Science, Practice, and the Reform of American Medical Education

180 p.Thesis (Ph.D.)--University of Illinois at Urbana-Champaign, 1988.Tension has been often felt between science and practice in practical occupations undergirded by science. The reform of medical education in America provided an occasion for the working out of this tension in medicine. In early nineteenth century American medicine the two sides of this divide were represented by followers of the Paris Clinical School and by advocates of the doctrine of specificity. The influence of these two opposite approaches to medical thinking and practice were reflected in the early debates between the Harvard medical faculty and the AMA over educational reform in the 1840s and 50s; and in the debates at Harvard over the Eliot reforms of 1871. The actual measures taken in the 70s and 80s at Harvard and elsewhere, however, did not constitute victory for either side of the controversy. Reform measures that palpably followed from a reductionist viewpoint were propounded only in the 1890s and after by militant basic scientists influenced by German laboratory research. The objections made to such measures by clinicians representing various shades of anti-reductionist opinion bore many similarities to those raised by earlier opponents of less tendentious reforms at midcentury. The eventual outcome of reform battles at Harvard and other medical schools in the late teens and 1920s cannot fairly be characterized as a straight forward victory for the reductionist scientists over practitioners. The basic scientists were able to transform medicine's fundamental branches according to their distinctive view of medical practice as the unproblematic application of their own disciplines. In the clinical branches and in other matters of medical school policy they were forced to compromise with their clinician opponents. Still less can reform be seen as a simple triumph of "science" over obscurantism. Most of those on either side of the debate favored the high standards, active teaching and larger role for research that were increasingly realized in elite medical schools by 1920.U of I OnlyRestricted to the U of I community idenfinitely during batch ingest of legacy ETD

Effect of general anaesthesia on functional outcome in patients with anterior circulation ischaemic stroke having endovascular thrombectomy versus standard care: a meta-analysis of individual patient data

Background: General anaesthesia (GA) during endovascular thrombectomy has been associated with worse patient outcomes in observational studies compared with patients treated without GA. We assessed functional outcome in ischaemic stroke patients with large vessel anterior circulation occlusion undergoing endovascular thrombectomy under GA, versus thrombectomy not under GA (with or without sedation) versus standard care (ie, no thrombectomy), stratified by the use of GA versus standard care. Methods: For this meta-analysis, patient-level data were pooled from all patients included in randomised trials in PuMed published between Jan 1, 2010, and May 31, 2017, that compared endovascular thrombectomy predominantly done with stent retrievers with standard care in anterior circulation ischaemic stroke patients (HERMES Collaboration). The primary outcome was functional outcome assessed by ordinal analysis of the modified Rankin scale (mRS) at 90 days in the GA and non-GA subgroups of patients treated with endovascular therapy versus those patients treated with standard care, adjusted for baseline prognostic variables. To account for between-trial variance we used mixed-effects modelling with a random effect for trials incorporated in all models. Bias was assessed using the Cochrane method. The meta-analysis was prospectively designed, but not registered. Findings: Seven trials were identified by our search; of 1764 patients included in these trials, 871 were allocated to endovascular thrombectomy and 893 were assigned standard care. After exclusion of 74 patients (72 did not undergo the procedure and two had missing data on anaesthetic strategy), 236 (30%) of 797 patients who had endovascular procedures were treated under GA. At baseline, patients receiving GA were younger and had a shorter delay between stroke onset and randomisation but they had similar pre-treatment clinical severity compared with patients who did not have GA. Endovascular thrombectomy improved functional outcome at 3 months both in patients who had GA (adjusted common odds ratio (cOR) 1·52, 95% CI 1·09–2·11, p=0·014) and in those who did not have GA (adjusted cOR 2·33, 95% CI 1·75–3·10, p<0·0001) versus standard care. However, outcomes were significantly better for patients who did not receive GA versus those who received GA (covariate-adjusted cOR 1·53, 95% CI 1·14–2·04, p=0·0044). The risk of bias and variability between studies was assessed to be low. Interpretation: Worse outcomes after endovascular thrombectomy were associated with GA, after adjustment for baseline prognostic variables. These data support avoidance of GA whenever possible. The procedure did, however, remain effective versus standard care in patients treated under GA, indicating that treatment should not be withheld in those who require anaesthesia for medical reasons