including prevention and early detection; unequal treatment when cancer is diagnosed; differences in behaviors that increase cancer risk, such as tobacco use, unhealthful diet, and lack of physical activity; differences in behaviors that decrease cancer risk, such as screening for breast, colorectal, and cervical cancer; and diverse cultural beliefs that influence the care-seeking behavior of patients. Advances in medical knowledge and technology also widen the disparity gap because technological innovations are differentially delivered to various groups and populations. Elimination of the screening gap between African American and white patients for breast, cervical, and colorectal cancer is perhaps the easiest way to influence cancer health disparity. Screening is at most an annual event, and at least for breast cancer and cervical cancer, most of the population has access to screening either through insurance, Medicare, or the Breast and Cervical Cancer Early Detection Program (colorectal screening is being added to the latter program incrementally). One approach to increase screening involves engaging low-income, low-education, mostly minority communities in a community-based participatory process that leads to “community efficacy,” a willingness on the part of community residents to help for the common good. This approach resulted in elimination of disparities in Medicare mammography screening rates between African American and white women in targeted counties in Alabama and Mississippi. Screening is in many ways the low-hanging fruit that allows programs to demonstrate success, and it also is an effective way to engage the community because the task is clear, achievable, and measurable in the short term. Other interventions, such as those aimed at tobacco cessation, healthful eating, and increased physical activity, require efforts that go beyond the individual behavioral change to a socioecological approach that engages all facets of the community—the individual, family, neighborhood, organizations, and policy makers. Because it is more complex, this approach is more difficult to implement. The first step is to engage the community. However, academic institutions, nongovernmental organizations, cancer volunteer organizations, and public health departments too often attempt health promotion from afar, working through the media, creating culturally relevant literature, and meeting with community members in conference rooms, without establishing an onsite presence in the community. Cancer control from a distance does not work in the geographic areas and demographic populations most at risk for disparities. Organizations and agencies must leave the comfort zone of the home base and begin engaging community members in the community, building mutual trust, offering guidance, sharing expertise, and empowering community volunteers to address the problem locally. Access to care will remain a major impediment to closing the disparity gap in cancer as long as substantial

Effect of 24-hour mandatory versus on-demand critical care specialist presence on quality of care and family and provider satisfaction in the intensive care unit of a teaching hospital*

The benefit of continuous on-site presence by a staff academic critical care specialist in the intensive care unit of a teaching hospital is not known. We compared the quality of care and patient/family and provider satisfaction before and after changing the staffing model from on-demand to continuous 24-hr critical care specialist presence in the intensive care unit. Two-year prospective cohort study of patient outcomes, processes of care, and family and provider survey of satisfaction, organization, and culture in the intensive care unit. Intensive care unit of a teaching hospital. Consecutive critically ill patients, their families, and their caregivers. Introduction of night-shift coverage to provide continuous 24-hr on-site, as opposed to on-demand, critical care specialist presence. Of 2,622 patients included in the study, 1,301 were admitted before and 1,321 after the staffing model change. Baseline characteristics and adjusted intensive care unit and hospital mortality were similar between the two groups. The nonadherence to evidence-based care processes improved from 24% to 16% per patient-day after the staffing change (p = .002). The rate of intensive care unit complications decreased from 11% to 7% per patient-day (p = .023). When adjusted for predicted hospital length of stay, admission source, and do-not-resuscitate status, hospital length of stay significantly decreased during the second period (adjusted mean difference -1.4, 95% confidence interval -0.3 to -2.5 days, p = .017). The new model was considered optimal for patient care by the majority of the providers (78% vs. 38% before the intervention, p < .001). Family satisfaction was excellent during both study periods (mean score 5.87 +/- 1.7 vs. 5.95 +/- 2.0, p = .777). The introduction of continuous (24-hr) on-site presence by a staff academic critical care specialist was associated with improved processes of care and staff satisfaction and decreased intensive care unit complication rate and hospital length of stay.

Vitis pollen dispersal in and from organic vineyards : I. Pollen trap and soil pollen data

The recent discovery of Roman vineyards in Britain [Antiquity 75 (2001) 745] based on both archaeological and palynological data has raised questions concerning the palynological record of viticulture in NW Europe. This paper presents data collected from 30 pollen traps and 29 soil pollen samples from within, and around, three organic vineyards in England. The soil trap data were collected over one flowering season. Within-vineyard pollen accumulation is compared with off-site accumulation and the soil pollen data. Although there is extremely high intravineyard variation in Vitis accumulation, the data confirm the role of stemflow transport and the exponential decrease in Vitis pollen accumulation with distance away from the vineyard. Pollen trap values of over 2% total pollen (TP) Vitis and soils with over 0.2% TP (based on 1000+ pollen sum) are likely to indicate the on-site presence of a vineyard. This is in accordance with the values recorded from known Roman vineyards in the Nene Valley. A compilation of occasional finds of Vitis pollen in England reveals typical values of 0.2% or less; although higher values are recorded, they are generally an artefact of a low total pollen count. However, the clustering of these occasional finds into the Roman and high Medieval periods suggests that long-distance Vitis influx increased during periods of widespread viticulture in NW Europe including England. The monitoring of Vitis pollen dispersal suggests that where encountered as part of routine pollen counting, the total pollen sum should be increased to ca. 1000 TP in order to establish a better estimate of the frequency of occurrence. This will allow palynology to play a less ambiguous part in the mapping of ancient viticulture.

Maintaining surgical standards beyond the city in Australia.

Many Australians, by choice or necessity, live and work in rural Australia. In the past broadly trained general surgeons and appropriately trained general practitioner (GP) surgeons provided much of the surgical management. Recently very few rural GPs have been trained in surgery and there is a shortage of specialist surgeons in many rural parts of Australia. Outreach surgery can assist in the provision of some surgical services but it is not as effective as an on-site surgical presence. The challenge for the Royal Australasian College of Surgeons Rural Surgical Training Programme is to provide an ongoing supply of well-trained surgeons in general surgery and the other specialties to provide adequate surgical services to rural Australians. This will be best achieved by having adequate numbers of surgeons resident in rural areas with appropriate outreach specialist services, and training and support of the procedural GPs in the smaller centres.

ASCE Site Safety Policy: Introduction

In 1987 the building collapse at L’Ambience Plaza in Bridgeport, Conn., resulted in several fatalities. This led to proposed federal legislation, which would have required that all construction projects be supervised by a professional engineer/architect ~E/A!. This would have required the E/A to maintain a constant on-site presence and would have made the E/A responsible for construction site safety.

At Pennsylvania Hospital, 250 years of care.

PHILADELPHIA—On a full city block in Society Hill, a short walk from Independence Hall, surrounded by azaleas and wisteria and overseen by a statue of state founder William Penn, sits the original Pennsylvania Hospital, the first hospital in this country. Established on May 11, 1751, by a charter granted by the Pennsylvania legislature through the efforts of Benjamin Franklin and Thomas Bond, MD, the hospital this week celebrates 250 years of caring for the community. Originally intendedtobeaplaceof refuge and cure for “the sick-poor and insane” of what was by 1776 the second largest English-speaking city in the British empire, the now greatly expanded Philadelphia facility uniquely combines the architectural and archival treasures of its colonial past with the mission of a 21st-century tertiary care hospital. A recent visit with Pennsylvania Hospital physicians revealed their intense pride in being part of this institution and their determination to carry forward and augment its distinguished heritage. According to R. Michael Buckley, Jr, MD, chief medical officer of the hospital and chair of its Department of Medicine (and also a professor at University of Pennsylvania School of Medicine), an outstanding feature of the place is the culture of collegiality fostered by its historic surroundings. Patients now come from a much wider area than did the 18th-century clientele who arrived on foot or by horse and carriage—Buckley estimated they comprise in equal part people from the neighborhood, the rest of the city, the suburbs, and a 100-mile radius including adjacent states—but physicians run across each other routinely in the beautifully preserved Pine Building, which is a National Registered Landmark. The Pine Building, facing Pine Street between Eighth and Ninth, was designed by colonial carpenter Samuel Rhoads, who also had a hand in Independence National Historical Park’s showplace Carpenter’s Hall. It was built in three parts: the East Wing (opened in 1756, it originally housed both physically and mentally ill patients), the West Wing (to which the mentally ill were moved when it opened in 1796), and the center section, which was opened in 1804 as a buffer between the two and contained the apothecary, library, offices, staff quarters, and surgical amphitheater. All now house administrative and physicians’ offices, as well as the Historic Library and contemporary libraries and meeting rooms. Two and a half centuries of expansion have added a number of more modern inpatient and outpatient facilities nearby. Somewhat unusually for a metropolitan hospital, said Buckley, “almost everyone who practices here practices only here.” He emphasized that the daily on-site presence of most staff makes possible a type of personal care much appreciated by patients. For example, he said, the response to a re-