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Letters

From the November 1999 ACP-ASIM Observer, copyright © 1999 by the American College of Physicians-American Society of Internal Medicine.

Community-based trials

While community-based trials certainly raise some concerns, many of the same criticisms apply to research grants given to academic based individuals for the same purposes. ("Community-based trials under scrutiny," July/August ACP-ASIM Observer, p.1)

For example, I have listened to many research presentations where the main concern was the objectivity of an individual's evaluation, presentation and analysis of data. I have also heard recommendations that seemed to obviously favor the entity financing the research.

Community-based trials are noteworthy for another reason, which I have yet to see mentioned. The population being studied in these trials may be of a different socioeconomic class than that studied in a clinical trial at an academic center. This could produce interesting results.

Although many self-righteous pronouncements are being made, I do not believe that we can legislate or control investigative honesty or a researcher's ethics.

I believe that many of the criticisms being leveled at community-based trials are not motivated by the patient's best interests or safety, or even the quality of the research. Rather, I suspect that the real concern may be that research dollars are being shifted out of academic centers.

Gary N. Butka, ACP-ASIM Member
Brownwood, Texas

AIDS infection prevention

One element of HIV care that is of increasing importance, at least here in Seattle, is preventing the spread of other infections. ("Caring for AIDS patients: not just medicine as usual," Sept. ACP-ASIM Observer, p. 3.)

Investigators looking at sexually transmitted disease (STD) here recently reported a resurgence of sexually transmitted bacterial diseases, most notably syphilis, among men who have sex with men (MSM). While King County had only one heterosexual case of syphilis in 1996, that number rose to 19 in 1997 (four in MSM) and 88 in 1998 (75 in MSM). Numbers remain high among that population in 1999.

Of even greater concern is the fact that among 79 MSM with early latent syphilis from 1997 through 1999, almost two-thirds also had HIV. Most of these men were aware of their HIV status, had access to ongoing primary care and were taking anti-retroviral cocktails. In the apparent belief that HIV seropositive men would not be at risk for STDs, providers missed or delayed diagnosing syphilis in some of the early cases.

Another concern is that syphilis and other STDs can greatly enhance transmission of HIV. The 79 MSM in the study reported 653 partners, many anonymous. Because so few partners were known, partner notification efforts were possible in only 6% of cases.

Robert Wood, FACP
Seattle

Editor's note: Dr. Wood is director of the HIV/AIDS Control Program for Seattle and King County, Wash.

Listening

I agree with Dr. Silk's observation that by listening to our patients, internists can have a profound effect on how they feel. ("When listening, not action, is the best medicine," Sept. ACP-ASIM Observer, p. 2.)

I was discouraged, however, to read that Dr. Silk does not feel he can be reimbursed for this service. Dr. Silk can be reimbursed for his services quite readily through the proper use of ICD-9 and E/M codes.

For the emphysema patient described in the article, Dr. Silk should list the diagnosis, document the total time of the visit and the time spent counseling the patient, and note what was discussed. If more than 50% of his face-to-face time was spent counseling the patient about her disease, he should use the time component of the appropriate E/M billing code.

The implication that all billing and coding problems "say something about the humanity of bureaucrats" is misguided. Dr. Silk's failure to realize that "listening" is not a diagnosis, and that he can bill for counseling time through the proper use of E/M codes is his error, not that of the "bureaucrats."

I realize that billing and coding issues are complex. But at this juncture, they are the best available way to tell third-party payers what we do. It is our obligation to understand and use the coding and billing tools to the best of our ability.

Andrew W. Murphy, ACP-ASIM Member
Bel Air, Md.

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