Dialysis raises issues
The September 2007 ACP Observer article "Dialysis might not be right call for the very old" raises several ethical principles including autonomy, beneficence and distributive justice.
An approach that addresses two of these principles asks whether dialysis is effective and is it of benefit. To determine efficacy, ask whether the dialysis alters the basic nature and progression of the patient's illness and comorbidities? To determine benefit, ask whether the anticipated dialysis treatment and result is what the patient desires? The distributive justice issue which imparts an economic factor remains primarily a societal issue and is not a factor of the physician-patient relationship.
Ralph Lucariello, FACP
Single payer challenged
In response to Robert Doherty's editorial in the September 2007 ACP Observer I would like to point out that the CHAMP plan moves health care in this country a long way down the road to a single payer system and increasing government control. Ask our Canadian colleagues if they are happy about their system. It only works well when you are well. The CHAMP plan would make government pay for health care for children to age 24 and with family of four incomes up to $80,000 per year. This would drive children out of private insurance plans into SCHIP. Government already controls over half of health care in the United States.
Funding the new massive program by cigarette taxes is an illusion. While we may benefit from less tobacco use, the planned tax revenue windfall will not occur. Sadly, 80% of cigarette use is in households with incomes less that $30,000 per year, a cruel tax on the poor.
Patrick Breaux, FACP
More on micropractices
The article, "No-frills space gives docs luxury of time," in the September issue of ACP Observer was very interesting. I admire Drs. Mandal and Hersch and others who have succeeded in micropractice and are enjoying it so much. I do, however, have some questions about this method.
In the past 25 years, gatekeeping has been imposed on internists by the HMOs, and that demands a great deal of time that seriously impairs direct patient care on a one-to-one basis. No one will argue this point. I wonder how micropractice manages gatekeeping, along with myriad hassles they face with reimbursements without even a secretary to make calls and do bill submissions. Technology cannot handle all aspects of solo practice, especially the nuances of correct billing and collections. Electronic records do speed up patient encounters and ordering of studies, but doctors have to be speed typists to make this work smoothly. Besides, no computer system is without periodic glitches, not to speak of outright crashes that occur. I have experienced this in that most successful electronic system, the VA. At these times does the micropractice physician pay attention to the patient or fix his equipment?
In some cases malpractice insurers will not cover such practices because of their perception that lack of para-medical help will increase litigation chances. More important, how does a solo doctor protect himself from charges of patient abuse, especially while doing uro-genital examinations without a female chaperone? I have practiced solo and managed to keep my practice overhead below 40-45%, but I certainly will not do without at least one constantly present office help, preferably female.
Byravan Viswanathan, FACP
Encourages stem cells
Gary Prechter's letter to the editor perpetuates the current party line mouthed by religious conservatives regarding embryonic stem cell research. Improperly using the fact that adult stem cells (which are eligible for federal funds and thus more available) are closer to therapeutic uses than embryonic stem cells, Dr. Prechter fails to realize that any advance made with any type of stem cell (embryonic, adult, amniotic fluid) necessarily will produce information on the other types and their therapeutic uses.
Embryonic stem cells, being the progenitor of all stem cells and all other cells, have the potential to unlock the most information which could push the entire field forward. It also must be emphasized that the embryos used for this research are ones slated for destruction and, if not used for research, end up in the garbage. To oppose embryonic stem cell research on embryos that will never progress to birth is to sacrifice the living to heaps of cells for the benefit of no one. It is pure nihilism.
Amesh A. Adalja, ACP Associate Member
In the hard world of overwork and under-appreciation in the practice of medicine, there are still bright spots.
Two times in the past month, I have been caught up in the desperate drama of a regional trauma and critical care unit with families facing sudden and overwhelming losses. Waiting with these fine people as their loved ones struggled, too young and productive to die, I saw the incalculable good of a magnificent physician: competent, hardworking and totally professional. His facility is worn and understaffed but his associates clearly reflect his standards, dedication and determination to provide excellent care. As a somewhat jaded, over-the-hill physician who has seen most everything in the last 50 years, I recognized in him the rare, right stuff that makes true heroes.
It is reassuring in these difficult times to see the eternal value of a fine physician. And, to know that beyond his demanding clinical work, he is a leader in American medicine: Vincent Nicolais, FACP, is Governor of the Georgia Chapter of the American College of Physicians. We should all be thankful for internists like him.
Robert B. Copeland, MACP
La Grange, Ga.
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