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03novKathy please pickup and place
Pinnacle 4-color ad from Sept
03 (one with logo: "Will you
be making the transition.?")
November 2003 ♦ Vol. 92 No. 11 BULLETIN of the Allegheny County Medical Society
Pill Box . 528
Thoughts from our
From the Mailbag . 516
Tegaserod (ZelnormtmTM) for Women with Medical Editor . 514
Escalating Prescription Drug Costs Society News . 516
Tucker Freedy, PharmD Safdar I. Chaudhary, MD ♦ Photo: Obstetrics/Gynecology Talk on Hormone Replacement Therapy Legal Report . 532
Getting There: Musings of a
♦ Urologists to meet Nov. 24 Long-awaited EMTALA Regs Add Flexibility Medical Student . 522
♦ Pediatric society to donate toys Tina Batra Hershey, Esq ♦ Medical 'biz in the 'Burgh William H. Maruca, Esq Jenny J. Linnoila In Memoriam . 517
Feature . 536
Technology & Medicine . 524
James E. Hanchett, MD Hospitality Houses: Caring for Patients Doctors and Patients: Enhancing the Lawrence B. Brent, MD and Their Families Relationship through Technology Elizabeth L. Fulton Kimberly P. Cockerham, MD Activities & Accolades . 518
Practice Management . 540
Dear Doctor . 519
Reducing Errors in Ambulatory CareKaren K. Davis Community Notes . 520
Its very hard to
Special Report. 545
take yourself too
Continuing Education . 521
Diabetes and Depression in Southwestern seriously when you
Calendar: November/December . 521
look at the world
Applications for Membership . 557
from outer space.
Special Report. 548
Classifieds . 558
Washington Update Thomas K. Mattingly II,
Timothy F. Murphy Apollo 16 astronaut
Special Report. 550
Smoking Cessation Efforts in Allegheny County
Perspective . 552
To Tell the Truth
Timothy Lesaca, MD
Special Report. 553
Profile . 554
by L. Alan Wright, MD
Medicine and Magic: Robert C. Cicco, MDLisa B. Petzel Dr. Wright is a psychiatrist. Affiliated with the Pennsylvania Medical Society and the American Medical Association Executive Committee of the
OFFICES: BULLETIN of the Allegheny County Medical Society, 713 Ridge Av- Safdar I. Chaudhary enue, Pittsburgh, PA 15212; (412) 321- 5030; fax (412) 321-5323. USPS #072920.
PUBLISHER: Allegheny County Medi- cal Society at above address.
The BULLETIN of the Allegheny County Edward Teeple Jr.
Medical Society welcomes contributions Christopher J. Daly David J. Deitrick from readers, physicians, medical students, members of allied professions, spouses, Kimberly P. Cockerham etc. Items may be letters, informal clinical Krishnan A. Gopal reports, editorials, or articles. Contribu- tions are received with the understanding that they are not under simultaneous con- sideration by another publication.
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Louis A. DiToppa/ writer and do not necessarily reflect the
Leticia Q. Jariwala opinion of the Editorial Board, the BUL-
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Publisher reserves the right to exclude any advertisement which in its opinion does not conform to the standards of the publication.
The acceptance of advertising in this publi- Frank H. Rittenhouse/ cation in no way constitutes approval or Krishnan A. Gopal Leticia Q. Jariwala endorsement of products or services by the Barbara M. Harley Allegheny County Medical Society of any company or its products.
Assistant to the Director Subscriptions: $25 nonprofit organizations; Dorothy S. Hostovich $35 ACMS advertisers, and $45 others.
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Nadine M. Popovich Allegheny County Medical
Society, 713 Ridge Avenue,
Pittsburgh, PA 15212.
THOUGHTS FROMOUR MEDICAL EDITOR SAFDAR I. CHAUDHARY, MD Among the cost drivers for Direct-to-consumer marketing is health care, prescription drug a recent phenomenon, leading to costs are escalating at a very rapid The prices of the 50
further demands by many patients pace. In day-to-day practice, it is a prescription drugs used for certain expensive medicine when
common struggle to find sources for most frequently have
an equally effective medicine could medications for our patients. Under- risen four times the rate be used instead. This makes the job
standably, ever rising costs of pre- of inflation in 1998.
of a physician even harder. Drug scription medications are difficult to industry critics say that pharmaceuti- absorb by the payers and employers.
cal money has been used in recent The prices of the 50 prescription years to keep the federal government drugs used most frequently have personal accountability and reduce from regulating the price of prescrip- risen four times the rate of inflation waste of medications as well.
tion drugs and loosening its restric- in 1998, according to Families USA, The group of seniors that is tions on advertising, for which the a nonprofit research group. And the among the least able to pay for its industry spends $1.5 billion a year.
elderly, the group likely to need the own medicine is also the least likely Health and Human Services most medicine, is the least likely to to have insurance to help pay for it.
Secretary Tommy Thompson on have insurance to cover the cost, Income for many seniors living on June 10, 2002, urged pharmaceutical according to the American Associa- fixed pensions and Social Security companies to cut the cost of pre- tion of Retired Persons (AARP).
payments hasn't kept up with grow- scription drugs to avoid a consumer Fully a third of the nation's 39.1 ing medicine bills. In 1998, 78 backlash. "People are going to start million Medicare beneficiaries had percent of the 31.7 million Ameri- questioning why drugs are so much no prescription coverage in 1999, can seniors who reported their more expensive in the United States according to a study by the AARP.
income received $25,000 a year or than in Canada, Mexico and Eu- Most patients also find that prescrip- less, according to the Census Bureau.
rope," he said. Indeed, in our prac- tion coverage is becoming more After paying about $200 a tices, we are noticing people getting expensive each year, if they can get it month for utilities and heat and medications from Canada.
at all. Patients are trying to manage $200 more on an overdue tax bill, As the United States leads the the cost of medication by asking for most patients do not have enough world in research and development free samples, taking less than the money to buy all the drugs which of new medical technology, it is amount prescribed or simply doing have been prescribed and still buy crucial that citizens of this nation get without. Insurance companies are groceries and other essentials. In a fair share of health care at an asking for co-payments for phar- addition, several patients are being affordable price, rather than having macy costs, which is a prudent hassled by creditors to pay medical to struggle with choosing to buy practice, one that may bring some bills accumulated over time.
groceries or prescription medica- 514 u The Bulletin MEDICALEDITOR continued For updates on medical liability, tions. The argument by pharmaceu- without the merits of clinical litera- call the PMS Liability Reform tical companies that a fair share of ture. After all, we all "pay" for what Action Center at (800) 566- costs associated with research and the "doctors prescribe." TORT (8678) or log on to development of new products is Dr. Chaudhary is a psychiatrist and medical built into pricing is unreasonable. A editor of the Bulletin. He can be reached at You also can call the country that takes pride in its email@example.com or (412) 427-6828. openness and homogeneity must Medical Society and The opinion expressed in this column
ask for tort reform uphold the dignity and humanity of is that of the writer and does not
updates (412) 321- its own citizens. So-called plans by necessarily reflect the opinion of the
5030 or log on to various pharmaceutical companies to Editorial Board, the BULLETIN, or the
Allegheny County Medical Society.
assist patients who can't afford tobuy medications requires paperworkhassle and offers no reasonable solution to a fundamental right to get medical care at affordable pric-ing.
In my opinion, it is time for New Phone or FAX Number?
pharmaceutical companies to rein inthese costs and provide sensible New address or e-mail?
pricing for their products, ratherthan sending in an escalating army Be sure to let the medical society know.
of pharmaceutical representatives.
That way you wont miss out on any of the Our lawmakers need to restrain this great benefits youre entitled to as a member! E-mail firstname.lastname@example.org or growing crisis of rising prescription call (412) 321-5030 and ask for drug costs. We as physicians need to Nadine Popovich (ext. 110) or Jim Ireland (ext. 101) help our patients make prudent andless costly choices and just not listento the next pharmaceutical rep The Bulletin u 515 September 25, 2003 speaker. Dr. Klein, whose clinicalinterests include all of urologic oncology and particularly clinical Back in August, I spoke with Chris- trials for localized and locally ad- tina Morton (ACMS communica- vanced prostate cancer, is the na- tions manager) about my difficulty tional study coordinator for the finding physicians who would be NCI-sponsored Selenium and willing to sort ENT surgical instru- Vitamin E Cancer Prevention Trial ments for a shipment of medical (SELECT). He has received numer- material aid that Global Links was ous awards, including the R.J. Behan sending to Haiti in mid-August. As (left to right): Drs. Joseph Sanfilippo
Prize for Excellence in Surgery from a result of an e-mail message for- (Pittsburgh), M. Michelle Blackwood
the University of Pittsburgh, the warded to ACMS members, a (recently of Stamford, Conn.) and Ian
Thorneycroft (Mobile, Ala.) recently
Probstein Award in Oncology from number of physicians expressed an presented a program titled Clarifying the
the Washington University School of interest in helping. We were able to role of hormone therapy in 2003. The
Medicine, and the Nightingale send 400 ENT-related instruments program, held at the Four Points Sheraton
Physician Collaboration Awards valued at $1,600 to surgeons in in Cranberry, was presented to assist
from the Cleveland Clinic Founda- Haiti, and work continues identify- gynecologists, family practitioners,
tion. To register for the program, ing and sorting surgical instruments endocrinologists and internal medicine
physicians work through the controversies
contact Nadine Popovich at (412) for future shipments. Thanks again related to hormone therapy and assist their
321-5030 or e-mail npopovich@ for the assistance from the medical patients in making decisions regarding use.
Urologists to meet Nov. 24
Pediatric society to donate toys
The Pittsburgh Urological Associa- The Pittsburgh Pediatric Society Elizabeth Clewett tion will host a meeting at the (PPS) is mounting a new toy drive in Director of Development medical society headquarters on support of the Allegheny County November 24, with registration and "Holiday Project" cocktails at 6 p.m., dinner at 6:45 Editor's Note: If you wish to volunteer for this and the program at 7:15. Eric Klein, children. Initiated project, call Ms. Clewett at (412) 361-3424, MD, head of the Section of Urologic over 20 years ago ext. 209, or e-mail email@example.com. Oncology at the Glickman Urologi- the Holiday Project cal Institute, Cleveland Clinic ensures that children and families— Foundation, is the invited guest through the Office of Children, PhyzBiz Inc. Your Business Partner A next generation software and service vendor: Practice
Management, Electronic Medical Record, Billing, Transcription,
Hardware/Network, Security, HIPAA One Stop Business Solution
Anticipating Healthcare Needs.Delivering Smart Solutions TM We empower physicians and office personnel to reduce cost and enhance revenue.
TEL: 412-349-0022 • FAX: 412-349-0034 • www.phyzbiz.com
516 u The Bulletin SOCIETY NEWS continued Youth and Families—receive holiday Carlow College has announced a James E. Hanchett, MD, age 68,
gifts, meals and other necessities.
major initiative for the entire college passed away on September 29. An The pediatric society is asking in the area of undergraduate forensic internist specializing in nephrology, members to collect and donate new study and a new undergraduate toys, games and books; gift certifi- degree program in medico-legal cates or monetary contributions will examinations. The multidisciplinary also be accepted. On December 6, initiative will cross all areas of the Cornell University PPS members will meet at the college including forensic sociology, medical society headquarters to forensic computing, forensic nursing and served residen- accept, sort and wrap gifts. For and other disciplines. Cyril H.
information on having a donation Wecht, MD, has accepted the Dr. Hanchett
Baylor College and picked up, call Dianne Meister at college designation as Distinguished Vanderbilt University hospitals. He (412) 321-5030.
Carlow College Professor, the first also served three years in the U.S.
such appointment by Carlow in its Air Force Medical Corps. Dr.
Medical biz' in the 'Burgh
Hanchett served on the medical Highmark Inc. plans to purchase a [10/2/03 Carlow College] society's Peer Review Board from pharmacy. Highmark has formed a 1996-1998. He is survived by his specialty pharmaceutical distribution Children's Hospital of Pittsburgh wife, Jeanne Pain Hanchett, MD; company called Medmark Inc., reported its lowest earnings in six three daughters, Leigh Hergatt, which agreed to buy Fisher's SPS, a years, with executives anticipating Paige Morse and Karen Serbin; two specialized pharmacy based in steep cuts to its Medicaid funding sons, Jeffrey and Scott; and 11 Pittsburgh. Highmark said the starting next July. Earnings of moves were an effort to control $378,000 for the year ending June rising costs of expensive injectable 30 represent a significant drop from Lawrence B. Brent, MD, age 74,
pharmaceuticals used to treat such the record-breaking $21.8 million in passed away on October 16. A ailments as hepatitis C, HIV, cancer gains the pediatric hospital posted cardiologist, Dr. Brent graduated in and infertility.
for the same 12-month period in [9/23/03 Pittsburgh Post-Gazette] 2002. Children's posted a $3.6 million gain in income from treating John Paul, UPMC's second-in- patients in 2003, while the amount pleted an intern- command, will not return to his job of free care it provided last year ship and residency as UPMC's chief financial officer jumped by more than 18 percent to and chief of operations. Paul, who almost $24 million. Children's had been one of the key leaders with officials say its investment losses Dr. Brent
and another resi- the region's largest healthcare pro- pose no long-term threat to the dency at the University of Pittsburgh vider until July when he went on hospital's $188 million endowment, Medical Center. While serving in the what UPMC officials said would a while Chief Executive Ronald L.
U.S. Navy, he co-founded the six-month sabbatical. The university Violi say plans are moving along for Cardiopulmonary Laboratory at the provided no reason for his departure construction of a new Children's Great Lakes Naval Hospital. Dr.
other than to say that Paul, the Hospital at the former site of the St.
Brent is survived by son Gary Ray, UPMC board of directors and Chief Francis Medical Center in daughters Kelly and Holly, and two Executive Officer Jeffrey Romoff Lawrenceville and for expansion of grandchildren, Alice and Alexander mutually agreed that his return services in Wexford.
"would not serve his best interests or [10/22/03 Pittsburgh Tribune-Review] those of the UPMC." [9/27/03 Pittsburgh Tribune-Review] The Bulletin u 517 ACTIVITIES & ACCOLADES Anthony M. DiGioia,
Radio and television Moises A. Arriaga,
personality Jerry MD, otology/
surgery, has been Bowyer interviewed neurotology, was an named chief of West- Judith S. Black, MD,
invited international speaker October 9-12 Dr. DiGioia
Hospital's division of Dr. Black
geriatric medicine, Dr. Arriaga
orthopaedic surgery. He joined the about trends affecting long-term Triological Society and National hospital in 2001 as director of the care, including declining govern- Otologic Congress in Rio de Janeiro, Institute for Computer Assisted mental reimbursements, soaring Brazil, lecturing on advances with Orthopaedic Surgery. Dr. DiGioia liability insurance costs and severe implantable hearing aids, hearing helped develop the Joint Care understaffing, and how those trends preservation, skull base tumor Center and is medical director of T9 can be resolved. The interview aired surgery, advances in rehabilitating Orthopaedic Unit.
on WPTT-1360 AM on Oct. 9.
patients with unilateral hearing lossand new strategies in medical and Leo R. McCafferty,
surgical treatment of Meniere's Academy of Ophthal- MD, chair, ACMS
Dr. Arraiga and Douglas A.
Michael J. Azar, MD,
Committee, moder- Chen, MD, otology/neurotology,
ophthalmology, as ated the Carnegie presented instructional courses on president of the acad- Dr. McCafferty Library of Pittsburgh's
technique and outcomes of special- emy after serving a year as president- Partners for a Healthy Pittsburgh ized cements in otologic surgery as elect. Dr. Azar has been an active program titled Women's Health— well as the results of phase I member of the academy since 1992 Hormone Replacement Therapy: The multicenter investigation of the and has also served as the Board of Risks, Benefits, Options on September Envoy totally implantable hearing Trustees' secretary of medical prac- 9 in Oakland.
aid system at the recent American tice and payment systems.
Academy of Otolaryngology, Head A reporter from the and Neck Surgery Foundation Carlow College has Valley News Dispatch National Meeting in Orlando.
named Cyril H.
Send your Activities & Accolades items to the Wecht, MD, as Distin-
President G. Alan
attention of Elizabeth Fulton at ACMS, 713 guished Carlow Col- Yeasted, MD, internal
Ridge Ave., Pittsburgh, PA 15212 or e-mail lege Professor, the first Dr. Yeasted
medicine, about the firstname.lastname@example.org. We also encourage you to Dr. Wecht
such appointment by medical malpractice crisis in Penn- send a recent photograph, indicating whether the college in its 74-year history. Dr.
sylvania and why physicians are or not it needs to be returned. Wecht has collaborated with the leaving the state to practice else- Cyril H. Wecht Institute of Forensic Science and Law and Carlow Col- lege science faculty to develop a new Stuart G. Tauberg,
undergraduate degree program in medico-legal examinations. He will disease, implanted a both teach and perform autopsy patient with the first pay your ACMS
examinations in the program. Dr.
fully digital pacemaker Wecht recently co-authored a new Dr. Tauberg
in the Pittsburgh area book, Mortal Evidence, detailing the at The Heart Institute at Jefferson forensics behind nine shocking cases.
Regional Medical Center.
dues for 2004?
518 u The Bulletin From Where I Sit: Viewpoint of
a Physician Executive
Contributors are needed for one of the Charles Berlin, MD,
Bulletins newest columns, From Where psychiatry, wrote about I Sit: Viewpoint of a Physician Execu- tive. If you are a physician in a leadership position at a hospital, managed care firm or other healthcare pulling, which he entity, please consider sharing your The answer to your question may Dr. Berlin
be just a phone call away. Your noted is more common experience with your peers by writing an medical society can almost always than most people realize, affecting occasional column on a topic of your give you an answer or direct you to about two to three choice for our readers (approximately 500-1,000 words in length). E- mail the exactly where you can get it.
percent of the popula- Bulletins medical editor, Safdar I.
tion. He explained Chaudhary, MD, at schaud2815@ that professional So get back to your patients.
They're the reason you became a treatment is available and that doctor in the first place.
support groups can be helpful.
The Dear Doctor column is published regularly in the Pittsburgh Post-Gazette'sHealth Section. To contribute a Dear Doctorcolumn, call Elizabeth Fulton at (412) 321- Working for Physicians.
5030 or e-mail email@example.com. The Bulletin u 519 Hospice team open house
Contact your Highmark provider Western Psychiatric Institute and Sivits Jewish Hospice team is hold- relations representative with questions.
Clinic Mercy Behavioral Health ing an open house on December 3 (412) 442-8910.
from 4:30-6 p.m. at the Charles Health clinics for the homeless
For more information on Health Morris Campus Wintergarden Health Care for the Homeless, a Care for the Homeless, call (412) Room in Squirrel Hill. For more local organization that reaches out to information or to RSVP, call (412) the area's homeless population, 422-5700. November is National operates medical clinics at a number Physicians needed for clinic hours
of locations and provides testing The Community Health Clinic services from a mobile van for (CHC) is looking for physicians Online health info for seniors
Hepititis B, C and HIV, as well as willing to serve clinical hours; any Thanks to a grant from the National chest X-rays to rule out TB or other hours that a physician is willing to Library of Medicine (NLM), a respiratory diseases. For the van work would be appreciated. A non- division of the federal National schedule, call Sandy Genes at the profit organization since 1971, the Institutes of Health, the Carnegie Health Department at (412) 578- clinic provides health care (including Library of Pittsburgh will train 8083. For clinic hours and locations, mental health) and medications for senior adults to use the Internet to call the numbers below: underserved, indigent, working locate and use electronic health poor, homeless, mentally challenged, information. Seniors can attend a (412) 391-1348, ext. 100 children and veterans in Allegheny, one-hour overview of the program at Armstrong, Butler and Westmore- various sites around the city that will Birmingham Salvation Army South land counties. For more informa- help them determine whether or not Side (412) 481-7900 tion, contact Josephine Guy at (724) they wish to enroll. Log on to East End Cooperative Ministries 335-3334 or admin@community www.carnegielibrary.org for a sched- healthclinic.org or log on to ule of demonstrations or call (412) Family Links Downtown 363-7679 for more information.
Highmark goes online with codes
Family Links McKeesport Highmark is making national alpha- numeric procedure codes available to Jubilee (412) 261-1535 Did you know we get the provider community online, as calls daily asking for opposed to using an annual Proce- Light of Life (412) 258-6100 referrals to physicians? dure Terminology Manual as in past Magee Women's Clinic years. The codes and their complete (412) 391-1348, ext. 100 membership information terminology (including all CMS and is up to date so that Operation Safety Net (412) 232-5739 you get connected, BCBSA codes are now available through Highmark's online Provider Pleasant Valley (412) 321-4272 √ Board Certifications Resource Center, accessible via Salvation Army Family Crisis Center √ Hospital Affiliations NaviNet or Highmark's website.
√ E-mail address CPT national codes and descriptors √ Correct phone/fax/ Salvation Army North Side (412) can be obtained from several sources including the American MedicalAssociation (AMA) at www.amapress.
Salvation Army South Side Detox E-mail firstname.lastname@example.org or com; call (800) 621-8335 for infor- call (412) 321-5030 and ask for mation about purchasing the 2004 Wood Street Commons Nadine Popovich (ext. 110) or CPT codes directly from the AMA.
Jim Ireland (ext. 101) 520 u The Bulletin November is the month for the following national awareness programs: Alzheimers disease, diabetic eye disease, diabetes, epilepsy, hospice and marrow. Nov. 23-29 is GERD Awareness Week and the American LECTURE SERIES IN HEALTH Cancer Societys Great American Smokeout is Nov. 20. Dec. 1 is World AIDS Day and Dec. 7-13 is National POLICY & MANAGEMENT— Hand Washing Awareness Week. (Source: U.S. Dept. of Health and Human Services). Dec. 10. U. of Pittsburgh Graduate School of Nov 18, 6 pm . ACMS Board of Directors Public Health. Sponsor: Health Policy Institute.
Nov 19, 11:30 am-3:30 pm . Emergency Medical Services 1.5 credits toward Physicians Recognition Award.
Nov 19, 3-5 pm . PMS Videoconference: Patient Advocacy Call (412) 624-6104.
Nov 21, 8:30 am-1 pm . Three Rivers Adoption Council 2004 VIDEOCONFERENCE SERIES. Sponsor: Nov 24, 5:30 pm. Pittsburgh Urological Association Western Psychiatric Institute & Clinic, et al.
Nov 27-28 . Thanksgiving Holiday: ACMS Office Closed CME available. For information, log on to Dec 1, 6 pm . Combined meeting: Pittsburgh Obstetrical/Gynecological Society and Pittsburgh Pediatric Society Dec 2, 6 pm . ACMS Executive Committee ONGOING CONTINUING EDUCATION PROGRAMS Dec 3, 8:30-11 am. PMS Videoconference: Membership & Member Services & CONFERENCES. Sponsor: Western Psychiatric Dec 3, 6 pm . American College of Surgeons Institute & Clinic, et al. CME available. For Dec 4, 3:30 pm . Pittsburgh Ophthalmology Society information, call (412) 624-2523 or log on to Dec 5 . AMA House of Delegates Dec 6, 9 am-noon . Pittsburgh Pediatric Society: Holiday Toy Drive/Gift Wrapping ONGOING MENTAL ILLNESS & SUBSTANCE ABUSE Dec 9, 6:30 pm . Medical Assistants (MISA) TRAINING SERIES. Sponsor: Western Dec 12, 8:30 am-1 pm . Three Rivers Adoption Council Psychiatric Institute & Clinic, et al. CME Dec 15, 5:30 pm. Pittsburgh Urological Association available. For information, call (412) 605-1227 or Dec 18, 1-3 pm . Sewickley Hospital Palliative Care Group The Bulletin u 521 GETTING THERE:MUSINGS OF A MEDICAL STUDENT JENNY J. LINNOILA As a third-year medical student, I from rheumatoid arthritis to depres- sion. What about the link to ho- sion and Parkinson's disease. Appar- mocysteine? With regards to this am occasionally asked for medical advice by friends and family.
ently, some researchers in Europe question, I had no idea how much While there is still much for me to have found benefits when studying SAM is contained in supplements or learn in order to become a reliable the compound on groups of fewer how much one would have to take in source of healthcare information, than 100 participants. According to order to potentially build up signifi- there is one aspect of medicine that I them, SAM-e is the next wonder cant levels of homocysteine. For all can confidently say that even most drug. Here in the U.S. a few recent of my schooling, I felt pretty useless.
physicians know little about: dietary studies have focused on the use of What was my response, finally? I SAM-e for the treatment of depres- wrote to my brother of the link My brother recently asked me sion, Alzheimer's disease and between homocysteine and heart about a supplement that his girl- disease. I explained that, although friend swears by: SAM-e (S- I seemed to recall coming across SAM is involved in the endogenous Adenosyl-L-Methionine). "What is SAM recently while studying bio- production of homocysteine, I had it, good/bad?" he asked. It took me a chemistry in preparation for the no idea how likely a consumer of while to formulate an answer to his much-feared "Boards," USMLE Step SAM-e would be to develop signifi- question. I turned to the PDR— 1. Hoping to be of some use, I cant levels of the amino acid precur- dosage, indications, contraindica- turned to my biochemistry textbook, sor. I wrote that, personally, I would tions and precautions—nothing, to find that, indeed, SAM serves as not risk taking the supplement, aside from the compound name and an activated methyl donor in reac- especially as I did not know how the name of its manufacturer. I tions throughout the body. An much compound is in the supple- flipped through two standard phar- example of such a reaction is the ment, how pure the SAM is, and macology textbooks in vain. My transformation of the amino acid whether or not there would be any initial search for information on methionine into homocysteine.
other drug interactions.
"SAMe" on PubMED and Google Then I remembered that high Unfortunately, this is true of turned up references to articles in homocysteine levels have been many so-called "dietary supple- Fortune magazine and ABCNews.
linked to cardiovascular disease.
ments" out there. The Food and com. Hmm…not exactly top But what did all this mean? I sat Drug Administration (FDA) does scientific literature. I did find out back and looked at what I knew not currently have the power or the that this compound has been popu- about SAM-e after a few hours of resources to ensure that manufactur- lar in Europe for 20-30 years and it research: not very much. It might be ers are truthful and accurate in has been prescribed for anything useful for the treatment of depres- printing claims, dosages, ingredients 522 u The Bulletin GETTINGTHERE continued whether or not one should takevitamin supplements. And that's just With annual profits in the billions of dollars and the
the tip of the iceberg in terms of popularity of dietary supplements rising daily, what
some of the supplement options outthere. With such a popular and is put onto drugstore shelves has less to do with
enormous industry knocking at the health and bodily needs than with market forces.
back door of our offices, we cannotafford to turn a blind eye to thematter. In the same way in which we and other information on bottle additives" and shifted the burden of design clinical trials to test the latest labels. There is very little regulation proof for product safety from supple- cytokine, we should take on, or at of the products, especially given that ment manufacturers to the FDA. I least push for, the task of sorting the FDA considers them "food." think that this has been to the through the "alternative" therapies There was an effort to regulate disadvantage of the American public.
out there. We should test these the industry in 1992, applying the With annual profits in the billions of products to root out the harmful Nutrition Labeling and Education dollars and the popularity of dietary from the beneficial. We should find Act of 1990 (NLEA) criteria to supplements rising daily, what is put out what dosages of certain com- dietary supplements. The NLEA onto drugstore shelves has less to do pounds are therapeutic and what acknowledges the FDA's authority to with health and bodily needs than precautions to take in using them.
evaluate diet-disease relationships on with market forces.
As so-called "experts" committed food labels. In addition, the FDA Do not misunderstand me. I to the preservation and promotion organized the Dietary Supplements have nothing against the idea of of health, don't we owe it to our Task Force to come up with specific "healthy," "herbal" or "natural" patients, families, friends and col- recommendations for the regulation therapies. In fact, I am encouraged leagues to push for the regulation of of supplements. However, these by the interest that the public is the dietary supplement industry? Or actions caused an uproar.
taking in their health. I am well shall we just sit back and place bets The dietary supplement industry aware of the immeasurable benefits on which drug will be the next organized a massive consumer that mankind has received from such campaign. The U.S. Congress natural compounds as aspirin, For additional information, visit received an incredible volume of penicillin and digitalis. I applaud the these web pages: http://vm.cfsan.
mail and calls in regards to this efforts of researchers looking in fda.gov/ dms/ds-oview.html (FAQ matter, and efforts to regulate faraway lands for potential cancer about the FDA's role with regards to supplements were essentially blocked drugs. I am awed by the ability of supplements); or http://www.
by two subsequent acts, the Dietary the right kind of maggots to debride Supplement Act of 1992 and the wounds beautifully, eating away dead html (FDA's backgrounder on Dietary Supplement Health and tissue while preserving living flesh. I Education Act of 1994. The act of am amazed at the use of leeches to 1992 placed a one-year moratorium restore blood flow to a severed finger Ms. Linnoila is a third-year MD/PhD student on the implementation of the NLEA after it's reattachment. Where would at the University of Pittsburgh. She can be with regards to supplements. The we be without recombinant antico- reached at email@example.com. 1994 act created a new category for agulants originally derived from the dietary supplements with less strin- saliva of leeches? The opinion expressed in this column
gent regulation than that used for However, I am well aware that, as is that of the writer and does not
necessarily reflect the opinion of the
traditional foods. This act blocked of April 29, 2003, as reported by the Editorial Board, the BULLETIN, or the
the FDA from classifying supple- New York Times, expert nutritionists Allegheny County Medical Society.
ments as either "drugs" or "food and doctors cannot even agree on The Bulletin u 523 TECHNOLOGY & MEDICINE Doctors and Patients:
Enhancing the Relationship
KIMBERLY P. COCKERHAM, MD In September, I discussed my recommendations for Q: How does a physician with minimal Internet knowledge components of a medical website and requested get started? comments from you, the readers. Glenn Ryerson, A: Mr. Ryerson: president of Web DMM (firstname.lastname@example.org ), I would start by doing a search through one of the responded to my column with a great critique of my major search engines of other like practices across the own website (www.kpcagh.com). My website was country (just type in the type of medicine you practice) designed by Einstein Medical, a California based com- and review a number of different websites. This will give pany that charges big bucks ($6,000) to link you to its you ideas on what you want to accomplish with your domain name (facialrejupittsburgh.com), design and site. If you happen to fall in love with one of the sites maintain your website for one year. As a website novice, you see, chances are the designer of the site is listed at I provided information to the company and went along the bottom and you can link to his or her site from the with its design. I was impressed with Mr. Ryerson's one you are viewing and contact the designer from there.
logical comments: Of course, a good web designer doesn't need to have You need a new domain name that is simple and easy experience designing medical sites, so don't settle for to remember.
mediocrity just because the designer has experience There is too much "stuff" on your home page…make doing sites in your field.
Q: How much does a good website cost? Your menu is vertical, but on the home page it is on A: Mr. Ryerson: the right and then on the inside pages it switches to Two years ago I redesigned the website of one the left. Be consistent.
company that paid another company over $250,000 to I hate pop-up pages. I think all of your pop-ups originally design it—nuts! You can also find a hundred should be customized for your site as just regular people who took a basic web design course and will inside pages.
create a site for under a thousand dollars—don't do it! In other words, my work-in-progress needs more Unless you have a very complex E-commerce site (most work. So whether you have an existing website or are physicians won't), you should be able to have a great considering developing one, I hope the following com- looking site designed for you, with strong support and ments are helpful!524 u The Bulletin TECHNOLOGY continued marketing, in the $5,000 range depending on the (AMA) and other specialty societies. A basic website is number of pages.
free to Pennsylvania Medical Society members (andtherefore Allegheny County Medical Society members).
Q: What are the biggest mistakes physicians with websites You can view our site at www.centurymedical.medem.
com. The medem feature that I have found most useful A: Mr. Ryerson: is the ability to custom build links to the tremendous Once a website is created, it's the most inexpensive archive of patient information topics provided by the and effective marketing and communications tool you AMA and, in my case, American College of Obstetri- could have. Unfortunately, many companies/practices cians and Gynecologists (ACOG). Medem offers a invest the money to launch a site but then don't main- variety of other online services including website content.
tain and update it, and do nothing to communicate theweb address. If you're on a site that was created in 2001 A: Dr. Weinstein: and you are visitor #79, there is a problem! I developed a website for our practice utilizing There are a lot of web design factories out there that Microsoft FrontPage. The first step in the process spend a lot of time marketing their companies, but they involves determining what information and image you generally produce generic, cookie-cutter sites. There are would like to present to the public. We described the talented independents, but they are usually artists who details of our practice and the clinical entities that we are not experienced in marketing and helping you grow diagnose and treat. We also scanned in maps of our your practice. Find the right partner to support your satellite offices that our patients can print out on their practice and everything you wish to accomplish with home computers.
continued on page 526 Five crucial components of an effective website are: The website represents your practice. Make it look great, unique and professional.
Business Records Management, Inc.
Select a domain name (website address) that is related Specializing in HealthCare Records Management with your practice and is easy to remember. Do thebillboard test—if you were driving 60 miles an hourand saw your web address on a billboard, would youremember it when you got home? The only reason you have a website is to attract new patients and communicate with current patients. Makesure your website does that.
EVERY communication from your practice should prominently promote your website.
Make sure your website partner has excellent design and marketing skills. You want to continually drive *Document Storage, Delivery & Management people to your website and have it show up well onsearch engines.
*Computer Media Storage & Rotation To get a sense of how some other physicians got started and how they are using the Internet to enhance *Disaster Recovery Services their practices, Dr. Steven Hasley and Dr. Gary *File Room Design & Consulting Weinstein provide their insights.
Q: How did you develop your website?A: Dr. Hasley: I have used www.medem.com, a joint venture website company of the American Medical Association The Bulletin u 525 TECHNOLOGY continued from page 525 For a modest fee, we uploaded the information for office locations, file to an Internet hosting company that policies and the types of surgery that was Microsoft FrontPage compliant.
we offer. The site is excellent for They assisted us with registering a internal marketing, but it is difficult domain name that clearly explains what for patients with a specific problem to we do: www.eyelidsurgeon.com.
locate us on the web. To achieve realvisibility, you must be willing to pay a Q: What do you think has been the most search engine to elevate your web page helpful aspect of your website? to the top of any search list.
A: Dr. Hasley: When I used to call patients to discuss Q: Do you find the virtual newsletter a dysplastic PAP smear, that discussion might worth the time it takes to produce? have taken 20 minutes or more. Now I direct A: Dr. Hasley: them to my site and have them read the links under the To further my efforts in patient education, I send heading Abnormal PAP Smear. This one feature alone has out a biweekly e-mail newsletter. Patients can sign up saved me a TON of time, and the patients seem to get from my medem site, and then they automatically all their questions answered and enjoy the experience as receive the newsletter from then on. It costs nothing to add a new subscriber, and I have over 3,000 people onmy list. This is a great way to keep your patients up on A: Dr. Weinstein: the latest developments in the field of women's health. I Our patients find this site to be a useful source of actually have an ob/gyn colleague who writes the news-letter, and he has found that over 30 percent of newslet-ter recipients forward every issue of the newsletter to afriend. That is an easy way to get noticed as a "techno-logically up-to-date doc." For my pregnant patients, I developed an e-mail pregnancy newsletter that automatically follows theirpregnancies week-by-week. Tips on the normal progressof pregnancy, background on testing, resources that myhealth system makes available (classes, tours, lactationconsultants, etc.), are all provided to the patient at theappropriate time in her pregnancy. More than 1,000patients have subscribed to this service since its incep-tion two years ago. Having a part of patient educationdone by e-mail enhances my role as an educator andprovides a reference for my patients instead of costlypamphlets that must be purchased. Another advantageof the newsletters is the fact that they are "pushed" to thepatient, instead of a more passive website that thepatient must go looking for.
A: Dr. Weinstein: I do not provide a newsletter, but this is an effective tool for physicians with the time to produce the content.
Q: How can the website provide a tool for patient interac-tion? 526 u The Bulletin TECHNOLOGY continued A: Dr. Hasley: A: Dr. Weinstein: For several years I have been using a computer to In 1995, I developed a mailing list for the American augment history taking, and I have a website that can do Society of Ophthalmic Plastic and Reconstructive this task as well (www.obgynpartner.com). Patients can Surgery to rapidly disseminate new technical, surgical, answer a series of questions, and the resulting printout product and economic information to the membership.1 helps me to understand their history better, does a more There are currently 220 members online from around complete risk analysis, upgrades my documentation and the world. Most postings are case presentations, often provides more directed patient education. I am now with enclosed photographs, soliciting opinions regarding working on a site that patients can be directed to prior medical or surgical treatment of rare or complex to the office visit where they can be educated about oculoplastics problems. Each response can be viewed by emerging PAP technology, screening for STDs, etc. In all of the members who are participating. This allows a this way, we can optimize their office visits.
free exchange of ideas and advice for each clinical pre- Google has 839,000 hits for herpes, but patients sentation and a timely second opinion from experienced want to know what their own doctor has to say. I can colleagues. An additional benefit is that complications offer my patients a range of options for education on the associated with new clinical products can be more Internet that have definitely saved me time and en- rapidly identified, thereby lessening the morbidity hanced the care of my patients.
associated with new devices or techniques.
A: Dr. Weinstein: This internal communication system (telemedicine Our website lists our e-mail addresses, allowing at its best) would be a value for all medical patients to contact us with questions. We offer brief replies when indicated, but are unable to provide pa-tients with comprehensive information or an onlinetextbook. In the latter situations, we suggest that pa- BOTTOM LINE: There are many resources
tients schedule a consultation.
available to enhance the efficiency and visibil-
ity of your medical practice. Remember,
Q: What does the future hold for physicians and the www.medem.com and www.pamedsoc.org are
there for YOU. Look for new features: Find a
A: Dr. Hasley: Physician and (in 2004) CME tracking to
The promise of computer technology to improve expedite credentialing and licensure.
patient care and simplify doctors' workloads remains anunrealized dream for most practitioners. The Holy Grailof an all seeing, all knowing electronic medical record Dr. Cockerham is an ophthalmologist. She can be reached at has consumed millions of dollars in ill-spent venture email@example.com. Best wishes to Dr. Cockerham and her husband, capital, frustrated thousands of users, and even in its Dr. Glenn C. Cockerham, also an ophthalmologist, who will soon be current best execution been rejected by most practicing relocating to California. We have appreciated her many contributions to physicians. The knowledge explosion continues to overwhelm us, and the medical error rate cries out for atechnologic solution… BUT I STILL don't know what my patient's hemoglobin was from yesterday.
1Kikkawa, DO, Weinstein, GS. Oculoplastic Surgery in Cyberspace.
However, there are some areas in which computers Ophthalmic Plastic and Reconstructive Surgery, 16:399, 2000.
have made some progress, made our lives easier andactually helped us to take care of patients. Some of us The opinion expressed in this column is that of the writer
have the benefit of well-funded, system-wide informa- and does not necessarily reflect the opinion of the Edito-
rial Board, the BULLETIN, or the Allegheny County Medical
tion systems; ideally these should be available to all physicians to improve the access to laboratory results,imaging studies and beyond.
The Bulletin u 527 Tegaserod (ZelnormTM) for
Women with Constipation-
TUCKER FREEDY, PHARMD Irritable bowel syndrome (IBS) is one of the most and afferent spinal neuron function and central nervous common gastrointestinal disorders encountered in system modulation of afferent input in such a way that clinical practice. It affects about ten to fifteen results in long-term sensitization of pathways involved in percent of North Americans and is more common in the transmission of visceral sensation. Serotonin, or women than men.1 IBS is not life-threatening, but it can 5-HT, one of the many neurotransmitters that regulate significantly impact a person's quality of life and general motor, sensory, and secretory activities within the well-being. The chronic and recurrent symptoms of IBS gastrointestinal tract has been strongly implicated in the can be disabling, disrupting both professional and pathophysiology of IBS.1 Since the effects of serotonin personal activities. It has a major impact on healthcare are mediated primarily through 5-HT and 5-HT expenditure in the United States. IBS is responsible for receptors distributed throughout the gastrointestinal at least 3.5 million annual physician office visits. Expen- tract, it has been suggested that agonists and/or antago- ditures related to IBS may cost the US healthcare system nists at these sites may be useful in normalizing the up to an estimated $30 billion annually in direct and motor and sensory dysfunction that occurs in patients with IBS.3 In the past, IBS was a diagnosis of exclusion.
The pathophysiology of IBS is not fully understood.
Today the diagnosis has shifted from one of exclusion to Visceral hypersensitivity is thought to be a major culprit a positive diagnosis. Use of symptom-based criteria, such in the pathophysiology of this condition. Current theory as the Rome II criteria, assists with a precise diagnosis.
suggests that visceral IBS is usually classified as diarrhea predominant, or 528 u The Bulletin PILL BOX continued alternating between diarrhea and constipation. Tradi- 5-methoxyindole-3-carboxylic acid glucuronide. This tionally, treatment for patients diagnosed with IBS has metabolite has little affinity for 5-HT receptors and is included fiber, anticholinergics, laxatives, antidiarrheal excreted mainly in bile.4,6,7 The second metabolic path- medications and/or antispasmodics/smooth muscle way is direct glucuronidation which produces 3 isomeric relaxants. However, no good evidence supports their N-glucuronides.7 Approximately two-thirds of the dose efficacy in relieving global IBS symptoms.1 Recently, is excreted in feces, with the remaining one-third ex- new two medications acting at the serotonin receptors creted in the urine.4 have been approved for use in IBS. Alosetron(Lotronex®) is a 5-HT antagonist indicated for the treatment of female IBS patients with severe diarrhea. It Tegaserod is indicated only in IBS that is constipa- acts by reducing intestinal secretion, decreasing visceral tion predominant. It should not be initiated in patients afferent nerve activity and reducing intestinal motility.
who are currently experiencing or frequently experience This review will focus on tegaserod (Zelnorm™), the diarrhea. Tegaserod should be discontinued immediately newest agent for treating IBS. Tegaserod, considered a in patients in patients with new or sudden worsening of priority drug review, gained FDA approval in July 2002.
abdominal pain.6 The most frequently reported sideeffects from one study included diarrhea, abdominal pain, headache, flatulence and fatigue (>10%).8 Other Tegaserod is a partial agonist of the 5-HT receptor.
side effects include loose stool, flu-like symptoms, back It is indicated for the short-term treatment of women pain, nausea, upper respiratory tract infection, and with constipation-predominant IBS. Tegaserod possesses continued on page 530 high affinity for the 5-HT receptors but displays negli- gible affinity for dopamine or 5-HT receptors.4 The 5-HT receptor is common in both the enteric nervous system and the smooth muscle lining in the GI tract. Itis known to mediate peristalsis and to be involved inelectrolyte secretion.5 It is believed that 5-HT receptors mediate the release of other neurotransmitters such assubstance P and calcitonin. These are involved in theoverall maintenance of gut motility and modulation ofvisceral nociceptive neural pathways.5 Tegaserod is rapidly absorbed in the fasting state and has a mean absolute bioavailability of 10-11%.4,6 Timeto peak concentration is reported to be between 1 and1.5 hours.7 The terminal half-life of tegaserod is 11 ± 5hours with a clearance of 77 L/hr.4 When the drug isadministered with food, the bioavailability is reduced by40% - 65% and C is reduced by approximately 20%- 40%. Tegaserod has a large volume of distribution of368 ± 223 liters with extensive distribution in thetissues.4 It exhibits extensive first-pass metabolismthrough two main pathways. After oral administration,tegaserod undergoes pre-systemic acid catalyzed hydroly-sis in the stomach, followed by subsequent oxidationand glucuronidation into the major metabolite, The Bulletin u 529 PILL BOX continued from page 529 An increase in abdominal surgeries was observed in higher response rate than the placebo group throughout patients on tegaserod (9/2,965; 0.3%) vs. placebo (3/ the 3 months of treatment.10 The difference between 1,740; 0.2%) in phase 3 clinical studies.6,11 This increase, each tegaserod group and placebo was statistically especially the increase in gall bladder surgery, was the significant [10.2% (P=0.017) for 2mg BID and 11.4% reason FDA issued a "non-approvable" letter in June (P=0.008) for 6mg BID]. The efficacy results in males 2001. A causal relationship was not established, and the were more variable across treatments and do not allow a company demonstrated that some of the gall bladder meaningful comparison to be made due to the relatively surgeries had been planned, helping pave the way for small numbers of male patients enrolled (17%). The subject's goal assessment of abdominal pain and discom- Cisapride (Propulsid®), a mixed 5-HT agonist/ fort, assessed weekly, was significantly improved in 5-HT antagonist gastric prokinetic agent, has been patients treated with tegaserod, 6mg BID. This effect shown to cause serious cardiac adverse events such as was sustained throughout the 3 months of treatment.
torsades de pointes ventricular arrhythmias. Studies with The severity of abdominal pain and discomfort, assessed tegaserod specifically evaluating cardiac conduction have daily, was also significantly reduced in patients treated shown that there is no effect over time on the frequency with tegaserod. This effect was observed early after the of prolonged QTc intervals either in absolute terms or initiation of treatment and was sustained throughout the compared with baseline.12 12 weeks of treatment. Additionally, patients treated Because of its metabolism through glucuronidation, with tegaserod had significantly fewer days with abdomi- tegaserod should not interact with drugs metabolized by nal pain and discomfort at the end of month 1, and the CYP 450 system. A pharmacokinetic interaction month 2 with a favorable trend at month 3. The effect study was done to determine the drug-drug interactions of tegaserod on number of days with bloating was only between tegaserod 12mg/day and dextromethorophan, significantly shown at month 1 with the 2mg BID dose.
theophylline, digoxin, warfarin and oral contraception.
However, a favorable trend in the reduction in the No clinically relevant interactions were reported and no number of days with abdominal bloating was observed.9 dosage adjustments seemed necessary.4,6 In the study by Novik et al tegaserod 6mg BID produced statistically significant greater response rate for the SGA of Relief than placebo at end-point (43.5% vs Three randomized, double-blind, placebo-controlled 38.8% of patients, respectively; p<0.033 vs placebo).13 studies document the efficacy of tegaserod in female Improvements were noted within the first week and patients with constipation-predominant IBS.10,13,14 All of maintained throughout the 12 weeks. Statistically these trials were large scale, multi-center trials that had significant improvements in the other efficacy variables similar design. In these trials patients were selected (abdominal pain/discomfort, bowel habits, bloating, following at least a 3-month history of irritable bowel stool consistency and straining) were noted as well.
syndrome (using Rome I or II criteria). Following a 3-4 Tegaserod was well tolerated. Diarrhea led to therapy week treatment-free baseline period, two trials compared being discontinued in 1.6% of tegaserod-treated patients tegaserod 6mg BID to placebo and one trial compared versus 0% in the placebo group.
tegaserod 2mg or 6mg BID to placebo for 12 weeks.
A third trial evaluated the safety and efficacy of The primary endpoint in two of the trials, briefly tegaserod in IBS patients (n=520) in the Asia-Pacific summarized below, was the Subject's Global Assessment region.14 The primary efficacy variable (over 1-4 weeks) (SGA) of Relief, which takes into account abdominal was the response to the question: "Over the past week do pain/discomfort, altered bowel function and overall well- you consider that you have had satisfactory relief from being.10,13 SGA was measured on a weekly basis by your IBS symptoms?" Secondary variables assessed answering questions in the diary about overall well-being overall satisfactory relief over 12 weeks and individual since starting the study.
symptoms of IBS. The mean proportion of patients with Muller-Lissner, et al. reported that both tegaserod overall satisfactory relief was greater in the tegaserod groups (4mg or 12mg/day) maintained a consistently group than in the placebo group over weeks 1-12 (62% 530 u The Bulletin PILL BOX continued vs. 44%, respectively; p<0.0001).
One recently published study evaluated long-term 1Olden KW. Irritable bowel syndrome: An overview of diagnosis and (1 year) safety of tegaserod. This was a multicentre, pharmacologic treatment. Cleve Clin J Med 2003;70 (Suppl 2):S3-7.
open-label study in 579 patients with constipation- 2Pathophysiology, Diagnosis and Current Approaches to the Management predominant IBS.15 Tegaserod was well tolerated and of Irritable Bowel Syndrome [CD-ROM]. Fisher RS, Garnett WR, eds.
Hackensack, NJ: Bimark Center for Medical Education; 2003.
considered safe over a 12-month period with no evi- dence of unexpected adverse events.
Wagstaff AJ, Frampton JE, Croom KF. Tegaserod: A Review of its Use in the Management of Irritable Bowel Syndrome with Constipation in In a small study in healthy subjects (12 male pa- Women. Drugs 2003;63(11):1101-1120.
tients), the prokinetic effects of tegaserod were demon- 4Zimmermann AE. A 5-HT Agonist for Women with Constipation- strated.16 Tegaserod induced a statistically significant Predominant Irritable Bowel Syndrome. Formulary 2002;37:449-461.
acceleration in gastric emptying, small intestinal transit 5Jones BW, Moore DJ, Robinson SM, Song F. A Systematic Review of and colonic transit. Another small study (19 patients) Tegaserod for the Treatment of Irritable Bowel Syndrome. J Clin Pharm investigated the effects of tegaserod for use in gastro- esophageal reflux disease (GERD).17 Tegaserod (1mg/day Zelnorm [package insert]. East Hanover NJ: 2002; Novartis Pharmaceuti- and 4mg/day) decreased acid exposure by more than 7Micromedex Healthcare Series, Vol. 115.
50% in the post prandial period in patients with abnor-mal acid exposure.
8Fidelholtz J, Smith W, Rawls J, et al. Safety and Tolerability of Tegaserod in Patients With Irritable Bowel Syndrome and Diarrhea Symptoms. Am J Gastroenterol 2002; 97(5):1176-1181.
Dosage and Administration
9Appel S, Kumle A, Meier R. Clinical Pharmacodynamics of SDZ HTF 919, Tegaserod (Zelnorm™ by Norvartis) is available in a new 5-HT Receptor Agonist, In a Model of Slow Colonic Transit. Clinical 2mg and 6mg tablets. The recommended dosage is 6mg Pharmacol Ther 1997;62:546-555.
twice daily orally before meals for 4 to 6 weeks. For 10Muller-Lissner SA, Fumagalli I, et al. Tegaserod, a 5-HT Receptor Partial those patients who respond to therapy at 4 to 6 weeks, Agonist, Relieves Symptoms in Irritable Bowel Syndrome Patients with Abdominal Pain, Bloating and Constipation. Aliment Pharmacol Ther an additional 4 to 6 week course can be considered.6 Anon. Tegaserod Maleate (Zelnorm) for IBS with constipation. The Medical Letter 2002;44(1139):79-80.
The cost of tegaserod (Zelnorm™) $136.84 for a 12Morganroth J, Ruegg PC, Dunger-Baldauf C, et al. Tegaserod, a 5- Hydroxytryptamine Type 4 Receptor Partial Agonist, Is Devoid of Electro- cardiographic Effects. Am J Gastroenterol 2002;97(9):2321-28.
13Novick J, Miner P, Krause R, et al. A randomized, double-blind, placebo- Tegaserod is the first selective 5-HT receptor partial controlled trial of tegaserod in female patients suffering from irritable bowel agonist for the treatment of constipation predominant syndrome with constipation. Aliment Pharmacol Ther 2002;16:1877-88.
IBS in women. Several large well designed trials have 14Kellow J, Lee OY, Chang Fy, et al. An Asia-Pacific, double-blind, placebo-controlled, randomized study to evaluate the efficacy, safety, and demonstrated that it is effective and well tolerated. In tolerability of tegaserod in patients with irritable bowel syndrome. Gut women who do not respond to increased dietary fiber or laxative therapy tegaserod appears to be a promising 15Tougas G, Snape Jr, WJ, Otten MH, et al. Long-term safety of tegaserod option. Additional long-term data and comparative data in patients with constipation-predominant irritable bowel syndrome.
Aliment Pharmacol Ther 2002;16:1701-08.
would be beneficial. It's efficacy in men has not been Degen L, Matzinger D, et al. Tegaserod, a 5-HT Receptor Partial Agonist, Accelerates Gastric Emptying and Gastrointestinal Transit in Healthy Male Subjects. Aliment Pharmacol Ther 2001; 15: 1745-51.
17Kahrilas PJ, Quigley EMM, Castell DO, and Spechler S. The effects of Dr. Freedy is director of the Allegheny General Hospital Drug tegaserod (HTF 919) on oesophageal acid exposure in gastro-oesoph- Information Center and an adjunct clinical instructor, Duquesne ageal reflux disease. Aliment Pharmacol Ther 2000;14:1503-09.
University Mylan School of Pharmacy. He can be reached at (412) 359-3192. The Bulletin u 531 Long-awaited EMTALA
Regs Add Flexibility
TINA BATRA HERSHEY, ESQWILLIAM H. MARUCA, ESQ Many physicians have reason to welcome the EMTALA requires hospitals to provide an appropri- final regulations under the Emergency Medi- ate medical screening examination to any person who cal Treatment and Labor Act (EMTALA) comes to the hospital emergency department and issued by Centers for Medicare and Medicaid Services requests treatment for an examination for a medical (CMS) on September 9, 2003. The regulations are condition. If the examination reveals an emergency intended to reduce confusion and ease the burdens faced medical condition, the hospital must either stabilize the by hospital emergency departments under the 1986 law, condition or, if appropriate, transfer the individual to while still ensuring that individuals will receive appropri- another medical facility. EMTALA applies to all hospi- ate screening and emergency treatment regardless of tals that offer emergency services and all individuals who their ability to pay. Most significant to physicians, the present at those hospitals, not just those who receive new regulations give hospitals greater flexibility in Medicare benefits.
establishing emergency department coverage schedules Both hospitals and physicians face penalties if they for physician specialists. The regulations took effect negligently fail to appropriately screen an individual November 10.
seeking medical care, negligently fail to provide stabiliz- Specialists in short supply, such as neurosurgeons, ing treatment to an individual with an emergency complain that EMTALA consider- medical condition, or negligently ations have pressured them into transfer an individual in an being on-call "24/7" as a condition inappropriate manner. The of maintaining hospital privileges.
sanctions can include civil fines As a result, many specialists have of up to $50,000 per violation limited themselves to covering and/or exclusion from partici- only one hospital or have pation in the Medicare and avoided hospitals where there Medicaid programs. EMTALA are insufficient numbers of also permits individuals who similar specialists. The new rules suffer personal harm to bring may reduce these pressures in private lawsuits for damages.
532 u The Bulletin LEGALREPORT continued "Comes to the emergency
driveway, but excluding other areas or structures that are not part of the EMTALA obligations are trig- hospital, such as physician offices, gered when an individual "comes to rural health centers, skilled nursing the emergency department" of a facilities or other entities that partici- hospital and requests an examination pate separately under Medicare, or or treatment of a medical condition restaurants, shops or other non- (or a request is made on the medical facilities.
individual's behalf ). The hospital (3) The individual is in a must provide an appropriate medical ground or air ambulance owned and screening examination within the operated by the hospital for purposes capacity of the hospital's emergency of examination and treatment for a department. If the hospital deter- medical condition at a hospital's mines that the individual has an emergency medical dedicated emergency department. Note that EMTALA condition, the hospital must either stabilize the indi- does not apply if the ambulance is operating under vidual or make an appropriate transfer. The final community-wide EMS protocols or EMS protocols EMTALA regulations clarify that an individual may mandated by state law that require it to transport the "come to the emergency department" in one of three individual to a hospital other than the hospital that owns the ambulance.
(1) The individual may present at a hospital's dedi- continued on page 534 cated emergency department and request examination ortreatment for a medical condition. "Dedicated emer-gency department" means any department or facility ofthe hospital, regardless of whether it is located on or offthe main hospital campus, which: is licensed by the state in which it is located under applicable state law as an emergency room or emer-gency department; is held out to the public (by name, posted signs, advertising or other means) as a place that providescare for emergency medical conditions on an urgentbasis without requiring a previously scheduled ap-pointment; or if, during the immediately preceding calendar year, it provides at least one-third of all of its outpatient visitsfor treating emergency medical conditions withoutrequiring a previously scheduled appointment.
(2) The individual presents elsewhere on hospital property in an attempt to gain access to the hospital foremergency care and requests an examination or treat-ment for what he or she believes to be an emergencymedical condition. Under the final rule, hospital prop-erty is defined as the entire main hospital campus(encompassing a 250-yard radius of the hospital's mainbuilding), including the parking lot, sidewalk and The Bulletin u 533 LEGALREPORT continued from page 533 In addition, the final rule provides that, even if an individual does not explicitly request an examination ortreatment, a request on behalf of the individual will beconsidered to have been made if a prudent layperson/observer would believe, based on the individual's appear-ance or behavior, that the individual needs examinationor treatment for a medical condition.
The final rule makes it clear that a new emergency medical condition which arises in a previously stableinpatient is not governed by EMTALA. CMS plans tomonitor any potential abuses of this exception.
Physician on-call requirements
Under EMTALA, and as a requirement for participa- tion in the Medicare program, hospitals must maintain alist of physicians who are on-call for duty to provide the treatment necessary to stabilize an individual with anemergency medical condition determined after the initial examination. If a physician on the list is called bya hospital to provide emergency screening or treatment new art to Typecraft and either fails or refuses to appear within a reasonableperiod of time, both the hospital and the physician maybe in violation of EMTALA. A common misunderstand-ing was that, whenever there are at least three physiciansin a specialty, the hospital must provide 24-hour/7-daycoverage in that specialty. The final rule debunks thismythical "three-specialist" rule and instead relies on allrelevant factors, including the number of physicians onstaff, other demands on these physicians, the frequencywith which the hospital's patients typically requireservices of on-call physicians, and the provisions thehospital has made for situations in which a physician inthe specialty is not available or the on-call physician isunable to respond.
The new, flexible approach on-call requirements under EMTALA represent a conscious effort by CMS toaddress unrealistic call coverage demands that haveemerged in some areas of the country. CMS explicitlyrecognized that physicians' treatment of other patients,vacations, days off, conferences and other similar issuesmay be considered in determining the availability ofphysicians. In addition, CMS recognized that compen-sating physicians for 24/7 availability strains alreadylimited hospital resources.
In the final rule, CMS provided that hospitals will have the discretion to create call schedules in a manner 534 u The Bulletin
LEGAL REPORT continued that best serves the needs of their communities, even ifthat means that certain specialists may not be available at It remains to be seen how the new
certain times. In such situations, hospitals are required to EMTALA regulations will affect
have a plan to deal with patients who need specializedcare. In particular, CMS clarified that exempting senior physicians and the effect is likely to
medical staff physicians from on-call coverage is not a vary based upon medical specialty
violation of EMTALA as long as the exemption does not affect patient care adversely. The final rule also allowsphysicians to perform elective surgery while on-call or tobe on call at more than one hospital.
capacity at multiple hospitals at the same time, rather Physician assistants and advance practice nurses can than limiting them to one hospital in the community.
be used by on-call specialists to respond to emergencies The ruling will also allow patients to schedule elective on a case-by-case basis under the direction of the special- surgery on a more timely basis, rather than having to ist, but only with the consent of the emergency room wait while that physician serves in an on-call capacity." However, the new EMTALA regulations have sparked some concerns that specialists will entirely Effect Of the new EMTALA regulations
abandon emergency departments. In particular, the The American Medical Association has applauded American College of Emergency Physicians (ACEP), the final rule, stating that it will "provide patients with while supporting many of the clarifications, has stated continued access to physician services in an on-call that the new regulations may add to the existing special-ist shortage. According to the ACEP, the final rules couldleave only a few hospitals in each community withmedical specialists, which would lead emergency patientsto flood their emergency departments. ACEP PresidentGeorge Molson, MD, states "It could result in conflictsbetween hospitals over who will provide specialty careand result in delayed care or more transfers of patients." Other physician groups, however, maintain that many specialists have already been forced into providingsimultaneous call services in their communities. Suchgroups believe that the rules will encourage certainspecialists to make their services available to morehospitals and, therefore, to more patients.
It remains to be seen how the new EMTALA regula- tions will affect physicians, and the effect is likely to varybased upon medical specialty and geography. What isclear is that hospitals and physicians will have to worktogether in order to develop adequate emergency depart-ment coverage under this new regulatory framework.
Only through such cooperation will appropriate cover-age be provided to the communities they serve.
Ms. Hershey is an associate with the Pittsburgh office of Fox RothschildLLP, which serves as counsel to the Allegheny County Medical Society.
She can be reached at firstname.lastname@example.org. Mr. Maruca is apartner with the firm and can be reached at (412) 394-5575 email@example.com. The Bulletin u 535 Hospitality Houses: Caring for
Patients and Their Families
ELIZABETH L. FULTON With Pittsburgh on the forefront of medical ments, designed for specialized, long-term housing, advances and treatments, people are coming opened next door to the original house. Ronald to the city to receive medical care from all McDonald House of Pittsburgh serves approximately over the country and the world. Many of them have 800 families a year. To be eligible to stay there, a family financial problems from extraordinary medical expenses must have a child 21 years old or younger who will be a that preclude staying at a hotel while they receive the patient at an area hospital, and the family's home must treatment they need.
be at least 40 miles away. The family also must have a Hospital hospitality houses are an inexpensive home- referral from the hospital, a physician or a social worker away-from-home for seriously ill patients and their verifying that the family has a child in treatment. About families who come from far distances to seek medical 95 percent of patients staying at the Pittsburgh house are care. It all began in 1972 with a hospital hospitality receiving treatment at Children's Hospital of Pittsburgh.
house in Buffalo, New York. The house was purchased For a small fee that may be reduced or waived for by Cyril and Claudia Garvey of Sharon, whose son had those unable to afford the full amount, the Ronald died of leukemia. As a memorial to their son, the house McDonald House provides private bedrooms, kitchens, was named "Kevin Guest House." laundry facilities, Internet access and playrooms. The The Ronald McDonald Houses, serving families of house also offers free daily food supplies such as milk, seriously ill children, are the most well known of hospi- eggs, orange juice, coffee and non-perishables. The tality houses. The story of Ronald McDonald Houses patient will also receive a gift of a brand-new toy, book begins in 1973 when the three-year-old daughter of or video, and some children may even be lucky enough Philadelphia Eagles tight-end, Fred Hill, was diagnosed to meet Ronald McDonald himself as he makes appear- with leukemia. While his daughter was receiving treat- ances at the houses.
ment, Hill and his wife noticed that many families, In addition to Ronald McDonald Houses, many including his own, ended up sleeping in hospital chairs non-profit agencies run hospitality houses throughout and eating vending machine meals. With the help of the country. Locally, Family House Inc. has three resi- Hill's teammates, a pediatric oncologist from Children's dences, two in Oakland and one in Shadyside, and Hospital of Philadelphia and several Philadelphia Allegheny General Hospital offers lodging through its McDonald's restaurants, the first Ronald McDonald Visitor Center.
House opened in Philadelphia in 1974 and became the Family House Inc., one of the largest hospital model for hospitality houses all over the country and the hospitality houses in the country serving about 7,200 patients a year, was founded in 1983 and serves any A Ronald McDonald House opened in the family who comes to Pittsburgh seeking medical care Shadyside section of Pittsburgh in 1979 near Children's from UPMC hospitals, VA Medical Center in Oakland, Hospital. In 1994, the Ronald McDonald House apart- Children's Hospital and Western Pennsylvania Hospital.
536 u The Bulletin FEATURE continued Its a gift finding this place (Family
House) and getting your life back
together and knowing you can live a
normal life again.
Anthony T.R. Russo
Family House also handles some of the overflow fromRonald McDonald House of Pittsburgh.
Carey Miller, director of development and public relations at Family House, explains some of the qualifi-cations for a family to stay at one of the residences. "Thefamily must be from at least 50 miles away to qualify,but we look at it on a case-by-case basis." she says,explaining that there have been families from Butler thathave stayed at Family House. "There are limited rooms,so we prioritize according to the severity of the illness."Also, patients who receive treatment on an outpatientbasis, such as transplant patients, get priority over Family House at Pittsburgh's Shadyside location has 44 family suites.
families of patients. Family House provides a total of115 guest rooms and averages 96 percent occupancy Oakland. Miller explains, though, that Family House over the course of a week. "Many nights, we are forced will usually try to have the family pay something. "Even to turn people away. However, we usually can accommo- as little as $10," she says. This gives the family the sense date our overflow in a few days time, and we have of ownership.
agreements with some local hotels for discounted rates There are several benefits to patients and patients' when available," Miller says. "We are keeping a close families who are staying in a hospitality house. "It's watch on the number of requests, averaging over 1,000 a comforting to the patient that family is nearby," Miller month, for future planning." says. "Studies have shown that families that are well- Each guest room provides a private bath, television rested give better support to the patient," she says. "And and telephone. In addition to guest rooms, Family the patient knows their loved ones are being taken care House also has suites that provide a family room area with a sofabed. Says Miller, "It feels most like a bed and Anthony "T.R." Russo of Boston, Massachusetts, breakfast." She adds that each residence has a communal and Kevin Hornbeck of Michigan are both transplant kitchen where each family has its own shelf in the patients staying at the Shadyside Family House.
refrigerator and cupboard. Also available at the resi- Russo was diagnosed with Crohn's disease 20 years dences are living rooms, television lounges, libraries, ago and, due to a surgical mistake, his small intestine Internet access and laundry facilities. Some residences was damaged. Not being able to eat solid food, he lived also have patios and exercise rooms.
on total parenteral nutrition (TPN) for a few years.
The rates to stay in a room at one of the Family "Unfortunately, that does a number on your liver in a lot House residences are inexpensive, but for those families of cases," he says. "The TPN was so taxing on my liver that may be unable to afford it, social workers will work that my liver went, and so it was my choice whether we with them to see if they qualify for help through the would figure out something else to do or look into a Family Assistance Fund which is offered at the houses in continued on page 538 The Bulletin u 537 FEATURE continued from page 537 possible transplant of his small intestine after his liverfailed. Hornbeck was given eight months to live beforecoming to Pittsburgh, where his surgeon told him it (atransplant) could be done without liver failure. "I hadthe worst attitude, and I was down. I was 118 pounds—all right, Mom and Dad, you want to transplant me, let'stransplant me," he said. His parents told him he had todo it, and he knew they were right, but he came toPittsburgh just to satisfy everyone else. "Then when Icame here (Family House), I met T.R. and all thesepeople who just finished having this done who arearound my age," Hornbeck says.
"That's the only reason why I'm here. I thought I'd be here and be the only sick one. Everybody else wouldbe cured." He was wrong and learned that many wanted Kevin Hornbeck (left) and Anthony "T.R." Russo, recent resi-
dents at Family House, hang out in the facility's library.
to help him. "I didn't approach them; you just don'twhen you get to that point. You pull yourself back.
transplant." A gastroenterologist in Boston gave him You're just kind of a loner," Hornbeck says. "They came information on the Starzl Transplantation Institute at to me. Someone called me on the phone before I even UPMC, which brought him to Pittsburgh for a five- got here." He says when he got to the house people organ transplant. The doctor also suggested Family approached him in the living room and began talking to him. Hornbeck then felt comfortable to ask them "It's a gift finding this place and getting your life questions about their transplant operations. "Now I'm back together and knowing you can live a normal life doing that for people who come here," he says.
again," Russo says. "Then there are things like getting Even Hornbeck's sister became a believer. His sister, down here, where to stay, tying in the transplant with a nurse, and brother-in-law, a doctor, had discouraged support groups, meeting people; and that's where Family him from coming to Pittsburgh for the transplant. She House comes in." Russo enjoys the supportive environ- was visiting when he got the call for the transplant. "Two ment at Family House. "No one could relate to what I people with transplants.came up to my room. I was was going through; my best friends, my closest family scared. I wouldn't get off the couch; I was scared to could sympathize and see the wounds and the ostomy death. And those guys came up to my room and said, bags and tons of medicine and all the supplies, but they ‘Come on. It's going to be all right.' I get down to the couldn't really relate to me," he says. "And here it was door and everybody's at the door seeing me off and like walking into this place where, instead of me being everything," he says. "It was just amazing. And my sister the outsider, it's the patients who are almost normal. You went back home. She met everybody here and said, ‘I meet all these people who are just like you, have experi- enced the same things that you have and know what you Russo believes there is an innate feeling among are talking about firsthand." Russo also likes that his transplant patients that they should give back. He came mother is taken care of when he is in the hospital.
from Boston earlier in the year to help with the Family "There are so many people around to give her support, House benefit polo match, and Miller explains that which is just as important in the family scheme," he says.
many do come back from long distances just to volun- Hornbeck knows that Family House was the reason teer. Many also come back just to visit.
he came to Pittsburgh for his transplant. He was diag- According to Miller, people from all over the coun- nosed about 20 years ago with pseudo-abdominal try and every part of the world have stayed at Family obstruction and was on TPN for six years. He was told House. Russo says, "One of our friends is kind of plot- there was nothing that could be done for him except a ting the states where we all are on a map so we can really 538 u The Bulletin FEATURE continued look it up, our support system, and see how it's grown are people out there dying everyday, and they don't even and see how many friends we have across the country." come here. I didn't want to come here. I live seven hours After explaining the friendships he's made living in a away," he says. "People from West Virginia don't even hospitality house, Hornbeck says, "In a hotel that know about this place.These places need to be talked wouldn't have happened. It wouldn't have happened in about on T.V. and bulletins on everything, on the news the hospital because you're sick in the hospital. You're or whatever is out there." just laying there. Here you get down here (the common Local hospital hospitality houses include: Family area), you get some air, you talk to people, which makes House Inc., (412) 647-7777; Ronald McDonald House you a thousand times better." He adds, "I was scared to of Pittsburgh, (412) 362-3400; and the Visitor Center death to come out of the hospital. I was in the intensive of Allegheny General Hospital, (412) 359-1200.
care unit for 28 days. Two days out, they sent me here.
My mom was like, ‘No way.' And I was like, ‘Uh-uh.' Ms. Fulton is communications assistant for the Allegheny County You know, because I've got all this stuff hooked up to Medical Society. She can be reached at firstname.lastname@example.org. me. And I came down here and everybody was helping." Kay Bebenek, manager of the Shadyside Family House, says hospitality houses can shorten the length of Family House Inc.: www.familyhouse.org stay at a hospital for many patients, but it can be a National Association of Hospital Hospitality Houses: www.nahhh.org Ronald McDonald House Charities: www.rmhc.com Catch-22 situation. "As far as managed care is Ronald McDonald House Charities of Pittsburgh: www.rmhcpgh.org concerned.they feel they can discharge the patientsright to us that aren't well enough to go back home," shesays. Bebenek adds that all patients must have a caregiverstaying with them because Family House does notprovide medical care.
Better emotional support from family and staying in a caring environment greatly help patients in the recov-ery process. Financially, hospitality houses contribute tolower healthcare costs to patients and their families.
They give a low-cost option of lodging to many familieswho otherwise may have to stay in expensive hotelrooms or sleep in hospital waiting rooms. Also, forpatients who require outpatient care or need accommo-dations before and after surgery, hospitality houses offeran inexpensive place to stay. But it still costs money. "Ireally think they need to do something about gettinghousing like this covered by insurance," Russo says. "It's$45 a night to stay here, so it adds up, especially whenyou don't know how long you're going to be here.
There's got to be something that can be done aboutthat." Hornbeck believes more people should know about hospital hospitality houses and that there should bemore houses around the country. "There are tons ofpeople who can donate, and physicians that can help getthese places built," he says. Hornbeck also believes morepeople should know about transplantation in conjunc-tion with the hospitality houses in Pittsburgh. "There The Bulletin u 539 PRACTICE MANAGEMENT Reducing Errors in
KAREN K. DAVIS Not many studies have looked at ambulatory care Graham Center study, 83 percent of the errors reported or primary care to find out what errors are were process errors and 13 percent of the errors reported common to those settings. A newly published were knowledge errors. (The other four percent of study does, though. A Preliminary Taxonomy of Medical reported errors were not considered errors by the re- Errors in Family Practice, published by the Robert searchers, and therefore were left out of the taxonomy.)1 Graham Center for Policy Studies in Family Practice and The main categories of process errors were: Primary Care, Washington, D.C., lists the results of an administrative failures (information missing or mis- effort to discover common errors that occur in ambula- filed, problem with patient "flow," message improperly tory primary care.
handled, appointment error); The Graham Center study selected a group of error when ordering, obtaining results of or notifying approximately 50 board-certified family physicians from patients about lab work, diagnostic imaging or other across the United States and asked them to report on errors in their practices. The physicians were told to error when ordering medications or implementing observe their practices in all locations—office, clinic, medication orders; nursing home, hospital and patient home—and to error in communicating with the patient or with report anything that made them think, "that should not another healthcare provider; and happen in my practice, and I don't want it to happen payment processing error.
again."* Physicians reported the first 10 errors in their The main categories of knowledge errors were im- practices after a specified start date.
proper performance of a clinical task, wrong diagnosis The researchers then analyzed the error reports and and wrong treatment decision.
established a taxonomy classifying the errors. The Researchers pointed out that one way the family taxonomy distinguishes two main kinds of errors: practice study differed from studies of inpatient care process errors and knowledge/skill errors. Process errors errors was that most of the mistakes in this study were are administrative-type errors that could be addressed from process problems rather than clinical problems.
and reduced by establishing different office procedures.
Also, there were fewer medication errors in the family Knowledge or skill errors result when a physician, nurse practice study than in those undertaken in hospital or other healthcare worker lacks the clinical information settings. Although the data discussed in this article come needed to properly diagnose or treat a patient. In the from family practice analyses, the risk reduction ideas in 540 u The Bulletin
the following discussion can be applied to other ambula-tory clinical practices.
Ideas for reducing process problems
The majority of errors identified in the Graham Center study were administrative errors. Therefore, it iswise for practices to try to keep the best possible track ofadministrative processes. From a legal standpoint, thephysician employers of a medical practice bear theultimate responsibility for the actions of all the people inthe office. Some tips to reduce process problems are: Make a notebook of office policies. Delineating specific procedures—for releasing medical records, filing andpulling patients' charts, taking messages, triaging calls,scheduling appointments, directing patients through theoffice, documenting phone calls, refilling prescriptions,and the like—will help to ensure that administrativetasks are done in a consistent way.
Hire competent staff. Physicians can cut risks in administrative processes by paying attention to hiring.
When hiring office personnel, you should look forapplicants who have appropriate technical training and Sale or LeaseAvailable 2004
ability for the positions they will fill, and should furtherassess the qualified applicants to find those who havegood "people" skills.
Formally orient new staff. When new office personnel start their employment at the practice, they shouldcomplete an orientation program during which theoffice administrative policies are explained and demon-strated to them.
Discuss administrative issues. Set up a method that allows staff to have occasional discussions about policies and procedures. This could be done periodically at 250 Clever Road, Robinson Twp., PA (12 miles to CBD & 3 miles to The Pointe) administrative staff meetings, for example. The discus- sions could focus on a review of certain procedures or on identifying problems with certain procedures.
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patients are expected to take responsibility for their ownhealth care, a review of legal cases shows that courts Utilities: Water, sewer, gas, electric
expect physicians to play a part in ensuring the patient Parking: 100 spaces (room for expansion)
gets appropriate care. Doctors' medical training gives them a better understanding of the consequences of 120-bed residential care facility (Citizens Care, Inc.) various treatment options as well as the consequences of ROY F. JOHNS, ASSOCIATES
delaying treatment. Therefore, a physician is expected to Contact: Ron Willis at (412) 264-8383
encourage the patient to get necessary tests or consults.
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continued on page 543 The Bulletin u 541 PhysiciansPMSLIC was established twenty-five years ago by physicians for physicians.
Our concern for health-care professionals practicing in Pennsylvania extends beyond writing policies. Our defense of good medicine is vigorous.
Risk management activities are tightly integrated with underwriting standards.
We lobby persistently for meaningful medical liability reform. While malpractice carriers falter and fail, PMSLIC is taking actions today to maintain a stable source of professional liability insurance for Pennsylvania physicians for the future.
An advocate for meaningful medical liability reform Founding partner of Citizens Allied for Pennsylvania Patients (CAPP) Endorsed by the Pennsylvania Medical Society Owned by NORCAL Mutual Insurance Company — formed and owned by physicians Rated B++ (Very Good) by A.M. Best Company physician owned, physician directed P.O. Box 8375777 East Park DriveHarrisburg, PA 17105-8375 Currently accepting applications only from physicians joining insured practices.
542 u The Bulletin PRACTICE MANAGEMENT continued from page 541 When there are test results to report to the Ideas for reducing knowledge problems
patient, the physician is expected to The second category of errors make sure the patient knows what identified in the Graham Center these results are, how they relate to his study can be characterized as knowl- or her condition, and what is likely to edge errors. Knowledge errors can happen depending on the course of lead to wrong decisions, wrong action the patient decides to take.
diagnoses, problems using equip- There are a number of ways to set ment, problems executing tasks and up a system for determining whether inaccurate X-ray or test interpreta- or not a patient has had a test or tion. Some general tips to reduce followed through with some other knowledge errors are: recommended action. Some offices use a Stay within a regular scope of logbook, some a tickler file, some a follow-up appointment, and some a computerized system to track Keep up with changes and advances in your specialty.
patient compliance with recommendations for tests and Monitor the allied health providers in your practice.
consults. Any system is appropriate as long as it provides Hone your history-taking skills by reading literature in a way to assure that the follow-up action is taken and as your field, attending continuing education programs, long as it guards against having issues "fall through the getting patients to focus on their most important or bothersome symptoms, asking open-ended questions Focus on communication with patients. Communica- to facilitate patients' descriptions of symptoms, con- tion is highly important in medical practice. Studies centrating on improving listening skills, and trying not have shown that, if communication is lacking, patients to interrupt the patient's initial statement.
are more likely to perceive a problem with the quality of Continue diagnostic pursuit until you have a diagnosis care and are also more likely to sue physicians. Some of for a patient's symptoms rather than using a "rule-out" the following techniques may help you develop better diagnosis that is never confirmed. If you use empirical rapport with patients: treatment, you should follow the patient closely and Make eye contact.
re-evaluate symptoms if they continue.
Solicit feedback with open-ended questions.
You can reduce the chances that mistakes will occur Ask the patient to summarize information back to you in your practice by examining its processes and looking to check his or her understanding of it.
for weaknesses. Data from the Graham Center study Ask patients about their willingness and ability to point to some types of errors that have been identified in follow their treatment plans.
ambulatory care practices. Checking to see if these types Communicate effectively with other care providers. It is of errors could happen in your practice and revising your essential that all the providers involved in a patient's processes in vulnerable areas will increase your capacity care—the referring physician and all the consultants— to protect your patients from harm and will reduce your understand who will be primarily responsible for the liability risk.
patient's care. Coordinating care can get complicatedwhen multiple specialists are involved in one patient's Ms. Davis is a risk management researcher and project manager for care. All physicians must keep abreast of who the other Pennsylvania Medical Society Liability Insurance Company (PMSLIC). involved physicians are and what treatments they are You can call her at (800) 445-1212 or e-mail email@example.com. rendering. A break in professional-to-professionalcommunication can translate into a misunderstanding about therapy that could jeopardize a patient's well 1Dovey SM, Meyers DS, Phillips RL, et al. A preliminary taxonomy of medical errors in family practice. Quality and Safety in Health Care. The Bulletin u 543
Sometimes the most dazzling gifts arent ones that sparkle.
This holiday season give the gift that will make someones life a little brighter.
Created, funded and administered by physicians since 1960, the ACMS Foundation has given more than $1 million back to the community to help people of all backgrounds live better, healthier lives. Last year the ACMS Foundation contributed to or sponsored the following organizations and activities. This year, give a gift that may help to brighten the lives of others. All contributions are tax-deductible.
Achieva: Individual Public Service Award Healthy 4 Life Initiative Allegheny County Respite Care Coalition, Inc.
Medical Student Award (3) Carnegie Science Center USE RED SPO
CCAC Education Foundation Nazareth Housing Service: Senior Childrens Hospital of Pittsburgh Foundation: Homeowner Assistance Program Sickle Cell Camp Escape 2003 Pittsburgh International Science and Family Medicine Education Consortium Technology Festival (2) Girls Hope of Pittsburgh, Inc.
Providence Corrections, Inc.
Greater Pittsburgh Council of Rx Council of W. Pennsylvania Boy Scouts of America: Salvation Army: Scouting for Youths at Community Health Service Award The Albert Schweitzer Fellowship: 2003- The Foundation of the Pennsylvania Medical Foundation, Inc.
544 u The Bulletin Diabetes and Depression in
TANIA LYON, PHDNAIDIA GRUNDEN Coalition partners in the Pittsburgh PRHI partners looked for ways to get timely Regional Healthcare Initiative information into physicians' hands through a (PRHI) are targeting depression secure internet-based connection. The result- and diabetes in our region. What's the ing model, called the Pittsburgh Health connection between these two seemingly Information Network (or PHIN—pro- unrelated conditions? Both are chronic nounced "fin"), is similar to models in diseases, usually in outpatients. Both Utah (UHIN), Delaware (DHIN) and affect a large and increasing percent- Santa Barbara County, California age of the population in Southwestern Pennsylvania. And both are widely undertreated.
The Diabetes and Depression Working Groups are It takes a village: collaboration
working to improve care among all populations illus- PRHI partners addressing this challenge included all trated in the above pyramid (Figure 1). The group four of Pittsburgh's commercial health plans, all three of decided to concentrate on people in the third tier: Pittsburgh's Medicaid health plans, and Pittsburgh's two patients who have been diagnosed with depression or largest commercial labs. Together with numerous diabetes, and are under a physician's care—before healthcare professionals, they proposed to create a database to gather relevant claims data from health plans The hypothesis: When practitioners and patients and results from lab tests and combine them into a have up-to-the-minute patient information when and simple, one-page document for each patient. This where needed, complications and unnecessary hospital- information could then be pulled by the physician at the izations related to depression and diabetes could be point of care through a secure Internet connection.
Information where, when needed
How it works now
The data could generate a list of chronic disease Currently, physician offices have to collect their own patients or an individual patient history of basic care data on diabetic and depressed patients, which arrive at received for diabetes or depression. This will: different times from many sources (commercial health allow physicians to keep better track of their patients plans, Medicare, Medicaid and multiple laboratories).
through the list/registry function; The paper reports must then be filed in time for a create opportunities to engage in better preventive care; patient visit, at which time the patient learns the results.
help reinforce a minimum standard of care that has The current system's inefficiencies conspire against been established for depression and diabetes through physicians' ability to provide proper care to every pa- evidence-based, nationally recognized measures; and tient, every time.
continued on page 546 The Bulletin u 545 SPECIAL REPORT continued from page 545 allow patients to access their data as a step toward cians are already liable for providing a minimum stan- becoming more educated and active in their own dard of care. PHIN is designed to help them provide disease management.
that care more easily and effectively.
The technical team addressed questions like these: Challenging what's possible
How will we handle data transmission? PRHI partners studied ways to make the informa- Can data be posted quickly enough to be useful to tion readily available securely online. Questions and perceived problems abounded. What entity could act as Can the QIO handle varying patient identifier systems a neutral, trusted repository for this information? Under from different organizations? strict new HIPAA guidelines, would such a data resource How can the QIO ensure that only physician practices be legal? Could it be confidential enough, yet allow that have a relationship with a patient can access that physicians and patients appropriate access? Could itwork technically, and still be easy to use? Neutral repository: Quality Insights
PRHI discovered a powerful partner in "Quality Insights," our regional Quality Improvement Organiza-tion (QIO) reporting to the federal Center for Medicareand Medicaid Services (CMS). It brings considerabledata management experience and infrastructure to bearon this project as part of its own mandate to improvecare for diabetes. The QIO will act as a neutral platformfor collecting and collating data from all other sources.
See Figure 2 on right.
Legal and technical challenges
With PHIN, claims data from health plans and lab values from diagnostic To systematically address the daunting legal and labs flow into the QIO database. These data can help physicians by providing the following information about the patients in their practice: technical concerns, PRHI formed two task forces madeup of representatives from health plans, labs, the QIO Lists of all diabetic and/or depressed patients and physician practices. The legal team tackled such Aggregate reports, allowing physicians to benchmark against regional What kind of business agreement can be used? For diabetic patients: Will physicians' current privacy statements for patients * Dates of last visit need to be modified? * Dates, values of hgb A1C tests * Dates, values of lipid profiles Under what conditions can data be shared across * Dates of dilated retinal exams multiple physicians? For depressed patients: What are the parameters for sharing mental health * Dates of follow-up visits data? Are extra safeguards needed? * Dates when prescriptions for antidepressant medications are filled or refilled Will physicians be liable for using PHIN data? Con- The QIO will add Medicare data and build a comprehensive regional versely, if the PHIN database creates a new standard of database. Rather than pushing yet another report to the physicians desk, care, will physicians be liable for not using it? physicians could draw data as needed through a website.
Perhaps the legal team's most surprising finding was ALL information will be available in a common formatno matter which the extent to which the dreaded HIPAA regulations plan or lab it came from.
actually help efforts like PHIN. HIPAA has actually And its two-way: physicians can amend and update data so it becomes reduced liability by establishing clear standards of more accurate with each use.
protection and an industry standard of due care. Physi- Patients will also have access to their own data.
546 u The Bulletin Group Purchasing Program
Endorsed by the Allegheny County Medical Society How will patient history follow a patient across Mike Gomber, Area Vice President
(412) 580-7900 Toll Free(800) 472-2791
Partner institutions conducted research that helped to navigate these challenges as well.
If you would like a copy of the summary document, Improving Care for People with Diabetes and Depression, A combined 310 years of Physician Healthcare Service call Tania Lyon, PRHI's chronic disease coordinator, at and solution experience in Pittsburgh. That means we (412) 535-0292, ext. 107, or e-mail firstname.lastname@example.org.
have the knowledge base to provide the best in medical Pilot testing begins
solution and service! Eleven physicians have agreed to act as a pilot group to test the database in its initial phases. A dozen major 22,000 square foot Pittsburgh warehouse means a Pittsburgh employers, offering health coverage to 90,000 commitment to our community to provide the best employees and dependents, are encouraging physiciansin their health plans to use this resource.
service, solutions, quality and price to your practice.
In addition, because both depression and diabetes disproportionately affect lower-income and certain racial Our factory-trained, locally certified service technicians groups, we are recruiting the participation of physicians provide expert service for your equipment, translating to serving those populations (i.e., via Medicaid health plans less down time.
and physician groups like the Gateway Medical Society).
Some commercial health plans have developed their own programs to improve the care of patients in their Consultant services to analyze your product use and systems (i.e., our partner Highmark's Smart Registry).
provide cost containment and produce standardization.
This project helps to ensure that all patients, no matter That means significant savings to reduce medical supply what their coverage, can have their chronic disease data and utilization costs with our customized programs.
made easily available to their physicians for improved care.
What if this works?
Physicians well know how to treat diabetes and Distributor of Choice (DOC) program provides depression effectively. Yet our region suffers excruciat- continual maintenance and calibration of diagnostic ingly high rates of almost always preventable complica- equipment (scale, BP, otoscope, ophthmoscope) and tions. If PHIN can be made to work, getting physicians sharp surgical instruments—accurate results for your and patients up-to-the-minute healthcare information, diagnostic and surgical procedures.
proper care can be given to every patient at every visit.
From this starting point, Pittsburgh can become the OUR MISSION is to serve each
Perfect Care Zone, where 100 percent of diabetic and customer as if he or she were the only depressed patients routinely receive the care they need.
customer by providing each office with Southwestern Pennsylvania could become the first placein the country to virtually eliminate the complications of the best healthcare services and diabetes and depression—a development that would solutions for quality patient care.
have national implications.
We value your partnership in helping us to serve you. Thank you, physicians, administrators and Ms. Lyon is chronic care coordinator for the Pittsburgh Regional office staff, for directing and advising us on medical Healthcare Initiative and Ms. Grunden is the organization's communi- supply products, services and costs.
cations director. Both can be reached at (412) 535-0292. Visitwww.prhi.org for additional information. The Bulletin u 547 TIMOTHY F. MURPHY In the past, most Americans have taken for granted to limit venue shopping, especially in the Philadelphia easy access to quality health care. Now, however, area. We also passed Act 13, which allowed for propor- there is unease about our healthcare system. The tional liability, collateral receipt and distributed pay- ranks of the uninsured are growing, there are double ments. Because many cases were filed before these bills digit increases in health insurance costs, seniors are took effect, it is too early to document whether or not worried about the high cost of prescription drugs and this legislation has made a substantive difference. It may physicians have yet to see the effects of changes in the take years to see a reduction in high payouts to plaintiffs medical liability system. Even in the midst of the War and subsequently a reduction in insurance costs.
Against Terror and economic concerns, there is a com- Earlier this year, the U.S. House of Representatives mitment to change. Reform of this system has become a passed H.R. 5 to implement reform. This legislation top priority of Congress and President Bush.
would ensure speedy resolution of claims, establish fair As one of the few healthcare professionals in Con- accountability by weighing the degree of fault, provide gress, I have used my experience of working at local maximum patient recovery by ensuring attorneys do not hospitals and the input of my fellow healthcare profes- misdirect awards, fully compensate for patient injuries sionals to explain to my colleagues in great detail the and put reasonable time limits on punitive, non-eco- struggles of healthcare providers. What follows is a brief nomic damages by ensuring the punishment fit the update on the status of two of the most pressing pieces offense. The key to H.R. 5 is a $250,000 cap on puni- of federal health care legislation in the works: medical tive awards. The bill is currently in the Senate for con- liability reform and the addition of a prescription drug sideration and, at the time of this article, this cap on benefit to Medicare.
non-economic damages remains a fundamental area ofdispute.
Medical Liability Reform
In the meantime, there is a concern on the federal The high cost of medical liability insurance is level about the growing exodus of physicians from states forcing physicians, especially those in high-risk fields, to with high insurance rates. A recent report from the flee Pennsylvania. Graduates of our medical schools and General Accounting Office (GAO) disputed the exist- residency programs are choosing not to remain. Physi- ence of a causal link between escalating premiums and cians are unwilling or unable to pay exorbitant insurance patients' access to health care. The goal of the study was costs and have relocated to states with reformed systems.
to determine if fewer people were able to access insur- Some blame physician error for the high costs due and ance in five of the states (Pennsylvania among them) seek to block changes to the system in order to protect a deemed to be "in a crisis" by the American Medical patient's right to sue for damages. Others see the system as broken and in need of major reform.
The GAO study determined that, although some While I was serving as a state senator, we took several people were having difficulty accessing care, these steps to help. The Pennsylvania legislature passed a bill 548 u The Bulletin SPECIAL REPORT continued be deducted to further wrap around the Medicareprogram to further reduce out-of-pocket expenses. In The ranks of the uninsured are
addition, I am working to ensure that Medicare reforms growing, there are double digit
would stabilize fair reimbursement rates for physicians increases in health insurance costs,
seniors are worried about the high
At the time this article was written, work was con- tinuing in the Senate and House on Medicare reform.
cost of prescription drugs and
Differences on level of coverage and out-of-pocket physicians have yet to see the
expenses are currently being worked out in conference.
effects of changes in the medical
There has been real progress on medical liability and Medicare reform. This is in no small part a result of theinvolvement of the healthcare community. I thank the incidences tended to occur largely in rural areas where many who have advised me on the current state of affairs problems were either long-term or traditional. This and on concerns particular to their practice. Your feed- report used only anecdotal information such as inter- back and comments are an invaluable part of this histori- views with hospitals and practices, and selective investi- cal movement for reform. We are close, but there is more gation of certain medical fields. Only two Pennsylvania work to be done.
settings were studied, and the number of available Congressman Murphy represents the 18th District in the United States physicians was based on a count of existing licenses.
House of Representatives. He can be reached at (412) 344-5583 or License statistics are largely skewed because they count residents, retirees, academic physicians, and physicianswho are licensed here but practice out of state. Thereport's dismissal of rural access problems suggests insensitivity to rural populations. (Pennsylvania has thecountry's highest rural population.) The study concluded that there is no physician shortage in Pennsylvania. Ihave challenged the GAO report and explained tocolleagues that its conclusions are invalid. This illustrates Getting your claims out is easy. Having the need to stay on top of this issue as it works its way the time to follow up is tough, espe- out of the Senate.
cially if your biller is pulled for patient care, scheduling, or whatever.
In June of 2003, the House of Representatives At FENNER, our billers are devoted passed H.R. 1 (Medicare Prescription Drug and Mod- 100% to managing accounts and fol- ernization Act) by a vote of 216-215. This legislation lowing up on difficult claims.
would amend the Social Security Act to provide forvoluntary prescription drug coverage under the Medicare If you think its time to outsource your program, modernize the Medicare program and allow adeduction to individuals for amounts contributed to billing, call us at 412-788-8007 or visit health savings security accounts and health savings I am working to ensure that a federal prescription drug plan would complement Pennsylvania's PACE and One Penn Center West PACENET programs. Since Medicare would cover Pittsburgh, PA 15276 much of what PACE covers, Pennsylvania would seehundreds of millions of dollars in savings, which could The Bulletin u 549 Smoking Cessation Efforts
in Allegheny County
LINDA DUCHAK Tobacco Free Allegheny (TFA), a new non-profit At the heart of all strategies to reduce the burden of organization supported by the Allegheny County mortality, morbidity and disability associated with Health Department, has taken advantage of the tobacco use is maintaining an understanding of the body of knowledge, scientific evidence and experience of substantial and expanding body of scientific knowledge other states in constructing a comprehensive, coordi- about the health consequences of tobacco use. Thou- nated tobacco control program in Allegheny County sands of studies detail its overwhelming health conse- that is sustainable and accountable. Funded through the quences, and a succession of U.S. surgeons general have Master Settlement Agreement of 1998 between 46 states reviewed and summarized the health effects associated and the tobacco industry, TFA joins the Pennsylvania with smoking and other forms of tobacco use. Past Department of Health in efforts to create an environ- decades of research have indicated that single-focus ment where it is uncommon to see, use or be negatively efforts (e.g. media campaigns, school programs) produce impacted by tobacco use.
little long-term change in the prevalence of tobacco use.
Tobacco has a long history of use in the United It has been those efforts that combine a number of States, and its serious health effects have been well coordinated, complimentary initiatives addressing the documented during the past half-century. In 1982, multiple issues of tobacco use by a variety of providers Surgeon General C. Everett Koop declared, "Cigarette that have resulted in the strongest, longest-lasting smoking is the chief, single cause of avoidable mortality reductions in tobacco use.
in the U.S. and the most important public health issue Multi-pronged efforts, including the development of of our time." Smoking has been the leading preventable prevention and cessation programs, public information cause of disease and death in this country for more than campaigns, legislative initiatives, advocacy activities and three decades and is responsible for more than 430,000 similar measures have produced results. A wide range of deaths annually, representing nearly one in five deaths.
organizations in the federal sector (e.g., Centers for Efforts to control tobacco use in the U.S. accelerated Disease Control, National Heart, Lung and Blood after the publication of the first surgeon general's Report Institutes), voluntary agencies (e.g., American Cancer on Smoking and Health in 1964. Considerable progress Society, American Lung Association), and others (e.g., has been made in reducing the prevalence of smoking in American Medical Association, Association of State and the U.S. over the past 25 years, during which time there Territorial Health Officers) have allied in efforts to has been a 34 percent reduction in adult smoking.
control tobacco use and its disease ramifications. Evi- Despite the increase in policies regulating smoking, dence has indicated that strengthening existing relation- litigation against the tobacco industry and heightened ships and facilitating cooperative linkages among others public awareness of the negative health consequences of who have not previously worked together foster success tobacco use, cigarette smoking remains firmly en- in tobacco control. In this way, with numerous organiza- trenched in American society today. Although the tions converging on the single issue of reducing tobacco demographics of smokers vary from those nearly 40 use through a wide variety of complementary activities, a years ago at the time of the 1964 report, nearly one- multiplicative effect is possible.
fourth of the population, or 67 million Americans, Tobacco Free Allegheny used a competitive process continues to smoke.
to assign funding that has resulted in the selection of 550 u The Bulletin SPECIAL REPORT continued more than 30 service providers from local hospitals, use tobacco and, if so, encouraging them to quit. Our clinics, faith-based organizations, voluntary health staff can provide information, literature and training by organizations, mental health agencies, universities, calling at (412) 578-7910.
community organizations and athletic organizations thathave implemented programs throughout the county in Linda Duchak is executive director of Tobacco Free Allegheny. She can the priority areas identified by the Centers for Disease be reached at (412) 578-7910. Control in its guideline, Best Practices for Comprehensive Tobacco Control Programs. Community-based, school- based, chronic disease and cessation programs offer an (1)U.S. Dept. of Health & Human Services, The Health Consequences of Smoking: Cancer. A Report of the Surgeon General. DHHS Pub. No (PHS) array of services in the community, including classroom 82-50179. Washington, DC: Government Printing Office, 1982.
instruction using evidence-based curricula, cessation (2) U.S. Department of Health and Human Services. Reducing the Health services for youth and adults, faith-based prevention Consequences of Smoking: 25 Years of Progress. A Report of the Surgeon General. DHHS Pub. N0. (CDC) 89-8411. Washington, DC: Government activities, peer education, parent education, early detec- Printing Office, 1989.
tion of tobacco-related diseases and continued treatment (3) Redmond, D.E. Tobacco and Cancer: The First Clinical Report. New of disease. An initiative to provide pharmacotherapy to England Journal of Medicine 282 (1961): 18-23.
participants of cessation programs has been imple- (4) American Cancer Society. Cancer Facts and Figures1994. ACS Pub.
mented. All services are provided at no charge to resi- No. ACS 94-375M 5008.94. Atlanta, Ga.: ACS, 1994.
dents of Allegheny County.
(5) Pertschuk, Michael. Strategies for Tobacco Control in the United States.
Advocacy Institute, Washington, DC.
Research is being done to identify issues with dispar- ate populations. Enforcement of youth access restrictionsto tobacco products and clean indoor air regulations isongoing. Concurrently, print and broadcast media isbeing used in countermarketing and advertising efforts.
Ongoing process and outcome evaluation is beingconducted by a team of researchers from the GraduateSchool of Public Health at the University of Pittsburghto determine individual and cumulative program effec-tiveness.
Of particular concern to Allegheny County is the unacceptably high rate of tobacco use during pregnancy(23.6 percent) as reported by the Annie E. Casey Foun-dation. Tobacco Free Allegheny has established outreachto pregnant women as a priority. The current focus of itswebsite (www.tobaccofreeallegheny.org) is on maternalsmoking. In addition to educational programs, cessationservices and print and broadcast media outreach, resi-dents at local hospitals and clinics are being trained toimplement interventions in their practices. Physiciansand their staffs are being trained to implement clinicalpractice guidelines as well as Clean Air for HealthyChildren, an intervention focusing on pregnant womenand mothers of young children.
Tobacco Free Allegheny recognizes the impact of the medical profession in prevention efforts. It is our hopethat every physician in Allegheny County will supportour efforts by asking each patient whether or not they The Bulletin u 551 To Tell the Truth
TIMOTHY LESACA, MD Regarding the issue of disclosure, patients and physicians largely agreed on the concept but disagreed Call us! We'll help you find the answers!" These are the closing words from one of the morememorable television ads for a prominent upon the definition. The patients unanimously wanted malpractice attorney. No doubt when people feel that information regarding an error's cause, consequences and they have been hurt, even before they seek justice or even future prevention. They stated that such disclosurevengeance, they instinctively seek some measure of would enhance their trust in the physicians' honesty and understanding. Knowledge is usually the most powerful would reassure them that they were receiving complete antidote against despair.
information about their overall care. Furthermore, the With this axiom in mind, I read with a sense of patients preferred that such disclosure be provided to enlightenment an article in the February 26, 2003, issue them forthrightly, rather than having to ask their physi- of the Journal of the American Medical Association by cian "numerous questions." They also wanted to know Thomas Gallagher, MD, titled "Patients' and Physicians' that the practitioner and institution regretted what had Attitudes Regarding the Disclosure of Medical Errors." happened and were taking steps to prevent future similar This study, designed as an in-depth exploration of attitudes about the disclosure of medical errors, involved52 patients and 46 doctors in a total of 13 focus groups.
The specific research questions pertained to the attitudes Regarding the issue of disclosure
of patients and physicians about medical error disclosure, (of medical errors), patients and
as well as explored whether physicians disclose theinformation patients desire about medical errors.
physicians largely agreed on the
Much to my surprise, this sample of patients con- concept, but disagreed upon the
ceived of medical errors very broadly. Despite being presented with a standard definition of medical errors,they perceived events such as long waits for routineappointments, non-preventable adverse events such as Many of the physicians, however, were reluctant to drug allergies, and interpersonal issues such as being provide patients with this extent of information. Al- addressed "rudely" by a physician as examples of medical though they endorsed error disclosure in principle, many described specific situations in which they might not I was much less surprised by the physicians' attitudes disclose an error that harmed a patient. Some physicians regarding medical errors. Most of the physicians worried felt that there was no need to disclose an error if the regularly about medical errors; in addition to fear that an harm was "trivial" or if the patient was unaware that the error might harm a patient, they also said that their error had taken place.
worst fears about errors included lawsuits, loss of patient Many of the physicians felt that error disclosure trust, loss of colleagues' respect and diminished self- involved being a "spin doctor," describing the event in confidence. They were also frustrated by the breadth of the most positive light, yet as factually accurate. They what patients considered to be errors and felt that spoke of "choosing their words carefully" when talking patients were often unduly upset about "minor" errors.
with patients about errors. Most often, this careful 552 u The Bulletin PROSPECTIVE continued choice of words involved mentioning the adverse eventbut not explicitly stating that an error had taken place.
The physicians' wariness in telling patients about errors reflected their fear of litigation, as well as a belief thatinformation about an error might "harm the patient."Interestingly, few patients shared this latter concern.
The patients believed that the way the error was Allegheny County Health Department
disclosed to them directly affected their emotional Selected Reportable Diseases
experience after the error. Many patients said they would Jan-Sept Jan-Dec be less upset if the physician disclosed the error honestly and compassionately and apologized. While some of the Campylobacteriosis . 52 . 97 . 99 physicians agreed that it would be helpful to say that Cryptosporidiosis . 4 . 4 . 3 they too were upset about the error, other physicians in E. coli 0157:H7 . 5 . 9 . 10 the group found this approach to be unprofessional.
Most of the physicians, however, did express a desire to apologize, but worried that an expression of regret might Giardiasis . 26 . 60 . 104 be construed by the patient as an admission of legal Guillain-Barre Syndrome . 2 . 7 . 8 Hepatitis A . 7 . 24 . 55 Physicians' reluctance to discuss the cause and Hepatitis B . 15 . 37 . 49 Hepatitis C . 104 . 220 . * future prevention of errors was particularly troubling to Legionellosis. 32 . 53 . 34 the patients. Furthermore, what some physicians defined Lyme Disease. 12 . 19 . 38 as an appropriate professional demeanor while discussing an error impressed some patients as being cold and Aseptic/Viral Meningitis . 34 . 63 . 68 impersonal, thus creating the mistaken impression that West Nile Meningitis . 1 . 1 . * the physician really did not care about what happened or Bacterial Meningitis: Haemophilus Grp. B . 0 . 2 . 4 was hiding what had actually happened.
Cryptococcal . 1 . 3 . 2 Many current institutional policies about disclosing Staphylococcal . 0 . 0 . 2 medical errors instruct physicians not to discuss why an Streptococcal . 3 . 9 . 5 error happened in a way that could imply fault. It is interesting to note, however, that in this study the Other/Unidentified. 2 . 2 . 7 patient group expressed a desire for disclosure not to Meningococcal Disease . 2 . 12 . 12 Pertussis . 19 . 29 . 26 affix blame, but rather to understand what happened to Salmonellosis . 42 . 80 . 133 them and to know that the institution and individuals Shigellosis . 2 . 6 . 6 involved had learned from the event. Although I believe Tuberculosis . 6 . 21 . 25 that it is naïve to assume that full disclosure of all medical errors with an apology would resolve the preva- lent malpractice and litigation crisis facing us today, it Gonorrhea . 428 . 1,135 . 2,166 Chlamydia . 803 . 2,520 . 4,216 does seem to me that our fear of litigation at times Early Syphilis . 5 . 16 . 13 interferes with our common sense and understanding of Carbon Monoxide Poisoning . 7 . 22 . 71 human nature. Instead, we have patients running tolawyers to find the answers.
Dr. Lesaca is a psychiatrist and serves as contributing editor to the Disease reports may be filed weekdays during regular business hours from 8:30 a.m. to 4:30 p.m. by calling Bulletin. He can be reached at email@example.com. (412) 578-8060. At all other times, please call the Health Departments 24-hour telephone line (412) 687-2243.
The Bulletin u 553 Medicine and Magic:
Robert C. Cicco, MD
LISA B. PETZEL Robert C. Cicco, MD
He dons a red nose, lots of makeup and a helped to influence his decision to become a physician.
silly hat and leaves loving notes for parents of He decided to pursue neonatology after his first year of sick children to lift their spirits. His job is to residency at Children's Hospital when he rotated to heal sick babies, but neonatologist Robert C. Cicco, Magee Womens Hospital. "It had a nice mix of dealing MD, often uses some of his magic learned at a "clown with many organ systems and dealing with families convention" to apply a different kind of healing for going through a crisis." Dr. Cicco says. "I always liked children, healing that comes from laughter and a positive dealing with kids and kids' issues," he adds.
outlook on life. "I've always been interested in magic," Dr. Cicco's lifelong interest in magic began to he says. "There are things other than just medicine that intensify around the same time the direction for his can affect your health." career began to unfold. Having married after his second Dr. Cicco's alter ego, Bobbles the Clown, does won- year of undergraduate work, he and wife Anita were ders to heal the souls of many a child in the hospital, as expecting their first baby while he worked as a "dorm well as at various settings in the community where he parent." Friends brought him a shoe box of magic stuff for a father's day gift, while they Although Dr. Cicco, assistant bought a changing table for his director of the West Penn Hospital wife on mother's day that year.
neonatal intensive care unit (NICU), His avocation of magic and seems a natural in his professional clowning grew steadily over the role, he did not always dream of years. Dr. Cicco has made as many becoming a physician. As an under- as 20 appearances per year as graduate at Case Western University Bobbles the Clown as part of the majoring in chemistry, he realized volunteer organization, Tri Rivers that a future working as a chemist in Clown Alley, of which he is past a lab "wasn't me," and anyone who president. Bringing humor and fun meets the gregarious physician would into the lives of others has become agree. His sister's husband, obstetri- a family affair for the Ciccos as all cian/gynecologist Richard Deitrick, four of his sons learned to juggle MD, as well as his father, a teacher, Bobbles the Clown
and do some type of clowning. "It 554 u The Bulletin PROFILE continued is so rewarding," he says. His son Brian performs semi-professionally on the weekends.
Although he doesn't regularly appear at the hospital in full clown gear, Dr. Cicco applies some of his "magic"such as making balloon animals or wearing goofy socks,and leaves notes to warm the hearts of parents andchildren at the NICU.
Clowning for people with disabilities, such as those at the Children's Institute, is a volunteer duty he findsvery gratifying and one that has led to more serious workhelping the disabled in the form of advocacy. Dr. Ciccosits on the board of the Metabolic Screening AdvisoryCommittee through the state's Department of Health,and he chairs the state's Bureau of Family Health. In this Dr. Cicco appeared on the Jumbotron at the September 17
Pirates game when he received recognition from Exceptional
role, he advocates a newborn metabolic screening pro- Parent magazine for his advocacy work on behalf of children.
gram to identify problems in newborns in order thatthey can begin treatment. He says such work has helpedPennsylvania hospitals to make it mandatory to screenfor some 40 diseases, when they screened for only twojust 20 years ago. "I work with the department of healthto make sure we're doing it right, make sure it is fundedand the infants can get treated," he says.
Dr. Cicco was recently recognized for such work when he was honored by Exceptional Parent magazineduring the September 17 Pirates game at PNC Park. Therecognition is part of Exceptional Parent's DisabilitiesAwareness Program, and he was honored along with twopeople who have accomplished much despite theirdisabilities. Dr. Cicco says the magazine has been suc-cessful in getting most of the ball clubs around thecountry to support it. "We want them to see that peoplewith disabilities are people," he says.
His partner of 20 years, Alan Lantzy, MD, says Dr.
Dr. Cicco entertaining children in Romania with "pocket magic."
Cicco's advocacy work has made an impact on the carethat babies receive and has helped to improve reimburse- through the Humana Foundation. During these trips he ment rates for pediatricians. "He is a very good advocate works alongside Romanian physicians to improve the for parents at a very critical time in their lives," he says.
care of newborns in hospitals there. During his last trip, Longtime friend and fellow magician, Jim N.
Dr. Cicco thrilled Romanian children with "pocket Tucker, MD, a pediatrician at Children's Community magic," drawing dozens of children to his side. "They Pediatrics, Allegheny, had nothing but praise for Dr.
were so enthralled," he says.
Cicco as well, both as a physician and as a magician. "He Dr. Tucker, who was unaware of Dr. Cicco's trips to is a rare kind of doctor. He has wonderful clinical Romania, says he is not surprised in the least at Dr.
judgment and is wonderful with families," he says.
Cicco's humanitarian efforts. "He has more zest for life Dr. Cicco's advocacy for children extended beyond than anyone else I know," he says.
the state and even the country four years ago when hebegan an annual trip with his wife Anita to Romania Ms. Petzel is a freelance writer in the Pittsburgh area. The Bulletin u 555 Do What You Do Best.
And well do what we do best. The Allegheny County Medical Society specializes in providing physicians with the best supplies and services at the best prices. And we only contract with those vendors who can meet the unique needs of physicians.
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556 u The Bulletin APPLICATIONS FOR MEMBERSHIP First Year
Bijan Eghtesad, MD, transplant surgery. 6018 Howe Jason J. Lamb, MD, thoracic surgery. 4815 Liberty Street, 15206. Pahlavi University School of Medicine Avenue, Suite 156, 15224. University of Virginia School (Shiraz University), Iran, 1978.
of Medicine, 1996.
Linda M. Farkas, MD, colon and rectal surgery. 5150 David L. Mandell, MD, pediatric otolaryngology. 5858 Centre Avenue, 4th Floor, 15232. Loyola University 1/2 Beacon Street, 15217. University of Maryland Stritch School of Medicine, 1989.
School of Medicine, 1996.
David M. Ferguson, MD, family practice. 6023 Harvard Michael J. Palumbo, MD, allergy and immunology. 180 Square, 15206. University of Pennsylvania School of Fort Couch Road, 15241. Pennsylvania State University, Medicine, 1996.
Jeffrey R. Gingrich, MD, urology. 5200 Centre Avenue, John Pensock, MD, cardiovascular disease. 209 Green 15232. University of Michigan Medical School, 1987.
Court, 15234. Pennsylvania State University, 1995.
Nitin M. Kamat, MD, nephrology. 100 Delafield Road, Joseph Scherer, MD, ophthalmology. 713 Washington Suite 212, 15215. Topiwala National Medical College Road, 15228. Memorial University of Newfoundland, Bombay University, India, 1989.
Faculty of Medicine, Canada, 1999.
Wendy Lemarquand, MD, family practice. 6023 Gerard J. Werries, MD, orthopedic surgery. 9 Blue Harvard Street, 15206. McGill University Faculty of Road, 15076. University of Pittsburgh School of Medi- Medicine, Canada, 1982.
Vered D. Lewy-Weiss, MD, pediatric endocrinology.
405 Jamesborough Drive, 15238. New York Medical Second Year
Nicolas De La Pena, MD, infectious diseases. 1420 Shawn O. Naseem, MD, internal medicine. 2550 Centre Avenue, 15219. College of Medicine University Mosside Boulevard, 15146. St George's University of Philippines, 1989.
School of Medicine, 1998.
Bradley B. Keller, MD, pediatric cardiology. 2599 Misha L. Pless, MD, neurology. 203 Lothrop Street, Wexford Bayne Road, 15143. Pennsylvania State Univer- 15213. Emory University School of Medicine, 1990.
Stacey H. Popko, MD, internal medicine/pediatrics.
Sarun Suwan, MD, general surgery. 6228 Riverfront 1470 Meadowbrook Drive, 15317. Medical College of Drive, 15238. Temple University School of Medicine, Pennsylvania, 1996.
Richard L. Raszewski, MD, plastic surgery. 620 Yvette L. Taylor, MD, family practice. 6417 Stanton Warrendale Road, 15044. University of Pittsburgh Avenue, 15206. University of Pittsburgh School of School of Medicine, 1986.
Sonia Saigal Dhawan, MD, internal medicine. 4750 Kevin B. Traub, MD, urology. 580 South Aiken Avenue, Oakhurst Avenue, 15044. Lady Hardinge Medical Suite 610, 15232. New York University School of College, Delhi University, India, 1994.
Joel S. Schuman, MD, ophthalmology. 203 Lothrop Street, Suite 816, 15212. Mount Sinai School of Medi- Steven R. Abo, MD, gastroenterology. 1515 Shady cine City University of New York, 1984.
Avenue, 15217. Albert Einstein College of Medicine, Robert P. Snyder, DO, internal medicine. 15 Nash Lane, 15090. University of Osteopathic Medicine and Health Bernard J. Costello, MD, craniofacial surgery. 3501 Sciences, 1996.
Terrace Street, Suite G32, 15213. University of Pennsyl- Jeannette E. South-Paul, MD, family practice. 373 vania School of Medicine, 1997.
continued on page 558 The Bulletin u 557 Help Wanted
2 Car Garage. Alexis Fitch, Pru- Clair Hospital. Free parking, dential Preferred Realty 412-877- space available for half days or full days. For additional information hours per week) salaried position contact Shirley at 412-687-2100.
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Reception room, business office, ACMS/box number MR Center, 437 Railroad Street, For more information or a pri- 3 exam rooms, 2 bathrooms, con- Bridgeville, PA 15017. EOE M/ vate showing, please call Bunny sultation room and lab. Some Pittsburgh PA 15212 Wolff or Lucy Oliver at 412-782- utilities included. 412-922-3333.
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BOARD CERTIFIED PHYSI-CIAN needed to perform outpa- tient aesthetic procedures under Recently renovated 4 bedroom local anesthesia in the South stone Colonial with great curb Hills. Will train. Please call Jerry appeal on 1+ acre of level lawn continued from page 557 at 412-429-1161, ext. 20.
and gardens includes a two storyden and family room, paneled Burrows St, 15213.
Northumberland Street, study, gourmet kitchen, detached ried position available at CMHC garage with space for possible University of Pittsburgh 15217-1238. University of in the South Hills to provide out- home office above. For more in- School of Medicine, 1979.
patient, partial hospitalization Kentucky College of formation or a private showing, and geriatric residential treatment Medicine, 1973.
please call Bunny Wolff or Lucy Diane C. Strollo, MD, psychiatric services to adults for Oliver at 412-782-3700 ext. 238 diagnostic radiology. 3048 vacation coverage. Board certifi- Katherine Leah Wisner, cation with DEA # and White Pine Drive, 15044- MD, psychiatry. 58 6161. Uniformed Services Locksley Drive, 15235.
required. To apply send resume For Lease
University of the Health to: Human Resources Depart- Case Western Reserve FOR LEASE–Monroeville, 2000 ment, Dept. B, Chartiers MH/ Sciences, 1981.
sq.ft. Medical office in a one MR Center, 437 Railroad Street, story, level entry Medical build- Henkie P. Tan, MD, PhD, Bridgeville, PA 15017. EOE M/ Guy A. Zimbardi, MD, ing. Contact Jeff or Irv Weiner at transplant surgery. MUH Irv Weiner Real Estate. 412-373-8900 N-725, 15213. Loma 4733 Centre Avenue, Linda University School of 15213. Boston University $385,000 SPECTACULAR For Sublease
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Inside this issue Mental Health innovationAward winning ADHB staffPacific expedition to make a RECOGNISING ADHB STAFF Taupiri AshbyMaori Health Worker (Early Childhood Services) Happy New Year A memorial service was held on 13 November 2009 at Greenlanefor Taupiri Ashby who died on 5 November. The memorial was
Received 29 Jan 2013 Accepted 25 Jul 2013 Published 22 Aug 2013 DOI: 10.1038/ncomms3354 MG53-induced IRS-1 ubiquitination negativelyregulates skeletal myogenesis and insulin signalling Jae-Sung Yi1, Jun Sub Park1, Young-Mi Ham1, Nga Nguyen1, Na-Rae Lee1, Jin Hong1, Bong-Woo Kim1, Hyun Lee1, Chang-Seok Lee1, Byung-Cheon Jeong1, Hyun Kyu Song1, Hana Cho1, Yoon Ki Kim1,