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



From the February ACP-ASIM Observer, copyright 2002 by the American College of Physicians-American Society of Internal Medicine.

Vaccine problems

We are now experiencing the second year in which large purchasers including commercial drug chains had access to flu vaccine before many physicians. ("Tips to overcome delays and other barriers to immunizing patients," October ACP-ASIM Observer, page 1.)

Here in San Mateo County, Calif., injection clinics started offering flu immunizations for $5 to $15 on a first-come, first-served basis in October. My supply of flu vaccine, however, didn't arrive until the end of November, and only after we switched suppliers. In addition, we had to pay nearly double last year's prices.

The article cited lack of insurance coverage as one reason that physicians don't offer immunizations. It went on to say, "Experts, however, say that should not keep you from doing the right thing." This statement implies that physicians—assuming that they can actually get flu vaccine—should supply it free of charge.

I wonder about the credentials of the experts who offer this advice. Are they economists, practice managers, scientists, government officials or physicians in some form of practice? There are innumerable unmet wants in health care, and unfunded mandates are about as likely to succeed in medicine as they are in government, which has the added advantage of being able to print money.

This year, I planned to meet the challenge by abandoning my usual hubris of wanting to do all things for my patients. I advised them to take advantage of community clinics, which offer flu vaccine for either less than or not much more than what it would cost me to supply it. I advised early immunization. And I ordered only small quantities of vaccine to take care of the stragglers.

Despite that plan, I twice had to order additional supplies of vaccine. I continued immunizing patients with serious chronic illnesses through the end of December, two months later than appropriate.

Philip R. Alper, FACP
Burlingame, Calif.

I used to provide flu shots for my patients. Because I'm a rheumatologist, many of these individuals are either elderly or immune compromised, or both.

Last year, however, I got clobbered when vaccine prices jumped from $18 for a 10-dose vial to $50. With Medicare paying $8 a patient, that doesn't cover my costs. When the vaccine that was promised for December arrived in late January and went unused, I lost most of the $1,000 I had invested.

The CDC, the AMA and everyone else who claims to put preventive health care at the top of their agenda need to understand a simple fact of economic life: I have to make a buck doing this. (I already have enough "loss leaders," thank you.)

I haven't seen the College—or anyone else—arguing for increased reimbursement for immunizations. I bet there will be many more deaths from flu than from anthrax.

Karen S. Kolba, ACP-ASIM Member
Santa Maria, Calif.

Editor's note: ACP-ASIM has worked with legislators to improve both the availability of vaccines and reimbursement for immunizations. More information about the College's efforts is available online at

"The rules" for young physicians

I was troubled by the advice offered to young physicians in the October issue of ACP-ASIM Observer. ("To succeed in medicine, try learning 'the rules,'" page 4.)

Clearly, as the article described, understanding "the rules"—informing oneself about workplace politics and learning new skills—is an important part of any profession. But the examples given raise many concerns.

Thomas Mulligan, MD, described a "promising young doctor" who declined to get involved in the care of a superior's relation. "It was a bungled opportunity" because the doctor "failed to realize" the superior could have helped his career. Isn't it possible that the physician felt unable to administer care objectively and thus made an ethical choice?

In another example, the article states that joining a physician union may "hurt your ability to advance in a managed care environment." That may be true, but it might help champion decent working conditions, better patient care and other important issues.

The philosophy expressed in the article will show young physicians what they must do to toe the line, be financially successful and not make waves. This attitude is partly to blame for American medicine's current sorry state.

Why not tell young physicians to learn as much as they can and do what they think is right, and think beyond the bottom line? Eventually, "the rules" change, as every physician who has been in practice during the past 20 years knows, to our chagrin. It's up to us to change those rules for the better.

Sheila Feit, ACP-ASIM Member
Syosset, N.Y.

ER call crisis

"Wanted: doctors willing to take ER call" (November ACP-ASIM Observer, page 1) correctly noted that the hospitalist concept is being embraced across America by hospitals and medical groups looking to effectively manage an increasing number of emergency room patients—both those with primary care physicians and those who are "unassigned." The reasons behind this trend are threefold:

  • Hospitalists are present at the hospital almost all the time, ready to provide care to most hospitalized patients.
  • Because hospitalists spend all their time treating hospitalized patients, they are highly effective in responding to acute situations.
  • Hospitalists can help manage the patient's care at every stage of hospitalization, from admission to discharge, providing improved continuity and enhanced quality.

While the National Association of Inpatient Physicians and its 2,300 hospitalist members strongly support this role for hospitalists, we recognize that hospitalists are only part of the solution.

Hospitals and government agencies must provide funding to cover the costs of inpatient care for acutely ill, uninsured—and usually unassigned—patients. Hospitals must also find ways to ensure that other specialists are available to hospitalists caring for acutely ill inpatients who require specialty expertise or procedures.

With such cooperation and participation, hospitalists can be an important part of the solution to the problems now reaching crisis proportions in American emergency rooms.

Ronald Angus, ACP-ASIM Member

Editor's note: Dr. Angus is president of the National Association of Inpatient Physicians.


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