- Email: [email protected]
Teaching ethics in Japan
Threat to German
p 1167) of problems with in screening Germany is incomplete. The not commented on, is that some of the major problem, sickness funds feel that larger screening mammography is too expensive, in view of a new government regulation that is expected to put competitive pressure on premiums. As a consequence, they filibuster in committee meetings and suggest time-consuming intermediate recommendations far short of the effective establishment of a national screening policy. One sickness fund refused to play this game and started to build a quality assurance programme, including mandatory double reading by certified experts, a reference centre, and statistical monitoring of results. The strategy is based on the German Mammography Study (GMS).’ GMS was a quality-assurance programme conducted in collaboration with office-based radiologists, gynaecologists, and general practitioners in the decentralised structure of German health care from 1989 to 1994. It was not designed
SIR-Werneke’saccount
(May 6,
breast-cancer
investigate population coverage or "uptake" (which was not even measured). Participation required individual referral by office-based physicians and, because of German data protection legislation, the written informed consent of the 37 626 participants. GMS thus differed from population-based screening programmes in other health services, and it can hardly be criticised for low uptake. The to
detection rate of breast cancers doubled to 5-0 per 1000 and the predictive value of open biopsies went up from 16% to 37% over the study period. Office-based physicians achieved the same detection rates and positive predictive values as four expert screening centres taking part as reference. The experiences gained in this study could be harvested nationwide, if the sickness funds were willing to invest in
quality. B Peter Robra
to
Yasuharu Tokuda 23 West Wheelock St, Hanover, NH 03755, USA
1 2 3 4 5
Yomiuri Shimbun 1995 (May 15-26). Kato N. What is bioethics? Tokyo: Miraisha, 1986 (in Japanese). Anon. Crimes and misdemeanors. Newsweek 1995 (March 27): 43. Daws G. Prisoners of the Japanese. Morrow, 1995. Nakamura Y. What is clinical thinking? Tokyo: Iwanamishoten, 1992
(in Japanese).
Manipulating medicine SiR-Horton’s
note (May 6, p 1167) ignores the medical savings account technique, which has been proposed by the Heritage Foundation and several Congressmen and endorsed by the Speaker, Newt Gingrich. This will gradually, as it is slowly introduced, result in substantial savings in Medicare costs as individuals begin to use their own money from their tax-free "medical savings account" to pay for routine medical expenses rather than having a third party pay everything for them. This is the one approach to the healthcare problem that promises to reduce total costs, rather than increase them, by introducing a real incentive not to order excessive tests and treatments and eliminating the expenses of a middleman between patient and physician.
George
Department of Social Medicine, University of Magdeburg, 39120 Magdeburg, Germany 1
ethics.2 Few medical schools offer lectures in the medical licensing examination hardly ever tests bioethics; of knowledge ethics; and few hospitals have their own ethics committee. Half a century ago, several Japanese doctors in the notorious Unit 731 did horrifying medical experiments in wartime Manchuria, China, including the infliction of bullet wounds and other injuries and infection with lethal bacteria such as Bacillus anthracis.3,4 The teaching of bioethical principles should be an essential part of the curriculum in Japanese medical schools.5
attention
cancer-screening plan
E
Shambaugh Jr
Shambaugh Hearing
Frischbier HJ, Hoeffken W, Robra BP, eds. Mammographie in der Krebsfrüherkennung—Qualitätssicherung und Akzeptanz. Stuttgart: Enke, 1994.
Infection and SIR-The
Teaching ethics in Japan SIR-In the wake of the March
20, 1995,
nerve-gas attack
Tokyo’s subways (April 15, p 980; June 3, p 1446), which killed 15 people and injured more than 5000, the police have arrested at least 30 staff members of the doomsday cult, Aumshinrikyou (Aum). They included young scientists and doctors who had graduated from universities and medical schools in Japan. Newspaper reports of Aum’s activities have shocked the Japanese people.’ Cult members, including doctors and scientists, allegedly did research on poison gas and other chemical weapons. Tens of thousands of people were pressured into becoming cult believers, and those who tried to flee were detained in the cult’s headquarters or at the cult’s affiliated hospital. Some reluctant recruits were tied up or injected with drugs (benzodiazepines, pentazocine, barbiturates) or deprived of sleep and food; others were tortured. Some of on
the scientists
seem to
have cultured Clostridium botulinum
as
biological weapon, this activity being interrupted by the police investigation. For young doctors to do such terrible things might simply reflect a naive willingness to become religious zealots or even sociopathic tendencies-but could Japanese medical education be partly responsible? Medical schools in Japan put too much emphasis on knowledge and pay too little a
1574
and
Allergy PC, 40 South Clay Street, Hinsdale, Illinois 60521,
USA
hospital laundry
laundering of clothing and bedding used in is hospitals largely taken for granted, but not uncommonly seems to be the source of outbreaks of infection. Some years ago in our hospital, attention was turned to this problem during an investigation of what seemed to be a recurring outbreak of streptococcal infection associated with the maternity unit. This infection reappeared in the winter months for three consecutive years. On each occasion, extensive environmental and epidemiological investigations were carried out, which indicated that babies were being infected very shortly after birth and perhaps in the delivery suite. A great deal of effort was spent in swabbing staff (reluctantly on our part and in the event without useful positive results), which was done only after other avenues had been exhausted and no obvious source for the outbreak had been established. The nursing techniques being implemented within the department seemed of a high standard. Finally, the control of infection team decided to look at the laundering of the vests usually given to newborn children. To our surprise, we found that these were washed in the local hospital mini-laundry and not under the normal laundry contract. Investigation of the mini-laundry, and in particular the hot air dryers, revealed extensive contamination with the MT type of Streptococcus pyogenes involved in the outbreak. Since then, all babies’ vests have been autoclaved and the outbreaks have ceased. Most people working in hospitals assume that laundry returned to them is in fact clean and therefore safe. Laundry
p 1167) of problems with in screening Germany is incomplete. The not commented on, is that some of the major problem, sickness funds feel that larger screening mammography is too expensive, in view of a new government regulation that is expected to put competitive pressure on premiums. As a consequence, they filibuster in committee meetings and suggest time-consuming intermediate recommendations far short of the effective establishment of a national screening policy. One sickness fund refused to play this game and started to build a quality assurance programme, including mandatory double reading by certified experts, a reference centre, and statistical monitoring of results. The strategy is based on the German Mammography Study (GMS).’ GMS was a quality-assurance programme conducted in collaboration with office-based radiologists, gynaecologists, and general practitioners in the decentralised structure of German health care from 1989 to 1994. It was not designed
SIR-Werneke’saccount
(May 6,
breast-cancer
investigate population coverage or "uptake" (which was not even measured). Participation required individual referral by office-based physicians and, because of German data protection legislation, the written informed consent of the 37 626 participants. GMS thus differed from population-based screening programmes in other health services, and it can hardly be criticised for low uptake. The to
detection rate of breast cancers doubled to 5-0 per 1000 and the predictive value of open biopsies went up from 16% to 37% over the study period. Office-based physicians achieved the same detection rates and positive predictive values as four expert screening centres taking part as reference. The experiences gained in this study could be harvested nationwide, if the sickness funds were willing to invest in
quality. B Peter Robra
to
Yasuharu Tokuda 23 West Wheelock St, Hanover, NH 03755, USA
1 2 3 4 5
Yomiuri Shimbun 1995 (May 15-26). Kato N. What is bioethics? Tokyo: Miraisha, 1986 (in Japanese). Anon. Crimes and misdemeanors. Newsweek 1995 (March 27): 43. Daws G. Prisoners of the Japanese. Morrow, 1995. Nakamura Y. What is clinical thinking? Tokyo: Iwanamishoten, 1992
(in Japanese).
Manipulating medicine SiR-Horton’s
note (May 6, p 1167) ignores the medical savings account technique, which has been proposed by the Heritage Foundation and several Congressmen and endorsed by the Speaker, Newt Gingrich. This will gradually, as it is slowly introduced, result in substantial savings in Medicare costs as individuals begin to use their own money from their tax-free "medical savings account" to pay for routine medical expenses rather than having a third party pay everything for them. This is the one approach to the healthcare problem that promises to reduce total costs, rather than increase them, by introducing a real incentive not to order excessive tests and treatments and eliminating the expenses of a middleman between patient and physician.
George
Department of Social Medicine, University of Magdeburg, 39120 Magdeburg, Germany 1
ethics.2 Few medical schools offer lectures in the medical licensing examination hardly ever tests bioethics; of knowledge ethics; and few hospitals have their own ethics committee. Half a century ago, several Japanese doctors in the notorious Unit 731 did horrifying medical experiments in wartime Manchuria, China, including the infliction of bullet wounds and other injuries and infection with lethal bacteria such as Bacillus anthracis.3,4 The teaching of bioethical principles should be an essential part of the curriculum in Japanese medical schools.5
attention
cancer-screening plan
E
Shambaugh Jr
Shambaugh Hearing
Frischbier HJ, Hoeffken W, Robra BP, eds. Mammographie in der Krebsfrüherkennung—Qualitätssicherung und Akzeptanz. Stuttgart: Enke, 1994.
Infection and SIR-The
Teaching ethics in Japan SIR-In the wake of the March
20, 1995,
nerve-gas attack
Tokyo’s subways (April 15, p 980; June 3, p 1446), which killed 15 people and injured more than 5000, the police have arrested at least 30 staff members of the doomsday cult, Aumshinrikyou (Aum). They included young scientists and doctors who had graduated from universities and medical schools in Japan. Newspaper reports of Aum’s activities have shocked the Japanese people.’ Cult members, including doctors and scientists, allegedly did research on poison gas and other chemical weapons. Tens of thousands of people were pressured into becoming cult believers, and those who tried to flee were detained in the cult’s headquarters or at the cult’s affiliated hospital. Some reluctant recruits were tied up or injected with drugs (benzodiazepines, pentazocine, barbiturates) or deprived of sleep and food; others were tortured. Some of on
the scientists
seem to
have cultured Clostridium botulinum
as
biological weapon, this activity being interrupted by the police investigation. For young doctors to do such terrible things might simply reflect a naive willingness to become religious zealots or even sociopathic tendencies-but could Japanese medical education be partly responsible? Medical schools in Japan put too much emphasis on knowledge and pay too little a
1574
and
Allergy PC, 40 South Clay Street, Hinsdale, Illinois 60521,
USA
hospital laundry
laundering of clothing and bedding used in is hospitals largely taken for granted, but not uncommonly seems to be the source of outbreaks of infection. Some years ago in our hospital, attention was turned to this problem during an investigation of what seemed to be a recurring outbreak of streptococcal infection associated with the maternity unit. This infection reappeared in the winter months for three consecutive years. On each occasion, extensive environmental and epidemiological investigations were carried out, which indicated that babies were being infected very shortly after birth and perhaps in the delivery suite. A great deal of effort was spent in swabbing staff (reluctantly on our part and in the event without useful positive results), which was done only after other avenues had been exhausted and no obvious source for the outbreak had been established. The nursing techniques being implemented within the department seemed of a high standard. Finally, the control of infection team decided to look at the laundering of the vests usually given to newborn children. To our surprise, we found that these were washed in the local hospital mini-laundry and not under the normal laundry contract. Investigation of the mini-laundry, and in particular the hot air dryers, revealed extensive contamination with the MT type of Streptococcus pyogenes involved in the outbreak. Since then, all babies’ vests have been autoclaved and the outbreaks have ceased. Most people working in hospitals assume that laundry returned to them is in fact clean and therefore safe. Laundry