Despite widespread support for the concept of advance care planning, few Americans have a healthcare proxy. It is not known if certain physician characteristics make it less likely that the discussion of a healthcare proxy will be initiated, particularly in the case of physicians in training. The objective of this descriptive, cross-sectional study was to determine if resident characteristics (specialty, race, age, gender, and religion) affect his or her decision to initiate discussions with patients regarding designation of a healthcare proxy. Participants consisted of primary care residents employed at The Brooklyn Hospital Center, Brooklyn, New York, from the departments of Internal Medicine, Pediatrics, Obstetrics and Gynecology, and Family Practice. An anonymous 14-item questionnaire was distributed to all primary care residents (N = 151) at the hospital during their respective conferences and grand rounds. Seventy-eight residents returned the instrument for analysis. When compared to other primary care specialties (n = 40), internal medicine residents (n = 38) were more likely to initiate healthcare proxy discussions with patients (p < 0.05). Residents who were younger than 35 were more inclined to encourage decision-making by surrogates (p < 0.05). Of the total number of residents, 92 percent correctly defined a healthcare proxy, and 66 percent thought a physician should initiate patient selection of a healthcare proxy, yet only 55 percent of physicians did so. Our results indicated that a little over half of the physicians surveyed initiated discussion for a surrogate decision-maker, even though most thought it was their duty. Younger internal medicine residents are more likely to ask patients about healthcare proxies. Some residents were unable to correctly identify the definition of a healthcare proxy, and this lack of knowledge is likely to result in poor advance care planning.

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Parents frequently visit their family physicians with concerns of gait abnormality in their children. Minor musculoskeletal anomalies and normal agerelated gait variation are the most frequent causes. Tethered cord syndrome is an uncommon pathologic entity that can be initially asymptomatic and subsequently manifest serious neurological sequelae. Prognosis depends on early recognition and prompt surgical correction for optimal outcome. We describe a case of a previously healthy 17-month-old child with abnormal gait who had tethered cord syndrome. Case ReportA 2-year-old boy was brought to our Family Practice Center with the complaint of abnormal walk for the past 6 months. He had been getting his health maintenance at our center since birth. His great grandmother first expressed concern about the way he walked at age 17 months, but no abnormality was detected at that time. There were no other associated symptoms, including injury, fever, headaches, or weakness.The prenatal history was remarkable for a maternal second-trimester chlamydial cervicitis that was treated with azithromycin. The child was born at 35 weeks' gestation by spontaneous vaginal delivery to a 21-year-old mother, para 1,1,1,2. The postnatal period was uncomplicated.His medical history was notable for a seconddegree facial burn at 8 months of age. Social services excluded the possibility of child neglect. He was also evaluated for failure to thrive (height and weight less than 10th percentile) at age 1 year despite apparent good nutrition. At that time there were no serious pathologic findings found on his initial medical workup.His immunizations were up-to-date, his developmental milestones were normal, and there was no family history of gait or feet abnormalities.He was a thinly built (height and weight remained at less than the 10th percentile), active child with normal temperature and blood. Respiratory and cardiovascular findings were unremarkable. He had lumbar levoscoliosis, overlapping toes, and increased joint laxity caused by possible hypotonia. He had equal length of both extremities, full range of motion, and good ankle dorsiflexion. There were no sacral dimples, tags, nevi, lipomas, or hypertrichosis. He had normal cranial nerves, normal sensory system, normal power (grade 5), normal tone and reflexes, and good coordination. Genitourinary and rectal findings were normal. His gait was characterized by elevation of the left shoulder and left hip with normal stance and balance. A complete blood count and chemistry profile were normal.Radiographs of the spine and pelvis showed L4 hemivertebra with sharp levoscoliosis. Spinal magnetic resonance imaging showed low-lying conus medullaris at L3, L4 hemivertebra with associated levoscoliosis. There were no intraspinal masses or lipomas. Findings of a renal sonogram and a voiding cystourethrogram were normal.The pediatric neurologist confirmed the above findings and noted generalized hypotonia. The chromosomal analysis was normal. Operative findings confirmed a low-lying conus medullaris with...