American College of Physicians: Internal Medicine — Doctors for Adults ®

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Letters

From the June 2001 ACP-ASIM Observer, copyright 2001 by the American College of Physicians-American Society of Internal Medicine.

The name debate

I don’t understand all the fuss regarding the term “internist.” (“Do internists need a name change?” November 2000 ACP–ASIM Observer, page 1.) Here’s what I’ve been telling my patients for years, and it works.

I describe internal medicine as care for adults, including the elderly and teenagers. I then tell them that I see healthy adults for physical examinations and minor ailments, as well as those with chronic ailments that need ongoing attention, such as diabetes, heart disease, etc.

I tell this to my patients of all educational levels in our urban setting. They never flinch but seem to understand what I do without needing a new label for me. One explanation is almost always enough. The rest of the idea (no babies, no surgery) seems to fall into place for them naturally.

Maybe that was the missing ingredient all along: getting back to the basics of one-on-one conversation instead of the high fallutin’ fast talk of the public relations industry.

Robert H. Digby, ACP–ASIM Member
Okemos, Mich.


Physician pay

Your article on pay trends emphasizes that unfair reimbursement for primary care persists. (“A look at trends in physician pay,” February ACP–ASIM Observer, page 1.)

I was in an internal medicine group practice for 34 years before retiring in 1998. During my last 10 years of practice, our group’s overhead went from 50% to 69%. As a result, I worked 30% harder to make 30% less.

Primary care will continue to remain at the bottom of the barrel unless HCFA and insurers recognize that insufficient reimbursement is a problem. Reimbursement must be made sufficient to cover practice expenses as well as physician services.

Jack W. Trigg Jr., FACP
Birmingham, Ala.


Diagnostic skills

I wholeheartedly agree that “Good diagnostic skills should begin at the bedside” (February ACP–ASIM Observer, page 7). The article, however, overlooked a fundamental aspect of physical diagnosis by failing to recognize that work (or a lack of work) is an important component of our adult patients’ lives.

When we ask our patients about their work, it builds rapport, linking us to a world where they have some control. Furthermore, it helps to know that the person whose blood sugar is swinging wildly out of control drives a taxi, or that the middle-aged patient with new-onset chest pain has just been downsized out of his life’s work.

Attending physicians as well as residents frequently overlook this area, but the College should not.

Rosemary K. Sokas, FACP
Washington


Alternative careers

I found it ironic that ACP–ASIM Observer featured a virtual primer on how to leave medical practice for greener pastures in the pharmaceutical industry, Wall Street, etc. (“When clinical practice isn’t enough, some physicians find new careers,” March ACP–ASIM Observer, page 1.) Perhaps an upcoming issue will advise us on law school admissions.

For those of us still caring for patients, the College’s efforts would be better directed at helping us fulfill the commitment we made when we chose a career in medicine.

Arthur E. Fass, FACP
Briarcliff Manor, N.Y.


Pain

I was interested to read the article on the management of chronic pain in which “complementary therapies” are recommended. (“Managing the fifth vital sign: your patients’ pain,” April ACP–ASIM Observer, page 4.) In an era when evidence-based medicine is—or should—be de rigueur, publication of such advice by ACP–ASIM seems inappropriate.

Saul B. Gilson, FACP
New York


Ethics and research

The authors of the ethics case study took some liberties with the facts about clinical trials. (“When are industry-sponsored trials a good match for community doctors?” March ACP–ASIM Observer, page 1.)

The article did not present any facts about the Code of Federal Regulations as it pertains to the safety of human subjects; nothing about good clinical practices and/or International Committee on Harmonization guidelines as they apply to clinical research; and nothing about the fact that institutional review board oversight and responsibilities are clearly spelled out in the Code of Federal Regulations.

I agree that any community doctor who undertakes clinical research must carefully review the protocol before agreeing to participate in a trial. In addition to the protocol, physicians must also carefully review the investigator brochure, which contains all information known about the drug under study at that time.

Physicians should also carefully assess the population the protocol requires. The protocol must offer something of value to the participants, or at least the chance to receive something of value, such as an alternative therapy.

I agree with the Declaration of Helsinki and its stand on placebo use in human subject research. However, the FDA controls and reviews all drug studies in the United States and it insists on placebo controls.

The ethical dilemma of placebos is offset by the fact that all study subjects are free to withdraw from a trial at any time, for any reason, and resume the current standard of care. If participating in a trial puts a patient/subject at risk due to delayed treatment, that person should not be enrolled in the trial to begin with. It is in violation of the Code of Federal Regulations to coerce anyone to participate in a clinical trial.

I know of no other industry that is as closely scrutinized from every angle as the research industry. It therefore bothers me that drug trials are so misrepresented.

Phyllis Thibado
Manchester, Conn.

Editor’s note: The author is a certified clinical research coordinator with a private medical practice.

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