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Letters

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

Presidential candidates

Your October issue featured a half-page discussion on the Republican and Democratic presidential candidates. ("ACP members champion their presidential candidates," October ACP Observer.) When did ACP become so politically partisan-and when did those candidates become the only available choices?

The Libertarian party will have its presidential candidate on the ballot in every state except Oklahoma, far more than other third party candidates.

The concept of a limited government, as expressed in the U.S. Constitution and the Bill of Rights, is indelibly etched in the Libertarian party's platform. This philosophy is not embraced by politicians from the two older parties who, in my opinion, run government by currying favor from special-interest groups.

With the Republicans and Democrats doing all that they can to stifle true electoral dissent, I would hope the College would not offend some members by extending a forum to some candidates that it's not willing to give to others.

Howard A. Grayson, FACP
Plainville, Conn.

Eye exams for diabetic patients

As an endocrinologist/diabetologist, I was intrigued by Brett Baker's article advising internists how to bill for eye exams for diabetes patients. ("How should you bill and code for patients with diabetes?" October ACP Observer.) These exams should almost always be done by ophthalmologists or optometrists, and you shouldn't encourage other physicians to do them.

Eye exams performed by eye specialists are the standard of care for diabetic patients. The American Diabetes Association's standards of care are online.

William W. Quick, FACP
Hillsborough, N.J.

Mr. Baker replies: Thank you for referencing the ADA's position statement.

The ACP Observer article was meant to provide coding and billing guidance on the full range of services furnished to diabetic patients. The guidance was not meant as a standard of care, and we encourage members to follow recommendations from organizations that maintain peer-reviewed, evidence-based clinical guidelines.

Health plan data

As a medical director of Hawaii's largest health plan and a Fellow of the College, I am always disturbed by the slant ACP takes in reporting aspects of managed care. ("Tiered physician networks spark controversy," September ACP Observer.) Given double-digit inflation in health care costs, health plans have no alternative but to shed doctors who run up costs but don't provide quality care.

For those of us who've spent years analyzing administrative data sets, the "flawed data" charge leveled in your article is an oxymoron. No one believes claims data can accurately profile physicians' medical care. Physicians deal with "flawed data" daily in every aspect of medical care, because of limited evidence. Why should doctors be so much angrier when limited data influences their income?

Until physicians confront the inherent weakness in current data and get behind efforts to improve data collection, we will continue to see inflammatory articles about flawed data and physician performance. For starters, I'd suggest that physicians stop gaming the system; accept the ICD-10 procedure coding to simplify the current procedural terminology coding system; and tap physicians in managed care who are trying to design a new health care system.

As an ACP member, I at times feel like I am ducking arrows from my own tribe. I'd appreciate a recognition that there is another voice within ACP that is not heard and rarely asked for input.

Joseph W. Humphry, FACP
Honolulu

Chronic stable angina

I believe there is an error in your article on chronic angina ("A look at ACP's guideline on managing chronic angina," September ACP Observer.)

For a first choice of stress testing modality, the article reads: "The guideline strongly recommends exercise echocardiography (ECG) for symptomatic patients ... " This should read "exercise testing without echo." There is no reason to begin with an exercise echo in subjects with a normal baseline ECG who can walk on the treadmill.

Exercise echo is appropriate for those with an abnormal ECG who can walk; dobutamine echo is appropriate for those who cannot, with or without an abnormal baseline ECG. Many believe that women should start with an exercise echo because of their high false positive rates, but I disagree with that approach.

Jonathan Abrams, FACP
Albuquerque, N.M.

The author was a member of the American College of Cardiology/American Heart Association task force that ACP collaborated with to update chronic stable angina guidelines in 2002.

Editor's note: The ACP Observer article should have read: "The guideline strongly recommends exercise electrocardiography" as the initial test for symptomatic patients.

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