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BACKGROUND: Reflective practice is associated with improved accuracy of medical diagnosis and superior performance in complex situations. Systematic observation of trainees’ reflective capacities constitutes a basis for an effective support of reflective practice within the training paradigm. We set out to examine the reflective capacity among anesthesiology trainees in a tertiary referral hospital. METHODS: We invited 61 anesthesiology trainees in Cork University Hospitals, Ireland, to participate. Each trainee was invited to respond to 2 investigator-written vignettes prepared by the investigators and suitable for evaluation using the Reflection Evaluation for Learners’ Enhanced Competencies Tool (REFLECT) and to produce and then respond to a written vignette based on their own experience. All responses were assessed by 2 independent assessors who had undergone training in the application of the REFLECT rubric, which gives quantifiable scores. Interrater reliability was assessed by weighted kappa coefficient. Association between years of training in medicine and level of reflective capacity was examined using correlation and multiple regression analyses, controlling for age. RESULTS: Twenty-nine trainees agreed to participate, the overall REFLECT Level was 2.16 (SD 0.7), corresponding to “thoughtful action,” indicating low to moderate reflective ability. Cronbach’s alpha for the 5 items of the REFLECT scale was excellent (r = 0.92). Weighted kappa was very satisfactory (k = 0.81). A strong association was demonstrated between years in medicine and scores on REFLECT, controlling for age of participant (F = −2.57, Beta coefficient = −0.30). Respondents with less experience had greater mean REFLECT scores than respondents with more experience (F = 5.5, P = .02; post hoc mean difference = 0.7, P = .03 for ≤32 months vs ≥99 months). There was a significant effect for gender (t = −4.3, P = .001), with women’s responses receiving greater REFLECT scores than men’s responses (mean difference = 0.67, P = .001). CONCLUSIONS: Overall, participants demonstrated low to moderate reflective capacity, as assessed by the REFLECT rubric. Reflective capacity of the anesthesiology trainees appears to decrease as years of medical training progress. However, our respondents were not sampled over time to fully support this conclusion. Further research is needed on the psychometric properties of the REFLECT rubric and the generalizability of our findings.

Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background Compassionate behavior in clinicians is described as seeking to understand patients’ psychosocial, physical and medical needs, timely attending to these needs, and involving patients as they desire. The goal of our study was to evaluate compassionate behavior in patient interactions, pain management, and the informed consent process of anesthesia residents in a simulated preoperative evaluation of a patient in pain scheduled for urgent surgery. Methods Forty-nine Clinical Anesthesia residents in year 1 and 16 Clinical Anesthesia residents in year 3 from three residency programs individually obtained informed consent for anesthesia for an urgent laparotomy from a standardized patient complaining of pain. Encounters were assessed for ordering pain medication, for patient-resident interactions by using the Empathic Communication Coding System to code responses to pain and nausea cues, and for the content of the informed consent discussion. Results Of the 65 residents, 56 (86%) ordered pain medication, at an average of 4.2 min (95% CI, 3.2 to 5.1) into the encounter; 9 (14%) did not order pain medication. Resident responses to the cues averaged between perfunctory recognition and implicit recognition (mean, 1.7 [95% CI, 1.6 to 1.9]) in the 0 (less empathic) to 6 (more empathic) system. Responses were lower for residents who did not order pain medication (mean, 1.2 [95% CI, 0.8 to 1.6]) and similar for those who ordered medication before informed consent signing (mean, 1.9 [95% CI, 1.6 to 2.1]) and after signing (mean, 1.9 [95% CI, 1.6 to 2.0]; F (2, 62) = 4.21; P = 0.019; partial η2 = 0.120). There were significant differences between residents who ordered pain medication before informed consent and those who did not order pain medication and between residents who ordered pain medication after informed consent signing and those who did not. Conclusions In a simulated preoperative evaluation, anesthesia residents have variable and, at times, flawed recognition of patient cues, responsiveness to patient cues, pain management, and patient interactions.

BackgroundObtaining reliable and valid information on resident performance is critical to patient safety and training program improvement. The goals were to characterize important anesthesia resident performance gaps that are not typically evaluated, and to further validate scores from a multiscenario simulation-based assessment.MethodsSeven high-fidelity scenarios reflecting core anesthesiology skills were administered to 51 first-year residents (CA-1s) and 16 third-year residents (CA-3s) from three residency programs. Twenty trained attending anesthesiologists rated resident performances using a seven-point behaviorally anchored rating scale for five domains: (1) formulate a clear plan, (2) modify the plan under changing conditions, (3) communicate effectively, (4) identify performance improvement opportunities, and (5) recognize limits. A second rater assessed 10% of encounters. Scores and variances for each domain, each scenario, and the total were compared. Low domain ratings (1, 2) were examined in detail.ResultsInterrater agreement was 0.76; reliability of the seven-scenario assessment was r = 0.70. CA-3s had a significantly higher average total score (4.9 ± 1.1 vs. 4.6 ± 1.1, P = 0.01, effect size = 0.33). CA-3s significantly outscored CA-1s for five of seven scenarios and domains 1, 2, and 3. CA-1s had a significantly higher proportion of worrisome ratings than CA-3s (chi-square = 24.1, P < 0.01, effect size = 1.50). Ninety-eight percent of residents rated the simulations more educational than an average day in the operating room.ConclusionsSensitivity of the assessment to CA-1 versus CA-3 performance differences for most scenarios and domains supports validity. No differences, by experience level, were detected for two domains associated with reflective practice. Smaller score variances for CA-3s likely reflect a training effect; however, worrisome performance scores for both CA-1s and CA-3s suggest room for improvement.

Dorsal penile nerve block is a widely used method of analgesia for infants undergoing penile surgery. Because of its potency, extended duration of action, and lack of vasoconstriction, bupivacaine remains the most commonly used local anesthetic. Rapid systemic absorption of bupivacaine, however, has been associated with profound central nervous system and cardiovascular side effects, including cardiac arrest. As determined by retrospective medical record analysis, the incidence of complications associated with dorsal penile blockade in our institution was 0.075%. This was significantly higher than previously reported prompting a change in institutional policy that has eliminated penile block complications.

Background/objectivesLeadership at all levels of a large children's hospital embraced the implementation of a standardized communication process, including techniques of assertion, closed-loop communication, and a situation briefing model organization-wide.Implementation/methodsKey administrative and clinical leaders underwent training in the techniques of the ‘Clarity in Communication’ initiative. The initiative was piloted in targeted areas of the organization over 6 months. The final model for training staff and evaluation of the initiative occurred hospital-wide over an additional 18 months. Evaluation focused on the use of a standardized communication strategy across the organization, including direct observation and survey techniques.ResultsFrom October 2006 to January 2008, more than 6500 interdisciplinary staff received training. Four hundred and fifty-six observations of the standardized communication processes were recorded, with 68% of the observations occurring during patient rounds an...

This article reviews medical team training using the principles of crew resource management (CRM). It also briefly discusses crisis resource management, a subset of CRM, as applied to high-acuity medical situations. Guidelines on setting up medical team training programs are presented. Team training programs are classified and examples of simulation-based and classroom-based programs are offered and their merits discussed. Finally, a brief look at the future of team training concludes this review article.

Objective: Simulation is a tool that has been used successfully in many high performance fields to permit training in rare and hazardous events. Our goal was to develop and evaluate a program to teach airway crisis management to otolaryngology trainees using medical simulation. Methods: A full-day curriculum in the management of airway emergencies was developed. The program consists of three airway emergency scenarios, developed in collaboration between attending otolaryngologists and faculty from the Center for Medical Simulation. Following each scenario, the participants are led in a structured, video-assisted debriefing by a trained debriefer. Didactic material on team leadership and crisis management is built into the debriefings. Pediatric otolaryngology fellows, residents, and medical students have participated in the four courses that have been held to date. Participants evaluated the program on a five-point Likert scale. Results: A total of 17 trainees participated in four pilot training courses. The survey data are as follows: overall program, 5.0 (SD, 0.00); course goals, 4.79 (SD, 0.43); realism, 4.36 (SD, 0.63); value of lecture, 4.71 (SD, 0.47); and quality of debriefings, 4.92 (SD, 0.28). Sample comments include: “This is a valuable tool for students and residents since true emergencies in ORL are often life-threatening and infrequent,” and “This is a great course—really all physicians should experience it.” Overall evaluation was extremely positive and both residents and fellows described the course as filling an important void in their education. Conclusion: Medical simulation can be an extremely effective method for teaching airway crisis management and teamwork skills to otolaryngology trainees at all levels.

Background: Valid methods are needed to identify anesthesia resident performance gaps early in training. However, many assessment tools in medicine have not been properly validated. The authors designed and tested use of a behaviorally anchored scale, as part of a multiscenario simulation-based assessment system, to identify high- and low-performing residents with regard to domains of greatest concern to expert anesthesiology faculty. Methods: An expert faculty panel derived five key behavioral domains of interest by using a Delphi process (1) Synthesizes information to formulate a clear anesthetic plan; (2) Implements a plan based on changing conditions; (3) Demonstrates effective interpersonal and communication skills with patients and staff; (4) Identifies ways to improve performance; and (5) Recognizes own limits. Seven simulation scenarios spanning pre-to-postoperative encounters were used to assess performances of 22 first-year residents and 8 fellows from two institutions. Two of 10 trained faculty raters blinded to trainee program and training level scored each performance independently by using a behaviorally anchored rating scale. Residents, fellows, facilitators, and raters completed surveys. Results: Evidence supporting the reliability and validity of the assessment scores was procured, including a high generalizability coefficient (ρ2 = 0.81) and expected performance differences between first-year resident and fellow participants. A majority of trainees, facilitators, and raters judged the assessment to be useful, realistic, and representative of critical skills required for safe practice. Conclusion: The study provides initial evidence to support the validity of a simulation-based performance assessment system for identifying critical gaps in safe anesthesia resident performance early in training.

Although former preterm birth infants are at risk for postoperative apnea after surgery, it is unclear whether the same is true of full-term birth infants. We evaluated the incidence of apnea in 60 full-term neonates and infants undergoing pyloromyotomy both before and after anesthesia. All subjects were randomized to a remifentanil- or halothane-based anesthetic. Apnea was defined by the presence of prolonged apnea (>15 s) or frequent brief apnea, as observed on the pneumocardiogram. Apnea occurred before surgery in 27% of subjects and after surgery in 16% of subjects, with no significant difference between subjects randomized to remifentanil or halothane anesthesia. This apnea was primarily central in origin, occurred throughout the recording epochs, and was associated with severe desaturation in some instances. Of the subjects with normal preoperative pneumocardiograms, new onset postoperative apnea occurred in 3 (23%) of 13 subjects who received halothane-based anesthetics versus 0 (0%) of 22 subjects who received remifentanil-based anesthetics (P = 0.04). Thus, postoperative apnea can follow anesthesia in otherwise healthy full-term infants after pyloromyotomy and is occasionally severe with desaturation. New-onset postoperative apnea was not seen with a remifentanil-based anesthetic.

Pyloric stenosis is sometimes associated with hemodynamic instability and postoperative apnea. In this multicenter study we examined the hemodynamic response and recovery profile of remifentanil and compared it with that of halothane in infants undergoing pyloromyotomy. After atropine, propofol, and succinylcholine administration and tracheal intubation, patients were randomized (2:1 ratio) to receive either remifentanil with nitrous oxide and oxygen or halothane with nitrous oxide and oxygen as the maintenance anesthetic. Pre- and postoperative pneumograms were done and evaluated by an observer blinded to the study. Intraoperative hemodynamic data and postanesthesia care unit (PACU) discharge times, PACU recovery scores, pain medications, and adverse events (vomiting, bradycardia, dysrhythmia, and hypoxemia) were recorded by the study's research nurse. There were no significant differences in patient age or weight between the two groups. There were no significant differences in hemodynamic values between the two groups at the various intraoperative stress points. The extubation times, PACU discharge times, pain medications, and adverse events were similar for both groups. No patient anesthetized with remifentanil who had a normal preoperative pneumogram had an abnormal postoperative pneumogram, whereas three patients with a normal preoperative pneumogram who were anesthetized with halothane had abnormal pneumograms after.The use of ultra-short-acting opioids may be an appropriate technique for infants less than 2 mo old when tracheal extubation after surgery is anticipated.

This report describes how realistic patient simulation can be used with video teleconferencing to conduct long-distance clinical case discussions with realistic re-enactments of critical events. By observing what appears to be a real procedure unfolding in real time, it is intended that audience members will better learn and appreciate the lessons from conferences. A commercially available mannequin simulator and video teleconferencing technology were used in nine sessions between a free-standing simulation center and different conference sites throughout the U.S. Transmission was via high-speed telephone lines. In each conference, a clinical scenario was simulated on a screen. Audience members asked questions of a live simulated "patient" and family and later advised the care team on routine treatments and management of urgent clinical problems that arose during management of the mannequin simulator in a highly realistic clinical setting. Ninety-eight percent of respondents from one audience of 150 (response rate 60%) judged the quality of the presentation as "very good or excellent." In response to the statement that "the educational value of the presentation was much greater than that of a standard case conference," 95% scored 4 or 5 on a five-point Likert scale (where 5 is highest agreement). While all conferences were conducted successfully, there were instances of technical challenge in using teleconferencing technology. Technical information about the teleconferencing system and scenario preparation, contingency planning for failures, and other details of using this new teaching modality are described. Although audiences were enthusiastic in their response to this approach to clinical case conferences, further study is needed to assess the added value of interactive simulation for education compared to standard conference formats.

Intergovernmental bodies, governments, agencies, commercial and philanthropic institutions, when deciding whether or not to invest in low income nations where there is developmental uncertainty, do not now include formal appraisals of investment risk as including economic crime and its milieu correlates. Informal evaluations seem common, but appear to be hazarded by psychosocial and methodological processes and problems of which conventional decision makers are probably not aware. The authors consider these cognitive, group information processing and data adequacy hazards, and seek to examine investment risk as it relates to published reports bearing on economic crime and associated factors. The inadequacy of current data and assumptions is emphasised. Bulgaria is the illustrative case of poor data misinterpreted, eg the role of the underground economy, of careless ‘master trait’ summary reporting, and thus of exaggerated uncertainty for investment. Because the undertakings of the newly elected Bulgarian Government affirm the principles of loan recipient soundness long demanded by the IMF, now the criterion for World Bank loans, there is reason to believe Bulgaria will increasingly be viewed as a candidate for investment and Western European integration. Nevertheless economic crime and its associated features pose a measurement and forecast weighting challenge as ‘intangibles’. It is the better definition and more rigorous measurement of these, and avoidance of distorting information‐transmitting events which can exaggerate error, which remains to be done. Hard criminological evidence supporting confidence exists, for examination of earlier crime rates shows a society with low crime rates, such that current transitional fraud and violence may be but anomalies. Further, by assigning arbitrary positive values to cultural history and current governmental intentions, it may be concluded, that given evidence of modernisation of regulations and massive police reform, and a necessary speed in instituting change, development growth is likely. The authors are themselves, like most forecasting institutions, cautiously optimistic about the investment potential of Bulgaria. They nevertheless counsel that decision makers ignore at their peril the dangers in any low income country of crime and its correlated milieu.

As part of the work of the Symposium a workshop was convened to consider the potential role of, and issues arising from, the expansion of previously political intelligence agencies into fighting international, organised economic (entrepreneurial) crime.

Offered here is a brief introduction to art and cultural heritage loss. The focus is on ‘crime’ so that ‘loss’ in fact means someone's gain. Nevertheless as is common in characterising international enterpreneurial activity, there may be little common ground on definitions of art and of crime, or willingness to be signatory to existing international treaties. Consider, for example, the failure of Japan and Western European nations, as archaeological treasure consuming—displaying nations to sign the UNESCO Convention intended to protect cultural heritages. Currently American readers learn that Turkey is acting under US civil law to recover its treasures from US collections. One, the Lydian Hoard, has just been returned by the NY Metropolitan Museum. But many legal battles lie ahead for Turkey, and, the list here is but illustrative, for Greece, Czechoslovakia, Russia, Hungary, Germany, the USA and UK, as nations fight over what came from where and belongs to whom. Also contested, what is the public versus private interest to be protected?

BACKGROUND: Safety climate is often measured via surveys to identify appropriate patient safety interventions. The introduction of an insurance premium incentive for simulation-based anesthesia crisis resource management (CRM) training motivated our naturalistic experiment to compare the safety climates of several departments and to assess the impact of the training. METHODS: We administered a 59-item survey to anesthesia providers in six academic anesthesia programs (Phase 1). Faculty in four of the programs subsequently participated in a CRM program using simulation. The survey was readministered 3 yr later (Phase 2). Factor analysis was used to create scales regarding common safety themes. Positive safety climate (% of respondents with positive safety attitudes) was computed for the scales to indicate the safety climate levels. RESULTS: The usable response rate was 44% (309/708) and 38% (293/772) in Phases 1 and 2 respectively. There was wide variation in response rates among hospitals and providers. Eight scales were identified. There were significantly different climate scores among hospitals but no difference between the trained and untrained cohorts. The positive safety climate scores varied from 6% to 94% on specific survey questions. Faculty and residents had significantly different perceptions of the degree to which residents are debriefed about their difficult clinical situations. CONCLUSIONS: Safety climate indicators can vary substantially among anesthesia practice groups. Scale scores and responses to specific questions can suggest practices for improvement. Overall safety climate is probably not a good criterion for assessing the impact of simulation-based CRM training. Training alone was insufficient to alter engrained behaviors in the absence of further reinforcing actions.

Background Human error and system failures continue to play a substantial role in adverse outcomes in health care. Anaesthesia crisis resource management addresses many patient safety issues by teaching behavioural skills for critical events but it has not been systematically utilized to teach experienced faculty. Methods An anaesthesia crisis resource management course was created for the faculty of our medical school's anaesthesia teaching programmes. The course objectives were to understand and improve participants' proficiency in crisis resource management (CRM) skills and to learn skills for debriefing residents after critical events. Through surveys, measurement objectives assessed acceptance, utility and need for recurrent training immediately post-course. These were measured again approximately 1 year later along with self-perceived changes in the management of difficult or critical events. Results The highly rated course was well received in terms of overall course quality, realism, debriefings and didactic presentation. Course usefulness, CRM principles, debriefing skills and communication were highly rated immediately post-course and 1 year later. Approximately half of the faculty staff reported a difficult or critical event following the course; of nine self-reported CRM performance criteria surveyed all claimed improvement in their CRM non-technical skills. Conclusions A unique and highly rated anaesthesia faculty course was created; participation made the faculty staff eligible for malpractice premium reductions. Self-reported CRM behaviours in participants' most significant difficult or critical events indicated an improvement in performance. These data provide indirect evidence supporting the contention that this type of training should be more widely promoted, although more definitive measures of improved outcomes are needed.

The causes of obstruction to airflow in the pediatric upper airway include craniofacial disorders, subglottic stenosis, choanal atresia, syndromes associated with neuromuscular weakness, and the most common, hypertrophy of the tonsils and adenoids. Abnormal breathing can adversely affect craniofacial growth, and abnormal craniofacial development can promote upper airway obstruction. Chronic upper airway obstruction often presents with evidence of obstructive sleep apnea syndrome; in severe cases these children also present with pulmonary hypertension and cor pulmonale. The development of pulmonary hypertension and right heart dysfunction from chronic upper airway obstruction is complex. Hypoxemia and hypercarbia-induced respiratory acidosis are potent mediators of pulmonary vasoconstriction that can lead to reversible and irreversible chronic changes in the pulmonary vasculature. It is likely that production of various neurohumoral factors in response to hypoxemia and respiratory distress may further promote pulmonary hypertension, right ventricular dysfunction, and consequent impairment of systemic cardiac output. The anesthetic considerations for children undergoing adenotonsillectomy for chronic airway obstruction are significant. These children are at high risk for complications such as laryngospasm, desaturation, stimulation of pulmonary hypertension and cardiac dysfunction, pulmonary edema, postoperative upper airway obstruction, and respiratory arrest. Because of underlying condition(s) (facial abnormalities, neuromuscular disease, etc.), successful adenotonsillar surgery may not improve upper airway obstruction significantly, especially in the immediate postoperative period when edema, bleeding and the effects of anesthetics and analgesics are present.

Computerized realistic simulation technology has been used as a training tool in fields such as aviation and military training and in the nuclear power industry. More recently, it has been adapted for use in anesthesia crisis resource management. We describe the effectiveness of a simulation program like that used by anesthesiology departments that we developed to teach radiologists the principles of crisis management.A mock CT scanner and patient simulator were used to simulate the environment in which radiologists encounter crises. Twenty-four residents attended the training program, four at each half-day session. Two responded to and two observed an initial crisis, after which they attended a lecture and watched a videotape review. The second pair then participated in a different crisis scenario. The scenario order was randomized. All scenarios were videotaped and randomly reviewed by two physicians not involved with the course. The following behavioral qualities of the participating residents were evaluated using a five-point scale, ranging from poor (1) to excellent (5): global assessment, communication skills, use of support personnel, use of resources, and role clarity. Residents then rated the course on a five-point scale using the following criteria: overall course usefulness, attainment of course goals, realism of scenarios, quality of lecture, and quality of videotape review.The trainees who had attended the lecture and watched the videotape review before participating in a scenario consistently scored higher than those who had not in the following areas (score after training/score before training): global assessment, 4.08/2.50; communication skills, 4.09/2.67; use of support personnel, 4.17/3.00; use of resources, 4.00/2.92; and role clarity, 4.17/2.67. Moreover, the participants gave the course the following average ratings: overall usefulness, 4.93; attainment of course goals, 4.78; realism of scenarios, 4.63; quality of lecture, 4.63; and quality of videotape review, 4.85.Although the critical assessment of a teaching method is difficult and subjective by nature, the improvement in behavioral performance scores suggests that simulation technology effectively conveyed the principles of crisis management. The course ratings show that the program was well accepted by participants.

The following document is both a critique of current American policy toward drug abuse and alcoholism and more important, a statement of recommended national policy for the future. It was prepared by Dr. Richard H. Blum on behalf of the Study Groups on Drug Abuse and Alcoholism of the Advisory Council of Elected Officials of the Democratic National Committee. The paper was twice reviewed by members of the Study Group, whose names and affiliations are attached. The Advisory Council of Elected Officials was intended to be a policy recommending body for the Democratic Party and is the successor to the Policy Council of the Democratic National Committee. In February, 1976, the paper was presented to the Democratic Platform Committee as an official recommendation of the Study Group. In July, 1976, a condensed version of the paper was inserted in the Congressional Record by Congressman Scheuer of New York (122 Cong. Rec. Daily Ed., p.p. H 7973–7980, July 29, 1976) during the floor debate preceding creation of the House Select Committee on Narcotics Abuse and Control, with the recommendation that the paper contained issues and directions worthy of the Select Committee's attention. The paper was subsequently revised for incorporation into the Fall, 1976 theme issue of the Journal of Drug Issues entitled, “Drug Issues: Reprospective and Prospective, Part I.” The editors believe that the article is particularly relevant to the current theme. Its recommendations remain well worth consideration by policy makers seeking more rational and effective measures to confront drug use and alcoholism.

This article examines some of the psychological processes that occur in work on contemporary biography, particularly in the interaction between biographer and subject or informant. The author emphasizes similarities between biographical work and scientific procedures in the study of personality and behavior. He describes the characteristics of the biographical interview and potential sources of error in the interview and in the biographer's structuring and interpretation. The author views the work of biography as a set of iterative steps through which the biographer and his informants achieve an approximation of truth.

This is a report of an experiment in drug education which took place over two years among entering 6th graders in five suburban California schools. Five types or modes of drug education were compared for their impact on non-medical psychoactive drug use. The study derived its rationale from our prior longitudinal evaluation of educational impact (Blum, Blum and Garfield, 1976). The present study had, as additional objectives, the replication of the prior study for 6th graders and a follow-up of students from the prior study to see if educational effects on drug use were maintained over the total four year period. Teacher substudies were also made.

The following document is both a critique of current American policy toward drug abuse and alcoholism and more important, a statement of recommended national policy for the future. It was prepared by Dr. Richard H. Blum on behalf of the Study Groups on Drug Abuse and Alcoholism of the Advisory Council of Elected Officials of the Democratic National Committee. The paper was twice reviewed by members of the Study Group, whose names and affiliations are attached. The Advisory Council of Elected Officials was intended to be a policy recommending body for the Democratic Party and is the successor to the Policy Council of the Democratic National Committee. In February, 1976, the paper was presented to the Democratic Platform Committee as an official recommendation of the Study Group. In July, 1976, a condensed version of the paper was inserted in the Congressional Record by Congressman Scheuer of New York (122 Cong. Rec. Daily Ed., p.p. H 7973–7980, July 29, 1976) during the floor debate preceding creation of the House Select Committee on Narcotics Abuse and Control, with the recommendation that the paper contained issues and directions worthy of the Select Committee's attention.

In this very personal article the author shares with us some of the lessons he has learned about drugs, drug abuse research and people during the course of his career in drug abuse research and in living among us.

Fifty California legislators holding committee posts important for drug legislation were interviewed. Goals were to elicit legislator conceptions of the effects and aims of drug legislation on behavior, to assess their views of public opinion on drug problems and their own reactions to controversial proposals for new laws, and to determine opinions of behavioral science and scientists as information sources for new legislation. Expressed views were related to party affiliation, liberalism-conservatism, and philosophical position. Half of the legislators said the behavioral sciences had too little information to give; one fifth rejected such research as useless or undesirable. The majority were critical of behavioral scientists, including psychiatrists, and gave little credence to their opinions. Interview rating of positions on drug issues correlated .91 with voting records on other issues rated as liberal or conservative. All liberals were Democrats; most conservatives were Republicans. Philosophical positions, rated as moral absolutism versus pragmatism, were related to political stance; but philosophy was a better predictor of acceptance or rejection of behavioral science than was political stance.

A review of historical patterns in drug use suggests common forms of use, likely social responses to innovation, the conditions under which drug use patterns change and the notion of “abuse” is most probable, and the conditions under which most unpredictable drug use and outcomes will occur. Examination of contemporary patterns of use yields evidence of a number of trends, one of which is the growth of use of quieting rather than stimulating substances in America. Although the major function of drugs is and will be to enhance sociability, the prediction is that our society will produce more redundant people who will be at risk of disabling use and effects. Several possible sociopolitical outcomes of these trends are considered, some optimistic and some pessimistic. The importance, for anticipating the future, of the existence of a sense of destiny is suggested.

The difficulty of assessing the effects of mind- altering drugs on human behavior, especially conduct in real-life situations, is discussed. Problems in classification of drugs are also noted; it is emphasized that assumed drug effects are, at best, statements of probability. In considering crimes associated with drug use, it is necessary to distinguish between crimes based on drug use itself, which include all offenses for illicit acquisition, possession, and use of dangerous drugs and narcotics, and dangerous behavior resulting from use. The evidence is clearest for alcohol, revealing a distinct relationship between alcohol use and health hazard, suicide, accidents, and violence. The evidence is less clear for heroin, since most users are delinquent prior to being identified as "addicts" so that continued criminality after heroin use cannot be "caused" by narcotics. That the kind of criminality engaged in is influenced by drug use does seem a reasonable conclusion. Evidence about the degree of risk for the use of other drugs (sedatives, stimulants, hallucinogens, volatile intoxicants, and the like) and crime is absent. Generally, it appears that most Americans use drugs without major ill- effects—including occasional illicit use. Those likely to be engaged in drug use and in crime are likely to be urban slum- dwelling males, with an overrepresentation of minority groups. Such behavior is apt to be part of a life pattern of deficit and disorder.

Mexiletine and tocainide were administered to 79 patients to determine whether the response to one of these drugs would predict the effect of the other. In 57 patients, the two agents were evaluated noninvasively with monitoring and exercise testing, and efficacy was judged by the suppression of spontaneous ventricular arrhythmia. In the remaining 22 patients, electrophysiologic testing was performed and efficacy was defined as the inability to induce more than two repetitive ventricular premature beats. An equal number of patients responded to mexiletine and tocainide (38 versus 39%). However, in only 42 patients (53%) were the results concordant. There was no difference in concordance when the results were analyzed by method of drug evaluation, left ventricular ejection fraction or etiology of presenting arrhythmia. It is concluded that mexiletine and tocainide have different clinical effects and must be evaluated individually.

Photic stimulation, the exposure of the human eye to repetitive flashes of light, has been employed in recent years in three ways; as a diagnostic, as a therapeutic, and as a research method. In each case, its use has opened new frontiers of inquiry into the borderlands of neurology and psychology.This paper presents certain observations which stem from the testing of exploratory hypotheses with regard to an expected relationship between photic stimulation and imagery, alpha rhythm, critical flicker frequency (CFF), personality test data, overt reactions, and after-images in three major diagnostic groups: schizophrenics, organic brain damage (paretics and others), and normal individuals (no history of brain damage or emotional disorder).Since this is a report of exploratory work, no attempt has been made to apply rigorous statistical tests nor to arrive at final conclusions. The aim is rather to stimulate further research which may employ more adequate instruments, larger groups, or different conceptual schemes.