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Letters

From the September ACP Observer, copyright © 2004 by the American College of Physicians.

Prisoner abuse

I congratulate you for running the piece on the College's position regarding torture. ("Why the College voiced its concerns on prison abuse," July/August ACP Observer.)

I work in a center for refugee health, doing medical assessments of torture victims who claim asylum there and for the asylum network of Physicians for Human Rights. The work can be disturbing, but it is very rewarding.

I have several questions I hope will be addressed at future hearings of the Senate Armed Services Committee. (I did not notice any mention of medical personnel in the first hearings on the Iraqi/Afghan/Guantanamo Bay prisons.) I would like to know: What role medical officers play in those prisons, and was their access to detainees restricted? What is the chain of command used by medical personnel, and did tortured detainees receive appropriate medical care? And did medical personnel attempt to cover up evidence of torture or even participate in the interrogation process?

Medical personnel should have been the first to sound the alarm that torture was taking place in these facilities. Along with their military code of conduct, medical officers have an additional code of ethics they must meet.

Michael Paasche-Orlow, MD
Boston

As an ACP member, I had urged the College to take a stand against prisoner abuse as long ago as April 2003. Now the College has done so, and ACP and Robert B. Doherty [Senior Vice President, Governmental Affairs and Public Policy] deserve our thanks, but with an important reservation.

ACP wrote to President Bush in October 2003. Despite a lack of response from Mr. Bush, the College did not follow up until after the Abu Ghraib prison revelations this spring. It is hard to believe the College would allow correspondence on a time-sensitive issue to languish unanswered for six months. Why did this happen?

If we are honest, we will concede the possibility that ACP leadership recognized the potential for controversy within the College—and for powerful officials to become less sympathetic to ACP on other issues.

The College's principles would have been better honored by a more insistent approach. While we should look back on our comments with pride, that pride should be tempered by the realization that we could have done more.

Charles G. Baynton, ACP Member
Whitefish Bay, Wisc.

Mr. Doherty responds: Dr. Baynton's support for ACP's stance on prisoner abuse is certainly appreciated. I disagree, however, with his suggestion that ACP would have been more effective if we had moved earlier to reiterate and publicize the concerns we originally communicated to President Bush in October 2003.

The potential value of raising the visibility of our initial and confidential communication needed to be weighed against the likelihood that a more public response would have been viewed as political grandstanding. We also decided that, given the gravity of the allegations, it was important to give the president a realistic amount of time to respond. When a response was not forthcoming after several months, we decided to send a second letter and to publicize our concerns.

It is true that ACP handled this issue differently than other issues that do not carry the same consequences. Writing to ask for an investigation of prisoner abuses at a time when the nation is at war needed a more reasoned, sensitive and deliberative approach than calling for changes in Medicare reimbursement policies.

Problem physicians

Your article on proposals from Lucian Leape, MD, to catch "problem doctors" was terrifying. ("To improve patient safety, try treating problem physicians," July/August ACP Observer.) It was also a good way to start a witch hunt.

We had a system similar to that proposed by Dr. Leape at our hospital several years ago. It included anonymous denunciations of physicians by nurses that were filtered through third parties, including other physicians.

The system presupposed that judgments would be made by wise medical experts. In fact, the process often gave physician administrators who were not familiar with the nuances of medical literature a chance to settle scores.

Physicians who faced accusations—and there were many—had complaints sprung on them without warning. The process was both harassing and intimidating.

It took courage, for instance, to advise an emergency department nurse not to give sublingual procardia to a patient with a minor cerebral infarct and elevated blood pressure of 180/90. The nurse and some emergency physicians "knew" it was necessary to lower blood pressure immediately—complaints that struck the "judges" as intuitively correct.

Problems such as these are not easy to sort out. A system like the one proposed by Dr. Leape does not automatically improve patient care or decrease the number of lawsuits against physicians.

Physicians already have enough rules controlling them as insurance companies, the government and malpractice lawyers try to justify lower reimbursements and uninhibited lawsuits. We don't need to pay dues to an organization that represents doctors but feels obliged to find "errors" and give comfort to our enemies.

The real threat to patient safety is incomplete medical science, such as the evidence behind hormone replacement therapy, quinidine for cardiac arrhythmias, meniscectomy for knee pain and "poudrage" for coronary artery disease.

Philip Mendell, FACP
Stuart, Fla.

Professional ethics

I commend the emphasis placed by College President Charles K. Francis, FACP, on the core values of internal medicine and medical professionalism. ("To unify internal medicine, look to professionalism," June ACP Observer.)

Dr. Francis has challenged College members to practice, not just preach, the ethical principles that are plainly spelled out in the Physician Charter on Medical Professionalism. We must demonstrate the kind of professionalism that, as Dr. Francis wrote, "places the public good above individual interest and advantage."

I believe medicine has gotten into the mess it's in because, as a profession, we have made one small unethical decision after another. If that observation is true, it means that our "mess" can be improved by making better ethical choices. We are faced with many such decisions daily. One choice we can make concerns "whistle-blowing" and supporting "whistle-blowers" in their efforts to improve patient care and safety.

In October 2003, the Pittsburgh Post Gazette ran an investigative series on physicians across the country who reported inadequate care and unsafe practices in their hospitals.

Instead of being thanked by hospital administrators and applauded by the public and their profession, these physicians were terminated from their positions or removed from hospital staffs. In many cases, the problems they reported went unaddressed.

The series documented an epidemic of "medicine by conspiracy." I doubt the situation will change as long as doctors who report unsafe conditions are attacked and disposed of, rather than acknowledged and responded to.

Let us meet the challenge Dr. Francis has posed and practice professional ethics. It will revitalize us, secure the patient-doctor relationship and maintain public trust. It will also go a long way toward fixing the malpractice crisis, the morale crisis, the error-reporting crisis and all the other "crises" that now attend modern medicine.

W. Harry Horner, FACP
Waynesboro, Va.

Editor's note: Dr. Horner is involved in a whistle-blower dispute in Virginia.

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