Medicine and health Rhode Island

488 Pages·1996·39.6 MB·English

by  Rhode Island Medical Society

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2016
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https://archive.org/details/medicinehealthrh7919rhod

FRaNCIS a countway lib of MED
EXCHANGE OFFICE
10 SHATTUCK STREET
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VoL. 79 No. 1 January 1996
\E FRANCIS A. COUNTW|
LIBRARY OF MEDICINE 1
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Teaching Human Anatomy to Medical Students
JUST BECAUSE EVERYONE IN THE STATE
NEEDS WORKERS’ COMPENSATION COVERAGE,
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JUST ANYONE IN THE STATE TO GET
IT.
Noticeto all physicians: mandatoryWorkers’ Most ofyou already knowusforfriendly, informed
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requiredto have Workers’ Compensation Insurance, benefit fromourextensive experiencewith healthcare
predominatelywith one carrier. This meansthatthose coveragecombinedwithourdetailed knowledgeofthese
private practiceswithout coveragewill needtoget it, and newrequirements. Inthisway, wecan helpyou adhereto
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will need toswitch attimeofrenewal. Becausethe RI maximizingyourinsurance protection. Please take thisstep
DepartmentofLabor is nowenforcingtliis legislationwith todayto avoid unncessary headaches: call IBC at 272-1050.
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Phone [phone] • Fax[phone] • RlTollFree800-559-6711
UEDNIDTEORRITAHLESJPOOINNSTORSHIPOF ^HOMedDiciEne ^Health Vou79 No.1 January1996
[STAND
BrownUniversitySchoolofMedicine
DonaldMarsh,MD,DeanofMedicine&
BiologicalSciences
RhodeIslandDepartmentofHealth Publication of the Rhode Island Medical Society
PatriciaNolan,MD,MPH,Director
RhodeIslandMedical Society COMMENTARIES
BarbaraSchepps,MD,President
4 A New Name, a Broader Mission, a Wider Audience
4 Evolutionary Morphology at Brown: What’s It All About?
EDITORIALSTAFF G.E. GosloWyJr, PhD
StanleyM.Aronson, MD
7 Anatomy and More
EditoT'in'Chief
DarleneTreu)Crist Lucile F. Newman, PhD
ManagingEditor
HugoTaussig, MD 8 Navel Encounters
BookReviewEditor
MD
SeebertJ. Qoldowsky, CONTRIBUTIONS
Editor-in-chiefEmeritus
EDITORIALBOARD Teaching Human Anatomy to Medical Students
*EdwardR.Feller, MD Guest Editor: G.E. Goslow, Jr, PhD
*StCahnalieyrmMa.nAronson, MD 10 Human Morphology at Brown (1990-1995): It’s All in the Team.
EPaduwlarCdalaMb.reBseii,seMr,DPhD,JD G.E. Goslow, Jr., PhD
*RichardA. Carleton, MD 15 Clinical Perspectives on Anatomy
*James P. Crowley, MMDD JohnJ. Cronan, MD, andMartin E. Felder, MD
* PeterA. Hollmann,
*MargtieriteA. Neill, MD 17 Additional Teaching Amenities in Morphology
MD
*FrankJ.Schaberg,MJrD., Ernest Wu, PhD, and G.E. Goslow, Jr, PhD
*FredJ.Schiffman,
WilliamJ. Waters,Jr., PhD 18 Outreach Programs
*MembersofPublicationsCommittee G.E. Goslow, Jr, PhD
OFFICERS 20 Research in Morphology at Brown
MD
BarbaraSchepps,
Dale Ritter, Katherine D. Earls, Jennifer Gray Chickering, PhD,
President
MD
ArthurA. Frazzano, David R. Carrier, PhD, ChristineJanis, PhD, Sharon Swartz, PhD,
President-Elect
J.JefferysBandola, MD and G.E. Goslow, Jr, PhD
VicePresident MD 33 The Next Five Years
MartinR. Phillips,
Secretary G.E. Goslow, Jr, PhD
MD
PeterA. Hollmann,
Treasurer MD COLUMNS
DavidP. Carter,
ImmediatePastPresident 35 Public Health Briefing:
DISTRICTANDCOUNTY Janet O’Connell, RN, MPH
PRESIDENTS
MD 37 Health by Numbers
PamelaA. Harrop,
WilBlriisatmolFC.oCuonstcyinMae,diMcaDlSociety Jay S. Buechner, PhD, and WilliamJ. Waters, Jr., PhD
KentCountyMedicalSociety 39 Vital Statistics “ F?A^'CIS A. COUNTWA^
MD
PeterD.T. Clarisse, Roberta A. Chevoya LloiwyKY CF MEDICINE
EugNeenwepoHr.tHCeoaulnetyy,MMedDicalSociety 40 Rhode Island Medical Journal Heritage BOS I ON, MA
E.PJaawnteucCkaertteMre,diMcaDlAssociation 41 New Managing Editor ^ .
ProvidenceMedicalAssociation 41 Information for Contributors
MD
RogerAshley,
WashingtonCountyMedicalSociety
JacquesL. Bonnet-Eymard, MD 42 CUMULATIVE INDEX FOR 1995
WoonsocketDistrictMedicalSociety
MedicineandHealth/RhodeIslandisownedandpublishedbytheRhodeIslandMedicalSociety, 106FrancisStreet,Providence,
RI02903,Phone:[phone]. Singlecopies$4.00-Subscriptions$40.00peryear(membersoftheRhodeIslandMedicalSociety
Cover: $5.00annually).PublishedarticlesrepresentopinionsoftheauthorsanddonotnecessarilyreflecttheofficialpolicyoftheRhodeIsland
A MedicalSociety,unlessclearlyspecified. AdvernsementsdonotimplysponsorshiporendorsementbytheRhodeIslandMedicalSociety.
graphic representation of SecondclasspostagepaidatProvidence,RhodeIsland. ISSN1086-5462. POSTMASTER:SendaddresschangestoMedicineand
electrophysiologic research into Health/RhodeIsland. 106FrancisStreet,Providence,RI02903.AdvertisingRepresentanve:ScholasticPublicarions,655Jefferson
Boulevard,Warwick,RI02886-1318,Phone:[phone].
vertebrate muscle movement.
^
Commentaries
A New Name, a Broader Mission, a Wider Audience
A scientificjournal representing the Rhode Island Medical Society has been pub-
lishedatmonthlyintervals, withoutinterruption, sinceJanuary 1917. Priortothatdate
the Societysupervisedthe editingofthe ProvidenceMedicalJournal, abimonthlypubli-
cation which had begun in 1899. Under a variety ofnames andformats, then, the
Society hasprovideditsmembershipwithascientificplatformfromwhichmedically ori-
— —
ented observations, interventions even speculations might be shared with the larger
health care community. As the ramifications ofgovernmental healthpolicy intersected
increasinglywith theprivatepracticeofmedicine, thejournalalsoreflectedthe Society's
politicalstands.
In recent decades, medicine has become hugely successful in its primary mission: to enhance the quality oflife and to prolong
survival. But medicine has also become substantially more complex. In Rhode Island, now, we have a young but scientifically
vigorous medical school which has assumed the leadership at all levels ofmedical education as well as the sole administration of
statewideresidencytrainingprograms. AndthereisnowanoutstandingDepartmentofHealthwhichplaysanincreasinglycriticalrole
in the diagnostic screening ofhuman disease, in the establishment ofrealizable health goals, in the maintenance ofan archive for
statewideepidemiologicdata, andin thefulfillmentofallofits conventiorwlsanitarianresponsibilities.
Foryears now, oureditorialboardhas debatedwhether the structure andpurpose ofthejournalwas keepingup with the rapidly
evolvingchanges inhealth; andithas concluded thatcertainchanges were nownecessary.
While this publication remains the property ofthe Society, the Boardrecognized the wisdom ofenlargingitselfby increasing the
representationfrom theDepartmentofHealthandBrown’smedicalschool. Thesenew;memberswillbeselected, respectively, by the
Directorofthe DepartmentofHealthand the DeanofMedicine. And toreflect this broadenedbase, we have elected tochangeour
name to Medicine and Health/Rhode Island.
Those readers who inspect the numbers in thejournal’s annualdemographic profile ofthepracticingphysicians ofRhode Island,
willhavenoticedthatBrown’smedicalschoolnowsurpassesbothTuftsandHarvardas theleadingsourceofthisstate’scomplementof
physicians. SincemanycurrentBrownmedicalstudents, yearshence, willbeestablishingtheirpracticeswithinthestate, theEditorial
Boardhasdecided todistribute onamonthly basis, copies ofthejournal toallBrownmedicalstudents.
Edward R. Feller, MD, Chairman, Editorial Board
Stanley M. Aronson, MD, Editor-in-Chief
Darlene TrewCrist, ManagingEditor
Evolutionary Morphology at Brown: What's it all About?
Q. E. Qoslow, Jr., PhD at Brown these days. Would you con- createdthreeadditionaltenuredorten-
siderputting together a special issue of ure track positions in what is now the
One afternoon about 18 months RhodeIslandMedicinedevotedtowhat DepartmentofEcologyandEvolution-
ago,Dr.StanleyAronsonandIwerevis- the morphology group is up to?” In a ary Biology. Within thisdepartmentof
itingandtheconversationturnedtothe momentofweakness,nodoubtprecipi- ten evolutionary biology faculty, four
anatomy class that had just vacated tated by my enthusiasm for what our constitutetheevolutionarymorphology
Eddy Auditorium tobegin adayofdis- group was doing that day (or from in- group.
section in the morphology laboratory. hqjingvolatilefumesformanyyears), 1 Ourteachingresponsibilitiesareun-
Stan asked me a couple of questions agreed. It has been fun. To celebrate dergraduatecoursesincomparativever-
about our approach to teaching and 1 ourfifth yearas anew group at Brown, tebrate anatomy, selected courses in
guess 1 startedgettinga bitanimatedas weofferyouthisissue; wehopeyouwill biomechanicsandfunctionalmorphol-
1 reviewed themorning’sevents. After find it enjoyable and informative. ogy, and first and fourth year medical
waiting politely for me to finish, he In 1989, concomitant with a gen- school courses in human morphology;
reached over, gently touched my arm eralreorganizationoftheDivisionofBi- i.e.,grossanatomy. Anadditionalmis-
(forearm,antehrachium)andsaid,"Ted, ology and Medicine at Brown sion is outreach to the hospitals and
1 think the medical community of University, a decision was made to as- community.Hospitaloutreachisaccom-
RhodeIslandwouldbequiteinterested semble a group ofevolutionary mor- plishedbyassistinginvariousresidency
inknowingwbatisgoingoninanatomy phologists. To accomplish this. Brown training programs of Brown’s Affiliate
4
MedicineandHealth/RhodeIsland
Hospitals.Wehavedone thisbyteach- adhocasclinicaltrainingprogressed. A fortably be classified as a mammal
ing(Neurosurgery,Orthopaedics)orby pivotalpublicationbyAbrahamFlexner among vertebrates, a primate among
providing facilities and materials for in 1910,however,setthewheelsinmo- mammals, and a Hominid among pri-
education in anatomy (Emergency tionformajorchangesthathavegreatly mates. In other words, man’s physical
Medicine, Plastic Surgery, Obstetrics affected anyone trained in medicine or andphysiologicalstateistheproductof
andGynecology,Radiology,andDerma- involved in medical education since.' millionsofyearsofnaturalselectionex-
tology).Ourcommunityoutreachcon- Flexner’s model provided for two years ertingitsinfluenceonthegeneticvaria-
sistsofhostingfieldtripsinourresearch of basic science taught by basic scien- tion ofman’s ancestors. The result of
space for local elementary andsecond- tists; followed by two years of clinical this is what we perceive our physical
ary schools, colleges and technical science taught by physiciansT (Curi- being to be today. An appreciation of
schoolsinRhodeIslandandMassachu- ously,weareagaininamedicaltraining thishastheeffectonstudentsofreplac-
setts. revolution that is tuggingforchange in ing a frosted window, through which a
Fromwithinthisgeneralframework, the structure and curricula of medical seeminglylimitlessnumberofanatomi-
wechose tofocus this issue on: schools across the country; 1 will out- calstructuresremainobscure,byacrys-
1) ourapproach to the teachingof line this new thrust later.) tal clear pane that allows focus on an
Human Morphology tofirst At least an entire yearwasdevoted understandable few. It hasn’t always
yearmedical students to the teaching ofanatomy during the been thisway.
2) communityoutreach, and firsthalfofthiscentury;embryologyand Longbeforewepossessedacontext
3) research activities ofourgradu- histology were often included. Since in which tounderstand thediversityof
ate studentsandfaculty. 1965, however, most medical schools life thatsurroundsus,wewere intellec-
have reduced anatomy to one semester tuallyengagedintryingtoputthemany
Anatomy and Medical Education, or about 185 hours ofclassroom time. kinds ofplants and animals into some
AnOverview: Unfortunately, as the time allotted for orderedarrangement (hierarchy). The
Forcenturies, theprimarysensesof anatomy dropped from three or more comparative method was a powerful
sight and smell were our only window years to one semester, the amount of tool. Understanding nature through
into the causes of illness and physical anatomyattempted, inmanyinstances, comparison and analogy was a strategy
breakdownofthebody. Asonlyarela- remainedthesame. Asaresult,anatomy Leonardo da Vinci used during his in-
tively few medicinal applications were hasabadraptheworldover. Anatomy quiries into human anatomy (1487-
known, it made sense that our knowl- is considered by many medical stu- 1505). Heacceptedthetraditionalview
edge base from which to prepare for a dents to be deadly dull, completely that the interior anatomy ofevery ter-
lifetime ofhealing was what we could overwhelmingandmind-numbing. 1be- restrial creature was essentially the
learn/teach through dissection. Until lieve this attitude stems from two same,buthealsorecognizeddifferences.
the middleofthe last century, medical sources: “Tocompare thestructureofthebones
school was more or less synonymous 1) In their excitement to share all of the horse with that of a man,” he
with gross anatomy. In Italy, for ex- of the anatomy they know and love, wrote,“youshouldshowthemanontip-
ample, the systematic teaching of some anatomists have simply forgotten toe in representing the legs.^” Though
anatomybydissectionhadbeenpreva- how long it really takes to master the we could see such physical similarities
lentsince theearlyfourteenthcentury, several levels ofdetail. TRey ask their among plants and animals on the one
with instructors using such standard students to learn in one semester what hand,andtheiruniquenessontheother,
guides as that written in 1316 by the it has taken themselvesyears to digest, we possessed no understanding ofhow
physician Mondinode’ Luzzi, professor and such patterns could be related. Enter
ofanatomy at the University of Bolo- 2)Anunfortunatebyproductofthe Charles Darwin. Darwin articulated
gna. Forthenext500years, studentsof fundingofscientistsinthiscountrysince (and documented) a few basic points,
medicine continued to view and study about 1950 has resulted in the staffing which to those who accepted and un-
anatomyasthescholarlycornerstoneof ofanatomydepartmentsbyoutstanding derstood them, immediately gave logi-
medicine.With time, ourknowledgeof cell biologists, with little training in cal insight into these observations and
the physiological processes associated grossanatomy.Thesescientistsareasked provided a framework within which
with anatomy increased. By the toteachasubjecttheyhave littleinter- they could be studied. Darwin recog-
latel600’s, Harvey had discovered cir- est inorknowledge about. nizedthatwithin anypopulationofor-
culation and an era leading to our un- ganisms, there existsvariation inform.
derstandingofmicrobiologyandsources EvolutionaryAnatomy: Thisiseasyforustoseeamonghumans
ofinfection, through the discoveriesof Just Monkey Business? (moving through the streets of Provi-
Pasteur, Lister and Semmelweiss, had Asevolutionarybiologists,itisonly denceorBoston itisnotdifficulttosee
begun. Thetimewhenanatomyformed natural that we frame our view of the individuality), but Darwinpointedout
theprimarydatabaseofmedicaleduca- human body in acomparative context. thatthesamedegreeofvariationexists
tion had passed; room in the curricu- Admittedly, humans are intellectually amongthetreesofaforestandbarnacles
lumforotherdisciplineshadtohemade. unique and possess abilities ofcreativ- at the seashore. Thisvariationhad not
Until the early 1900’s, physicians itythatfaroutstripanythingwewitness beenappreciated. Second,Darwinrec-
taughtfuturephysicians. Anybasicsci- among other members of the animal ognized that the source for this varia-
ence taught, was presented somewhat kingdom.But,physically,mancancom- tion was heritable, but he had no
5
Vol. 79 No. 1 January 1996
concept of the gene or the laws of and author ofan influential book that Thecomplexchemicalsthatmakecof-
Mendel (thesewouldcomelater). Dar- many ofmy generation cut their teeth feesoappealingaretoxinsthatprotect
winreasonedthatwithin thesettingof on ingraduateschool in the 1960’sen- coffee seeds from insects and small
their particular environment during titledAdaptationandNaturalSelection.'* mammals. Wecansafelyconsumeveg-
their reproductive years, someofthese RandolphNesseisarespectedpsychia- etables and even coffee because we
variantswouldproducemorereproduc- trist who has published many papers have evolved effective detoxification
tively-successful offspring than would thatconsidervariouspsychiatric disor- mechanisms. Sincewe likediversedi-
others. Finally, Darwinspentalifetime ders in an evolutionary context’"^. In ets, we will eat small amounts ofava-
tryingtocriticallyidentifythoseaspects their 1991 paper, Williams and Nesse riety of these toxic plants and our
of an organism’s environment that pointed out that while evolution by evolved detoxification mechanisms
might influence the success or failure natural selectionhaslongbeenafoun- willhandlethemeffectively. If,onthe
ofthese variants to reach reproductive dation for biomedical science, it has otherhand, we eat excessive amounts
status. Collectively, hecalled these in- recently gained new power to explain ofthose toxinsthatwerescarceduring
fluencingfactors natural selection. manyaspectsofdiseaseand mental ill- our evolutionary history (e.g., pesti-
So thereyouhave it. Variationex- ness. Theyconsideredinfection,forex- cides, nickel and mercury), we are in
ists for any biological trait that has a ample, inlightofhostparasitecontests, trouble.Evolutionaryargumentstoex-
genetic component influencing itsfor- anddiscusswhomaybethebeneficiary plain morning sickness during preg-
mation. A “trait” may be morphologi- (host or parasite) ofthe symptoms as- nancy and allergic response also are
calorabiochemicalprocessattheprotein sociated with infection. Mechanical discussed.
synthesis level, physiological process at injuries and associated swelling and Williams and Nesse consider ge-
thesystemiclevel,orbehavioratthein- painarediscussedasoptimalforStone netic diseases in light ofthe selection
dividual/population level. The precise Age conditions. For example, an evo- ofgenes that may be favorable for the
mechanisms by which natural selection lutionistmightaskwhatcomponentof attainmentofreproductionbut not so
acts on variation to produce evolving swellingandpainofasprainedankle is subsequently. They propose that the
populations/individuals in the patterns incidental to the trauma, and to what diseasesofagingmaybeparticularlyas-
weobserveinthefossilrecordandthose extent is it an adaptation to immobi- sociated with genes selected for early
we see around us today are fiercely de- lize thejoint infavorofhealing? benefits. Finally, a substantial part of
bated,continuouslyrefined,andmakeup Toxins areconsideredfrom afasci- thepaperisdevotedtoaconsideration
the“stuff’ofevolutionarybiology. Nev- natingperspective. Arguments center of the idea that human biology is de-
ertheless, Darwin’s insights provided us on the notion that we as humans like signed for a Stone Age environment.
with an intellectual framework for un- diversedietsandasaresult,wecanand In 1986,Endler’articulatedwhatisim-
derstandinghowsome individualsgain willeatplantsthatpossesstoxins.Why plicit inevolutionary theory: Adapta-
more genetic representation in future doplantscontain these toxins? Plants tionsareproducedandmaintainedonly
generationsthanothers. Itisthisframe- defend themselves against herbivores intherangeofenvironmentsinwhich
work within which we cast our teach- mainlybysynthesizingtoxicchemicals selectiontakesplace. Forearlyhumans,
ingofgross anatomy at Brown. (the resins of trees discourage insects the socioeconomic environment con-
It would be difficult for any group from making the wood a tasty meal). sistedofsmall groups hunting, gather-
ofevolutionarymorphologists to teach
gross anatomyfrom anyotherperspec-
tive than a comparative one set in an
evolutionary framework. Quite hon-
estly,itjustdoesn’tmakesensetousany
otherway! 1 amaware thatformostof
you, however, the details of gross
anatomy do not form the building
blocks ofyourday-to-day practice. So
let me diverge from our discussion of
anatomyperse togive you a moreglo-
bal feel for the potential of an evolu-
tionary perspective across the entire
medical training curriculum. Within
medical education in general, the
stirringstoframeentirecomponentsof
thecurriculuminanevolutionarycon-
texthavebegun. In 1991 GeorgeWil-
ltieaamms,edPhupDaannddwRraontdeolapr,hevNieeswsea,rtMicDle tFhirguoruegh1o.utLheisonsakredtcohdeasVainndcin'ostpeas.ssOionnffoloiroc2o2mpraerctaotiofvethaenfaiftthoQmuyaadnedrnhou,mtahnepaenlavticomliymbisoufbaiqrueiatroiunsg
entitled “The Dawn of Darwinian horseiscomparedtothelo\«erlimbofman,withthenote:“Oftherelationshipthatexistsbetween
thearrangementofthebonesandmusclesoftheanimalsandthatofthebonesandmusclesofman.
Medicine’’^ George Williams is a Tocomparethebonestructureofthehorsewiththatofamanyoushouldshowthemanontiptoe
highly-respectedevolutionarybiologist inrepresentingthelegs."
6
MedicineandHealth/RhodeIsland