The Council on Long Range Planning and Development of the American Medical Association has identified trends in the environment of medicine and the implications of these trends for specific medical specialties. This report considers the evolution of family practice as a specialty and its role in the future of health care delivery. As a specialty established less than 20 years ago, family practice has successfully surmounted several obstacles to achieve recognition within the medical community and among the public. However, the Council has identified new challenges and opportunities facing this specialty. In particular, the areas of graduate medical education, reimbursement, professional liability, and several health-related societal and ethical issues will pose challenges for and place constraints on family physicians. Family practice will encounter a number of opportunities in the evolving environment of medicine, due in part to demographic trends in the population and the growth in managed care. The Council concludes that, despite the challenges, the increasing demand for the services of family physicians has positive implications for the future of this specialty.

This report discusses some of the inherent limitations of cancer studies in animals and humans and presents a qualitative carcinogen risk assessment of a number of pesticides based on the judgment of national and international authorities who have reviewed the available experimental and epidemiologic evidence. A large number of pesticidal compounds have shown evidence of genotoxicity or carcinogenicity in animal and in vitro screening tests, but no pesticides--except arsenic and vinyl chloride (once used as an aerosol propellant)-definitely have been proved to be carcinogenic in man. Resolution 94 (1-86), which was referred to the Board of Trustees, calls for the American Medical Association, through its scientific journals and publications, to alert physicians to the potential hazards of agricultural pesticides, to provide physicians with advice on such hazards for their patients, and to urge that these substances be appropriately labeled. This report addresses the potential carcinogenicity of pesticides by review of the available literature.

Within medicine there is growing uneasiness and debate about changes in medical care delivery. Much of this concern centers on the evolution of organizations and the role of physicians. The emergence of multi-institutional organizations, the rise of investor-owned health care corporations, and the expansion of group medical practice illustrate the increasing organizational influence in medicine. Added to these trends are new financial incentives confronting both physicians and organizations so that the environment increasingly favors conflict. This article reviews the primary strategies for resolving physician-organization conflicts, including cooperation between physicians and organizations, having physician representatives in governance and management, restructuring incentives, and restructuring organizations. Although these strategies have various merits, we suggest that every physician has a personal responsibility to become more involved in organization and management issues. Physicians can play an important role in guiding the evolution of medicine.

Fish oil supplements are currently being nationally advertised, and many physicians are being queried about their clinical utility. Epidemiologic studies reveal a low incidence of cardiovascular disease in people, such as the Eskimos, who eat large amounts of seafood. Cardiovascular health may be improved because fish and fish oil supplements lower plasma lipid levels (especially triglycerides), inhibit platelet aggregation, and may decrease blood pressure and viscosity and increase high-density lipoprotein (HDL) levels. Preliminary observations also suggest a potential future role for fish oils in the treatment of some autoimmune diseases, such as atopic dermatitis, psoriasis, and rheumatoid arthritis. Patients with serum triglyceride levels greater than 5.64 mmol/L and/or cholesterol levels greater than 7.75 mmol/L refractory to dietary management may benefit from a medically supervised trial of fish oil supplements. Data currently available are insufficient to recommend fish oil supplements for the general public, or for patients with other diseases, and side effects must also be considered. These include occasional adverse lipid changes, potential for bleeding and vitamin E deficiency, and, with some preparations, vitamin A and D toxicity.

The use of the computer in medical education has been in evolutionary development since the early 1960s; its adoption, however, has been less widespread than the promise of the medium should warrant. Computer-assisted instruction enhances learning, allowing the student the discretion of content, time, place, and pace of instruction. Information conveyed can take several forms, some better suited to undergraduate medical education, others more applicable to graduate and continuing education. The use of the computer in certification and licensure could, within a decade, transform the way competence is assessed. Its greatest promise, however, may lie in providing pertinent information at the time when, and in the place where, patient care takes place. New developments in data storage and retrieval forecast applications that could not have been imagined even a year or two ago.

Fires caused by cigarettes through the ignition of upholstered furniture and mattresses are a serious public health problem, accounting for more than 1500 deaths and 7000 serious injuries per year in the United States. Fire-resistant fabrics and stuffings, public education, and smoke detectors have had a limited impact on this problem. The federal government recently has completed a three-year study of possible modifications in cigarette design. The study has demonstrated the technical feasibility of product design changes that would substantially reduce the propensity of cigarettes to ignite fires. Legislation currently is pending in Congress and in three state legislatures to mandate a cigarette fire safety standard. This legislation deserves strong support by the medical profession.

All randomized controlled trials of adjuvant therapy of colorectal cancer, published up to December 1986 in English, were reviewed. Eight trials compared radiotherapy groups with control groups in rectal cancer (3062 patients), and 17 trials compared chemotherapy groups with control groups in colorectal cancer (6791 patients). The results of trials testing radiotherapy or chemotherapy were combined. Fluorouracil-containing regimens resulted in a small benefit of therapy in terms of overall survival, with a mortality odds ratio of 0.83 in favor of therapy (95% confidence interval, 0.70 to 0.98). All other combinations of trials failed to show statistically significant differences between treated and control patients, even though the odds of death tended to be slightly lower in treated patients, especially those with rectal tumors. Some overall survival benefit from adjuvant therapy cannot be excluded, but it is likely small. Such small benefit, if real, would be far from negligible in a common case of malignancy with long survival expectancy. Trials much larger than those published up to now are needed.

Over the next few years, computer-stored medical records will become technically and economically feasible on a broad scale. Hybrid systems that include computer and traditional paper versions of the medical record and obtain their data from existing ancillary service systems will soon be widely available. Completely electronic medical records will follow. However, standards for exchanging clinical information between independent computers are needed to eliminate the reentry or interfacing costs otherwise required to obtain data from computerized ancillary services. Three kinds of benefits may be expected: (1) improved logistics and organization of the medical record to speed care and improve care givers' efficiency, (2) automatic computer review of the medical record to limit errors and control costs, and (3) systematic analysis of past clinical experience to guide future practices and policies.

Recent improvements in the clinical care of individual patients are rooted in advances in two distinct fields of modern medicine: biomedical research and clinical ethics. In this article, we review the differing roles of these two disciplines in guiding decision making for individual patients. Particular attention is placed on decisions involving risk factor intervention, using the common problem of mild hypertension as an illustration. Both the importance and the limitations for decision making of some recently published clinical trials are reviewed. Differences in interpretation of these trials are a source of major disputes about the proper threshold for medical intervention. The ethical aspects of treatment decisions are then reviewed, with particular emphasis on the doctrine of informed consent and on the role of patient participation in treatment decisions. Finally, new directions for clinical research are suggested that may yield a more complete scientific basis for treatment decisions and that may aid in fulfilling the ethical ideals that underlie the physician-patient relationship.

Attempts to explain wound ballistics (the study of effects on the body produced by penetrating projectiles) have only succeeded in mystifying it. This review explains the projectile-tissue interaction and presents data showing the location, type, and amount of tissue disruption characteristically produced by various projectiles. Data on tissue disruption are presented graphically as wound profiles. The major misconceptions in the field are listed, analyzed, and disentangled. Failure in adhering to the basic precepts of scientific method is the common denominator in all of the listed misconceptions; the result has been diversion of attention from the element essential to understanding and properly treating the gunshot wound--objective evaluation of the wound itself.

We present a review of the international literature on the medical and psychological effects of torture. Our review reveals that certain tortures and their physical and emotional sequelae are more prevalent than previously appreciated. They include the common occurrence of sexual violence during the torture of women and female adolescents and the high frequency of head injury and associated neuropsychiatric consequences. We recommend the use of standardized diagnostic criteria in the evaluation of patients who have survived torture; this will facilitate patient care and the documentation of human rights violations.

Recent studies have linked regular physical activity with reduced likelihood of developing coronary heart disease. Even low- and moderate-intensity exercise such as walking, when carried out consistently, is associated with important cardiovascular health benefits. Walking has also been shown to reduce anxiety and tension and aid in weight loss. Regular walking may help improve cholesterol profile, help control hypertension, and slow the process of osteoporosis. Recent physiological studies have demonstrated that brisk walking provides strenuous enough exercise for cardiovascular training in most adults. A recently developed submaximal 1-mile walk test provides a simple and accurate means for estimating aerobic capacity and guiding exercise prescription. These new insights and tools will assist the clinician in the prescription of safe and effective walking programs.