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Narrowing the gap between the rhetoric and the reality of medical ethics
ular vision. The author concluded that the results "support a therapeutic plan of surgical correction of only definite orbital deformities and ocular dystopia shordy after injury." In the absence of a clear abnormality, observation and close follow-up is an appropriate option.—George B. Bartley *Longwood Skull Base Program, 300 Longwood Ave., Boston, MA 02115.
• Pulsed carbon dioxide laser resurfacing of photoaged facial skin. Fitzpatrick RE*, Goldman MP, Satur NM, Tope WD. Arch Dermatol 1996; 132: 395-402.
T
HE USE OF THE CARBON DIOXIDE LASER TO REJUVE-
nate facial skin has become popular during the past two years, but few peer-reviewed studies of its effects have been published. In this report, the authors devised a nine-point clinical scoring system to evaluate the degree of skin wrinkling and photodamage and to assess changes that were effected by treating periorbital and perioral wrinkles with a carbon dioxide laser. Photodamaged skin was treated with multiple passes of confluent single pulses of laser energy (a 10,600 nm, 3-mm collimated beam, <1-millisecond pulse, 450 mj per pulse, 2 to 5 W). The tissues were cleansed and debrided with normal saline between passes. Photographs taken before and after treatment were scored independently by four masked reviewers. All three classes of photoaged skin (mild, moderate, and severe) responded equally well. The most superficial wrinkles were eliminated, whereas deeper wrinkles were markedly improved. Loose, folded skin was tightened by the laser treat ment as collagen shrinkage was induced, an unantici pated but favorable sequela. Side effects included transient erythema and hyperpigmentation; one pa tient developed an isolated hypertrophie scar. The authors concluded that carbon dioxide laser skin resurfacing is a predictable and safe technique for rejuvenating photodamaged skin.—George B. Bartley *Dermatology Associates of San Diego, Inc., 9850 Genesse Ave., Suite 408, La Jolla, CA 92037.
VOL.122, No. 2
• Narrowing the gap between the rhetoric and the reality of medical ethics. Silverman DR*. Acad Med 1996;71:227-37.
A
MAJOR CHALLENGE FOR ACADEMIC MEDICAL EDU-
cation is to sensibly balance the needs of stu dents and residents for hands-on training with the rights of patients to receive the highest quality of care. Two aspects of the debate over this issue have received a great deal of attention: the appropriate degree of patient control over the makeup of the treatment team, and the proper role of supervision and account ability for attending physicians. Although the law has ostensibly resolved the conflict between the goals of student participation and the principles of patient autonomy and informed consent, the record of medi cal practices is too often inapposite. The divergence of law and reality is primarily a reflection of the law's flawed medical model, which poorly matches the dynamics of the physician-patient relationship and ineffectually attempts to reshape it. But the disso nance is also attributable to medicine's autonomous professional culture, which undervalues patient in volvement and reinforces benign paternalism. Coher ent policy requires a recrystallization of both the legal ideal and the medical reality. Lawyers and ethicists should loosen their rigid consumerist conception of medicine, and physicians should become more con scious of the infiltration of paternalism and instrumentalism into their decisions.—Author's abstract *1045 Santa Cruz Ave., Apt. F, Menlo Park, CA 94025.
• Cost-effectiveness analysis in a setting of budget constraints. Is it equitable? Ubel PA*, DeKay ML, Baron J, Aasch DA. N Engl J Med 1996;334:1174-7.
T
HE PROVISION OF HEALTH CARE SERVICES INCREAS-
ingly is effected by budget constraints. Costeffectiveness analysis can be used to maximize the health care benefits attainable within a budget. One of the tenets of cost-effectiveness analysis is that it is preferable to achieve the greatest total benefit per unit expenditure even if an intervention is offered to only a portion of a population. To test this assumption, the
ABSTRACTS
295
• Pulsed carbon dioxide laser resurfacing of photoaged facial skin. Fitzpatrick RE*, Goldman MP, Satur NM, Tope WD. Arch Dermatol 1996; 132: 395-402.
T
HE USE OF THE CARBON DIOXIDE LASER TO REJUVE-
nate facial skin has become popular during the past two years, but few peer-reviewed studies of its effects have been published. In this report, the authors devised a nine-point clinical scoring system to evaluate the degree of skin wrinkling and photodamage and to assess changes that were effected by treating periorbital and perioral wrinkles with a carbon dioxide laser. Photodamaged skin was treated with multiple passes of confluent single pulses of laser energy (a 10,600 nm, 3-mm collimated beam, <1-millisecond pulse, 450 mj per pulse, 2 to 5 W). The tissues were cleansed and debrided with normal saline between passes. Photographs taken before and after treatment were scored independently by four masked reviewers. All three classes of photoaged skin (mild, moderate, and severe) responded equally well. The most superficial wrinkles were eliminated, whereas deeper wrinkles were markedly improved. Loose, folded skin was tightened by the laser treat ment as collagen shrinkage was induced, an unantici pated but favorable sequela. Side effects included transient erythema and hyperpigmentation; one pa tient developed an isolated hypertrophie scar. The authors concluded that carbon dioxide laser skin resurfacing is a predictable and safe technique for rejuvenating photodamaged skin.—George B. Bartley *Dermatology Associates of San Diego, Inc., 9850 Genesse Ave., Suite 408, La Jolla, CA 92037.
VOL.122, No. 2
• Narrowing the gap between the rhetoric and the reality of medical ethics. Silverman DR*. Acad Med 1996;71:227-37.
A
MAJOR CHALLENGE FOR ACADEMIC MEDICAL EDU-
cation is to sensibly balance the needs of stu dents and residents for hands-on training with the rights of patients to receive the highest quality of care. Two aspects of the debate over this issue have received a great deal of attention: the appropriate degree of patient control over the makeup of the treatment team, and the proper role of supervision and account ability for attending physicians. Although the law has ostensibly resolved the conflict between the goals of student participation and the principles of patient autonomy and informed consent, the record of medi cal practices is too often inapposite. The divergence of law and reality is primarily a reflection of the law's flawed medical model, which poorly matches the dynamics of the physician-patient relationship and ineffectually attempts to reshape it. But the disso nance is also attributable to medicine's autonomous professional culture, which undervalues patient in volvement and reinforces benign paternalism. Coher ent policy requires a recrystallization of both the legal ideal and the medical reality. Lawyers and ethicists should loosen their rigid consumerist conception of medicine, and physicians should become more con scious of the infiltration of paternalism and instrumentalism into their decisions.—Author's abstract *1045 Santa Cruz Ave., Apt. F, Menlo Park, CA 94025.
• Cost-effectiveness analysis in a setting of budget constraints. Is it equitable? Ubel PA*, DeKay ML, Baron J, Aasch DA. N Engl J Med 1996;334:1174-7.
T
HE PROVISION OF HEALTH CARE SERVICES INCREAS-
ingly is effected by budget constraints. Costeffectiveness analysis can be used to maximize the health care benefits attainable within a budget. One of the tenets of cost-effectiveness analysis is that it is preferable to achieve the greatest total benefit per unit expenditure even if an intervention is offered to only a portion of a population. To test this assumption, the
ABSTRACTS
295