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In January 1997, after a lengthy, careful, and difficult process, an ad hoc group, chaired by Dr. Alan R. Fleischman, a Senior Vice President of the New York Academy of Medicine (NYAM), with representation from clinical medicine, biomedical ethics, law, and the clergy, developed a position on the difficult and contentious issue of physician-assisted suicide. After substantial debate, the Board of Trustees of NYAM authorized a letter from the President of the Academy to the Justices of the United States Supreme Court and to the attorneys on both sides of the cases about to be argued before the Court. The text of that letter, which summarizes the views of the New York Academy of Medicine, is reproduced here.
This paper considers policy and programmatic consequences of shifting measurement of prenatal care utilization from the Kessner Index (KI) to the Adequacy of Prenatal Care Utilization Index (APNCUI). In gauging the adequacy of prenatal care utilization, the KI considers the timing of prenatal care initiation and the number of prenatal visits. The APNCUI also considers both timing of initiation and number of visits, but the approach taken to conceptualizing and measuring these two aspects of prenatal care utilization is more refined. We used birth certificates to calculate the KI and the APNGUI for 217,183 New York City (NYC) births in 1991-1992. We used cross-tabulations and bivariate odds ratios to compare the classifications resulting from the respective indexes. The APNCUI detected some important dimensions of the problem of inadequate prenatal care use that are not evident when using the KI. The proportion of births with inadequate use increases from 18% with the KI to 35% with the APNGUI. Groups of women at elevated risk for inadequate use are the same, but the KI understates significantly the risk for Hispanic women, teens, women who are less well educated, and those on WIC and Medicaid. The APNGUI yields a fuller picture of the degree to which some urban women are at risk for inadequate prenatal care use. Use of the APNGUI in quality assurance, monitoring, and research is recommended.
The diagnosis and classification of primary bone tumors remains as much a challenge today as it has for the last 80 plus years. Although pathology is invariably equated with the image of a diagnostic microscope, the vast majority of diagnoses are made grossly with the unaided eye, as are the tissue specimens selected for microscopic "confirmation." Radiologic studies, particularly plain radiographs, remain the gold standard in gross pathologic diagnosis of the skeleton. Today, confirmation and final classification continue as the pathologist's domain, but perhaps not for long, considering the evolving ancillary imaging techniques and progressive sophistication of magnetic resonance (MR) imaging. The bone tumor cases collected and compiled by Ernest Codman, M.D. during the second through fourth decades of this century formed the basis of the first tumor registry. The Codman Bone Sarcoma Registry demonstrated among other things the importance of radiographic/pathologic correlation, underscoring the reliability of a bone tumor's location, margin (host bone/tumor interface), periosteal reaction, and matrix patterns as an accurate guide to classification and likely future biologic behavior. "A General Theory of Bone Tumors," written by Lent C. Johnson nearly 50 years ago and published in the Bulletin of The New York Academy of Medicine (February 1953, second series, vol. 29, no. 2, pp. 164-171), provided a conceptual cellular approach to the understanding bone tumor dynamics reinforcing radiologic/pathologic correlation as a reliable diagnostic tool. At the time of Dr. Lent C. Johnson's death (1910-1998), he was literally working on an updated version of his original article, the latter of which is being reprinted as the core of this illustrated revision. Our continued experience with bone tumors over the past five decades has only served to validate, on a daily basis, the fundamental principles outlined in Johnson's original article. In like fashion, it is important to keep in mind that terminology and nomenclature has also evolved since 1953, despite a continued inability to achieve complete consensus.
In 1974, Patrick Romanell (1912-2002) published a paper in the Bulletin of the New York Academy of Medicine taking William Osler (1849-1919) to task for dismissing philosophy as a distinguishing feature of the nature of medicine. Osler had expressed this thought in the Silliman Lectures given at Yale in 1913 on the Evolution of Modern Medicine. That the nature of medicine is underpinned by an understanding of the nature of man requires that the pedagogy and practice of medicine incorporate not only the empirical science that is the basis for clinical practice, but also the logical and metaphysical concepts of the nature of man. These concepts are informed by the humanities that include history, literature, and the arts. Despite Romanell's critique of Osler's statement, Romanell ultimately corroborates other statements made by Osler in the lecture series, substantiating Osler's deep appreciation for the nature of man and a philosophy of medicine that deserves emulation.
Pedestrian injuries to children represent a major urban health problem in the United States. Thousands of children each year are struck by moving motor vehicles; such collisions result in numerous hospitalizations and deaths. At particular risk are young school-age children between the ages of 5 and 9 years. Using a survey methodology, we collected data regarding the method by which children in an urban setting travel to and from school, in addition to the number of streets they cross in a typical school day. This information was compared with data from police records on street intersection locations of pedestrian collisions. There is a wide variation in the number of streets children cross in 1 day, calculated as the number of streets crossed in the entire day, not only those crossed to and from school. Children whose parents own a car and home cross an average of 3.7 streets per day, whereas children whose parents do not own both a car and home cross an average of 5.4 streets per day; this difference is highly significant (P < 0.0001). The largest differences in traffic exposure are between families reporting car- and-home ownership (x = 3.70 streets) versus those who do not own both a car and home (x = 5.39 streets) (Mann-Whitney = -5.5, P < 0.0001). There is a significant correlation between the proportion of children driven home from school and the rate of pedestrian injury in different regions of Baltimore. In areas where children are driven home, rates of pedestrian injury are significantly lower, whereas in areas where children walk home, rates of pedestrian injury are high (r = -0.79, P < 0.01). This study underscores the importance of adapting the child's environment to prevent injury. Interventions that alter the nature of the hazard are indicated. Changing the environment may ultimately prove more useful than attempting to change children's behavior.
This article discusses how the paradigm of Cartesian mind-body dualism has shaped the cultural and institutional life of modern science and medicine. John Dewey (1859-1952) made this case in a speech to the New York Academy of Medicine in 1927, "Preoccupation with the Disconnected," an expanded version of which was published as "Body and Mind" in the Bulletin of the New York Academy of Medicine in January 1928. From the perspective of Dewey's broader philosophy, the most urgent aspect of mind-body dualism is of a practical, not theoretical, nature. Medicine at present has an opportunity in both education and practice to reconcile internally disparate trends that result from mind-body dualism and to renew its mission.
The purpose of this study is to present data on the distribution and etiology of nonfatal injuries resulting in hospital discharges in New York City (NYC). Records of all NYC residents discharged for injuries from acute stay hospitals 1990-1992 were tabulated. Injuries from surgical and medical procedures, adverse effects of drugs in therapeutic use, and late effects of injury were excluded. The results indicate that there was a marked geographic variation in rates: higher rates of assaults, self-inflicted injuries, burns, unintentional injuries from firearms, and injuries to bicyclists in disadvantaged neighborhoods. The data show that injuries in NYC have distinctive features that should form the basis for targeted prevention activities.
Empire is a smaller and more financially stable company that no longer has an externally imposed social mission. The board and management of Empire have decided to convert to a for-profit company, to compete in the marketplace. In light of this decision, they also decided to turn over the company's charitable value to a new foundation. Because Empire's board has chosen not to maintain a social mission, the Panel strongly supports its proposal to turn over the full value of the charitable asset. This will allow the asset to be used for purposes that are in keeping with Empire's original social mission. Exactly how this asset should be valued, what form it should take, when it should be turned over, who should control the assets, and what activities it should support are just a few of the many important issues that must be resolved during the next few months. Empire will not and should not remain stagnant during the next few months. Given the rapidly evolving health-care market, Empire's board and management must continue to pursue a market strategy that strengthens the company. However, given the factors discussed earlier--hospital deregulation, the increasingly competitive managed-care market, and other pressures in the health-care environment--it is clear that the road ahead for Empire will not be a smooth one and that the company's financial resurgence is no guarantee of continued stability. Much hard work remains. I am confident that Empire's board and its management will continue to do its part, that the Panel will continue to do likewise.
The objective of this survey was to demonstrate whether a primary care track internal medicine residency program emphasizing community-based health care of the urban sick poor trains physicians who will continue to practice in general internal medicine or similar fields. Thirty-five primary care residents (100% of graduates) who trained from 1976 through 1993 in the Adult Primary Care Track of the Internal Medicine Residency Program at St. Vincent's Hospital, New York were used as participants.
Public health is paying increasing attention to elusive urban populations such as the homeless, street drug users, and illegal immigrants. Yet, valid data on the health of these populations remain scarce; longitudinal research, in particular, has been hampered by poor follow-up rates. This paper reports on the follow-up methods used in two randomized clinical trials among one such population, namely, homeless men with mental illness. Each of the two trials achieved virtually complete follow-up over 18 months. The authors describe the ethnographic approach to follow-up used in these trials and elaborate its application to four components of the follow-up: training interviewers, tracking participants, administering the research office, and conducting assessments. The ethnographic follow-up method is adaptable to other studies and other settings, and may provide a replicable model for achieving high follow-up rates in urban epidemiologic studies.
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