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



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

Micropractices are bad examples

Micropractices are bad examplesThe article in the September issue of ACP Observer by Ryan DuBosar, “No-frills space give docs luxury of time,” reminds me of the famous article, “The Emperor Has No Clothes.” Are we really supposed to hold these physicians up as examples?

These physicians have received highly specialized training. Much of their training, especially in state-supported universities and medical schools, has been subsidized by taxpayers. Now these physicians have decided that they can work part-time, employing very little staff. This is touted as being in the name of spending more time with patients. Let’s be honest! This has very little to do with the patient. This simply has to do with a lifestyle choice by these physicians. They are basically lazy.

We all went into medicine with open eyes. We all knew it was a demanding profession. Unfortunately, many physicians have decided that caring for sick patients, including after-hours access, seeing them in the hospital, etc., is simply too hard. I agree it is hard work. Every doctor should take steps to have adequate coverage and partners so that they can have most of their evenings and weekends off.

However, if we all go part-time, who is left to see the patients? Twenty patients a week simply does not provide access to the volume of patients that need to see a doctor. Further, these physicians clearly have a spouse that provides access to health insurance and retirement benefits. No mention was made of these important aspects of full employment. Lastly, these physicians provide no employment to individuals in the community and almost no economic impact to the community.

Don’t hold these physicians up as examples. They are examples; they are examples of why general internal medicine is dying.

John Matlock, ACP Member
San Antonio, Texas

Dr. Soma Mandal is quoted as saying that with her reduced overhead she is now able to spend 20 minutes with a follow-up patient and 40 minutes with a new patient. I am the chief of the Department of Medicine at Gouverneur Healthcare Services, the Lower East Side practice where Dr. Mandal worked. During the time she was here, follow-up patients were given 20 minutes and new patients were given 40 minutes—the same time she allots in her new practice.

You state that she had only 5-7 minutes for clinical work. Why would 15-minute slots allow for only 5-7 minutes of clinical work? Then, as now, all doctors have a one-on-one medical assistant, an appointment scheduling center, a billing department, a managed care office to handle pre-authorizations for referrals, and an electronic medical record. Our size allows for these efficiencies, which result in more time spent with patients.

Lastly, Gouverneur Healthcare Services, and countless clinics like it, serve a disproportionate percentage of patients who are uninsured and have limited English proficiency. Will these micropractices feel the social responsibility for providing care for these patients who are more time consuming and cannot afford to pay?

David Stevens, MD
New York

Time to abolish codeine

People vary widely in their ability to make morphine from codeine. Some patients have genetic mutations that lead to no enzyme activity and no morphine production. For them, codeine is a placebo. Others, such as the woman reported in ACP ObserverWeekly (“Nursing mothers must be wary of codeine, FDA says,” Aug. 28, 2007) whose baby died of morphine toxicity, have excessive enzyme and make far more than the average amount of morphine from codeine. This difference in the amount of morphine made by the body from a dose of codeine accounts for much of the variation from patient to patient in the response to codeine.

Recent genetic studies have found the likelihood of a person making little, if any, morphine is 5%-10% if the patient is of European ancestry, 1% if of Middle Eastern or Asian ancestry, and 5%-19% if of African ancestry. On the other hand, the risk of a person making a lot of morphine from codeine is 1%-2% if European (except for people of Spanish background for whom it is 7%-10%), about 1% if Asian, and anywhere from 1%-10% if of African ancestry.

Codeine is really a pro-drug with little, if any, analgesic activity. Its analgesic and toxic effects are due to the morphine made from it by the body. Rather than give a pro-drug with an unpredictable amount of morphine produced, prescribe the actual dose of morphine desired. There is no pharmacological reason to prescribe codeine. Some of the controlled substances rules will have to be changed to make it as simple to prescribe 3-6 mg morphine in combination with acetaminophen or NSAIDs as it is now to prescribe 30-60 mg codeine with these other drugs.

Prescribing the intended dose of morphine instead of the unpredictable amount of morphine by giving codeine will make the response to the analgesic more predictable. More predictable means both safer and more effective.

It is time to abolish codeine.

Marcus M. Reidenberg, FACP
New York


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