Correlates of young physicians' support for unionization to maintain professional influence.

PURPOSE: A resolution in support of physicians' unionization was recently approved by the American Medical Association's House of Delegates. This study investigated the factors associated with young physicians' approval of unionization. METHOD: A survey was mailed to all 1987-1992 Jefferson Medical College graduates (n = 1,272); 835 (66%) responded. RESULTS: Of the respondents, 43% supported unionization, 31% did not support unionization, and 26% expressed no opinion. Surgeons, medical subspecialists, pediatricians, and hospital-based specialists were more likely to support unionization than were family physicians. Significant predictors of support for unionization were negative views of the changes in the health care system, negative perceptions of the quality of care provided by managed care, the belief that physicians' independence had been impaired by changes in the health care system, and the belief that physicians' personal satisfaction should take precedence over societal needs in determining the future of health care. Support for unionization correlated with physicians' perceptions that mental health patients should be referred to psychiatrists, physician-assisted suicide should be legalized, and the involvement of nurse practitioners in diagnosis and treatment could compromise the quality of care. CONCLUSIONS: Young physicians' support for unionization is a function of frustration with market-driven policies that compromise the quality of care and negatively affect physicians' autonomy and personal satisfaction.

Chaperone use by residents during pelvic, breast, testicular, and rectal exams.

We designed a questionnaire survey to study internal medicine residents' plans to use a chaperone during the pelvic, breast, rectal, and testicular examinations. We found chaperone use by male and female residents differed markedly, and neither group planned to use chaperones universally. When examining female patients, male residents overall were very likely to use a chaperone during a pelvic exam, but less likely for the breast exam and rectal exam. For the female resident, there was a significantly lower likelihood of using chaperones during the pelvic, breast, or rectal exams. There was a much lower rate of chaperone use during the sensitive portions of the male physical examination compared with the female examination, with somewhat higher use by female residents. We concluded that male and female residents differ significantly in their patterns of chaperone use. It would be valuable to develop guidelines for chaperone use to help residents understand the issues involved in the choices, and to protect the residents from the possible medico-legal consequences of forgoing chaperones.

Accelerated progression of chronic renal insufficiency after parathyroidectomy.

Three patients with chronic renal failure developed secondary hyperparathyroidism, complicated by severe bone disease in two patients and by acral skin necrosis in the third. Following subtotal parathyroidectomy, the bone disease and the necrotic lesions rapidly improved, but the rate of loss of renal function accelerated concomitant with administration of calcium and vitamin D, although no hypercalcemia developed. Avoiding postoperative administration of calcium and/or vitamin D, unless indicated for symptomatic hypocalcemia, may prevent accelerated loss of renal function in patients requiring subtotal parathyroidectomy.

Metabolic effects of L-phenyllactate in perfused kidney, liver, and muscle.

L-Phenyllactate (L-PL) can promote growth of normal and germ-free rats eating a phenylalanine (Phe)-free diet, but the sites and pathway of its conversion to Phe have not been extensively studied. We perfused rat kidneys, livers, and hindquarters with L-PL and measured Phe release and effects on organ function. Renal release of Phe the during perfusion with L-PL was 3.0 times control (P less than 0.001) and increased 2.5-fold with addition of glutamine (P less than 0.001); with phenylpyruvate (PP), it was 3.5 times control (P less than 0.001). Sixty-four percent of L-PL disappearance could be accounted for by appearance of PP and Phe. Although renal gluconeogenesis from lactate was inhibited 28% by L-PL, neither glomerular filtration rate (0.44 ml . min-1 . g wet weight-1) nor sodium reabsorption (94.3%) were impaired. There was no net release of Phe or PP by rat livers or hindquarters perfused with L-PL and hepatic gluconeogenesis, urea synthesis, and potassium balance were unaffecte by L-PL. Thus, the kidney, but not skeletal muscle or liver, converts L-PL to Phe, presumably by the pathway L-PL leads to PP leads to Phe. In acute experiments with isolated organs, L-PL does not cause significant renal or hepatic dysfunction.

Evidence for luminal uptake of gentamicin in the perfused rat kidney.

Gentamicin nephrotoxicity is preceded by proximal tubular accumulation of the drug. To determine whether gentamicin enters cells from the peritubular surface or from the tubular lumen after filtration, we studied filtering and non-filtering isolated perfused rat kidneys. Filtering kidneys were perfused with 6 g/dl of albumin, non-filtering kidneys with 11 g/dl of albumin and a lower perfusion pressure after ureteral occlusion. Accumulation of [14C]gentamicin in filtering or non-filtering kidneys was compared to that of [14C]cephaloridine, which is taken up primarily at the antiluminal cell surface. Renal accumulation of gentamicin was approximately 4 times greater in filtering than in non-filtering kidneys after 1 hr of perfusion. In contrast, accumulation of [14C]cephaloridine was 38% greater in the non-filtering model. Gentamicin did not significantly change sodium reabsorption or glomerular filtration rate during the 60-min study. Fractional potassium excretion, however, was slightly but significantly increased by perfusion with gentamicin. Our results indicate that 1) renal tubular gentamicin uptake is primarily by filtration and subsequent reabsorption and 2) the non-filtering and filtering isolated perfused rat kidney may be used to investigate mechanisms of renal accumulation of other nephrotoxic agents.