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In England Now
212 allocation to treatment, randomisation, trial design, ethical aspects, and statistical analysis of results, and protocols that emerged on the last day were discussed at the plenary session. The WHO consultants for this workshop were Prof J. C. Petrie (Aberdeen), Prof Ranjit Roy Chaudhury, WHO representative in Burma, and Dr Yupha Onthuam, of the Institute of Health Sciences Research, Chulalongkom University, Bangkok. On March 24 Professor Petrie delivered a lecture under the auspices of the Burma Medical Association on the theme of Rational Use of Drugs. That evening members and fellows of the Royal College of Physicians of the United Kingdom gave a dinner in honour of Dr Daw Khin Kyi Kyi, professor of pharmacology at the Medical Institute I, who had chaired the meeting. Under the direction of Dr U Tin U, director-general of health services, a programme of essential drugs is now being implemented, with funding from Burma’s regular WHO budget and, initially, with extra funding from the Drug Action Programme, WHO Geneva. The monthly Cardiovascular Newsletter, produced by the project manager of the WHO Cardiovascular Project, featured essential drugs in the May, 1988, issue. And in Rangoon a recent workshop on intensification of primary health care discussed how four components of the primary health care programme could be integrated functionally and at managerial level. Provision of essential drugs was one of the four elements, the others being acute respiratory infections, control of diarrhoeal diseases, and immunisation.
United States MEDICAL RATINGS
THE Federal Government’s survey of mortality rates for six thousand hospitals, published some time ago, was criticised for not taking into account the great differences between hospitals in their patient population. No doubt there will be similar reactions when the review of quality of care in several thousand nursing homes is published. But now a very much larger study is being planned to assess the quality of care given by the 300 000 physicians who treat Medicare patients. While hospital Medicare funding increased by only 3% between 1986 and 1987, physician spending grew by 18% over the same period. Was this justified, and did the Government get value for money? Although it may be all right to study which procedures and tests are effective, critics of the proposed study are asking whether the effectiveness of individual practitioners can be satisfactorily assessed. What is most striking about such a survey, however, is that it indicates a lowering of the status of the medical profession as a whole. Although most patients have great respect for and confidence in their own physicians and are satisfied with the treatment they receive from their local hospital staff, the profession as a whole is not so highly regarded as it was or would like to be. This is partly because some physicians are charging large fees to their Medicare patients. Medicare pays only 80% of the "reasonable" fee, and the other 20% has to be found by the patient. Many physicians accept only the basic fee, but others charge much higher fees, up to the legal ceiling in some states, and add on various charges. Medicare is not a charity, it is a universal health insurance plan for the elderly irrespective of their personal income, and some doctors are claiming that many Medicare patients can afford to pay full fees. In New York State, where the average yearly income for over-65s is$10 130, the average income of physicians, after all expenses (including malpractice insurance) are paid but before taxes, is $120 000 (so much for the complaints of the high cost of malpractice insurance), a high "reasonable" fee seems unwarranted. Moreover there have been several instances of physician fraud in Medicare matters. The upshot of the Federal study is likely to be that Medicare patients will be steered to the more effective and reasonable physicians, and the Government will save money.
In
England Now
THE peripatetic correspondent who had his clinical judgment made for him by his district general manager (April 23, p 930) need not feel alone. About a year ago I had an elderly patient who had been successfully treated for an acute illness and who was ready for discharge. His wife decided that she did not want him back (he was not the nicest of people and in that respect they were ideally suited) and appealed to her local councillor, a member of the health authority, for help, claiming that the patient was not fit to be
discharged. visit from the councillor, case in detail and she was convinced that the man was not fit to leave hospital. I asked her what she based her judgment on. She had visited the ward and, by pulling rank as a health authority member, had bullied the staff into not only giving her the patient’s notes to read but also allowing her to conduct an examination of him-making him stand by his bed, walk up and down the ward, attempt to climb stairs, and so on. I was indignant, but found total lack of support from the administration, who were all pressing me to accept the councillor’s "findings" just to "save trouble". I stuck to my decision. After all, as I pointed out, I had someone who was really ill to whom I had already promised that bed -indeed, had already given the date for admission. The district general manager saw no problem there. "Give me the name," he said "and I will see to it that they are told they cannot come in." I refused to divulge such confidential matters-especially as I suspected that what the DGM was implying was that the admission existed only in my mind. So the man duly left the ward by ambulance-only to be returned a few hours later. Prompted by the good councillor, his wife had locked up the house and departed to a secret address. So he sat in one of our beds for a while, then blocked a geriatric bed, until, having turned his face to the wall, he died a few months later. The first I knew of all this
was a
informing me that she had gone into the
*
*
*
I THINK we, as doctors, should all go to the aid of a collapsed man, and as a cardiologist I have some experience of cardiovascular resuscitation. My wife, a pathologist, our two children, and I recently met with two friends (a married couple, both GPs) and their young daughter in a Shropshire town to visit the museum there. As we were walking down the road, we saw a man lying on the pavement. He was being tended by a young man and woman in their mid-twenties. My friend and I went over to see if we could help, leaving our wives to carry on walking with the children. The man was unconscious with acidotic breathing but had a good radial pulse. As we were examining him he made minor convulsive movements. We decided he must have had a fit, so we moved him over into the coma position. The young man removed his teeth. It transpired that the two young people were not accompanying the man but had been first on the scene and had already decided he had had a fit before we came to the same conclusion. The man seemed to be stable and postictal, and my friend and I were anxious to get back to our families, so I started to ask the crowd of onlookers who had gathered around us to see if the casualty had any friends who could stay with him. Another man, who had just returned after telephoning for an ambulance, said that he had seen the man collapse. We asked him if he would stay and tell the ambulance crew what he saw. I announced that I thought the victim would be all right if left alone on the floor and in the coma position until the ambulance arrived. The first young man agreed. "He’ll be OK," he said. "I’m a doctor and [pointing to his girlfriend] she’s a nurse." My friend and I exchanged glances. "Oh good," I said, "you won’t need us then." Relieved of the responsibility of staying, my friend and I left chuckling. How fortunate for the epileptic man that five doctors and a nurse were passing as he collapsed.
United States MEDICAL RATINGS
THE Federal Government’s survey of mortality rates for six thousand hospitals, published some time ago, was criticised for not taking into account the great differences between hospitals in their patient population. No doubt there will be similar reactions when the review of quality of care in several thousand nursing homes is published. But now a very much larger study is being planned to assess the quality of care given by the 300 000 physicians who treat Medicare patients. While hospital Medicare funding increased by only 3% between 1986 and 1987, physician spending grew by 18% over the same period. Was this justified, and did the Government get value for money? Although it may be all right to study which procedures and tests are effective, critics of the proposed study are asking whether the effectiveness of individual practitioners can be satisfactorily assessed. What is most striking about such a survey, however, is that it indicates a lowering of the status of the medical profession as a whole. Although most patients have great respect for and confidence in their own physicians and are satisfied with the treatment they receive from their local hospital staff, the profession as a whole is not so highly regarded as it was or would like to be. This is partly because some physicians are charging large fees to their Medicare patients. Medicare pays only 80% of the "reasonable" fee, and the other 20% has to be found by the patient. Many physicians accept only the basic fee, but others charge much higher fees, up to the legal ceiling in some states, and add on various charges. Medicare is not a charity, it is a universal health insurance plan for the elderly irrespective of their personal income, and some doctors are claiming that many Medicare patients can afford to pay full fees. In New York State, where the average yearly income for over-65s is$10 130, the average income of physicians, after all expenses (including malpractice insurance) are paid but before taxes, is $120 000 (so much for the complaints of the high cost of malpractice insurance), a high "reasonable" fee seems unwarranted. Moreover there have been several instances of physician fraud in Medicare matters. The upshot of the Federal study is likely to be that Medicare patients will be steered to the more effective and reasonable physicians, and the Government will save money.
In
England Now
THE peripatetic correspondent who had his clinical judgment made for him by his district general manager (April 23, p 930) need not feel alone. About a year ago I had an elderly patient who had been successfully treated for an acute illness and who was ready for discharge. His wife decided that she did not want him back (he was not the nicest of people and in that respect they were ideally suited) and appealed to her local councillor, a member of the health authority, for help, claiming that the patient was not fit to be
discharged. visit from the councillor, case in detail and she was convinced that the man was not fit to leave hospital. I asked her what she based her judgment on. She had visited the ward and, by pulling rank as a health authority member, had bullied the staff into not only giving her the patient’s notes to read but also allowing her to conduct an examination of him-making him stand by his bed, walk up and down the ward, attempt to climb stairs, and so on. I was indignant, but found total lack of support from the administration, who were all pressing me to accept the councillor’s "findings" just to "save trouble". I stuck to my decision. After all, as I pointed out, I had someone who was really ill to whom I had already promised that bed -indeed, had already given the date for admission. The district general manager saw no problem there. "Give me the name," he said "and I will see to it that they are told they cannot come in." I refused to divulge such confidential matters-especially as I suspected that what the DGM was implying was that the admission existed only in my mind. So the man duly left the ward by ambulance-only to be returned a few hours later. Prompted by the good councillor, his wife had locked up the house and departed to a secret address. So he sat in one of our beds for a while, then blocked a geriatric bed, until, having turned his face to the wall, he died a few months later. The first I knew of all this
was a
informing me that she had gone into the
*
*
*
I THINK we, as doctors, should all go to the aid of a collapsed man, and as a cardiologist I have some experience of cardiovascular resuscitation. My wife, a pathologist, our two children, and I recently met with two friends (a married couple, both GPs) and their young daughter in a Shropshire town to visit the museum there. As we were walking down the road, we saw a man lying on the pavement. He was being tended by a young man and woman in their mid-twenties. My friend and I went over to see if we could help, leaving our wives to carry on walking with the children. The man was unconscious with acidotic breathing but had a good radial pulse. As we were examining him he made minor convulsive movements. We decided he must have had a fit, so we moved him over into the coma position. The young man removed his teeth. It transpired that the two young people were not accompanying the man but had been first on the scene and had already decided he had had a fit before we came to the same conclusion. The man seemed to be stable and postictal, and my friend and I were anxious to get back to our families, so I started to ask the crowd of onlookers who had gathered around us to see if the casualty had any friends who could stay with him. Another man, who had just returned after telephoning for an ambulance, said that he had seen the man collapse. We asked him if he would stay and tell the ambulance crew what he saw. I announced that I thought the victim would be all right if left alone on the floor and in the coma position until the ambulance arrived. The first young man agreed. "He’ll be OK," he said. "I’m a doctor and [pointing to his girlfriend] she’s a nurse." My friend and I exchanged glances. "Oh good," I said, "you won’t need us then." Relieved of the responsibility of staying, my friend and I left chuckling. How fortunate for the epileptic man that five doctors and a nurse were passing as he collapsed.