Physicians In Various Specialties Research Articles

Finding Meaning.

Finding Meaning.

Out-patient Visit to the Pulmonologist: Peculiarities of Medical Pare Provision amid the COVID-19 Pandemic

Abstract. The coronavirus pandemic has significantly affected the health care system and continues to make adjustments to the work of physicians in various specialties.
 The aim of the study was to analyze the work of a pulmonologist of the polyclinic amid the pandemic COVID-19.
 Material and methods of the study. An assessment of appeals to the pulmonologist consultation in the medical center “Frankomed” in Ivano-Frankivsk from July 2020 to February 2021 has been performed.
 Research results.There were 143 patients, who made 185 visits and applied for an appointment with a pulmonologist within 8 months. Among those studied there were 72 women and 71 men. The age of patients was from 18 to 87 years, the average age of women was 49.31 ± 2.14 years, the average age of men was 48.86 ± 2.73 years.
 The reasons for seeking medical help from a pulmonologist were the following ones: acute bronchitis – 5 (2.73%), exacerbation of chronic bronchitis – 54 (29.51%), COPD – 12 (6.56%), bronchial asthma – 8 (4.37) %), pneumonia – 42 (22.95%), coronavirus disease – 30 (16.39%), idiopathic pulmonary fibrosis – 2 (1.09%), tuberculosis – 6 (3.28%), neoplasms – 3 (1.63%), metastatic lung damage– 1 (0.55%), pneumofibrosis – 18 (9.84%) cases.
 The vast majority of appeals is accounted for the chronic non-specific pulmonary pathology, namely chronic bronchitis, COPD, etc. All pulmonary beds of the region during the COVID-19 pandemic were repurposed to Covid ones, specialized diagnostic and therapeutic care could not be provided to such patients.
 In the second place there are coronavirus disease, pneumonia and post-pneumonic pneumofibrosis. The reasons for such patients’ appeals were their desire to receive a consultation of a narrow specialist, excessive workload of family doctors, and others.
 Isolated cases of tuberculosis and neoplasms of unknown etiology were reported. The latter patients were immediately advised to consult TB and thoracic specialists.
 Conclusions. During the coronavirus infection pandemic, temporary restrictions led to later visits to a pulmonologist in case of exacerbations, which could provoke the development of life-threatening conditions and required hospitalization.
 Patients who applied to the medical center, had the opportunity to get the professional opinion and treatment.
 Important work was done by a pulmonologist to identify important medical-social problems.
 Key-words: outpatient, pulmonologist, COVID-19

Pelvic congestion syndrome: historical aspects and a modern view on the problem (a literature review)

Pelvic congestion syndrome is a relatively recent, but actual and separate nosological form. Pelvic varicocele is a form of varicose disease, which is increasingly regarded as the main cause of chronic pelvic pain in women with various clinical manifestations. A woman with chronic pelvic pain is a difficult patient with combative behavior, who contacts with physicians in various specialties. There are many causes of chronic pelvic pain, but pelvic congestion syndrome has a special place. In recent years, in addition to widespread use of diagnostic radiology, the relevance of this pathology is beyond any doubt. The aim of the study was to summarize and present literature data on the etiology, pathogenesis, clinical manifestations, diagnosis and treatment of pelvic congestion syndrome by analyzing the literature data. Materials and methods. A non-systematic review was conducted using PubMed, Web of Science, Google and Google Scholar databases. The review included free full-text articles published between 1974 and 2021 using key words: pelvic congestion syndrome, pelvic varices, pelvic venous disorders, pelvic varicocele, pelvic venous stasis, chronic pelvic pain, gonadal veins, ovarian veins, vena ovarica, Nutcracker syndrome, May–Thurner syndrome. Conclusions. Pelvic congestion syndrome is still a rarely diagnosed pathology in patients with chronic pelvic pain. Detailed medical history, physical examination as well as maintaining diagnostic algorithm would allow the disease to be diagnosed correctly and timely. The choice of method for surgical intervention is a key point in the treatment of patients with pelvic congestion syndrome, but today there are no criteria for the choice of one, so the problem is far from being resolved and requires further study and research.

Emotional Intelligence Level Higher in Residents Who Took a Gap Year Before Medical School.

IntroductionEmotional intelligence (EI) is the skill of understanding yourself, managing yourself, understanding others, and managing relationships. Studies have begun analyzing the level of EI demonstrated by resident physicians in various specialties. Very few studies have assessed EI levels of residents in multiple specialties within one institution. The purpose of our study was to assess the EI level of all residents at our institution and to determine which variables were associated with higher EI scores.MethodsIn 2018, residents voluntarily participated in the study by completing two online surveys. The first survey was a de-identified survey monkey asking demographic and other training information. The second survey was an online emotional intelligence survey assessing their EI skills, the Emotional Quotient Inventory 2.0 (EQ-i 2.0).ResultsA total of 176 of 486 residents (36.2%) completed the study. There was no significant association between EI level and age, gender, type of medical degree, having an advanced degree, or being in a specific specialty. We found that residents who took time off before matriculating into medical school had higher overall EI scores than those who did not take time off (p = 0.02). Similarly, those who took time off before medical school scored higher in interpersonal skills (p = 0.04), empathy (p = 0.03), decision-making (p = 0.02), and impulse control (p = 0.03).ConclusionResidents who had taken time off before matriculating in medical school had higher overall EI scores and higher scores in the EI components of interpersonal skill, empathy, decision-making, and impulse control.

Characteristics of physicians with dermatology board certification by the American Board of Physician Specialties

To the Editor: The American Board of Medical Specialties (ABMS) and American Osteopathic Association (AOA) are nationally recognized organizations that collaborate with member boards, including the American Board of Dermatology and the American Osteopathic Board of Dermatology, to offer specialty board certification. The American Board of Physician Specialties (ABPS) is another organization offering board certification to physicians in various specialties, including dermatology. Given little data exist, we evaluated the characteristics of physicians with ABPS dermatology board certifications (DBCs).

Textbook of Echocardiography for Intensivists and Emergency Physicians, 2nd ed

More than ever, echocardiography has become an important diagnostic and monitoring tool for physicians in various specialties. Critically ill patients in the intensive care unit (ICU) and emergency room are routinely being evaluated by focused ultrasound examination to assist clinicians with medical decisions. This broader application of echocardiography requires educational resources that focus on relevant information for the clinician. The Textbook of Echocardiography for Intensivists and Emergency Physicians, second edition, provides a broad review of the fundamentals of bedside echocardiography and ultrasound for rapid assessment and diagnosis. The second edition of the popular first textbook is completely revised, with additional illustrations, tables, figures, and 10 entirely new chapters. This edition begins with fundamentals and the standard echocardiographic examination, followed by cardiac/vascular/valvular anatomy and ultrasound. There are several sections dedicated to the application of echocardiography for specific disease states, such as myocardial ischemia, making it easier to browse the text for patient care. Most chapters begin with key points and conclude with suggestions for further reading. Although some chapters reference other textbooks for suggested reading, there are several primary resource papers highlighted. The textbook is divided into 5 parts, with the first section providing a brief overview of ultrasound physics. The second section focuses on patient and probe positioning for transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE). In this section, there is a concise table listing the standard views, landmarks, and angling of the probe required to achieve the views. Recognizing that ICU patients have unique challenges to performing a TTE examination, there is a chapter dedicated to showing how to optimize views in patients who may be difficult to examine. A practical section on “utilizing echocardiographic indexes that are less dependent on image quality” has also been added. Applications of 3-dimensional echocardiography and speckle tracking are also discussed in one chapter; however, the emphasis throughout the textbook is on 2-dimensional echocardiography. Section 3 is dedicated to functional anatomy, with a discussion on diastolic dysfunction, tissue Doppler imaging, and valvular and ventricular function. Within this section, echocardiographic findings and concepts are discussed as they pertain to patient care. Compared with other current texts on echocardiography, Section IV proves to be unique in that each chapter focuses on echocardiography and ultrasound by specific disease states. The supplementary section V covers essential topics for intensive care professionals, such as ultrasound for venous thrombosis, lung and pleura, percutaneous tracheostomy, transcranial Doppler, and regional analgesia. This textbook serves as a useful study guide for critical care physicians interested in competency and certification in echocardiography. It covers specific content for the new Examination of Special Competence in Critical Care Echocardiography, such as dynamic evaluation of hemodynamics, whole body ultrasonography, diagnosis of disease, and placement of central/peripheral lines. The book could be improved by the addition of chapters focusing on extracorporeal membrane oxygenation and ventricular assist devices. Online video content on TTE and ultrasonography techniques would be valuable additions as well. There is some overlap and repetition of concepts and content between chapters; however, that allows the reader to access the chapters independently without referring to previous chapters. Authors throughout the text have a varied style of writing, with different levels of complexity in describing the concepts. The progression of the content throughout the textbook is easy to follow, and in many cases, difficult ideas are simplified. The corresponding illustrations are not necessarily unique; in fact, similar examples can be found in other textbooks, but they are on point and correspond nicely to the content. An electronic version is also available, and proves to be easy to navigate and search. The editors have managed to capture the essence of echocardiography as it applies to the diagnostic care for critically ill patients. This textbook is a great reference for physicians looking to incorporate echocardiography and ultrasound into routine practice for patient management, but it is not comprehensive and not an essential buy. As a practicing cardiac anesthesiologist in academic medicine, I would buy this book as a teaching adjunct for fellows and residents. This textbook helps to bridge the gap between diagnostic echocardiography and pragmatic clinical care. Richa Dhawan, MD, MPHMark Chaney, MDDepartment of Anesthesia and Critical CareUniversity of Chicago HospitalsChicago, Illinois[email protected]

Shifting Liability with Licensing: An Empirical Analysis of Medical Malpractice and Scope-of-Practice Laws

Abstract Medical malpractice liability plays an important role in the healthcare system, as evidenced by the many studies finding that changes in malpractice liability risk induce changes in the delivery and consumption of care. Importantly, the effect of malpractice liability depends on who is held liable, and recent developments in the healthcare system have clouded which providers face the risk of liability in certain situations. In particular, as the United States continues to face a physician shortage, nurse practitioners (NPs) have assumed greater roles within the healthcare system. Their ability to provide care, however, depends on state scope-of-practice (SOP) laws which often mandate that physicians supervise NPs’ practices. These mandatory supervision laws can facilitate the ability of injured patients to use various familiar doctrines, e. g. respondeat superior and negligent supervision, to hold supervising physicians liable based on the acts of NPs. As healthcare becomes increasingly team-based and as NPs deliver more care traditionally provided by physicians, understanding the interaction between malpractice liability and SOP laws will become critical. This Article reports novel empirical evidence on the interplay between malpractice liability and SOP laws. Examining a unique dataset of the malpractice premiums charged to physicians in various specialties, I analyze the extent to which SOP laws requiring that physicians supervise the practices of NPs impact the malpractice liability risk faced by physicians. In general, eliminating physician supervision requirements reduce the malpractice risk faced by physicians (as measured by the premiums paid to insure against this risk) by 7.5 %. In addition to elucidating a previously unappreciated interaction between tort law and state SOP laws, this evidence suggests that the imposition of physician supervision requirements may blunt the role of tort law in deterring the provision of unsafe or low-quality care. If SOP laws facilitate the shifting of liability risk from NPs to physicians through various tort doctrines, then neither NPs nor physicians will be appropriately deterred. Indeed, reaching optimal deterrence for one group would necessarily imply suboptimality for the other. This Article reviews several options to address this problem and recommends removing physician supervision requirements from state SOP laws.

Multistage implantology-orthodontic-prosthetic treatment: A case report

Background and OverviewPatients increasingly expect esthetic and comfortable fixed restorations on implants, are aware how important it is to maintain healthy tooth tissue, and draw attention to the final result of treatment. Case DescriptionIn this case report, the authors describe implantology-orthodontic-prosthetic treatment provided on a patient who reported symptoms of head, back, and neck pain and had an impaired prosthetic plane, lack of space for prosthetic crowns after the introduction of the implants and no good treatment plan, and broken tooth roots of the mandibular anterior teeth. In addition, the patient wanted to correct the shape and color of the rest of her teeth. The authors present the different stages of the implantology-orthodontic-prosthetic treatment and the final result after treatment. The patient was satisfied with the achieved results of the treatment in terms of functionality and esthetics. She felt a significant reduction in pain in the temporal, masseter, and sternocleidomastoid muscles. The clenching of teeth at night decreased, and she began to sleep better. Her well-being improved. Conclusions and Practical ImplicationsBefore the beginning of the treatment, dentists should make an accurate diagnosis and determine if patients qualify for the treatment and the appropriate materials are selected. Achieving the desired functional and esthetic effect often requires cooperation with physicians in various specialties and multistage treatment.

Just fun or a prejudice? \u2013 physician stereotypes in common jokes and their attribution to medical specialties by undergraduate medical students

BackgroundMany jokes exist about stereotypical attributes of physicians in various specialties, which could lead to prejudices against physicians from a specific specialty. It is unknown whether and when medical students are aware of stereotypes about different specialties. The goal of this study was to analyze the degree of stereotypes that exist about medical specialties amongst undergraduate medical students at different stages of their education.MethodsOne hundred fifty-two jokes with different content about attributes of physicians from different specialties were found by an internet search. In total, 36 characteristics of the five specialties of anesthesia, general surgery, internal medicine, orthopedics, and psychiatry were extracted from the jokes and they constituted the basis for the development of an online questionnaire. The questionnaire allowed each characteristic to be assigned to one of the five specialties and was sent to 999 undergraduate medical students from semester 1, 7, and 12 at the Medical Faculty of Hamburg University.ResultsThree hundred eight (30.8%) of the invited students completed the survey. The characteristics of general surgeons and psychiatrists were assigned congruently most frequently (>50%). For internists and orthopedics, there was a significantly more congruent assignment of the characteristics by final year students versus students in their first semester. Male students assigned the characteristics of anesthetists and internists significantly more congruently than female students. The three characteristics “…are a bit slow on the uptake”, “…consider income to be relatively unimportant”, and “...apologize a lot” were not assigned to any of the five specialties by more than 50% of the students.ConclusionsWhile stereotypes about physicians from certain specialties seem to exist commonly, medical educators need to be aware that stereotypes about specialties might develop during undergraduate medical training. In order to support students in their professional identity formation without developing stereotypes, medical educators should receive training. Performing a similar study with physicians in postgraduate training would shed some light on stereotypes and prejudices that might develop at a later stage in medical education.

The determinants of defensive medicine practices in Belgium.

In 2010 the Belgian government introduced a low cost administrative procedure for compensating medical injuries to overcome the major shortcomings of the existing tort system. This paper examines, for the first time, to what extent this reform had an impact on physician specialists' defensive practices and what are the relevant determinants affecting physicians' clinical decision making. Based on a survey of 508 physicians, we find evidence of a relatively modest increase in defensive practices among physicians in various specialties. In general, 14% of the respondents, who were aware of the reform, reported to have increased their overall defensive behaviour, while respectively 18 and 13% altered their assurance and avoidance behaviour. Commonly used physician characteristics, such as claims experience and gender, have a similar impact on defensive medicine as documented in existing literature. Furthermore, the determinant physician's access to an incident reporting system is found to have a significant impact on most of the defensive medicine measures. Health care institutions may therefore play an important role in controlling and reducing physicians' defensive practices.

PHYSICIANS' KNOWLEDGE ABOUT RADIATION DOSE AND POSSIBLE RISKS OF COMMON MEDICAL TESTS: A SURVEY IN IRAN.

Recent data suggest that knowledge of radiation exposures among physicians is inadequate. This study, therefore, aimed to evaluate their knowledge of the radiation doses their patients received and awareness of associated biological risks of radiation exposure. A questionnaire in multiple-choice format consisted of four sections with a total of 10 questions based on the literature review. A total of 136 questionnaires were returned from 69 general practitioners and 67 physicians in various specialties from 10 different hospitals in the capital city of Tehran, Iran. Fifty-four percent of general practitioners and twenty-five percent of specialties declared that they are not aware of biological risks of radiation exposure. Fifty-six percent of physicians did not know the correct definition of absorbed dose. Only 33% of physicians knew the dose exposure of a chest X-ray and only 31% knew the approximate doses of various procedures relative to a chest X-ray. Forty-seven percent of physicians incorrectly distinguished the stochastic effects of radiation from the deterministic effects, and thirty-eight of physicians did not know the organs of the body that are most sensitive to ionizing radiation. Only 23.5% of physicians were aware of the one in 2000 risk of induction of fatal carcinoma from computed tomography of the abdomen. Seventy-nine percent of physicians incorrectly underestimated the contribution of nuclear and radiological tests in exposure of an average person. The mean score of the specialties trended toward being more accurate than general practitioners (4.18±1.28 vs. 3.89±1.46, respectively, from a potential accurate total score of 9), but these differences were not statistically significant. Among specialists, orthopedics had the highest scores. The present study demonstrated the limited knowledge of radiation exposures among general practitioners and specialists and a need to improve their knowledge by means of targeted training and re-education.

Influence of the treatment schedule on the physicians' decisions to refer bone metastases patients for palliative radiotherapy: a questionnaire survey of physicians in various specialties.

We investigated whether the treatment schedule influences physicians' decisions to refer their patients for radiotherapy. We presented a questionnaire to 104 physicians in various specialties at three hospitals. It included three hypothetical patients with uncomplicated painful bone metastasis: patients with an expected life span of one year (case 1), 6 months (case 2), and 2 months (case 3). The physicians were asked whether they would refer their patients for radiotherapy when a radiation oncologist presented three different treatment schedules: a short (8 Gy/1 fraction/1 day)-, a medium (20 Gy/5 fractions/1 week)-, and a long (30 Gy/10 fractions/2 weeks) schedule. We used Cochran's Q-test to compare the percentage of physicians across the three schedules and a mixed-effect logistic model to identify predictors of the selection of only the one-day schedule. Of the 104 physicians, 68 (65%) responded. Of these, 37 (54%), 27 (40%), and 26 (38%) chose to refer patients for radiotherapy when the short-, medium-, and long schedules, respectively, were proposed in case 1 (p = 0.14). These numbers were 44 (65%), 29 (43%), and 15 (22%) for case 2 (p < 0.001), and 59 (87%), 12 (18%), and 1 (1%) for case 3 (p < 0.001). Hypothetical patient and the physicians' years of practice and perspective regarding side effects were independently predictive of the selection of only the one-day schedule. In conclusion, the treatment schedule influenced the physicians' decisions to refer patients for radiotherapy.

Factors associated with the choice of general medicine as a career among Japanese medical students

BackgroundIn Japan, there is a shortage of young physicians in various specialties; the present situation of general medicine or family medicine (GM/FM) in particular is risky. The factors influencing the career choice of Japanese medical students are poorly understood. This study aims to identify factors related to choosing GM/FM as a career.MethodsThe study was designed as a cross-sectional survey. Students at one medical school in Japan filled out a questionnaire. Students were asked to state their intended medical specialty, and they rated the importance of specific individual and occupational aspects using a 4-point likert scale. Factor analysis was performed on the variables. Reliability of the factor scores was estimated using Cronbach‘s alpha coefficients; biserial correlations between the factors and career choices were calculated. Furthermore, multiple linear regression analysis was performed using career choice (GM/FM vs. others) as the criterion variable and the factors plus demographic characteristics as confounding variables.ResultsFactor analysis produced six factors that explained future career plans. Medical students in this study had a positive and realistic idea about GM/FM, but only 18.8% of them chose GM/FM first as a career. The significant variables associated with choosing GM/FM first as a career were: ‘Admission from hometown’ (β=0.189, P=0.001), ‘Student preparing for the entrance exam’ (β=0.172; P=0.001), ‘Intent for rural practice’ (β=0.123, P=0.016), and ‘Work–life balance’ (β=0.126, P=0.013). While significant variables that were negatively associated with choosing GM/FM were ‘Presence of medical relatives’ (β=−0.107, P=0.037) and ‘Scientific orientation’ (β=−0.125, P=0.013).ConclusionsStrategies have been suggested, such as recruiting medical students with significant variables that were associated with choosing GM/FM first as a career. By engaging students early in their choice of career, we may be able to increase enthusiasm for this specialty.

ABCDE steps to prevent heart disease in breast cancer survivors.

Breast cancer is the most common invasive cancer diagnosed in women. Of every 8 women, 1 woman is diagnosed with breast cancer in her lifetime. In 2013, more than 230 000 women were diagnosed with breast cancer in the United States alone, resulting in nearly 40 000 deaths. Breast cancer can also occur in men, although the incidence is much lower, with a total of 2240 men diagnosed in 2013 (accounting for less than 1% of all breast cancers). Over the past 2 decades, death resulting from breast cancer has been declining each year. This decrease in mortality is due in part to improvements in cancer treatment. These treatments have come about as a result of collaborations among physicians in various specialties. These physicians include medical oncologists (who give systemic treatments like chemotherapy and hormonal therapy), surgeons (who perform surgery such as mastectomy and lumpectomy), and radiation oncologists (who treat patients with radiation therapy). Radiation therapy, in particular, has increasingly become an important part of management of most patients with breast cancer. Radiation therapy has been demonstrated not only to prevent recurrence of cancer in the breast or chest wall area but also to improve long-term survival in women. In addition, radiation therapy allows women to undergo a less radical form of surgery in which the breast tissue is conserved, thus improving body image for breast cancer survivors without compromising survival. As a result of this progress in treatment and improved detection of early breast cancer, in 2012, there were nearly 3 million breast cancer survivors in the United States alone, a number that will increase in the coming years. Women who survive breast cancer may face many health challenges, but the number 1 cause of death in breast cancer survivors (and, in fact, all women) remains heart disease. Unfortunately, although systemic …

Will the ACA Increase Access to Psychiatrists

It is hoped that the Affordable Care Act will make it easier to get healthcare as more people obtain medical insurance. Using data from a national telephone survey of a representative sample of U.S. physicians who provide outpatient care, researchers analyzed changes from 2005–2006 to 2009–2010 in the percentages of physicians in various specialties who accept insurance (mean of annual respondents, …

Periorbital (eyelid) dermatides

Physicians in various specialties—and dermatologists in particular—frequently encounter various forms of inflammation of the eyelids and of the anterior surface of the eye. Distinguishing the cause of itchy, painful, red, edematous eyelids is often difficult. Because the uppermost layer of the eyelids is part of the skin that wraps the entire body, almost every skin disease in the textbook can affect the periorbital area as well. In this contribution, we focused on the most common such disorders that require special consideration, as a result of their special appearance, their challenging diagnosis, or the nature of their treatment. We reviewed the key features of several common dermatides that affect the eyelids, such as atopic dermatitis, seborrheic dermatitis, allergic contact dermatitis, airborne contact dermatitis, rosacea, psoriasis, and others. We focused on the special clinical features, causes, and treatments specific to the delicate skin of the eyelids. Because structures of the eye itself (ie, the conjunctiva, the cornea, the lens, and the retina) may be involved in some of the discussed periorbital skin diseases, we found it useful to add a brief summary of the eyelid complications of those diseases. We then briefly reviewed some acute sight-threatening and even life-threatening infections of the eyelids, although dermatologists are not likely to be the primary care physicians responsible for treating them.

Long-term systemic glucocorticoid therapy: Patients’ representations, prescribers’ perceptions, and treatment adherence

IntroductionGlucocorticoids have been used since 1948 for their anti-inflammatory and structural effects in various inflammatory diseases. The optimal use of glucocorticoids remains controversial. Patients may have a number of concerns about the effects of glucocorticoids. Many factors can adversely affect treatment adherence. ObjectivesTo evaluate the main adverse effects reported by patients and physicians, and to assess representations associated with glucocorticoid therapy and the underlying disease, via measurements of treatment adherence, with the goal of optimizing treatment strategies and improving patient information. MethodsFrom December 2011 to May 2012, we conducted two surveys in 125 patients receiving long-term glucocorticoid therapy and followed-up at the rheumatology department of the teaching hospital in Casablanca, Morocco, and in 85 hospital physicians in various specialties, respectively. ResultsMean glucocorticoid therapy duration was 6years, mean maximal prescribed dosage was 44.87mg/d, and 50.4% of the patients had inflammatory joint disease. Adverse neuropsychiatric effects were reported by 70 out of 125 (56%) patients. Weight gain was the adverse effect deemed most bothersome by the physicians, who significantly underestimated the occurrence of neuropsychiatric adverse effects (27% vs 56%, P=0.034). Adherence was poor in 80 out of 125 (64%) patients, and 22 out of 125 (18%) patients reported episodes of treatment discontinuation. ConclusionPrescribers underestimate the frequency of neuropsychiatric adverse effects of long-term systemic glucocorticoid therapy. Regular follow-up visits during treatment, with collection of systemic adverse effects might improve treatment adherence.

A Gift From a Patient

When I first met Mr. Rozenkier, nothing about him struck me as being in any way distinctive. He was a Jewish man in his late 70s, a veteran of the Korean War. His wife was always with him at each clinic visit. They appeared to be very close, very devoted to each other, amidst some occasional bickering between them. They reminded me of other older couples from Brooklyn I had met in my years living and working in that populous and ethnically rich and diverse borough. Despite his age, Mr. Rozenkier possessed an animated and spirited manner. He spoke with what seemed to be a sense of urgency, wanting to tell his story, even if it was merely to relate how he had been feeling recently and what symptoms he had been experiencing. He sometimes would focus persistently on some fact, such as about one of his medications or what one of his other physicians had told him or on one of his symptoms. I would try to explain to him and to answer his questions as best I could, hoping that would satisfy him, but he often kept returning to the same point. I would do my best to hide my frustration and my awareness that I had limited time and that other patients were waiting for me as I would repeat and then repeat again what I had just told him. He was always polite and appreciative of whatever small amount of advice I managed to impart, and there was a pleasantness to him that was easy to see. He was a small man, short in stature, and probably did not weigh much more than he had as a young man. He did not betray in his energetic persona and affable manner that there was a special weight he carried with him. I became Mr. Rozenkier's physician after I had replaced a colleague who had moved away. The first time I met him, he had come to see me at the veterans hospital to get a medicine for his prostate cancer. At that time, he was being cared for by several physicians in various specialties in private practice. I saw in one of my colleague's earlier notes that, along with his other medical conditions, he had been sterilized in a concentration camp. This, of course, caught my attention. It is not the sort of medical history a physician encounters commonly in most practices. I am certain I said nothing to him about it in our first meeting, being shocked by my contact with someone who had survived one of the most horrific periods and series of events in human history. I felt it would be a violation of his most painfully intimate feelings and memories for me to inquire, but of course I was curious. I did little more than make a referral to the oncologists so that he could get his medication and told him to return when he needed to. I felt I had nothing else to offer him because he already had several physicians attending to his various illnesses. Mr. Rozenkier came to me again a few months later. He usually saw me to get the medications prescribed to him by his private physicians. Sometimes, he would get confused or forget exactly what the other physicians had done, so it would entail another visit to get things cleared up. In the course of these visits it came out somehow, and I do not recall now how or when it first happened, about his experience with the Nazis. Mr. Rozenkier talked freely of his past, despite the horrors he had seen. He wanted to share the experiences; he wanted other people to know. Once the subject was broached the first time, on subsequent visits invariably I would hear more, even without my alluding to it. He was born in Wroclawek, Poland in 1926. When the Nazis invaded Poland in September 1939, Mr. Rozenkier was 13 years old. German soldiers came to his home to arrest his father. When Mr. Rozenkier's sister dared to protest, she was shot and killed. Both of his parents, four sisters, and a brother died at the hands of the Nazis. Mr. Rozenkier was sent, along with the town's other Jews, to a ghetto outside the town. He managed to escape and spent several months sleeping in a cemetery. Eventually he was arrested and sent to a camp. …

Ocular Allergy

The eye is probably the most common site for the development of allergic inflammatory disorders, because it has no mechanical barrier to prevent the impact of allergens such as pollen on its surface. Physicians in various specialties and subspecialties who provide some form of primary care frequently encounter various forms of inflammation of the anterior surface of the eye that present as "red eye." However, the eye is rarely the only target for an immediate allergic-type response. Typically, many patients have other combinations of allergic disorders, such as rhinoconjunctivitis, rhinosinusitis, asthma, urticaria, or eczema. Even so, ocular signs and symptoms can frequently be the most prominent features of the entire allergic response for which a patient visits his or her physician. An improved differential diagnosis provides the basis for improved treatment algorithms. Over the past 20 years, we have witnessed an astonishing growth in therapeutic advances, ranging essentially from derivatives of simple aspirin to various newly developed biologic immunomodulatory agents, utilizing implantable drug-delivery devices that exceed the safety and efficacy of those available for other organ systems, and resorting to advanced surgical techniques for the correction of sight-threatening, disease-related complications. Overall, with the expanding knowledge base, the intricacy of ocular inflammation appears to be becoming ever more manageable and, with the team approach between the primary care physician, the ophthalmologist, and the clinical allergist/immunologist, the new "immuno-ophthalmology" approach improves patient outcomes.

Stroke, Disability, and Unconscious Bias: Interrelationships and Overdetermination in Medical Decisions

Many factors influence what and how we communicate with patients after stroke. As physicians, we have a responsibility to examine our medical decisions and prognostication regarding each stroke patient. We must understand how many factors come into play in decisions regarding care, including perspectives that reflect the specific training of physicians in various specialties. How the physician responds to the patient with a stroke is highly individual. The more familiar the physician is with stroke recovery and the more time he or she has for individualized and less automatic approaches, the less likely decisions will be reflexive, based on bias. By examining our unconscious biases, we can provide individualized care that gives patients more latitude to create their own stories of recovery.