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ABLEnews MedNotes

                         American Medical News (1/9/95)

               ABLEnews Editor's Note: As we enter the new year,
               we resolve to renew the dissemination of MedNotes,
               our comprehensive directory of the American Medical
               News, published by the American Medical Association.
               This issue's theme is "Embracing the Future." System
               reform dominates the news, but smaller-scale innovations
               promise dramatic changes in how, and where, doctors
               practice medicine. AMNews tells you what to expect--
               and what to watch out for.

So What's New (2)
   The old riddle about the tree falling down in the forest where nobody
   hears it suggests a modern medical parallel: What happens if there is
   a research breakthrough but doctors don't notice? Studies presented
   at the annual meeting of the American Heart Association last November
   revealed that despite 10 years of demonstrating the effectiveness of
   beta blockers in treating heart attacks, and the ineffectiveness and
   possible harm of channel blockers, community physicians in 1992 were
   more often prescribing the latter. "It was as if all the clinical
   trials showing the benefit of these drugs did not exist," Harvard
   researcher Elliott Antman, MD, told the Chicago Tribune. The sheer
   volume of medical information and the rapid growth of medical
   knowledge have made the imperative that physicians "stay on top" of
   developments in their field a formidable challenge. And today, with
   information and communications systems themselves changing so
   rapidly, doctors must also keep up with the state of keeping
   up--tracking where information is coming from and how to tap into it.

Getting Up to Speed (3)
   The Internet, a superstructure of links among computer networks
   around the globe, was started in 1969 by the US Defense Department to
   exchange information among researchers. In 1980, there were 200
   computers on it; by 1991, there were 727,000. Today, there are more
   than 2 million...And among these millions of users and cruisers are
   many doctors. According to John Gosbee, MD, director of medical
   informatics for Michigan State University in Kalamazoo, more than 90%
   of academic physicians, and one of five of all community doctors,
   have travelled the Internet...These doctors are logging on to get
   access to vitally useful information data bases, as well as dozens of
   areas where physicians can "talk" to others in their specialty and
   exchange advice and tips.

Big Boost or Big Brother? (4)
   Guidelines on-line may soon be a crucial new tool in every
   physician's black bag, experts say. And though systems built around
   automated guidelines now are used most frequently by managed care
   companies as utilization review or physician profiling tools, vendors
   see growing interest among physicians in similar products. The
   reason: As physicians take on more of the financial risk of care
   through their capitated contracts, they're looking for high-tech help
   to fine-tune their treatment process...Practice guidelines long have
   been touted as effective mechanisms for...reducing inappropriate
   practice variation. Policymakers also like their cost-cutting
   potential...But doctors also see potential pitfalls. They fear that
   guideline programs offered by for-profit companies may be more geared
   toward cost control than quality improvement. And they're concerned
   that those originally intended for utilization review may not allow
   clinicians enough flexibility to tailor care for specific patients."
   CURE Comment: We share the concerns of such conscientious physicians.
   As AMN notes, "In effect Big Brother has gone on-line. Worse, he may
   be on- line with a false guideline."

Promising Tool, Still Needs Work (6)
   Thousands of doctors and hospitals are increasing using [diagnostic
   support systems] to help determine what's ailing their patients. The
   sophisticated programs also provide information about diseases, lab
   tests, drug interactions, and references to current literature. But
   the interactive systems are more than a series of textbooks on disk.
   By spelling out how they arrive at a diagnosis and analyzing
   alternative diagnoses, they provide physicians with a second
   opinion...Attorneys and insurers also have used them to establish
   what constitutes appropriate care. And managed care companies,
   interested in reducing inappropriate consultations and referrals to
   "expensive" specialists, are testing the systems. CURE Comment: Call
   us old-fashioned but we prefer our "second opinions" come from flesh-
   an-blood physicians, preferably with a sense of moral responsibility
   that transcends the bottom line of some HMO.

More Than an Apple a Day (8)
   If you're a primary care physician, you can bank on the fact that
   you'll be spending more of your time on disease prevention and health
   promotion in the years ahead. For those who want to build prevention
   into their practices but don't where to start, the US Public Health
   Service has put out several new tools to get you going. There's a
   400- page clinician's handbook that distills the recommendations of
   the experts into practical advice. Supporting materials aim to get
   your staff involved. And the most popular item is a guide that lets
   patients track their own tests and immunizations so they can tell you
   when it's time for the next mammogram or booster shot...Experts
   credit the national debate over health system reform with bringing
   the concept of prevention to the forefront, since most reform
   proposals included at least some clinical preventive services as
   basic benefits. ABLEnews Editor's Note: For further information,
   contact: US Public Health Service; Office of Disease Prevention and
   Health Promotion; 330 C Street, SW, Room 2132; Washington, DC 20201.
   [phone].

Seeking a Way Out (9)
   Imagine you're living every physician's worst nightmare. A patient in
   your care has been injured, as the result of something you did or
   failed to do in the course of treatment. The consequences are
   familiar and terrifying. The patient gets a lawyer and files a
   malpractice lawsuit. Your professional liability insurer secures a
   lawyer to defend you and, unless you settle, a multiyear battle
   ensues. Experts second- guess your judgment and competence,
   economists estimate the patient's medical costs and lost earnings. If
   you lose, it can leave an indelible mark on your reputation, maybe
   ruin you financially...Now imagine if instead of going to court, the
   patient could file a claim with and independent administrative
   agency...No lawyers, no courts. The scenario is not a pipe dream. Two
   statewide research projects--funded by the Robert Wood Johnson
   Foundation...want to make it a reality within five years...Efforts to
   make the system work better--by capping noneconomic "pain and
   suffering" award and limiting attorney contingency fees--have often
   run into brick walls...Trial lawyers and consumer groups...have
   successfully argued that proposed reforms are merely efforts to save
   doctors, hospitals, and their insurers while limiting the redress of
   injured patients." CURE Comment: Gee, I wonder where they would get
   an idea like that? Now, we're expected to trade our day in court for
   some bureaucrat? No wonder the AMA trade paper lists "consumer groups
   may balk" as a pitfall for this scheme.

Surgeons Share the Burden (10)
   Time after time, William Schecter, MD, a general surgeon at San
   Francisco's Kaiser Foundation Hospital, found himself telling
   patients he couldn't do basic procedures, like hernia repairs, unless
   they put up $2,000--which he knew they couldn't afford. "I'd feel
   embarrassed to tell them I couldn't do their surgery. That's not why
   I went to medical school." Before too long, he says, the patients
   would reappear, only this time on an operating table as an emergency
   patient. Some, like the 40-year-old woman he recently treated for an
   obstructed colon, barely survived. Some didn't." CURE Comment: Expect
   the body count for checkbook euthanasia to escalate. As AMN reports,
   "In an era of intense competition, private hospitals are becoming
   increasingly unable or unwilling to share the growing burden of
   uncompensated care. And as public and private reimbursements decline,
   cost-shifting is becoming nearly impossible. Public hospital
   surgeons...are being stretched too thin by routine surgery, emergency
   care, and other demands that come with being part of the nation's
   fraying social net."

Grants Offered for Private Care (10)
   The Ambulatory Surgery Access Coalition was one of 22 physicians'
   groups awarded $2.2 million by the Robert Wood Johnson Foundation.
   Called "Reach Out: Physicians' Initiative to Expand Care to
   Underserved Americans," the program aims to mobilize private
   physicians to improve access to care for the underserved. The goal is
   to get physicians to work with other providers and community-based
   organizations. The four-year project is expected to include up to 50
   communities and total $14 million in funding... The initial 22
   projects got one-year planning grants of up to $100,000 each and will
   be eligible for three-year implementation grants averaging $200,000.
   A workshop for interested second-round applicants will be held
   January 20; application deadline is March 14. ABLEnews Editor's Note:
   Dr. Denman Scott, the Reach Out program director, may be reached at
   [phone].

Out of the Hospital Into the Future (11)
   When residents of Chicago's northwest suburbs want the latest in
   surgery, many drive to the local hospital--and keep right on going
   another block to a high-rise office building with no connection to
   the hospital. There in five compact ORs, patients of Northwest
   Surgicare have their gallbladders removed laparoscopically, knee
   ligaments repaired arthroscopically, or endometrial growths vaporized
   with a laser. They also can have ENT, gastrointestinal, urologic,
   pediatric, ophthalmologic, and cosmetic procedures...Most of the
   patients are awake and alert soon after surgery and are likely to be
   home before lunch; within minutes of suturing, their places in the
   ORs are taken by new patients...In Philadelphia, very sick congestive
   heart failure patients also are avoiding the hospital. If they notice
   a big overnight weight gain signalling fluid retention and imminent
   heart failure, they can call Cardiac Solutions, a specialized home
   care agency. A nurse arrives at the home...Instead of going to the
   hospital eight times a year--not unusual for this type of
   patient--many Cardiac Solutions patients don't go at all. In San
   Diego, even elderly people who fall and sustain pelvic fractures may
   skip the ambulance ride to the hospital. A service named Call Doctor
   will send...[a] physician to their doors...In virtually every area of
   medicine, the hospital is becoming less and less necessary...and it's
   cheaper to boot. Driving the shift are technology advances, growing
   costs pressures, and changing attitudes.

Designs for Healing (12)
   Hospitals have long been sterile environments--in more ways than one.
   All too often, their germ-free operating rooms have been accompanied
   by "institutional green" hallways and drab, overcrowded patient
   rooms. Medical centers have poured millions of dollars into high-tech
   equipment and treatments, while ignoring common miseries within their
   walls that hamper healing. As a result, even the most sophisticated,
   complex interventions have been undermined by the subtle horrors of
   hospitalization: strange noises, unsavory sounds, little privacy, and
   no accommodation for family and friends. In such environments,
   "patients have a sense of hopelessness," said Tali Neumann, RN, who
   heads the Center for Innovation at 627-bed St. Luke's Episcopal
   Hospital in Houston. "The patient and his or her family feel no
   control." CURE Comment: CURE recommends that in critical care
   situations family members remain with the patient at ALL times. We
   deplore the imposition of obstacles, deliberately or inadverently, to
   this critical need. My mother was with my father during virtually all
   of his hospitalizations during the decade he lived with us at home in
   coma. At times, hospitals would show their resentment at our defense
   of my father's life by removing reclining or even simply comfortable
   straight chairs from his room in which Mom might catch an hour or two
   of sleep in the wee hours of the night. Such harassment is an all too
   typical experience of the families CURE counsels and is designed to
   induce the "hopelessness," nurse Neumann rightly indicts.

Redesigning Care on a Tight Budget (12)
   One Houston hospital has created a warm, healing atmosphere for
   patients without spending millions of dollars. What's even more
   impressive it that the transformation at...St. Luke's Hospital is
   being driven from the bottom up. The change is largely the work of
   the Healing Environment Council, a multidisciplinary group of staff
   who've taken on the task of devising "cost-efficient ways to increase
   the healing potential of St. Luke's," said Tali Neumann, RN...But
   even the most innovative healing concepts are only as strong as the
   people who carry them out, Neumann said. "You can dress things up,
   but unless you work with people, you're not going to have a healing
   space."

Does Prevention Save Money? (13)
   As director of the maternal and child health program and professor of
   health services at the University of Washington, Frederick Connell,
   MD, MPH, is a longtime advocate of prevention as a health tool. But
   he is also a scientist and skeptical of unproven claims. So he felt
   torn when, after reviewing 11 studies, he and Jane Huntington, MD, of
   the Group Health Cooperative in Seattle, found no conclusive evidence
   that prenatal care for low-income women saves money. "Questioning the
   cost savings of prenatal care is like speaking out against motherhood
   and apple pie," he admitted. In a review article...published November
   10 in the New England Journal of Medicine, Dr. Connell explained that
   he and Dr. Huntington meant to challenge the presumption of cost
   savings without discounting the value of the services. CURE Comment:
   And, no doubt, the care- cutting pols and their pals in the insurance
   industry will show the say consideration. Say, doc, did you happen to
   notice if prenatal care saves any lives? I see, not a ledger item.

Arizona Calls Domestic Violence a Public Health Threat (16)
   With domestic violence apparently on the rise, the state will try to
   better identify victims by declaring the problem a serious public
   health threat. The move reportedly makes Arizona on of the first
   states to make such a declaration. "Domestic violence must be viewed
   as one of the nation's major public health threats, and not simply a
   matter for the police and courts," said Jack Dillenberg, director of
   the Arizona Department of Health Services. But the effort is an
   uphill battle because physicians and other health professionals are
   having trouble simply identifying domestic violence victims and
   referring them to appropriate agencies.

Who Will Shape Medicine's Future (editorial) (17)
   There is no big bang theory for medicine. The history of medicine is
   one of many little, innovative bangs, with some medium-sized ones
   thrown in. This special issue of AMNews explores some of the
   innovations that have caught our attention as we cover the
   socioeconomic side of medicine...All told, this issue of AMNews
   presents a generally positive group of innovative approaches to the
   practice of medicine. [ABLEnews Editor's Note: We would say rather "a
   generally positive view" of such innovations.] But change, under the
   banner of innovation--and especially these days also can work against
   the best interests of patients. That's because change also comes from
   the fusion of medicine and business...As the delivery of medicine
   becomes more corporate, so, too, comes greater potential for
   "innovations" that seem to make good book- keeping sense but bad
   medical sense. For that reason, physicians must keep a strong,
   effective voice in setting the course and application of innovation
   in medicine...Why is this a role for the medical profession? Because
   at its core is science and ethics. By contrast, at the core of
   business is profits...When profit considerations intrude too much
   into decision-making, there's a chance that corners will be cut and
   patients will suffer. (Government, which also has a role, often
   compounds the problem with its own mix of law, budget, regulation,
   and compromise.) We're not saying that all doctors are saints or that
   the medical profession has never made a misstep of its own. But on
   balance, there is plenty to be said for taking direction and counsel
   from a profession whose central tenet is "first do no harm," rather
   than relying on the integrity of those more comfortable with "buyer
   beware."

Simple Solutions: Don't Charge, Don't Prescribe (17)
   In your editorial of December 5, 1994, suggesting that recent
   measures in Oregon and California turn doctors into cops and mercy
   killers is quite wrong. In California if you wish to treat illegal
   aliens, do so, but don't charge. In Oregon, if you don't wish to
   prescribe lethal drugs for your patients, don't. Now wasn't that
   simple? --James Michael Bestler, MD, Martinsville, VA, letter-
   editor. CURE Comment: Simple-minded, perhaps. The matter of forced
   participation by health care providers, for example, pharmacists, in
   killing their patients is far from settled under the Oregon law now
   enjoined by the courts, and the ramifications of turning physicians
   into contract killers is anything but simple.

Assisted Suicide Sign of Decadent Society (17)
   "Oregon doctors divided on assisted suicide." This sounds like the
   dying gasp of the Hippocratic oath (AMNews, November 28, 1994). It
   seems to me that the Hippocratic oath was, and is, a good thing.
   Oregon doctors (and others) should try to distinguish themselves from
   our decadent society." --James Ivey, MD, Lakeland, FL, letter-editor.
   CURE Comment: The Hippocratic oath proclaims: "I will neither give a
   deadly drug to anybody if asked for it, nor will I make a suggestion
   to this effect."

AMA Should Stay Out of Proposition 187 Fray (17)
   Regarding "Voters send more doctors to Congress" (AMNews, November
   21, 1994): The article states that the AMA has offered support to the
   California Medical Association in the latter's attempt to prevent the
   institution of the voter approved California Proposition 187...The
   AMA has no mandate from its members (and very few of the people
   affected by Proposition 187 are members) to interfere with local
   politics, especially when the voters themselves...voted for a
   measure. This was true democracy and the AMA has no right to be
   involved. --Marc Feldstein, MD, Chicago, IL, letter-editor. ABLEnews
   Editor's Note: Proposition 187 denies government benefits, including
   most medical care, to illegal aliens.

Follow Lead of Honduras (18)
   "Anti-immigrant vote sparks California public health concerns" paints
   a gut-wrenching picture of the blighted illegal immigrant (AMNews,
   November 28, 1994). Understand clearly that the operand word is
   illegal (equals "criminal"). Even though criminal, they are denied no
   emergency care. I am a legal resident of Honduras, yet they afford me
   (nor anyone else) no care beyond "in extremis."...I am not
   complaining; their action is reasonable (and vice versa). --Donald
   Steele, MD, Newport Beach, CA, letter-editor.

Add Managed Care to Stressors That Bedevil Physicians (18)
   I have noticed the articles in the last few issues of the AMNews
   about stress (October 24/31, November 7, 1994)...Aside from the usual
   stressors of medicine, the responsibility, the calls in the middle of
   the night, the threat of malpractice, etc., comes the upheaval of
   managed care and all the uncertainty that goes with it--new
   alliances, fragmentation of the medical community, shifts in referral
   patterns. Which way do you jump? --Mike Harper, MD, Dayton, OH,
   letter-editor.

Kellogg Foundation Giving Aid in South Africa (18)
   I commend you for the informative article related to the changing
   South African health care system (AMNews, November 7, 1994)...The
   Kellogg Foundation has committed $25 million to assist seven
   individual projects in making major changes within their settings
   over the next five years. This is in addition to our funding of a
   wide range of other projects related to health, rural development,
   and education...The United States has much to learn from these
   experiences in other parts of the world. --Helen Grace, PhD, vice
   president, program, WK Kellogg Foundation, Battle Creek, MI,
   letter-editor. ABLEnews Editor's Note: And much to learn about the
   motivation of foundations such as Kellogg. For starters, see Kellogg
   Capers in the November 1993 ABLEnews Reviews (ANR9311.*).

More Study, Review Needed of Alternative Medicine (18)
   Your articles on alternative medicine in the October 17, 1994 issue
   were timely and useful, pointing out the rapid increase in popularity
   of alternative medicine and its potential benefits and dangers. Like
   it or not, the use of alternative medicine is increasing rapidly and
   physicians are generally unaware that their patients are also users
   of alternative medicine. There is also a rapidly rising demand for
   greater availability of alternative medicine--and insurance coverage
   for it--from all socioeconomic groups. Unfortunately, we know little
   about its modalities. We need a great deal more information about
   their content, use, efficacy, and safety. Well done studies and
   careful review of the data with publication and wide dissemination of
   the results are going to be necessary. The establishment of the
   National Institutes of Health's Office of Alternative Medicine is a
   good first step, but its apparent politicization is regrettable.
   --Raymond Murray, MD, East Lansing, MI, letter-editor.

A Title Can Mean a Lot, So Call This Physician 'Doctor' (op-ed) (18)
   As a physician, I have participated in many conferences and symposia.
   In the last few years I have noticed that many of these choose to
   delete the MD degree from the list of attendees. This makes it
   impossible to distinguish the MDs from the RNs, MSWs, or JDs. I
   suspect this is intentional. Egregious examples of this occurred with
   the White House Task Force for Health Care Reform and in the White
   House Professional Review Group, of which I was a part. Published
   lists of task force members deleted all professional degrees, no
   doubt to disguise the paucity of doctors. Members of our review group
   carefully addressed each other in the most politically correct way,
   using first names for everyone, never the title doctor...There is
   more than anti- intellectualism and exaggerated egalitarianism at
   work here. By using the leveling technique, society takes away the
   prestige and respect that would otherwise accrue to the title doctor.
   Perhaps in time we shall all call each other comrade or citoyen
   [citizen]...Once we have all become equalized, there is no reason why
   nonphysicians should not assert power or control over
   physicians...The title doctor has value, and we must guard it
   carefully.  --Susan Adelman, MD, past president, Michigan State
   Medical Society. CURE Comment: We agree, doctor, and one of the best
   ways to guard it is by deeds as well as words.

Make Your Voice Heard (19)
   Health care reform may look like an idea whose time has gone, but it
   hasn't disappeared. With limited prospects on Capitol Hill, it's
   merely fled to more promising climes--like your state capital.
   Several states shelved reform measures pending resolution of the
   national debate. Expect some to reappear. And states that have never
   formally considered reforms may consider them now for the same
   reasons their neighbors have--growing pressure to clean up insurance
   marketing practices, improve access, and control Medicaid costs. But
   just because the debate has moved closer to home doesn't mean the
   impact of reform will be any less. Based on experience to date, state
   reforms can mean trouble for doctors. For example, if Tennessee
   physicians want to see Blue Cross-Blue Shield patients, they must
   also agree to see Medicaid patients at a deeply discounted rate. In
   neighboring Kentucky, reform has been financed by a provider tax that
   essentially cuts Medicaid rates by one third. And one state, Vermont,
   made serious progress toward a single-payer system before reform
   stalled. What's a doctor to do?

New Year a Good Time to Resolve to Resolve to Keep Better Records (22)
   Is one of your New Year's resolutions to do a better job of
   recordkeeping in your practice? The beginning of a new year is a good
   time to start preparing files and accumulating appropriate
   information.

Medicare to Pay for Home Care (24)
   Starting this month, physicians for the first time will get paid for
   supervising patients' care at home and in hospices. This change, long
   sought by medicine, was part of new payment rules published by the
   Health Care Finance Administration last month...But there are sharp
   limitations on allowable payment and several issues remain
   unresolved. Also, HCFA did not allow payment for managing care of
   patients in nursing homes.

Hospitals Respond by Expanding Outside Care (24)
   Hospitals, their survival threatened by the shift to nonhospital
   care, aren't standing still. Many have developed ambulatory care and
   home health centers to compete with corporate-controlled and
   independent facilities. As of 1993, hospitals operated 6% of the
   nation's 1,862 ambulatory surgery centers., while 77% were
   independent, and 17% were corporate-owned, according to SMG Marketing
   Group in Chicago.

CDC Studies Gun Injuries, Aims to Prevent Shootings (25)
   Like police scouring a crime scene, the Centers for Disease Control
   and Prevention is tracking gun victims for clues on how they enter
   the line of fire, to learn how to prevent future shootings. The CDC
   is funding a three-year pilot to examine the circumstances
   surrounding deaths and injuries from shootings...Researchers will
   pore through records from medical examiners, police and emergency
   departments to trace the victim's history, the location of the
   shooting, what time it happened, and what may have triggered the
   violence.

Court Upholds Transplant Denial (25)
   The state's denial of a welfare-paid liver transplant for an
   alcoholic didn't violate Michigan's Handicapped Civil Rights Act, the
   Michigan Court of Appeals ruled...in a 3-0 decision late last year.

     [The above listing, prepared for ABLEnews by CURE,
     includes all significant articles  and a representative
     selection of the remainder.]

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