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ABLEnews MedNotes

                       American Medical News (1/17/94)

Will Attention Bring Action? (1)
   "There is an insidious pessimism developing among those working on
   HIV [human immunodeficiency virus] and a lessening of interest among
   those not involved in the effort." --Randolph Wykoff, MD, MPH,
   director, Office of AIDS and Special Health Issues, Food and Drug
   Administration.

Mandated Drug Review Expands Role of Pharmacists (1)
   "Physicians may find their autonomy and authority to prescribe drugs
   undermined as third-party payers and state Medicaid programs intro-
   duce prospective drug utilization review. Under prospective DUR,
   pharmacists must determine whether a prescription is appropriate,
   cost effective, and medically necessary before filling it...Many DUR
   advocates favor giving pharmacists electronic access to patient
   records to facilitate this. Some private payers already reimburse
   pharmacists for counseling...For instance, some private payers pay
   pharmacists a percentage of the savings from convincing customers
   and their doctors to use cheaper drugs." CURE Comment: As Joseph
   Cranston, PhD, of the American Medical Association's Department of
   Drugs, quite properly notes, "This is very problematic because the
   financial incentives for pharmacists are too big to ignore and could
   conflict with their professional judgment." This is just another
   gatekeeper to bar the door to quality medical care in the name of
   cost cutting.

Can Individual Mandate Extend Coverage to All? (1)
   As a result of a grassroots revolt by its members, the AMA has
   softened it support for President Clinton's employer mandate by
   offering equal backing to a Republican call to require individuals
   to buy health insurance coverage.

Data Driving Quality Advance (2)
   Year-end outcomes data released in California, New York, and Cleve-
   land calls into question the significance of such findings as a
   guide for consumer choice. For example, in New York just one of 37
   hospitals and 8 of 87 surgeons had death rates significantly higher
   than the state average, while only one hospital and four surgeons
   performed significantly better. Such statistical clustering provides
   little data to educate consumers.

Health Spending to Top $1 Trillion (2)
   Up 12.5% from 1993, predicts Commerce Department.

TMA Sues to Block TennCare (2)
   Tennessee Medical Association says managed care Medicaid alternative
   violates state law by denying public review and comment on program
   rules.

$89 Million HMO Award (2)
   after California health maintenance organization refuses to pay fro
   bone marrow transplant for breast cancer patient.

Abortion Funding Ordered (2)
   by Health Care Finance Administration chief Bruce Vladeck, inter-
   preting Congress's removal of ban as mandate regardless of state
   policy.

Woman, 59. Gives Birth (2)
   to twins after in vitro fertilization. British doctors question
   ethics of test-tube pregnancies for older women.

Doctors Oppose Insurance Limit (2)
   Sue Fairbanks (AK) Memorial Hospital for imposing a mandatory
   minimum of $1 million in professional liability insurance.

Braving the New World: Managing Prevention, Cost, Ethical Issues Will
Be Key Clinical Skills of the Future (3)
   "Welcome to 2005. Those affluent baby boomer patients you picked up
   back in the 1980's are older now, and more likely to suffer from
   chronic diseases associated with aging...Diseases exacerbated by
   poverty are widespread because there are so many poor people...There
   have been a lot of exciting advances in technology...But with these
   advances, as always, come questions. How do you balance cost con-
   siderations with treatment imperatives? [CURE Comment: Generally
   over the coffins of the victims of checkbook euthanasia.]...The
   treatments you order are closely monitored for cost...Practice
   guidelines are a fact of life. And, oh yes, the pressure to cut
   costs hasn't abated in the last decade or so. In fact, thanks to an
   aging population...and unshrinking federal deficit, you may be
   thinking back wistfully to the bountiful 'good old days' of 1994."

Braving the New World: Doctors' Toughest Challenge: Accepting the
Necessity of Change (3)
   "The hardest part has been just admitting that I'm going to have to
   do this when I really don't want to. Many of us hate to see the
   profession of medicine become the business of medicine. That doesn't
   feel right. We're doing this out of necessity, not desire." --Ramon
   Neufeld, MD, family practitioner, Bakersfield, CA, on abandoning
   private practice medicine to work for managed care plans.

Physicians Can Make Future Work for Them (7)
   "Many physicians view the prospect of increasing managed care and
   other shift in the health care landscape with gloom. And with health
   system reform likely to speed up the changes, some are starting to
   feel the practice of medicine isn't worth the effort any more...
   Doctors have generally assumed that they were well paid as com-
   pensation for the time they devoted to learning highly sophisticated
   skills, and for the huge debts they ran up getting that education.
   The truth is that they are paid well because of basic economic
   principles: high demand for their services and short supply of those
   providing them." CURE Comment: Meanwhile Hillary Clinton promises to
   cut cost by slashing the number of specialists. This only adds up if
   people die earlier as a result.

New European Workweek Limits Won't Affect Residents (11)
   Last November the 12 members of the European Union: the former
   European Community adopted a 48-hour workweek law but the region's
   200,000 medical residents are exempted. British officials had
   threatened to veto the directive if residents, who can be compelled
   to work up to 83 hours a week in Britain--and often work more--were
   included.

Women Physicians Report Patient Sexual Harassment (11)
   Three of four female physicians surveyed in Canada say they were
   sexually harassed by patients. The most common complaints are
   "suggestive looks" and "sexual remarks." Less than one in four woman
   doctors deem sexual harassment a serious problem.

Study Says AZT Helps HIV-Infected Pregnant Women (11)
   Expectant mothers with the human immunodeficiency virus face a 25%
   risk of passing the AIDS virus to their babies. Efforts to reduce
   the risk range from washing the birth canal with germicides during
   labor to vaccinating newborn infants. Yvonne Bryson, MD, of the
   University of Los Angeles, CA, reports that while 11 of 35 women who
   did not receive AZT (zidovudine) passed the virus to their children,
   none of the 19 mothers who received it did.

Female Condom Getting Good Marks (12)
   "The FDA [Food and Drug Administration] said it had approved the
   female condom quickly because of the concern about AIDS prevention,
   but that it can't be sure of the condom's effectiveness."

Staying Well in Changing Times (13)
   Psychologist Jim Polidaro, PhD, of the University of California,
   Davis, offers these strategies for physicians trying to cope with
   the changes rocking the health care system: 1) Get in touch with who
   you are. 2) Be more than a physician. 3) Take care of your body. 4)
   Be your own best friend. 5) Be flexible. 6) Have a sense of humor.
   7) Connect with other people. 8) Listen and communicate. 9) Don't be
   afraid of change.

Dr. Mullan: Federal Controls Can Boost Primary Care (15)
   Veteran federal bureaucrat Fitzhugh Mullan, M.D., has served ad-
   ministrations from Nixon to Bush. The co-chairman of the Clinton
   health reform task force subgroup on health care work force supply,
   he was a key architect of the White House proposal to favor primary
   care at the expense of medical specialists through restricting
   residency positions.

Needle-Exchange Found to Reduce Disease Spread (17)
   "Although illegal, Prevention Points (an all-volunteer syringe-
   exchange program in San Francisco) has operated without major
   disruption from police and with tacit approval from two successive
   mayoral administrations."

Staying Afloat in Changing Times (editorial) (19)
   "It is foolish to ignore signs as clear as the ones facing the
   medical profession today...The practice of medicine is undergoing
   major economic and structural changes--an upheaval that will con-
   tinue regardless of the fate of federal reform legislation...The
   more managed care and capitation spread, the more physician autonomy
   and traditional fee-for-service medicine hit the ropes...Rationing,
   mandatory practice guidelines, report cards, and physician profiling
   are seeping into the health care system. Gatekeepers are in demand.
   Subspecialists are finding out...they, too, are vulnerable when big
   economic changes hit. Meanwhile, the more things change, the more
   friction there is within the profession."

Screening Mammography Finds Cancers Early (letter-editor) (19)
   "The large number of breast cancer patients in the 40s would indi-
   cate that aggressive screening has picked up cancers early in life.
   Our 23 patients in the 40s who had a positive mammogram...would
   likely have had a significant delay in diagnosis had screening
   mammography not been done." --William Meyer, M.D., Minneapolis, MN.

'Teamwork Must Replace Domination' (letter-editor) (19)
   "Physicians eager to accept capitation for both outpatient and
   inpatient services to their patients will subcontract with hospitals
   for the use of beds...Doctor groups will find themselves increasing-
   ly responsible, as payers, for the efficient operation of contract-
   ing hospitals. They will have created an HMO-like structure." --
   Richard Prescott, M.D., former associate executive director, The
   Permanente Medical Group, Inc., Oakland, CA.

The Choice: Single-Payer or Be "Defacto Employee' (letter-editor) (20)
   "While the Clinton plan does maintain...a fee-for-service sector,
   its high cost will prevent all but the richest from using it. Most
   physicians counting on continued unregulated fee-for-service for
   survival are being unrealistic. The vast majority of us will be
   working for HMOs or insurers--assuming there is a demand for our
   particular specialty...Thus the real reform question is would it be
   better to work in a negotiated fee, single-payer environment that...
   allows a modicum of professional autonomy, or would it be better to
   become defacto employees of the insurers and HMOs...to avoid govern-
   ment intrusion?" --Alex Malter, M.D., Seattle, WA. CURE Comment: The
   "real" reform question for patients is will quality medical care
   survive if the best we can expect is a "modicum" of freedom for
   physicians to practice medicine?

The View from 1939: The More Things Change... (op-ed) (21)
   "Chiefly, state medicine's sourest fruits would seem to be: 1)
   Lowered morale on the part of the profession; 2) Inadequate service
   toward the clientele due to bureaucratic red tape, inadequate
   recompense, and inadequate study and diagnosis of individual cases
   due to mass clientele; 3) Too much lay control of scientific prac-
   tice; 4) Too political and too unscientific a control; 5) Too much
   taxation for results to taxpayers; 6) Government interference with
   affairs of nature [too] involved to be regimented under human
   mechanistics." (Illinois Medical Journal, July 1939)

We Need to tend to Our 'Nonmedical' Responsibilities (op-ed) (21)
   "If there is a single lesson for physicians to learn from America's
   past 20 years, it is that health care and community health are
   extremely vulnerable to political and social factors normally
   considered remote and 'nonmedical.' Our capacity to prevent disease
   and death, relieve suffering, and restore health has been profoundly
   diminished over the past two decades by conditions and trends in
   society that have nothing to do with our knowledge, expertise, or
   technical capability." --Brian Johnston, MD. emergency physician,
   East Los Angeles, CA.

In Reform, Treat Patients Like People, Not Cattle (op-ed) (23)
   "Once, some years ago, when I was a surgical intern, my professor
   lectured me on compassion. 'I remind you, doctors,' he said, as we
   were making rounds, 'these are people, not cattle!' It was a power-
   ful lesson. My professor would be appalled at the travesty unfolding
   today. The Clinton administration is out to replace our health care
   system with a socialistic monster. Wonks are talking price controls,
   higher taxes, rationing, and something called managed competition, a
   baffling system of heartless bureaucracies--alliances--where we can
   be herded like cattle, stripped of self-determination, assigned
   numbers, and told what to do." --Daniel Cloud, MD, founding presi-
   dent, Phoenix (AZ) Children's Hospital.

Treatment Was Experimental, Not Negligent (24)
   "A woman with cancer in the neck had undergone almost every known
   treatment...In 1983 she tried an experimental treatment called
   hyperthermia...After the treatment session her left lower ear
   appeared pale. Eventually it necrotized and had to be excised. When
   the patient died of other problems a short time later her estate
   sued for malpractice. At trial the jury said the physician had
   deviated from the established protocol and standard of care, but the
   deviation did not cause the patient's injuries. The court entered
   judgment dismissing the action...The (appellate) court affirmed the
   jury's verdict for the hospital and the physician. (Hamby v. Univer-
   sity of Kentucky Medical Center)

Mononucleosis a Reasonable Diagnosis (24)
   "A physician at a university medical clinic was not negligent in
   failing to diagnose and treat an intracerebral abscess in the
   frontal lobe of a patient who died the next day, a New York ap-
   pellate court ruled...The trial court (had) dismissed the malprac-
   tice claim. The appellate court affirmed." (Sciarabba v. State)

No Legal Action for Mother and Parents (24)
   "A minor and her parents were not entitled to bring an action
   against a physician and a hospital for malpractice, ruled a court of
   appeals in Washington...A 16-year-old girl gave birth to a child
   during an emergency cesarean. The premature baby weighed only 1.7 kg
   and had severe respiratory distress syndrome. Surgical intervention
   was required to treat pneumothorax and intracranial hemorrhage...
   The mother and her parents sued the obstetrician and hospital for...
   violation of the Consumer Protection Act [among other things]...
   Dismissal of the CPA claim was upheld on the ground's the physi-
   cian's decision to maintain the child on a ventilator was not
   motivated by 'entrepreneurship.' and in any case had in no way
   caused a compensable injury." (Benoy v, Simons)

Patient's Records Disclosed to Judge (24)
   "A trial court did not err in ordering a psychiatrist to produce a
   patient's record for review by a judge in chambers, the Illinois
   Supreme Court ruled. The Department of Professional Regulation filed
   a complaint with the medical disciplinary board against a psychia-
   trist, alleging he engaged in improper treatment of a patient
   diagnosed with bulimia and borderline personality." (Goldbert v.
   Davis)

Physician Not Liable for Failure to Warn (24)
   "A patient's primary care physician was not negligent in failing to
   warn him to avoid strenuous activity, a federal appellate court for
   Illinois ruled. The patient underwent a cardiac stress test at the
   request of his primary care physician. The cardiologist found
   evidence of heart disease. The primary care physician received test
   results and informed the patient there was some abnormality but did
   not indicate the need to take special precautions. Two days later
   the patient moved a service pump weighing 30 pounds. The next
   morning he had a heart attack." (Patel v. Gayes)

Staying Solo (25)
   "With the outcome of the current debate on health reform still
   undecided, the days of black bag medicine may, or may not, be
   nearing an end. But the uncertain climate and the growth of managed
   care have prompted a lot of talk--and possibly even a trend--of
   physicians moving away from private practice. While a majority of
   doctors are still self-employed, their ranks are thinning, particu-
   larly among younger doctors who view launching a solo or small group
   practice as a far riskier venture than those who wrapped up their
   residencies in the past."

Blues Plans Clean Up Act (26)
   Blue Cross-Blue Shield of the National Capitol Area, which lost
   200,000 customers last year, plans to discharge as many as 600 of
   its 1900 employees by the middle of this year. The nonprofit in-
   surance giant has been criticized for "overcharging customers,
   paying excessive salaries to executives, and questionable bookkeep-
   ing practices."

New Computer System Could Help You Stay Competitive (27)
   "When I computerized my office about 10 years ago, my vocabulary
   included hardware, software, and byte. Now with advances in technol-
   ogy, I have increased my vocabulary to include networking, modems,
   and electronic billing." --Neil Baum, MD, urologist, author, "Marke-
   ting Your Clinical Practice."

"Virtual Medical Center' Set Up Computer Network (27)
   "When the health community thinks of telemedicine, much attention is
   focused on video medicine technology. While video telemedicine does
   have its advantages, it shouldn't overshadow new developments in
   electronic bulletin board systems, or BBSs, which are proving to be
   a more versatile, much less expensive, and moral practical method of
   transferring information between health professionals. The BBS I am
   involved with is called, the Virtual Medical Center, which operates
   from Montana State University in Bozeman." --Robert Flaherty, MD.
   ABLEnews Editor's Note: ABLEnews has provided files to the Virtual
   Medical Center, which, at our last contact with Dr, Flaherty, did
   not carry echo mail.

Don't Forget the New Wage Base for Social Security (28)
   Doctors Business Calendar.

[The above listing, prepared for ABLEnews by CURE, includes all major
articles in the cited issue and a representative selection of the
rest.]

...For further information, contact CURE, 812 Stephen Street, Berkeley
Springs, West Virginia 25411 (304-258-LIFE/258-5433).