The Surgical clinics of North America
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Complex thoracic injuries are a leading cause of death in trauma patients. Four difficult problems of diagnosis and treatment are discussed, including (1) air leak not associated with pneumothorax, (2) management of major thoracic esophageal injuries, (3) penetrating trauma, and (4) retained hemothorax and empyema.
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The histogenesis of Paget's disease has been hotly debated, and only recently has epidermotropic theory become widely accepted. With the evolution of our understanding of breast cancer, it became apparent that the prognosis of Paget's disease was more a reflection of that of the underlying carcinoma, be it intraductal or infiltrating. ⋯ A breast-conserving algorithm for the treatment of Paget's disease of the breast is proposed. Further refinements or modifications to the algorithm should be made as data from ongoing trials redefine our understanding of breast pathology and treatment.
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Surg. Clin. North Am. · Feb 1996
Review"Routine" preoperative studies. Which studies in which patients?
The utility of mass screening of preoperative patients has never been demonstrated for the majority of tests. Although screening patients to uncover occult disease appears logical, in reality it has resulted in excessive expenditure of our health care dollars with limited benefit. ⋯ A selective utilization of routine examinations can accurately supplement the clinician's evaluation, providing the patient with a complete preoperative assessment. The benefits of selective testing must be balanced against the possible omission of warranted examinations, highlighting the need for a more reliable system for test ordering.
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Effective policies to reduce true costs will require integrated information systems and demand behavioral changes from providers. A congenial environment must be created among medical educators, providers, vendors, and consumers if cost reduction is to be accomplished without compromising quality or access to critical care services. Physicians should do everything they believe may be of benefit for their patients, but we have an obligation to educate the public about the limitations of our art and the fact that "doing everything" is not always best for the patient or the grieving family. ⋯ We must first contribute more by achieving a greater understanding of the medical care process. Only then can we know how to do less at the bedside. We can and must distinguish between costly and high-quality care--they are not necessarily synonymous.
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The key to increasing operating room efficiency is increasing productivity. Standardizing and streamlining of internal procedures reduce bottlenecks, and computers speed the flow of information so that continuous improvement of the system becomes possible. Patterns and themes can be discovered only when one sits back and listens and watches, shifting the focus from fixing problems to discovering patterns and the structures underlying them. Rethinking the system and evaluating all aspects of the care delivery cycle, abandoning the "sacred cows" of operating room practice, and creating a vision for health care in the future are essential to survival in the managed care environment.