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Letters

From the March ACP Observer, copyright 2007 by the American College of Physicians.

Controversy over kidney disease

In his recent letter, Dave Moskowitz, FACP, ("Promoting dialysis alternative," ACP Observer, December 2006) described the increasing burden of chronic kidney disease and refers to an ACE-inhibitor treatment regimen he has developed. But his statement that "the renal community is finally [emphasis added] interested in early kidney failure" is puzzling.

The cost of CKD is indeed enormous, in terms of both human suffering and economic burden. We share with Dr. Moskowitz a deep concern for people with kidney disease, and we wholeheartedly welcome high-quality basic and clinical research proposals that would enhance understanding of CKD and improve quality of life for patients.

The NIH has a long history of interest in and support for major projects to describe the burden of kidney disease, to understand the course of the disease and to improve treatment. Numerous NIH-funded studies provide clinical evidence for the use of ACE inhibitors and other management tools for CKD, empowering NIH's National Kidney Disease Education Program to raise awareness and improve patient care, especially among populations at greatest risk. In fact, recent data from NIH's US Renal Data System show that ACE inhibitors are increasingly used for African Americans, suggesting that research results are, indeed, making their way into clinical practice.

Before potential treatments or regimens are widely adopted, evidence of safety and effectiveness must be established. Dr. Moskowitz has published few specific details about his treatment regimen, thus limiting public review and debate and making it impossible for others to validate his findings. Our institute has previously extended invitations to Dr. Moskowitz to apply for an NIH research grant. We continue to welcome applications in this area of tremendous public health importance.

Robert A. Star, MD
Acting Director, Division of Kidney, Urologic, and Hematologic Diseases
National Institute of Diabetes and Digestive and Kidney Diseases
Bethesda, Md.

As the President of the Renal Physicians Association (RPA), I am disappointed at the ACP Observer's decision to publish the letter of David Moskowitz, FACP ("Promoting dialysis alternative," ACP Observer, December 2006).

Dr. Moskowitz's letter is inaccurate, inflammatory and misleading. The RPA has, along with other nephrology societies, been working for years to educate primary care physicians as well as nephrologists in identifying and caring for patients with chronic kidney disease. Indeed, the specialty of nephrology is quite advanced in its development and utilization of clinical practice guidelines to address the needs of patients with chronic kidney disease (CKD) as well as end-stage renal disease (ESRD). We have worked closely with National Kidney Disease Education Program to bring to the attention of physicians the crisis facing this country due to the increasing numbers of CKD patients. Our efforts include the 2002 RPA clinical practice guideline on Appropriate Patient Preparation for Renal Replacement Therapy, among other publications.

Dr. Moskowitz's comment "no nephrologist has wanted to jeopardize 90% of his or her income despite having taken an oath to help their patients" is not only incorrect, but demonstrates a lack of knowledge of the enormous amount of work carried out by the RPA and others in the renal community. It flies in the face of the multiple efforts nephrologists are making to diagnose CKD early, treat patients early, reduce complications of CKD and prevent progression to ESRD.

Robert Provenzano, FACP
President, Renal Physicians Association
Rockville, Md.

Editorial Note: At the time of his December 2006 letter to the editor, David W. Moskowitz, FACP, was president and CEO of Genomed, a St. Louis-based medical genomics company working on cures for kidney failure and other diseases.

Principles for reform fall short

I am writing in response to the announcement about physician groups that recently endorsed the Principles for Reforming the U.S. Health Care System (ACP Observer Weekly, Jan. 16, 2007). I agree that many of the new members of Congress were elected because of deep concerns regarding the current state of health coverage. However, I was quite disappointed that the principles did not stake out a truly comprehensive and decidedly needed overhaul of the U.S. health care system.

The three major problems in the current system are rapidly increasing costs, the high number of uninsured and poor quality in some areas. The U.S. spends $5,711 per capita per year while other countries spend substantially less. Despite this, the U.S. lags behind many other developed countries in such health indices as life expectancy, infant mortality and maternal mortality. We in the U.S. are paying more for less.

The Principles recommend that all citizens be able to afford and obtain health insurance but this fails to address a most relevant issue: Why is for-profit health insurance necessary, particularly for basic essential health care? The for-profit health insurance industry not only has failed to solve the major problems enumerated above but has actually contributed to higher costs and rising numbers of uninsured. The administrative overhead of for-profit health insurance companies (shown in studies to vary from 16% to 26%) substantially exceeds that of Medicare (3.1%).

The ACP and other medical groups should explicitly and unequivocally endorse and advocate for universal access to health care. We are the only country in the developed world that does not consider health care a right. This is shameful for a country as wealthy as ours. The ACP and other medical groups also should endorse and advocate for a nonprofit, single-payer system, which would be substantially less costly yet more comprehensive than what we now have. The role of for-profit health insurance companies should be limited to the provision of health services that are not considered medically necessary.

In 2005, Rep. John Conyers, Jr., of Michigan introduced into Congress the U.S. National Health Insurance Act (or the Expanded and Improved Medicare for All Act)—H.R. 676. The summary states that this bill "establishes the U.S. National Health Insurance Program to provide all individuals residing in the U.S. and U.S. territories with free health care that includes all medically necessary care, such as primary care and prevention, prescription drugs, emergency care and mental health services." Endorsement of this bill by ACP and others would be a bold move, one that could advance the cause of true improvement in our health care system.

Donald W. Mitchell, ACP Member
Seattle

Listening: a lost art?

I was astounded to see the picture accompanying the article, "More doctors tell patients 'we'll see you today,' " (ACP Observer, November 2006). I was taught to examine all parts of the body with a stethoscope by placing the bell/diaphragm directly on the skin over the part being examined. More than 50 years of practice has indicated to me that attempting to listen through any garment or sheet is an inadequate way of hearing the subtle sounds which the human body produces.

But, sadly, nowadays I see all levels of medical personnel not bothering to ask the patient to disrobe to do a proper examination. I also have had my own blood pressure taken with the cuff wrapped around my arm while I was wearing a long sleeved shirt and my lungs examined through an undershirt and a dress shirt!

I certainly hope that the technique which you show is not taught in medical schools and postgraduate training programs. And I hope that ACP does not condone this method of using this still very important diagnostic tool.

John L. Friedman, FACP
Phoenix

I'm moved to write by a photo that appeared with the article, "More doctors tell patients 'we'll see you today'" (ACP Observer, November 2006). It features a photo of a doctor examining the chest (lungs) of a patient with a stethoscope. The physician appears intent, in part I bet, because she's trying to decide whether what she's hearing originates in the chest or is adventitious noise generated by the shirt that the patient is wearing.

In the good old days, the days when ABIM certification required examination of two patients to the satisfaction of the examiner, examining the chest in this manner would have resulted in a quick dismissal of the candidate with instructions to return another time, after perfecting the fundamentals of physical examination. Those days are gone, of course, and perhaps rightly so. However, should not the College continue to endorse quality in those two pillars of patient care, the history and the physical examination?

Is the need to see patients in such a hurry that baring relevant body parts for examination is prohibitively time-consuming? One wonders whether adoption of open-access scheduling may be inconsistent with patient care of the highest quality.

David J. Kudzma, FACP
Vero Beach, Fla.

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