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By the turn of the millennium deeply-rooted traditions cheap antabuse 250 mg with visa, such as those of self-regulation and the independent contractor status of GPs antabuse 500mg with mastercard, had effectively been abandoned buy 250mg antabuse fast delivery. Fundamental changes had been introduced in medical education and training generic antabuse 250mg on-line, linked to changes in the place of medical science in medical practice and in the nature of the doctor/patient relationship buy 250 mg antabuse otc. What was perhaps most remarkable was that there was little resistance to these revolutionary changes and indeed little comment upon them at all. The breaching of the Berlin Wall on New Year’s Eve 1989 was a highly symbolic event. It followed the collapse, one by one, of the Soviet-sponsored regimes of Eastern Europe, and it anticipated the collapse of the Soviet Union itself, in 1992. It marked the end of the world order established after the Second World War and consolidated through forty years of Cold War. Long fundamental divisons —between East and West in foreign affairs, between Left and Right at home—rapidly lost their force. The collapse of ancient polarities was linked to the decline of familiar collectivities (classes, unions, political parties, churches) and to the exhaustion of ideologies (socialism, communism, nationalism, even conservatism). In 1989 capitalism and liberal democracy claimed victory, but their triumphalism was always muted and the celebrations proved short-lived as the 1990s came to be dominated 143 THE CRISIS OF MODERN MEDICINE by preoccupations about the social and environmental dangers of globalised economic forces. In an era of lowered horizons and diminished expectations a climate of scepticism about established forms of expertise—in science and technology, in politics and academic life, in traditional professions and institutions—became widespread. People became sceptical, not only about particular sources of authority, but in general, about the possibility of expertise in any area, especially in relation to any social or political objective. This was not a radical outlook, that was critical of the way things were from a perspective of how they might be changed for the better. It was a fatalistic one, which was cynical about the way things were because it had drawn the gloomy conclusion from the experience of the twentieth century that any attempt to change things could only make them worse. The changes that were implemented in medicine in the course of the 1990s originated in a section of the medical elite. The old structures were overthrown by a movement initiated from above, not by a revolt from below. In this respect there is also a striking parallel with the ‘velvet revolutions’ of Eastern Europe: like the Stalinist bureaucracies, the old medical elite experienced an internal moral collapse and was replaced by a new clique emerging largely from its own ranks, drawing in some new blood and winning widespread approval from the younger generation in the profession. A series of events in the early 1990s signalled the capitulation of the old order and the ascendancy of the new. One was the shift in the medical attitude towards non-orthodox therapies as the traditional concern to uphold scientific principles and maintain a clear demarcation was displaced by a more open and collaborative approach. This shift was symbolised by the reversal in the BMA line in its 1993 report on ‘complementary medicine’. Another key change was heralded by the publication of the GMC’s Tomorrow’s Doctors in 1993: after decades of stasis a major reform of medical education was not only announced, but rapidly implemented. The quest for reassurance about the quality of medical practice was expressed in the pursuit of various forms of audit and in the adoption of guidelines in different areas of clinical practice. These methods became widespread in the early 1990s and towards the end of the decade were absorbed into the framework of managerial control known as ‘clinical governance’. In response the BMA established a working party, which produced its report in 1986. The report expressed a distinctly curmudgeonly attitude to what its authors clearly regarded as the Prince’s rather tiresome hobbyhorse. It recognised an ‘identifiable growth of an underlying hostility to technology and science, allied to a distrust of innovation’ from which ‘orthodox medicine’ was not immune (BMA 1986:3). With some disdain, the BMA noted ‘a demand which is scarcely rational for instant cures for the currently incurable diseases of mankind’ and dismissed the ‘ill-founded suspicion that nothing is being done to attack these problems’ (BMA 1986:4). In a tone of increasing rancour, the report warned of the danger of ‘turning back to primitive beliefs and outmoded practices, almost all purposeless and without a sound base, however well-meaning’. The BMA first offered a lengthy history and defence of the traditions of scientific medicine, taking up about one third of the report. Only then did it provide a series of (overwhelmingly dis- paraging) assessments of a range of alternative therapies, including acupuncture and homeopathy, herbalism and hypnotherapy. It concluded that these and many other therapies had ‘little in common between them, except that they pay little regard to the scientific principles of orthodox medicine’ (BMA 1986:77). The report emphasised that the ‘fundamental division’ separating orthodox and alternative approaches was ‘the scientific principle which underlies the former, and the testing of theories by systematic observation which that principle implies’: The steadily developing body of orthodox medical knowledge, based on science, has led to large, demonstrable, and reproducible benefits for mankind, on a scale which the alternative approach cannot match. It also acknowledged that medical development had in the past been assisted by concepts and techniques derived from unorthodox sources, but emphasised that these must be evaluated by ‘systematic, scientific’ methods before they could be incorporated into the mainstream. By the evidence of this report, in the mid-1980s mainstream medicine was confident about the methods and proud of the achievements of medical science and unwilling to make any concessions to unorthodox alternatives, even at the behest of the royal patron of the BMA.

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You have to use your discretion about how much you do this as there might be occasions when somebody is unwilling or too nervous to contribute 500 mg antabuse free shipping. You often find that buy antabuse 250mg low cost, even though you have negotiated a time buy 250mg antabuse with amex, people enjoy the discussion and want to continue discount antabuse 250mg line, although at this stage you must make it clear that people can leave discount antabuse 500mg line, if they wish. Often, some of the most useful and pertinent information is given once the ‘official’ time is over. Also, you will find that people talk to you on an individual basis after the group has finished, especially those who might have been nervous contribut- ing in a group setting. It is useful to take a notepad and jot down these conversations as soon as possible after the contact as the information might be relevant to your re- search. Finishing the focus group When you have finished your focus group, thank the par- ticipants for taking part and leave a contact name and number in case they wish to follow up any of the issues that have been raised during the discussion. It’s good practice to offer a copy of the report to anybody who wants one. However, this might not be practical if the final report is to be an undergraduate dissertation. You could explain this to the participants and hope that they under- stand, or you could offer to produce a summary report which you can send to them. HOW TO CONDUCT FOCUS GROUPS/ 79 TABLE 8: STRATEGIES FOR DEALING WITH AWKWARD SITUATIONS SITUATION STRATEGY Break-away Say: ‘I’m sorry, would you mind rejoining the group as this conversations is really interesting? Dominance First of all stop making eye-contact and look at other people expectantly. If, however, leadership tendencies aren’t immediately obvious, but manifest themselves during the discussion, try to deal with them as with ‘dominance’, above. If this still fails, as a last resort you might have to be blunt: ‘Can you let others express their opinions as I need to get as wide a variety as possible? The other members were happy to do this as they were free to express themselves and their opinions were quite different from those of their self-appointed ‘leader’. Disruption by On rare occasions I have come across individuals whowant participants to disrupt the discussion as much as possible. They will do this in a number of ways, from laughing to getting up and walking around. I try to overcome these from the start by discussing and reaching an agreement on how participants should behave. Usually I will find that if someone does become disruptive, I can ask them to adhere to what we all agreed at the beginning. Sometimes, the other participants will ask them to behave which often has a greater influence. Defensiveness Make sure that nobody has been forced to attend and that they have all come by their own free will. Be empathetic – understand what questions or topics could upset people and make them defensive. Try to avoid these if possible, or leave them until the end of the discussion when people are more relaxed. These facilities can be hired at a price which, unfortunately, tends to be beyond the budgets of most stu- dents and community groups. Your local college or university might have a room which can be set up with video recording equipment and the in- stitution may provide an experienced person to operate the machinery. If your institution doesn’t provide this fa- cility, think about whether you actually need to video your focus group as the more equipment you use, the more po- tential there is for things to go wrong. Most social re- searchers find that a tape recording of the discussion supplemented by a few handwritten notes is adequate (see Chapter 7 for further discussion on different methods of recording). Ideally, it needs to be small and unobtru- sive with an inbuilt microphone and a battery indicator light so that you can check it is still working throughout the discussion, without drawing attention to the machine. A self-turning facility is useful as you get twice as much recording without having to turn over the tape. The recorder should be placed on a non-vibratory surface at equal distance from each participant so that every voice can be heard. Before the participants arrive, place it in the HOW TO CONDUCT FOCUS GROUPS/ 81 centre of the room and test your voice from each seat, varying your pitch and tone.

Among his many activities he found time to direct for 35 years the Archivio di Ortopedia discount antabuse 250 mg otc, the 111 Who’s Who in Orthopedics oldest periodical devoted to orthopedics and for many years the official journal of the Italian Orthopedic Society order antabuse 500 mg with mastercard. Galleazzi’s work was recognized by the conferment upon him of many honors buy generic antabuse 500 mg on-line, both in Italy and in many foreign countries buy 250 mg antabuse fast delivery. And his great friend and admirer Vittorio Putti collected to- gether a number of important scientific papers in a volume dedicated to his honor generic antabuse 250 mg mastercard. Gaucher, a leading French physician at the turn of the century, described the disease since named after him in 1882 but was not aware of possible bone involvement. Later Pick and Stout published pathologic material demonstrat- ing bone lesions. Alfred Baring GARROD 1819–1907 Sir Alfred Baring Garrod of London was an eminent physician. His first book in 1859 established his interest in the field, but his views were established in the more readable third edition of 1876. Gout was known to the ancients and to physicians in all subsequent centuries. Garrod reviews the history of the great writings quite comprehensibly in the first chapter of this book. It was with the publications of this classic volume that the modern concept of gout began. It was Sir Alfred’s son, Sir Archibald Edward Garrod (1857–1936), who later started modern rheumatology theories with his division of the arthritic syndrome into rheumatoid arthritis and osteoarthritis. Before permitting publication of any material, he applied a rigid formula: “No one has any right to publish unless he has something to say and has done his best to say it aright. These “presented uncom- mon clarity of mind and lucidity of language Born in Edinburgh, Scotland, in 1883, Alexander which enabled him to make the complicated Gibson received a classical education. The “fish-tail graft” introduced the of the University to earn all the scholarships principle of an interlocking graft in spine fusion. Following this period he began his career in orthopedic surgery and was associated for several years with the late H. Later, as Associate Professor of Surgery, he was responsi- ble for orthopedic teaching in the University of Manitoba. His remarkable lectures on applied anatomy made a distinct contribution in bridging the gap between the basic sciences and the clini- cal field. His hospital appointments included: Orthope- dic Surgeon, Winnipeg General Hospital; Direc- tor of the Department of Orthopedic Surgery, Deer Lodge Hospital, Department of Veterans’ Affairs; and Consultant to the Sanatorium Board of Manitoba. During World War I, Gibson was active as a surgeon in the Royal Army Medical Corps in India and Egypt, and World War II found him again in service as orthopedic surgeon in charge of Hermeirs Red Cross Hospital in Scotland. During the war years, from 1942 to 1945, he was Surgeon-in-Chief of the Alfred I. Bruce Gill was always interested in the care of the crippled child; he held state clinics in central Pennsylvania during the whole of his active pro- fessional career. He was Chairman of a Joint Committee on Crippled Children of the American Academy of Orthopedic Surgeons, the American Orthopedic Association, and the American Medi- cal Association from 1942 until 1952. From 1942 to 1950 this committee was called the Com- mittee for the Study of the Public Care of the Arthur Bruce GILL Indigent Orthopedic Cripple and then, from 1951 to 1952, the Committee on the Public Care of 1876–1965 Crippled Children. He was a member of the Advi- sory Committee on Crippled Children to the Arthur Bruce Gill was born of Scotch ancestry on Federal Children’s Bureau for many years. He December 12, 1876, in western Pennsylvania, was at one time Chairman of the Committee on at Greensburg. He received his BA degree in Legislation and Medical Economics of the Amer- 1896 at Muskingum College in Ohio, from which ican Academy of Orthopedic Surgeons and of the college, 42 years later, he received an honorary Committee on the Treatment of Infantile Paraly- Doctor of Science degree. Bruce was always interested in education and He interned at the Presbyterian hospital in research: he was Chairman of the American Philadelphia, with which institution he was asso- Orthopedic Association’s Committee on Under- ciated for 47 years, for many years as Chief of the graduate Education for many years. Ashurst, of the Episcopal Hospital in posium on undergraduate education was held at Philadelphia, first talked to Bruce about going the Joint Meeting of the British, Canadian, and into orthopedics, but it was Dr. Davis as the third Professor of honorary member of the Ambrose Paré Society of Orthopedic Surgery at the University of Pennsyl- France, of the Pennsylvania Orthopedic Society, vania, which position he held until 1942. He was and of the Orange County (Florida) Orthopedic on the staff of the Philadelphia Orthopedic Hos- Society.

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At about this active duty with the American Expeditionary time he became instructor of surgery at the Forces 250mg antabuse otc. Bob Osgood obtained his commission in the In 1910 buy 250 mg antabuse otc, in collaboration with Dr antabuse 500mg without a prescription. This operation forecast the pattern of the Expeditionary Forces order antabuse 250mg with mastercard, he was transferred to the operation that has since been followed order antabuse 250 mg without prescription, only the British Medical War Office in London, where he silk suture has been replaced by stainless-steel served 6 months as deputy to Major General Sir wire and fusion has been combined with the Robert Jones, chief of the orthopedic section of fixation. This assignment brought him into The First World War presented a great chal- close personal relationship with Sir Robert Jones, lenge to medical science in meeting the emergen- whom he quickly learned to love. Indeed, it was cies and needs of caring for thousands of because of the friendly relations he established wounded. When the French and British armies with the British orthopedic surgeons that he was were locked in trench warfare with the Germans able, at the end of the war, to help in the found- along the Belgian and French frontiers in 1915, ing of the British Orthopedic Association, which there was formed a Harvard surgical unit to work had seemed impossible previously, largely in rotation with other American university units because of local rivalries and failure to attain at the American Ambulance in Neuilly. Full headed by Harvey Cushing, with Robert Osgood acknowledgment has been made by some of the 253 Who’s Who in Orthopedics founding members of this Association of the ship because it brought together for the first time unique role played by Robert Osgood in its for- general surgeons who were interested in fractures mation. In February 1918, Robert Osgood was attended by 50 or more general and orthopedic attached to the office of the chief surgeon of the surgeons of great individuality and reputation. It American Expeditionary Forces at Tours, where seemed impossible that such men as Ashley he served as a deputy to Colonel Goldthwait, who Ashurst of Philadelphia, William Sherman of was then responsible for development of the army Pittsburgh, Charles Scudder of Boston, Kellogg orthopedic service under the chief surgeon. Later Speed of Chicago, to name only a few, could get Bob Osgood was recalled to the United States to together with a group of orthopedic surgeons and serve as orthopedic consultant to the Surgeon achieve a meeting of the minds on the treatment General. In this position he did valuable work of fractures; yet, this was accomplished and through periodic visits to the large base hospitals the results were published in a bulletin of the in the United States, where he was able not only American College of Surgeons entitled A Primer to examine the quality of the work being done but of Fracture Treatment. This was reprinted many also, because of his large experience, to help in times and was later translated into many foreign the solving of individual problems. From this first meeting emerged the charged in 1919 with the rank of Colonel in the Fracture Committee of the American College of Medical Reserve Corps. Surgeons, an organization on a national scale, Upon returning to Boston and upon the retire- which was established to improve both the ment of Dr. Elliott Brackett, Bob Osgood was emergency care and the final treatment of frac- promoted to head of the orthopedic service of the tures. His weekly expanded to become the Committee on Trauma of orthopedic rounds were stellar performances, not the American College of Surgeons. Ultimately he summarized the pedic Service at the Boston Children’s Hospital; discussions, which clearly guided the final deci- this carried with it the title of Professor of Ortho- sions as to treatment. In enough to maintain his technical skill, feeling 1924, he was made John B. In accepting this himself to his residents, learning to know them appointment, Bob Osgood insisted upon and and their families personally, so that he was famil- obtained a concession from the Dean and Faculty iar with all their problems. When a man did not of Medicine of the Harvard Medical School that come up to the standards required, he redoubled henceforth eligibility for the title of Professor of his efforts in the hope that he would find a way Orthopedic Surgery should not be limited exclu- to stimulate him and set him on the right path. Children’s Hospital into a single program under He held this post until 1930, when he retired vol- the aegis of Harvard Medical School. This gave a untarily, earlier than necessary, in order to make 12-month residency at each of the two institutions room for a younger man. It was the most setts Medical Society, the American Medical advanced and comprehensive program of ortho- Association, the New England Surgical Society pedic training in the United States and served as (past president, 1928–1929), the American Ortho- a model for many other medical schools. In 1925, he fractures, a 2-day meeting, which was held at the served as Hugh Owen Thomas Lecturer at the Massachusetts General Hospital in 1921. He was a member represented a triumph of diplomacy and leader- of the International Society of Orthopedic 254 Who’s Who in Orthopedics Surgery and Traumatology, Honorary Member clinics in Germany, the Netherlands, and France. With the American Committee on Rheumatism, he his textbook Monstrum humanum Extremitatibus helped to organize the American Rheumatism incurvatus. He was the first anatomica in Vratislaviae Museum, published by Chairman of the Advisory Board of Orthopedic Anatomico-Pathologieum Breslau in 1841, Otto Surgeons to the Trustees of the Shriners’ Hospi- has been credited with the first clinical descrip- tal for Crippled Children. He was a member and tion of an infant with arthrogryposis multiplex later Chairman of the Advisory Committee for congenital. In 1943, he was made an Honorary Fellow of the Royal College of Sur- geons, the Fellowship being conferred on him by Major General Sir William Heneage Ogilvie at the British Embassy in Washington. He was awarded the degree of Doctor of Science, honoris causa, by Amherst College in 1935. His former pupils and associates combined on the occasion of his 70th birthday to publish in the Archives of Surgery a special number dedicated to him; in the following year another group of pupils and associates united to arrange for the painting of his portrait by Mr. Robert Bayley Osgood died on October 2, 1956, in Boston, at the age of 83.

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