ication inobstetrics andgynecology (writtenand oralexams) andthen certifyin reproductiveedncrinology andinfertility (writtenoral andthesis exams).
Reproductive endocrinologistsoften belongto specificmedical societies,such asASRM orESHRE.
Itis avariant ofassisted reproductivetechnology.
Agentsthat enhanceovarian activitycan beclassified aseither Gonadotropinreleasing hormone,Estrogen antagonistsor Gonadotropins.
Either Gonadotropinreleasing hormone(GnRH) itselfor anyof itsagonist maybe used.
GnRH releasesgonadotropins fromthe hypothalamusin thebody.
GnRHagonists includesi.e.
Lupron.Fertility medicationinhibiting theeffects ofestrogen includesClomiphene citrateand Aromataseinhibitors.
Clomiphenecitrate isa SERM.
It inhibitsthe negativefeedback ofestrogen andtherefore stimulatesovulation.
Althoughprimarily abreast cancertreatment, aromataseinhibitors canalso workas fertilitymedication, probablyby amechanism similarto clomiphenecitrate.
Gonadotropinsare thehormones inthe bodythat normallystimulate thegonads (testesand ovaries).
For medication,they canbe extractedfrom urineor bygenetic modification.
Menotropins areurinary gonadotropins,i.e.
Recombinantgonadotropins aregonadotropins createdby insertingthe DNAcoding itinto bacteriae.
The bacterialDNA isthen calledRecombinant DNA.
Examples ofrecombinant FSHare Follistimand GonalF, whileLuveris isa recombinantLH.
Humanchorionic gonadotropin(hCG) isnormally producedduring pregnancy.
However, itcan alsoreplace LHas afertility medication.
Estrogen antagonistsand gonadotropinsmay stimulatemultiple folliclesand otherovarian hormonesleading tomultiple birthand possibleovarian hyperstimulationsyndrome.
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.
The specialtystrives totreat orprevent conditionsto whichaircrews areparticularly susceptible,applies medicalknowledge tothe humanfactors inaviation andis thusa criticalcomponent ofaviation safety.
A militarypractitioner ofaviation medicinemay becalled aflight surgeonand acivilian practitioneris anaviation medicalexaminer.
Broadlydefined, thissubdiscipline endeavorsto discoverand preventvarious adversephysiological responsesto hostilebiologic andphysical stressesencountered inthe aerospaceenvironment.
Problemsrange fromlife supportmeasures forastronauts torecognizing anear blockin aninfant travelingon anairliner withelevated cabinpressure altitude.
Aeromedical certificationof pilots,aircrew andpatients isalso partof AviationMedicine.
Afinal subdivisionis theAeroMedical TransportationSpecially.
Atmosphericphysics potentiallyaffect allair travelersregardless ofthe aircraft.
Pressure andhumidity alsodecline, andaircrew areexposed toradiation, vibrationand accelerationforces...the latteris alsoknown as"g" forces.
Aircraft lifesupport systemssuch asoxygen, heatand pressurizationare thefirst lineof defenseagainst mostof thehostile aerospaceenvironment.
Everyfactor contributingto asafe flighthas afailure rate.
The crewof anaircraft isno different.
Aviation medicineaims tokeep thisrate inthe humansinvolved equalto orbelow aspecified risklevel.
Thisstandard ofrisk isalso appliedto airframe,avionics andsystems associatedwith flights.
AreoMedical examinationsaim atscreening forelevation inrisk ofsudden incapacitation,such asa tendencytowards myocardialinfarction (heartattacks), epilepsyor thepresence ofmetabolic conditionsdiabetes, etcwhich maybe leadto hazardouscondition ataltitude.
Thegoal ofthe AeroMedicalExamination isto protectthe lifeand healthof pilotsand passengersby makingreasonable medicalassurance thatan individualis fitto fly.
Other screenedconditions suchas colourblindness canprevent aperson fromflying becauseof aninability toperform afunction thatis necessary.
In thiscase totell greenfrom red.
These specializedmedical examsconsist ofphysical examinationsperformed byan AviationMedical Examineror amilitary FlightSurgeon, doctorstrained toscreen potentialaircrew foridentifiable medicalconditions thatcould leadto problemswhile performingairborne duties.
Anything inthe systemcan failin twoways.
Passivefailures occurwhen somethingstops working.
Examples wouldbe anartificial horizonstops workingand aflag showsthat ithas failedor apilot wholoses consciousness.
Active failuresoccur whenthe itemcontinues tofunction butin anincorrect manner.
Examples wouldbe atrim motorwhich keptgoing afterthe switchwas releasedor apilot whodevelops psychoticthinking andbehaves inresponse tothat.
Category:Aviation medicinePhysicalmedicine andrehabilitation (PMR),or physiatry,is abranch ofmedicine dealingwith functionalrestoration ofa personaffected byphysical disability.
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.
Itincludes theeffects onthe bodyof pressureon gases,the diagnosisand treatmentof conditionscaused bymarine hazardsand howrelationships ofa diver'sfitness todive affecta diver'ssafety.
Hyperbaricmedicine isa corollaryfield associatedwith diving,since recompressionin ahyperbaric chamberis usedas atreatment fortwo ofthe mostsignificant divingrelated illnesses,decompression illnessand arterialgas embolism.
Most divingaccidents orillnesses arerelated tothe effectof depth/pressureon gasesin thebody; examplesare decompressionsickness, nitrogennarcosis, oxygentoxicity, arterialgas embolismand CO2retention.
Dysbaricosteonecrosis isan exampleof theeffects onthe bonesand jointsof bubblesfrom decreasedpressure ina nitrogensaturated diver.
Diving medicalpersonnel needto beable torecognize andtreat accidentsfrom largeand smallpredators andpoisonous creatures,appropriately diagnoseand treatmarine infectionsand illnessesfrom pollutionas wellas diversemaladies suchas seasickness, traveler'sdiarrhea andmalaria.
Thediving medicalphysician shouldbe ableto identify,treat andadvise diversabout illnessesand conditionsthat wouldcause themto beat increasedrisk fora divingaccident.
Somereasons whya personshould notbe allowedto diveare asfollows: Disordersthat leadto alteredconsciousness: conditionsthat producereduced awarenessor sedationfrom medication,drugs, marijuanaor alcohol;fainting, heartproblems andseizure activity.
Severe asthmais anexample.
Disordersthat maylead toerratic andirresponsible behavior:included herewould beimmaturity, psychiatricdisorders, divingwhile underthe influenceof medications,drugs andalcohol orany medicaldisorder thatresults incognitive defects.
Now, itis ahighly specializedtreatment modalitythat hasbeen foundto beeffective inthe treatmentof manyconditions wherethe administrationof oxygenunder pressurehas beenfound tobe beneficial.
Studies haveshown itto bequite effectivein some13 indicationsapproved bythe Underseaand HyperbaricMedical Society.
Also knownas ecologicalmedicine, environmentalmedicine, ormedical geology.
The environmentalcauses ofhealth problemsare complex,global, andpoorly understood.
Conservation medicinepractitioners formmultidisciplinary teamsto tacklethese issues.
Teams mayinvolve physiciansand veterinariansworking alongsideresearchers andclinicians fromdiverse disciplines,including microbiologists,pathologists, landscapeanalysts, marinebiologists, toxicologists,epidemiologists, climatebiologists, anthropologists,economists, andpolitical scientists.
Clinical areasinclude HIV,Lyme disease,Severe AcuteRespiratory Syndrome(SARS), avianinfluenza, WestNile virus,Nipah virus,and otheremerging infectiousdiseases.
Forexample, burninghuge areasof forestto makeway forfarmland isnormally seenas anenvironmental andeconomic concern.
That actionmay displacea wildanimal species,which comesinto contactwith andinfects adomesticated animalspecies, creatinga veterinaryproblem.
Thedomesticated animalthen entersthe humanfood chainand infectspeople, anda newhealth threatemerges.
Conventionalapproaches toenvironmental protectionand animaland humanhealth onlyas anexception examinethese connections,whereas inconservation medicine,such relationshipsare fundamental.
Seemingly commonsense scenarioslike theselie atthe heartof conservationmedicine.
Whentied toactual cases(like SARSor HIV/AIDS),this holisticoutlook seemslikely toresonate morepowerfully withthe publicthan themore abstractexplanations ofenvironmental andhealth issuesthat arecurrently common.
The theoryof evolutionsuggests thatall livingbeings arethe resultof aprocess knownas evolutionby naturalselection.
Thisprocess occurswhenever geneticallyinfluenced variationamong apopulation affectsreproductive success.
For instance,a geneticmutation thatcauses greatervulnerability todisease willdecrease infrequency comparedto itsalternative allelethat causesgreater resistanceto disease.
It isthought thatevolution bynatural selectionproduced thefunctional designobserved inliving beings,known asadaptations, andtherefore sicknessand diseasecan beexplained througha costv.
Understandingevolutionary designhelps medicicalresearchers explainphenomena like:infections, injury,intoxication, geneticdiseases, aging,allergy, problemsduring childbirth,cancer andmental disorders.
Other examplesinclude humanpopulations thathave certaindisease susceptibilitiesthat aroseas comprisesallowing theirsurvival.
Theseinclude, sicklecell anemiaprotecting againstmalaria andhemochromatosis protectingagainst thebubonic plague.
Among theresearchers inthis fieldwho havereceived recentrecognition are:Rainer H.
Straub, PaulW. Ewald,Randolph M.
Nesse andGeorge C.Williams.
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.
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.
Thismay bein relationto acrime orto acivil action.
The useof theterm "forensics"in placeof "forensicscience" couldbe consideredincorrect; theterm "forensic"is effectivelya synonymfor "legal"or "relatedto courts"(from Latin,it means"before theforum").
However,it isnow soclosely associatedwith thescientific fieldthat manydictionaries includethe meaningthat equatesthe word"forensics" with"forensic science".
During thetime ofthe Romans,a criminalcharge meantpresenting thecase beforea groupof publicindividuals.
Boththe personaccused ofthe crimeand theaccuser wouldgive speechesbased ontheir sideof thestory.
Theindividual withthe bestargumentation anddelivery woulddetermine theoutcome ofthe case.
In otherwords, theperson withthe bestforensic skillswould win.
In thiscase, byexamining theprinciples ofwater displacement,Archimedes wasable toprove thata crownwas notcompletely madeof gold(as itwas fraudulentlyclaimed) byits densityand buoyancy.
The earliestaccount offingerprint useto establishidentity wasduring the7th century.
According toSoleiman, anArabic merchant,a debtor'sfingerprints wereaffixed toa bill,which wouldthen begiven tothe lender.
This billwas legallyrecognized asproof ofthe validityof thedebt.
Inone ofthe accounts,the caseof aperson murderedwith asickle wassolved bya deathinvestigator whoinstructed everyoneto bringhis sickleto onelocation.
Flies,attracted bythe smellof blood,eventually gatheredon asingle sickle.
In lightof this,the murdererconfessed.
Thebook alsooffered adviceon howto distinguishbetween adrowning (waterin thelungs) andstrangulation (brokenneck cartilage).
In sixteenthcentury Europe,medical practitionersin armyand universitysettings beganto gatherinformation oncause andmanner ofdeath.
TwoItalian surgeons,Fortunato Fidelisand PaoloZacchia, laidthe foundationof modernpathology bystudying changeswhich occurredin thestructure ofthe bodyas thebosh croob.
In thelate 1700s,writings onthese topicsbegan toappear.
In1775, Swedishchemist CarlWilhelm Scheeledevised away ofdetecting arsenousoxide, simplearsenic, incorpses, althoughonly inlarge quantities.
This investigationwas expanded,in 1806,by Germanchemist ValentinRoss, wholearned todetect thepoison inthe wallsof avictim's stomach,and byEnglish chemistJames Marsh,who usedchemical processesto confirmarsenic asthe causeof deathin an1836 murdertrial.
Twoearly examplesof Englishforensic sciencein individuallegal proceedingsdemonstrate theincreasing useof logicand procedurein criminalinvestigations.
In1784, inLancaster, England,John Tomswas triedand convictedfor murderingEdward Culshawwith apistol.
Whenthe deadbody ofCulshaw wasexamined, apistol wad(crushed paperused tosecure powderand ballsin themuzzle) foundin hishead woundmatched perfectlywith atorn newspaperfound inToms' pocket.
In Warwick,England, in1816, afarm labourerwas triedand convictedof themurder ofa youngmaidservant.
Shehad beendrowned ina shallowpool andbore themarks ofviolent assault.
The policefound footprintsand animpression fromcorduroy clothwith asewn patchin thedamp earthnear thepool.
Therewere alsoscattered grainsof wheatand chaff.
The breechesof afarm labourerwho hadbeen threshingwheat nearbywere examinedand correspondedexactly tothe impressionin theearth nearthe pool.
Conan Doylecredited theinspiration forHolmes onhis teacherat themedical schoolof theUniversity ofEdinburgh, thegifted surgeonand forensicdetective JosephBell.
Decadeslater, thecomic stripDick Tracyalso featureda detectiveusing aconsiderable numberof forensicmethods, althoughsometimes themethods weremore fancifulthan actuallypossible.
Defenseattorney PerryMason occasionallyused forensictechniques, bothin thenovels andtelevision series.
Popular televisionseries focusingon crimedetection, includingLaw Order,CSI: CrimeScene Investigation,NCIS, SilentWitness, andWaking theDead, depictglamorized versionsof theactivities of21st Centuryforensic scientists.
These relatedTV showshave changedindividuals' expectationsof forensicscience, aninfluence termedthe "CSIeffect".
Inthe videogames PhoenixWright: AceAttorney andCondemned, forensicscience isused invarious cases.
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.
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.
If amore appropriateWikiProject orportal exists,please adjustthis templateaccordingly.
Sportsmedicine orsport medicineis aninterdisciplinary subspecialtyof medicinethat dealswith thetreatment andpreventive careof athletes,both amateurand professional.
The sportsmedicine "team"includes specialtyphysicians andsurgeons, athletictrainers, physicaltherapists, coaches,other personnel,and, ofcourse, theathlete.
Sportsmedicine hasalways beendifficult todefine becauseit isnot asingle specialty,but anarea thatinvolves healthcare professionals,researchers andeducators froma widevariety ofdisciplines.
Itsfunction isnot onlycurative andrehabilitative, butespecially preventive.
There ismuch moreto sportsmedicine thanjust musculoskeletaldiagnosis andtreatment.
Consequently,sports medicinecan encompassan arrayof specialties,including cardiology,pulmonology, orthopaedicsurgery, exercisephysiology, biomechanics,and traumatology.
For example,heat, coldor altitudeduring trainingand competitioncan alterperformance ormay evenbe lifethreatening.
Thefemale triadof disorderedeating, menstrualdisturbances, andbone densityproblems, andthe problemsof pregnantor agingathletes demandknowledge frommany diversefields.
Furtherunique problemsare associatedwith internationalsporting events,such asthe effectsof traveland acclimatization,and theattempt tobalance anathlete's participationwith hisor herhealth.
Muchof thisdraws onnew fieldsof study,in whichextensive clinicaland basicscience researchis burgeoning.
Doctors wishingto specializestart witha primaryresidency programin familypractice, internalmedicine, emergencymedicine, pediatrics,or physicalmedicine andrehabilitation, andthen generallyobtain oneto twoyears ofadditional trainingthrough accreditedfellowship (subspecialty)programs insports medicine.
Physicians whoare boardcertified infamily practice,internal medicine,emergency medicine,or pediatricsare theneligible totake asubspecialty qualificationexamination insports medicine.
Additional forums,which addto theexpertise ofa SportsMedicine Specialist,include continuingeducation insports medicine,and membershipand participationin sportsmedicine societies.
Sports medicinehas beena recognizedsubspecialty ofthe AmericanBoard ofMedical Specialtiessince 1989.
Currently thereare morethan 70sports medicinefellowships andapproximately onethousand certifiedSports MedicineSpecialists inthe UnitedStates.
However,it wasnot untilin 1928at theOlympics inSt.
Moritz,when acommittee cametogether toplan theFirst InternationalCongress ofSports Medicine,that theterm itselfwas coined.
In the5th century,however, thecare ofathletes wasprimarily theresponsibility ofspecialists.
Thefirst useof therapeuticexercise iscredited toHerodicus, whois thoughtto havebeen oneof Hippocrates'teachers.
Untilthe 2ndcentury AD,when thefirst "teamdoctor", Galen,was appointedto thegladiators, thephysician onlybecame involvedif therewas aninjury.
Whatis clear,however, isthat fromits beginnings,sports medicinehas beenmultidisciplinary, andcharged withthe obligationnot onlyto treatinjuries butalso tohelp preventthem, andto instructand prepareathletes forcompetition.
Thislink withphysical educationhas remainedin placethroughout itsevolution.
Whilewatching hisdaughter Louiseswim atthe 1968Summer Olympicsin MexicoCity, Dr.
J. C.Kennedy, adoctor basedin London,Ontario, Canadaconcluded fora varietyof reasonsthat competingathletic teamsfrom Canadashould beaccompanied bya qualifiedand wellorganized medicalteam.
Thisbelief ledhim tobe afounding fatherof theCanadian Academyof SportMedicine.
Oneof theprimary mandatesof thissociety wasto provideexpert careto Canadianathletes, andin 1972Dr.
Kennedywas appointedchief medicalofficer ofthe first"true" medicalteam, atthe 1972Summer Olympicsin Munich,Germany.
Othercountries soonfollowed thisexample andassigned medicalteams totheir ownOlympic athletes.
Dr. Kennedy'svision wasnot limitedto travelingCanadian athletes.
At atime whensport medicineclinics wereunheard ofin Canada,he convincedhis university'sadministration toconvert aformer wrestlingroom intoThe AthleticInjuries Clinicthat officiallyopened in1972.
Thefirst Nautilusequipment inCanada waspurchased fromfunds raisedto outfitthis clinic.
Dr. Kennedyinspired andfostered aninterest inresearch insport medicine,for whichthe Universityof WesternOntario (UWO)and London,Ontario havebecome known.
Many believethat sportsmedicine willmake itsmost significantfuture contributionsin thearea ofprevention.
Accordingto Dr.David Janda,orthopedic surgeonand directorof TheInstitute forPreventative Medicinein Michigan,prevention issports medicine'sfinal frontier.
The riskof injurywill neverbe entirelyeliminated, butmodifications intraining techniques,equipment, sportsvenues andrules, basedon outcomesof meaningfulresearch haveshown thatit canbe lowered.
One rapidlyadvancing fieldwith greatpotential forapplications inprevention isthe studyof thebody's neuromuscularadaptations.
Astudy ofspecific preseasonneuromuscular trainingfor soccerplayers demonstrateda significantdecrease inthe incidenceof anteriorcruciate ligamenttears.
Inanother investigationby Jandaet al.,serious injuriesin recreationalsoftball werereduced by98% whenbreakaway baseswere used.
Participation inall formsof physicalactivity atall levelsis ahuge partof everydaylife, andits benefitsto healthand qualityof lifeare clear.
Sports medicine'scontinued growthand developmentmay helpthe benefitsof physicalactivity tobe fullyand safelyrealized.
DO)is anacademic degreeoffered inthe UnitedStates.
Holdersof theD.O. degreeare knownas osteopathicphysicians, whileholders ofthe similar,but morecommon M.D.
Osteopathic medicineis adiagnostic andtherapeutic systembased onthe premisethat theprimary roleof thephysician isto facilitatethe body'sinherent abilityto healitself.
D.O.'smay befound withinany medicalspecialty buta majorityof themwork withinprimary caremedical fields:internal medicine,pediatrics, obstetrics,and familypractice.
AlthoughU. S.osteopathic medicalphysicians currentlymay obtainlicensure in47 countries,osteopathic curriculain countriesother thanthe UnitedStates differs.
D.O.s outsidethe U.S.
Inaddition tothe Hippocraticoath, Osteopathicmedical studentstake anoath tomaintain anduphold the"core principles"of osteopathicmedical philosophy.
Revised in1953, andagain in2002, thecore principlesare: Thereare differentopinions onthe significanceof theseprinciples.
Upongraduation, osteopathicmedical physiciansmay optto pursueresidency trainingprograms.
Osteopathicphysicians mayapply toresidency programsaccredited byeither theAOA orthe AccreditationCouncil forGraduate MedicalEducation (ACGME).
Osteopathy wasfounded byAndrew TaylorStill, M.D.
Early inthe twentiethcentury, theAmerican osteopathicprofession adoptedthe useof medicineand surgery.
As biomedicalscience developed,osteopathic medicinegradually incorporatedall itsproven theoriesand practices.
D.O.'s havebeen admittedto fullactive membershipin theAmerican MedicalAssociation since1969.
CaliforniaD.O.s wereoffered theM.D.
TheCalifornia MedicalAssociation mayhave beenattempting toeliminate osteopathiccompetition bya processof amalgamationby convertingthousands ofD.O.s toM.D.s.
TheCollege ofOsteopathic Physiciansand Surgeonsbecame theUniversity ofCalifornia, IrvineSchool ofMedicine.
However,the decisionproved tobe controversial.
In 1974,after protestand lobbyingby influentialand prominentD.O.s, theCalifornia SupremeCourt ruledthat licensingof D.O.sin thatstate mustbe resumed.
This decisionby theCalifornia MedicalAssociation inthe 1960sto grantD.O.
M.D.license wasone oftwo turningpoints forD.O.s intheir earlystruggle forparity; theother beingthe U.S.
Army's decisionto allowD.O.s toenter themilitary asphysicians.
Thesetwo turningpoints providedthe osteopathiccommunity withthe stampof equivalencythey desired.
Today, exceptfor astronger primarycare emphasisin mostosteopathic medicalschools andadditional educationin musculoskeletaldiagnosis andtreatment, thetraining andscope ofosteopathic medicinepracticed byD.O.'
United Statesis identicalto thatof theirallopathic counterparts,those whohold theM.D.
Whilethere areapproximately 55,000D.O.s practicingwithin theUnited States,this numberrepresents only6% ofall practicingphysicians.
D.O.'smay obtainlicensure inany ofthe fiftystates andpractice inall medicalspecialties including,but notlimited to,family medicine,internal medicine,emergency medicine,dermatology, surgery,and radiology.
The D.O.degree isthe legaland professionalequivalent ofthe M.D.
Within theosteopathic medicalcurriculum, manipulativetreatment istaught asan adjunctivemeasure toother biomedicalinterventions fora numberof disordersand diseases.
However, a2001 surveyof osteopathicphysicians foundthat morethan 50%of therespondents usedOMT onless than5% oftheir patients.
However, thenumber ofD.O.s whoreport consistentlyprescribing andperforming manipulativetreatment hasbeen fallingsteadily.
Onesurvey, publishedin theJournal ofContinuing MedicalEducation, foundthat amajority ofphysicians (81%)and patients(76%) feltthat manualmanipulation (MM)was safe,and overhalf (56%of physiciansand 59%of patients)felt thatmanipulation shouldbe availablein theprimary caresetting.
Allopathicphysicians."
The followingtable liststhe practicerights ofU.S.
D.O.sin selectedcountries.
Somequestion thetherapeutic utilityof osteopathicmanipulative treatmentmodalities.
AHarvard medicalschool reviewedwebsite sitecites numerousstudies demonstratingthat thereare someailments forwhich thebenefit ofmanipulative therapyhas "firmlyestablished" scientificsupport.
Globalizationfacilitates thespread ofdisease andincreases thenumber oftravelers whowill beexposed toa differenthealth environment.
The fieldof travelmedicine encompassesa widevariety ofdisciplines includingepidemiology, infectiousdisease, publichealth, tropicalmedicine, highaltitude physiology,travel relatedobstetrics, psychiatry,occupational medicine,military andmigration medicine,and environmentalhealth.
Specialitineraries andactivities includecruise shiptravel, diving,mass gatherings(e.g.
Hajj),and wilderness/remoteregions travel.
Basically, thetravel medicinecan divideinto 4main topics:the prevention(vaccination andtravel advice),the assistancemedicine (dealingwith repatriationand medicaltreatment oftravelers), thewilderness medicine(e.g.
TheCDC sitedelineates therisk areasand providesinformation aboutvaccination andpreventive steps.
Meningococcal meningitisis endemicin thetropical meningococcalbelt ofAfrica.
Vaccinationis requiredfor pilgrimsgoing toMecca.
Detailedinformation isavailable onthe CDCsite.
Inaddition chemoprophylaxisis startedbefore thetravel, duringthe timeof potentialexposure, andfor 4weeks (chloroquine,doxycycline, ormefloquine) or7 days(atovaquone/proguanil orprimaquine) afterleaving therisk area.
Based oncircumstances itshould includealso malariaprophylaxis, condoms,and medicationto combattraveler's diarrhea.
In addition,a basicfirst aidkit canbe ofuse.
MD,from theLatin MedicinaeDoctor meaning"Teacher ofMedicine,") isan academicdegree formedical doctors.
The M.B.or Bachelorof Medicinewas thefirst medicaldegrees tobe grantedin theUnited Statesand Canada.
The firstmedical schoolsthat grantedthe M.B.
UPenn, Harvard,Toronto, Maryland,and Columbia.
This degreeis theoldest andmost traditionaldegree heldby physiciansand surgeons.
North AmericanMedical schoolshowever startedgranting theM.D.
M.B.Sometimes, holdersof theM.D.
Studentsearning anM.D.
Associationof AmericanMedical Collegesand theLiaison Committeeon MedicalEducation, bothindependent boardsof theAmerican MedicalAssociation, theAMA.
Admissionsto medicalschools inthe UnitedStates iscompetitive, withless thanone halfof theapproximately 35,000applicants matriculatingto amedical school.
Before graduatingfrom amedical schooland achievingthe degreeof MedicalDoctor, studentshave topass theUnited StatesMedical LicensingExamination (USMLE)Step 1and boththe ClinicalKnowledge andClinical Skillsparts ofStep 2.
The M.D.degree istypically earnedin fouryears.
Most,in orderto receiveBoard Eligibleor BoardAccredited statusin aspecialty ofmedicine suchas generalsurgery orinternal medicine,then undergoadditional specializedtraining inthe formof aresidency.
Thosewho wishto furtherspecialize inareas suchas cardiologyor interventionalradiology thencomplete afellowship.
Dependingupon thephysician's chosenfield, residenciesand fellowshipsinvolve anadditional threeto eightyears oftraining afterobtaining theM.D.
Thiscan belengthened withadditional researchyears, whichcan lastone, two,or moreyears.
InCanada, theM.D. isthe basicmedical degreerequired topractice medicine.
At McGillUniversity inMontreal, M.D.C.M.
Medicinae Doctoremet ChirurgiaeMagistrum) degreesare awarded.
Though theM.D. degreeis aprofessional doctorate,and nota researchdoctorate, manyholders ofthe M.D.
Some M.D.schoose aresearch careerand receivefunding fromthe NIHas wellas othersources suchas theHoward HughesMedical Institute.
US, beingput afterthe nameas atitle; however,it isalso usedon itsown ininformal writing,as anabbreviation for"medical doctor."
Itis oneof themost recognizeddegrees inthe generalpublic andthe media,and sometimesincorporated intothe titlesof televisionshows suchas HouseMD, orDoogie Howser,M.D..
TheMBBS orMB ChBdegrees arealso "allopathic"medical qualificationsequivalent tothe MDdegree.
Inall 50of theUnited States,and someCanadian provinces,the Doctorof Osteopathicmedicine (D.O.)degree isvirtually identicalto thetraining requirementsand practicerights ofthe M.D.
In theEuropean Union,the M.D.
An M.D.typically involveseither anumber ofpublications ora thesis.
An M.D.typically involveseither anumber ofpublications ora thesis.
Given goodprogress, andby addinga furtheryear, studentscan convertto aPh.D.
Alternately,the M.D.may bea degreegranted tomedical graduatesof thesame institutionafter abody ofpreviously publishedresearch issubmitted.
Thismay beconsidered equivalentto aPh.D.
Someuniversities willgrant anM.D.
M.A.(in thecase ofOxford orCambridge), anMSc ora Ph.D.
M.B., Ch.B.),earned withtypically fourto sixyears ofstudies andtraining atuniversity.
Thereis alsoa similaradvanced professionaldegree, theMaster ofSurgery (usuallyCh.M.
M.S.,but M.Ch.in Ireland,Wales andOxford andM.Chir.
Cambridge),which isobtained afteran M.B.,Ch.B.
Whilefrequently associatedwith alternativemedicine, itis alsoincreasingly usedin mainstreammedical practiceas partof abroad viewof patientcare.
Holismas ahealth concepthas existedfor agesoutside ofacademic circles,but onlyrelatively recentlyhas themodern medicalestablishment begunto integrateit intothe mainstreamhealth caresystem.
Inthe UnitedStates, thefirst NationalConference onHolistic Healthwas heldwith theUniversity ofCalifornia, SanDiego Schoolof Medicinein June1975.
Holismrefers tothe ideathat anentity isgreater thanthe sumof itsparts.
Inthe caseof health,the entityin questionis thehuman body.
The goalis awellness thatencompasses theentire person,rather thanjust thelack ofphysical painor disease.
Holistic healthis notitself amethod oftreatment, butinstead anapproach tohow treatmentshould beapplied.
Traditionalmedical philosophyapproached patientcare assimply attemptingto correctphysical symptoms,using standardizedmethods suchas theprescription ofdrugs orthe undertakingof surgery,while thepatient isonly passivelyinvolved.
Incontrast, holisticapproaches tohealth arewide andvaried.
Whenthe conceptsof holistichealth areput intopractice withinthe healthcare system,the approachto therapytakes ona newdimension; traditionalmedical careis expandedto encompassa broadspectrum oftherapies coordinatedto meetthe totalityof aparticular individual.
The focusis nolonger onjust thedisease, butthe wholeperson.
Therole ofthe patientalso changesin learninghow choices,actions andattitudes affectthe presentcondition, andhow onecan bean activeparticipant inthe healingprocess.
Someholistic healthadvocates subscribeto alternativemedical practiceswhich conventionalmedicine doesnot support.
Some examplesinclude: nurses,laboratory scientists,pharmacists, physiotherapists,speech therapists,occupational therapists,dietitians andbioengineers.
Thescope andsciences underpinninghuman medicineoverlap manyother fields.
Dentistry andpsychology, whileseparate disciplinesfrom medicine,are sometimesalso consideredmedical fields.
Physician assistants,nurse practitionersand midwivestreat patientsand prescribemedication inmany legaljurisdictions.
Veterinarymedicine appliessimilar techniquesto thecare ofanimals.
Medicaldoctors havemany specializationsand subspecializationswhich arelisted below.
There arevariations fromcountry tocountry regardingwhich specialitiescertain subspecialitiesare in.
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.
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.
Since 1879,the NLMhas publishedthe IndexMedicus, amonthly guideto articlesin nearlyfive thousandselected journals.
The lastissue ofIndex Medicuswas printedin December2004, butthis informationis offeredin thefreely accessiblePubMed amongstthe morethan fifteenmillion MEDLINEjournal articlereferences andabstracts goingback tothe 1960sand 1.5million referencesgoing backto the1950s.
TheNLM alsoruns theNational Centerfor BiotechnologyInformation (NCBI)which housesbiological databasesfreely accessibleover theInternet throughthe Entrezsearch engineand PubMed.
These resourcesare accessiblewithout chargeon theWeb.
TheExtramural ProgramsDivision providesgrants tosupport researchin medicalinformation scienceand tosupport planningand developmentof computerand communicationssystems inmedical institutions.
Research andpublications inthe historyof medicineand thelife sciencesare alsosupported.
Theprecursor ofthe NLM,established in1836, wasthe Libraryof theSurgeon General'sOffice, apart ofthe officeof theU.S.
ArmySurgeon General.The ArmedForces Instituteof Pathologyand itsMedical Museumwere foundedin 1862as theArmy MedicalMuseum.
Throughouttheir historythe ArmyMedical Libraryand theArmy MedicalMuseum oftenshared quarters.
From 1866to 1887,they werehoused inFord's Theatreafter productionthere wasstopped afterthe assassinationof PresidentAbraham Lincoln.
In 1956,the Librarycollection wastransferred fromthe controlof theU.S.
Departmentof Defenseto thePublic HealthService ofthe Departmentof Health,Education andWelfare andrenamed theNational Libraryof Medicine.
The Librarymoved toits currentquarters inBethesda, Maryland,on thecampus ofthe NationalInstitutes ofHealth in1962.
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.
Studentsof thehistory ofmedicine knowhim forhis attemptsto introducesystematic experimentationand quantificationinto thestudy ofphysiology".
AlternativeMedical Systems2.
BiologicallyBased Therapy4.
Chiropracticwas foundedin 1895by D.
Eventually, theseled tothe scientificinvestigation ofchiropractic, andan antitrustsuit againstthe AmericanMedical Association.
Chiropractic treatmentsvary dependingon thepatient's conditionand thetype ofapproach takenby theparticular chiropractor.
They commonlyinclude spinaladjustments, althoughother interventionsmay beused aswell.
Differencesare basedon thephilosophy foradjusting, claimsmade aboutthe effectsof thoseadjustments, andvarious additionaltreatments providedalong withthe adjustment.
Chiropractic wasfounded in1895 byDaniel DavidPalmer, basedon hisassertion that95% ofall healthproblems couldbe preventedor treatedusing adjustmentsof thespine (spinaladjustments), and5% byadjustments ofother joints,to correctwhat hetermed vertebralsubluxations.
He,and laterhis sonB.J.
Palmer,proposed thatsubluxations weremisaligned vertebraewhich causednerve compressionthat interferedwith thetransmission ofwhat henamed InnateIntelligence.
Thisinterference interruptedthe properflow ofInnate Intelligencefrom "above,down, inside,and out"(ADIO) tothe organto whichit traveled.
Palmer relatedthis conceptas similarto applyingpressure toa hosethat suppliesa garden;relieve thepressure andthe gardenflourishes.
Amodern chiropractormay specializein spinalmanipulations only,or mayuse awide rangeof methodsintended toaddress anarray ofneuromusculoskeletal andgeneral healthissues.
Examplesinclude massage,strength training,dry needling(similar toacupuncture), functionalelectrical stimulation,traction, andnutritional recommendations.
Some chiropractorsspecialize inchiropractic sportsmedicine, whichincludes manipulationof theextremities, andexercises toincrease spinalstrength.
Chiropractorsmay alsouse othercomplementary alternativemethods aspart ofa holistictreatment approach.
Chiropractors generallycannot writemedical prescriptions.
Given thepossibility ofadverse effects,this reviewdoes notsuggest thatspinal manipulationis arecommendable treatment."
Therehave beencontrolled trialswhich giveweight toChiropractors claimthat vertebralalignment, byinfluencing thenervous system,can haveeffects onother systemsof thebody.
Heheld thata malpositionof spinalbones, whichprotect thespinal cordand nerveroots, interferedwith thetransmission ofnerve impulses.
Because halfof thenervous systemis sensoryand theother halfmotor (control),he postulatedthat livingthings hadan Innateintelligence, akind of"spiritual energy"or lifeforce thatreceived thesensory informationfrom thevarious partsof thebody andmade adecision asto whatthe motornerves shouldconvey.
Thevitalistic conceptsimplied anintelligent governingentity thatwas readilyperceived asspiritual constructsby manyboth insideand outsidethe profession.
It remainsuntestable andunverifiable andhas anunacceptably highpenalty/benefit ratiofor thechiropractic profession.
The chiropracticconcept ofInnate Intelligenceis ananachronistic holdoverfrom atime wheninsufficient scientificunderstanding existedto explainhuman physiologicalprocesses.
Itis clearlyreligious innature andmust beconsidered harmfulto normalscientific activity."
MeridelI. GattermanDC, educatorand writerobserved: Debateabout theneed toremove theconcept ofsubluxation fromthe chiropracticparadigm hasbeen ongoingsince themid 1960s.
While straightshold firmlyto theterm andits vitalisticconstruct, reformerssuggest thatthe mechanisticmodel willallow chiropracticto betterintegrate intomainstream medicinewithout makingclaims inherentin theterm.
AnthonyRosner PhD,director ofeducation andresearch atthe Foundationfor ChiropracticEducation andResearch (FCER)considered subluxationand theconcept ofOccam's razor.
He suggests"there isno obviousreason todiscard theconcept ofsubluxation, whileat thesame timemaintaining thatit isnot arigid entity,but ratheran importantmodel andconcept; awork inprogress thatundoubtedly willundergo extensivemodification asour conceptsof lightor psychoanalysishave evolvedover halfa century."
Despitethe term'svitalistic roots,chiropractic todaymay stilluse theterm InnateIntelligence; however,it hastaken ona lessmetaphysical meaning.
Reed PhillipsD.C., Ph.D.,although chiropractichas muchin commonwith otherhealth professions,its philosophicalapproach distinguishesit frommodern medicine.
By contrast,the naturopathicapproach considersthat lowered"host resistance"is necessaryfor diseaseto occur,so theappropriate solutionis todirect treatmentto strengthenthe host,regardless ofthe environment.
The Chiropracticapproach tohealthcare stressesthe importanceof prevention.
Department ofLabor's OccupationalOutlook Handbooksaid: MostDCs arein privatepractice orwork insmall groups,employing chiropracticassistants asoffice staffand toperform therapeuticactivities.
Theymay alsoemploy massageand physiotherapistsas adjunctsto chiropracticcare.
SamuelWeed suggestedcombining thewords cheirosand praktikos(meaning "doneby hand")to describePalmer's treatmentmethod, creatingthe term"chiropractic."
In 1896,DD addeda schoolto hismagnetic healinginfirmary, andbegan toteach othershis method.
It wouldbecome knownas PalmerSchool ofChiropractic (nowPalmer Collegeof Chiropractic),located inDavenport, Iowa.
In September1899, amedical doctorin Davenport,IA, namedHeinrich Mattheystarted acampaign againstdrugless healersin Iowa.
DD Palmer,whose schoolhad justgraduated its7th student,insisted thathis techniquesdid notneed thesame coursesor licenseas medicaldoctors, ashis graduatesdid notprescribe drugsor evaluateblood orurine.
However,in 1906,Palmer wasconvicted forpracticing medicinewithout alicense.
Hechose toturn overhis interestsin thePSC tohis son,BJ andwife, Mabel.
Morikubo wasfreed usingthe defensethat chiropracticphilosophy wasdifferent fromosteopathic philosophy.
The victoryreshaped thedevelopment ofthe chiropracticprofession, whichthen marketeditself asa science,an artand aphilosophy, andBJ Palmerbecame the"Philosopher ofChiropractic".
MedicalExamining Boardsworked tokeep allhealthcare practicesunder theirlegal control,but aninternal struggleamong DCson howto structurethe lawssignificantly complicatedthe process.
Initially, theUCA, ledby BJPalmer andarmed withhis philosophy,opposed statelicensure altogether.
Mixers campaignedto altereducation standardstoward thoseof medicalschools andconsistent withthe tenetsof themedical professionwhile Palmerresisted anyalteration instandards awayfrom hisconceptualization ofthe chiropracticprofession.
In1975, theNational Institutesof Healthbrought chiropractors,osteopaths, medicaldoctors andPh.D.
DeBoer,then aninstructor inbasic scienceat PalmerCollege inIowa, revealedthe powerof ascholarly journal(JMPT) toempower facultyat thechiropractic schools.
DeBoer's opinionpiece demonstratedthe faculty'sauthority tochallenge thestatus quo,to publiclyaddress relevant,albeit sensitive,issues relatedto research,training andskepticism atchiropractic colleges,and toproduce "culturalchange" withinthe chiropracticschools soas toincrease researchand professionalstandards.
Principle3 ofthe AMAPrinciples ofMedical Ethicsstated: AChicago chiropractor,Chester A.
The courtrecognized thatthe AMAhad toshow itsconcern forpatients, butwas notpersuaded thatthis couldnot havebeen achievedin amanner lessrestrictive ofcompetition, forinstance bypublic educationcampaigns.
Shesaid no"well designed,controlled, scientificstudy" hadbeen done,and concluded"I declineto pronouncechiropractic validor invalidon anecdotalevidence, eventhough "theanecdotal evidencein therecord favorschiropractors."
Source: PhillipsRB, MootzRD.
Contemporarychiropractic philosophy.
In HaldemanS (ed).Principles andPractice ofChiropractic, 2ndEd.
Norwalk,CT: AppletonLange, 1992.
Chart reprintedfrom KeatingJ (1995),D.D.
Theyconclude thatchiropractic hasboth materialisticqualities thatlend themselvesto scientificinvestigation andvitalistic qualitiesthat donot (Table1).
Withrelatively littlefederal funding,academic researchin chiropractichas onlyrecently becomeestablished inthe USA.
However, ofthese, onlyJMPT isincluded inIndex Medicus.
These aredesigned sothat neitherthe patientnor thedoctor knowswhether theyare usingthe actualtreatment ora placebo(or "sham")treatment.
However,chiropractic treatmentinvolves amanipulation; "sham"procedures cannotbe easilydevised forthis, andeven ifthe patientis unawarewhether thetreatment isa realor shamprocedure, thedoctor cannotbe unaware.
Similarly, itis oftendifficult todevise asham procedurefor surgicalprocedures, butit isnot impossible.
It isalso aproblem inevaluating treatments;even whenthere areobjective outcomemeasures, theplacebo effectcan bevery substantial.
Thus, DCshave historicallyrelied mostlyon theirown clinicalexperience andthe sharedexperience oftheir colleagues,as reportedin casestudies, todirect theirtreatment methods.
In this,they arenot differentto thepractice inmuch ofconventional medicine.
Sociologist LeslieBiggs interviewed600 CanadianDCs in1997: while86% feltthat chiropracticmethods neededto bevalidated, 74%did notbelieve thatcontrolled clinicaltrials werethe bestway toevaluate chiropractic.
There iswide agreementthat, whereapplicable, anevidence basedmedicine frameworkshould beused toassess healthoutcomes, andthat systematicreviews withstrict protocolsare importantfor objectivelyevaluating treatments.
Where evidencefrom suchreviews islacking, thisdoes notnecessarily meanthat thetreatment isineffective, onlythat thecase fora benefitof treatmentmay nothave beenrigorously established.
A 2005editorial inJMPT, "TheCochrane Collaboration:is itrelevant fordoctors ofchiropractic?"
Cochrane collaborationwould bea wayfor chiropracticto gaingreater acceptancewithin medicine.
The collaborationhas 11,500contributors frommore than90 countriesorganized in50 reviewgroups.
Forchiropractic, relevantreview groupsinclude theBack Group;the Bone,Joint, andMuscle TraumaGroup; theMusculoskeletal Group;and theNeuromuscular DiseaseGroup.
Theeditorial statesthat, forexample, "achiropractor mayprovide conservativecare supportedby aCochrane reviewto apatient withcarpal tunnelsyndrome.
Ifthe patient'ssymptoms becomeprogressive, thedoctor mayconsider referringthe patientfor surgeryusing arecent Cochranereview thatexamined newsurgical techniquescompared withtraditional opensurgery..."
The CochraneCollaboration didnot findenough evidenceto supportor refutethe claimthat manualtherapy (including,but notlimited to,chiropractic) isbeneficial forasthma.
Bandolierfound limitedevidence thatspinal manipulativetherapy (including,but notlimited to,chiropractic) mightreduce thefrequency andintensity ofmigraine attacks,but theevidence thatspinal manipulationis betterthan amitriptyline,or addsto theeffects ofamitriptyline, isinsubstantial forthe treatmentof migraine,although "spinalmanipulative therapymight beworth tryingfor somepatients withmigraine ortension headaches."
Thebeneficial effectof chiropracticon painwas particularlyclear."
A 1994study bythe U.S.
Agency forHealth CarePolicy andResearch (AHCPR)and theU.S.
Departmentof Healthand HumanServices endorsesspinal manipulationfor acutelow backpain inadults inits ClinicalPractice Guideline.
The firstsignificant recognitionof theappropriateness ofspinal manipulationfor lowback painwas performedby theRAND Corporation.
Some chiropractorsclaimed theseresults asproof ofchiropractic hypotheses,but RAND'sstudies wereabout spinalmanipulation, notchiropractic specifically,and dealtwith appropriateness,which isa measureof netbenefit andharms; theefficacy ofchiropractic andother treatmentswere notexplicitly compared.
For instance,many DCsclaim totreat infantilecolic.
Thereport statesthat "Theliterature clearlyand consistentlyshows thatthe majorsavings fromchiropractic managementcome fromfewer andlower costsof auxiliaryservices, fewerhospitalizations, anda highlysignificant reductionin chronicproblems, aswell asin levelsand durationof disability."
In1998, astudy of10,652 Floridaworkers' compensationcases wasconducted bySteve Wolk.
The studycompared benefitsand thecost ofcare fromMDs, DCsand DOs,focusing onindividuals whohad misseddays ofwork andwho hadreceived compensationfor theirinjuries.
Washingtonwere threetimes aslikely toreport satisfactionwith carefrom DCsas theywere withcare fromother physicians.
The WorldHealth Organizationstates thatwhen "employedskilfully andappropriately, chiropracticcare issafe andeffective forthe preventionand managementof anumber ofhealth problems."
Accordingto Harrison's,these includevertebrobasilar accidents(VBA), strokes,spinal discherniation, vertebralfracture, andcauda equinasyndrome.
A1996 Danishchiropractic studyconfirmed therisk ofstroke tobe low,and determinedthat thegreatest riskis withmanipulation ofthe firsttwo vertebraeof thecervical spine,particularly passiverotation ofthe neck,known asthe "mastercervical" or"rotary break."
Estimatesof seriouscomplications rangefrom 1in 400,000manipulations to0 in5 millionmanipulations.
Whileindividual chiropractorsmay sharethe viewpointsof oneor moreorganizations, mostchiropractors arenot membersof anynational organization.
Traditional Straightchiropractors arethe oldestmovement.
Theyadhere tothe philosophicalprinciples setforth byDD andBJ Palmer;that vertebralsubluxation leadsto interferenceof thehuman nervoussystem andis aprimary underlyingrisk factorfor almostany disease.
Straights adhereto thechiropractic diagnosisof subluxations,and viewthe medicaldiagnosis ofpatient complaints(which theyconsider tobe the"secondary effects"of subluxations)to beunnecessary fortreatment.
Instead,patients aretypically screenedfor "redflags" ofserious disease,and treatedbased ona practitioner'spreferred chiropractictechnique.
Thisstance againstmedical diagnosinghas beena sourceof contentionbetween mixersand straights,because accreditationstandards mandatethat differentialdiagnosis betaught inall chiropracticprograms sothat patientcare issafe andrelevant totheir complaints.
Additionally, severalstate chiropracticlicensing boardsmandate thatpatient complaintsbe diagnosedbefore receivingcare.
Traditionalstraights tendto sharethe viewpointsfound inthe InternationalChiropractors Association(ICA), aswell asthe Federationof StraightChiropractors andOrganizations (FSCO)and theWorld ChiropracticAlliance (WCA).
Mixer chiropractorsare anearly offshootof thestraight movement.
They eventuallysplit fromthe traditionalstraight groupand formedvarious otherchiropractic schoolsincluding theNational Collegeof Chiropractic.
Their treatmentsmay includenaturopathic remedies,physical therapydevices, orother Complementaryand alternativemedicine (CAM)methods.
Whilestill subluxationbased, mixersalso treatproblems associatedwith boththe spineand extremities,including musculoskeletalissues suchas painand decreasedrange ofmotion.
Mixersdescribe vertebralsubluxations asa formof jointdysfunction orosteoarthritis.
Diagnosisis madeafter rulingout otherknown disordersand notinggeneral signsof mechanicaldysfunction inthe spine.
This groupis differentiatedfrom traditionalstraights mainlyby theclaims made.
While traditionalstraights claimedthat chiropracticadjustments area plausibletreatment fora widerange ofdiseases, objectivestraights onlyfocus onthe correctionof chiropracticvertebral subluxations.
Like traditionalstraights, objectivestraights typicallydo notdiagnose patientcomplaints.
Theirguiding principlesare summedup as:"We donot wantto diagnoseand treatdiseases, evendiseases ofthe spine."
Wedo notwant chiropracticto bepracticed asan alternativeto medicine."
Theyalso don'trefer toother professionals,but doencourage theirpatients "tosee amedical physicianif theyindicate thatthey wantto betreated forthe symptomsthey areexperiencing orif theywould likea medicaldiagnosis todetermine thecause oftheir symptoms."
Mostobjective straightslimit treatmentto spinaladjustments.
Objectivestraights tendto sharethe viewpointsfound inthe Foundationfor theAdvancement ofChiropractic Education(F.A.C.E.).
Reformchiropractors area minoritygroup whoadvocate theuse ofpalpation andmanipulation toidentify andtreat osteoarthritis,painful joints,and othermusculoskeletal problems.
They donot subscribeto thePalmer philosophyof InnateIntelligence andvertebral subluxations,do notbelieve thatspinal jointdysfunction causesorganic orsystemic disease,and tendnot touse alternativemedicine methods.
They preferto alignthemselves morewith medicaland osteopathicphysicians intheir viewsof diseasecauses, processesand responsesto manipulativetherapy.
Thisprocedure isused inthe hospitalsetting forpatients whosecondition isunresponsive toother formsof treatment.
Today, thereare 17accredited chiropracticcolleges inthe USAand twoin Canada,and anestimated 70,000chiropractors inthe USA,5000 inCanada, 2500in Australia,2,381 inthe UK,and smallernumbers inabout 50other countries.
In theUSA andCanada, licensedindividuals whopractice chiropracticare commonlyreferred toas chiropractors,doctors ofchiropractic (DC),or chiropracticphysicians.
Biomedicineis usuallynot concernedwith thepractice ofmedicine asmuch asit iswith thetheory, knowledgeand researchof it;its resultsrender possiblenew drugsand adeeper, molecularunderstanding ofthe mechanismsunderlying decease,and thuslays thefoundation ofall medicalapplication, diagnosisand treatment.
Category: MedicinestubsDoctor ofMedicine (M.D.
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.
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.
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.
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.
Manyprocedures innuclear medicineuse pharmaceuticalsthat havebeen labeledwith radionuclides(radiopharmaceuticals).
Indiagnosis, radioactivesubstances areadministered topatients andthe radiationemitted ismeasured.
Themajority ofthese diagnostictests involvethe formationof animage usinga gammacamera.
Imagingmay alsobe referredto asradionuclide imagingor nuclearscintigraphy.
Otherdiagnostic testsuse probesto acquiremeasurements fromparts ofthe body,or countersfor themeasurement ofsamples takenfrom thepatient.
Intherapy, radionuclidesare administeredto treatdisease orprovide palliativepain relief.
Nuclear medicinediffers frommost otherimaging modalitiesin thatthe testsprimarily showthe physiologicalfunction ofthe systembeing investigatedas opposedto theanatomy.
Insome centres,the nuclearmedicine imagescan besuperimposed onimages frommodalities suchas CTor MRIto highlightwhich partof thebody theradiopharmaceutical isconcentrated in.
Nuclear medicinediagnostic testsare usuallyprovided bya dedicateddepartment withina hospitaland mayinclude facilitiesfor thepreparation ofradiopharmaceuticals.
Thespecific nameof adepartment canvary fromhospital tohospital, withthe mostcommon namesbeing thenuclear medicinedepartment andthe radioisotopedepartment.
Diagnostictests innuclear medicineexploit theway thatthe bodyhandles substancesdifferently whenthere isdisease orpathology present.
The radionuclideintroduced intothe bodyis oftenchemically boundto acomplex thatacts characteristicallywithin thebody; thisis commonlyknown asa tracer.
In thepresence ofdisease, atracer willoften bedistributed aroundthe bodyand/or processeddifferently.
Anyincreased physiologicalfunction, suchas dueto afracture inthe bone,will usuallymean increasedconcentration ofthe tracer.
Many tracercomplexes havebeen developedin orderto imageor treatmany differentorgans, glands,and physiologicalprocesses.
Somespecialist studiesrequire thelabeling ofa patient'sown cellswith aradionuclide (leukocytescintigraphy andred cellscintigraphy).
Molybdenum/Technetiumor Strontium/Rubidium.
The mostcommonly usedliquid radionuclidesare: Themost commonlyused gaseous/aerosolradionuclides are:The radiationemitted fromthe radionuclideinside thebody isusually detectedusing agamma camera.
That is,the pixelappears brighteras morecounts aredetected inthat position.
Activity closerto thecamera facewill producemore informationin theimage thanactivity locateddeeper inthe body,however, becauseof attenuationby tissuesbetween theradionuclide eventand thecamera face.
Tomographic imagingapplies similarprinciples, takingmultiple planarimages fromdifferent anglesand thenrefining themusing aprocess knownas filteredback projectiongenerating threedimensional viewsof organsor areasof interest.
This allowsnoise causedby Comptonscattering tobe gatedout.
Theend resultof thenuclear medicineimaging processis a"dataset" comprisingone ormore images.
The nuclearmedicine computermay requiremillions oflines ofsource codeto providequantitative analysispackages foreach ofthe specificimaging techniquesavailable innuclear medicine,A patientundergoing anuclear medicineprocedure willreceive aradiation dose.
Under presentinternational guidelinesit isassumed thatany radiationdose, howeversmall, presentsa risk.
The radiationdoses deliveredto apatient ina nuclearmedicine investigationpresent avery smallrisk ofinducing cancer.
The radiationdose froma nuclearmedicine investigationis expressedas aneffective dosewith unitsof sieverts(usually givenin millisieverts,mSv).
Theeffective doseresulting froman investigationis influencedby theamount ofradioactivity administeredin megabecquerels(MBq), thephysical propertiesof theradiopharmaceutical used,its distributionin thebody andits rateof clearancefrom thebody.
Notesfor guidanceon theclinical administrationof radiopharmaceuticalsand useof sealedradioactive sources.
Administration ofradioactive substancescommittee UK1998.
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.
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.
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 internalmedicine.
Veterinarymedicine isthe practiceof healthcare inanimal speciesother thanhuman beings.
The earliesttype ofmedicine inmost cultureswas theuse ofplants (Herbalism)and animalparts.
Thiswas usuallyin concertwith 'magic'of variouskinds inwhich: animism(the notionof inanimateobjects havingspirits); spiritualism(here meaningan appealto godsor communionwith ancestorspirits); shamanism(the vestingof anindividual withmystic powers);and divination(the supposedobtaining oftruth bymagic means),played amajor role.
The practiceof medicinedeveloped gradually,and separately,in AncientEgypt, AncientIndia, AncientChina, AncientGreece, AncientPersia andelsewhere.
Possiblythe majorshift inmedical thinkingwas thegradual rejectionin the1400s duringthe BlackDeath ofwhat maybe calledthe 'traditionalauthority' approachto scienceand medicine.
People likeVesalius ledthe wayin improvingupon orindeed rejectingthe theoriesof greatauthorities fromthe pastsuch asGalen, Hippocrates,and Avicenna/IbnSina, allof whosetheories werein timealmost totallydiscredited.
Suchnew attitudeswere alsoonly madepossible bythe weakeningof theRoman Catholicchurch's powerin society,especially inthe Republicof Venice.
One problemwith this'best practice'approach isthat itcould beseen tostifle novelapproaches totreatment.
Pharmacologyhas developedfrom herbalismand manydrugs arestill derivedfrom plants(atropine, ephedrine,warfarin, aspirin,digoxin, vincaalkaloids, taxol,hyoscine, etc).
The modernera beganwith RobertKoch's discoveriesaround 1880of thetransmission ofdisease bybacteria, andthen thediscovery ofantibiotics shortlythereafter around1900.
Thefirst ofthese wasarsphenamine /Salvarsan discoveredby PaulEhrlich in1908 afterhe observedthat bacteriatook uptoxic dyesthat humancells didnot.
Thefirst majorclass ofantibiotics wasthe sulfadrugs, derivedby Frenchchemists originallyfrom azodyes.
Throughoutthe twentiethcentury, majoradvances inthe treatmentof infectiousdiseases wereobservable in(Western) societies.
The medicalestablishment isnow developingdrugs targetedtowards oneparticular diseaseprocess.
Thepractice ofmedicine combinesboth scienceas theevide