WORK INJURY—A Second Look at the Doctor's First Report

Injured employees require medical care and, if disabled, compensation payments for subsistence. The law requires that the employer or insurance carrier supply these benefits promptly. In the absence of prompt and adequate information from the attending physician, these benefits are withheld. The necessary information required to process employee''s claim is that called for on the standard accident report form, commonly called the “pink slip.” Not to supply this minimum information may constitute a hardship on the employee. By supplying more elaborate information than that called for, the physician may be increasing his load of “paper work” immeasurably.     

The Compensable Injury

The complexities and interferences in the doctor-patient relationship during the treatment of the compensably-injured workman create an unusually high incidence of delayed recovery, complications, and permanent disability. Many persons, once injured, never return to economic self-sufficiency. Among the factors that may have a bearing in producing this situation are: The psychological context of the injury itself; the personality of the patient; the “reverse incentive” created by reward for illness; third-party interference from attorneys, insurance claims adjusters, and union representatives; consequent hostility of the patient toward a doctor he usually has not chosen; and, too often, hostility of the physician toward his patient. Iatrogenic complications may also be present when ill-advised surgical procedures are used in the presence of psychological complications.To improve the situation the adversary system should be removed and outside interferences in treatment should be reduced. Physicians treating patients in such circumstances should learn more about psychiatric diagnosis and management. They should give more attention to remotivation and rehabilitation.     

Why it's time for a national health program in the United States.

The United States lacks a coherent national health program. Current programs leave major gaps in coverage and recently have become more restrictive. Influential policies that have failed to correct crucial problems of the health-care system include competitive strategies, corporate intervention, and public-sector cutbacks with bureaucratic expansion. A national health program that combines elements of national health insurance and a national health service is a policy that would help solve current health-care problems. Previous proposals for national health insurance contained weaknesses that would need correction under a national program. Based on the experiences of other economically advanced countries, a national health program could provide universal entitlement to health care while controlling costs and improving the health-care system through structural reorganization. Current proposals for a national health program contain several basic principles dealing with the scope of services, copayments, financing, cost controls, physician and professional associations, personnel and distribution, prevention, and participation in policy making. Support for a national health program is growing rapidly. Such a program would help protect all people who live in this country from unnecessary illness, suffering, and early death.     

From Chattel to Consenter: Adolescents and Informed Consent: 2009 Grover Powers Lecture

Angela Holder was to give the Grover Powers Memorial Lecture at the weekly Grand Rounds conducted by the Yale Department of Pediatrics on Wednesday, May 27, 2009, but unfortunately, she died one month earlier, on April 22, leaving behind her prepared address, “From Chattel to Consenter: Adolescents and Informed Consent,” which she had regarded as the pinnacle of a remarkable career, much of it spent at Yale. As the Grover Powers honoree, the department’s highest honor, Ms. Holder was only the fourth woman of 46 recipients and the first who was not a physician. On the date scheduled for her address, tributes were presented by her son, John Holder, and her longtime colleague, Dr. Robert Levine, co-founder of Yale’s Interdisciplinary Bioethics Center. Their comments follow Angela Holder’s completed but undelivered Grover Powers address. — Myron Genel, MD, Professor Emeritus of PediatricsUnder the common law of England and in the early years of the United States, a minor (defined as anyone under 21) was a chattel or possession of his or her father [1-4]. A father had the right to sue a physician who treated his son or daughter perfectly properly but without the father’s permission because such an intervention contravened the father’s right to control the child. Beginning in the early years of the 20th century, by the end of World War II and into the 1950s, the notion that a 16-year-old was a legally different entity from a 6-year-old gradually became law in all states.¹ The first hospital unit for adolescents was created in 1951 at Boston Children’s Hospital, and the concept of “adolescent medicine” was born [5].As the law in this area currently defines “adolescent,” we are discussing someone 14 or older who may be (1) living at home with his or her parents; (2) Not living at home but still dependent on parents (i.e., a 16-year-old college freshman living in a dorm); (3) an “emancipated minor” who is married, emancipated by a court order, or a parent (other than in North Carolina), living away from home and self-supporting; or (4) a runaway or throwaway. At any time in this country, there are about 200,000 adolescents living on the streets with no adult supervision or involvement [6].Regardless of the age of the patient, informed consent consists of five elements: (1) An explanation of what will happen; (2) explanation of the risks; (3) explanation of the projected benefits; (4) alternatives (including doing nothing); and (5) why the physician thinks it should be done, which I interpret as a right to know one’s diagnosis. While the doctrine of “therapeutic privilege” means that in rare cases a physician may withhold some information from an adult patient if she or he believes the patient cannot “deal with the information,” there can never be any withholding of information from an adolescent. If the patient can’t deal with the information to be presented, then parents have to be involved and give permission to treat the adolescent.In some cases, when parents are involved, they do not want their adolescent to know his or her diagnosis. While this is usually not a good idea, it normally falls under the rubric of “professional judgment,” and the physician has every right to decide to follow the parents’ instruction if she agrees with it. In some situations, however, the adolescent must be told what his or her illness is, whether parents like it or not. For example, if a teenager is HIV positive, he or she must be told, must be instructed about safe sex, and must be asked to divulge the names of any sex partners. Parents who say, “Oh, no, don’t tell him, he would never do anything like that, so it doesn’t matter,” should be tactfully but firmly led to accept the fact that he may well have and if he hasn’t yet, he will certainly in the future. There has been at least one successful malpractice case in which the physician did not, at the request of the parents, tell his adolescent patient that he had HIV. The patient’s girlfriend caught it and sued the physician [7]. I feel sure there are many more cases like this that have been quietly settled and no one will ever hear about.Usually, questions about adolescents giving consent to treatments that their parents don’t know about involve outpatient treatment. In the first place, hospital administrators, who are much more interested in getting paid than they are in advancing the rights of autonomous adolescents, are not going to admit for a non-emergency problem a minor whose parent has not made some sort of financial arrangement to pay for it. Secondly, in most households, if Little Herman doesn’t show up for supper or throughout the evening, someone notices and a few telephone calls later discovers that Little Herman is in the hospital.     

Medicaid and the Mainstream: Reassessment in the Context of the Taxpayer Revolt

California''s Medicaid program—Medi-Cal—attempted to implement the ideal of mainstream medical care for the poor by giving program beneficiaries a “credit card” for use in the private health care marketplace. This exposed the program to the perverse economic incentives of the fee-for-service, costplus health care system, and contributed to a high rate of increase in program costs. Attempts to control costs have been equally perverse, resulting in low payment rates, the second-guessing of physician professional judgments, the probing of medical and fiscal records, and the use of computerized surveillance systems.Attempts to shift to the use of more efficient delivery systems have had small success. Attempts to attain cost containment through restructuring the Medi-Cal program have been rejected in the name of the mainstream ideal. Costs have continued to escalate, with annual increases as high as 20 percent in some years. Medi-Cal now costs $4 billion per year, the largest single program in California state government.The taxpayer revolt in California is creating a fiscal crisis that will force rethinking of the premises of publicly funded health care for the poor, and a restructuring of strategies for reaching that objective. In the short run, it appears that the issue may not be whether the indigent will have access to mainstream medical care, but whether they will have access to any medical care. In the longer run, the crisis should represent an opportunity for building a system of health care that can serve the financially disadvantaged at a cost tolerable to our society.     

Health Insurance Status as a Barrier to Ideal Cardiovascular Health for U.S. Adults: Data from the National Health and Nutrition Examination Survey (NHANES)

Background

Little is known about the association between cardiovascular (CV) health and health insurance status. We hypothesized that U.S. adults without health insurance coverage would have a lower likelihood of ideal cardiovascular health.

Methods and Results

Using National Health and Nutrition Examination Survey (NHANES) data from 2007–2010, we examined the relationship between health insurance status and ideal CV health in U.S. adults aged ≥19 years and <65 (N = 3304). Ideal CV health was defined by the American Heart Association (AHA) as the absence of clinically manifested CV disease and the simultaneous presence of 6–7 “ideal” CV health factors and behaviors. Logistic regression modeling was used to determine the relationship between health insurance status and the odds of ideal CV health. Of the U.S. adult population, 5.4% attained ideal CV health, and 23.5% were without health insurance coverage. Those without health insurance coverage were more likely to be young (p<0.0001), male (p<0.0001), non-white (p<0.0001), with less than a high school degree (p<0.0001), have a poverty-to-income ratio less than 1 (p<0.0001) and unemployed (p<0.0001) compared to those with coverage. Lack of health insurance coverage was associated with a lower likelihood of ideal CV health; however, this relationship was attenuated by socioeconomic status.

Conclusions

U.S. adults without health insurance coverage are less likely to have ideal CV health. Population-based strategies and interventions directed at the community-level may be one way to improve overall CV health and reach this at-risk group.     

THE MISTREATED CHILD

“The battered child” has recently attracted the attention of physicians and social workers, but despite the fact that inflicted trauma produces characteristic x-ray changes, physicians are often reluctant to admit this cause. The neglected child may be more difficult to diagnose and is probably more common. The most typical example is the infant who is admitted to the hospital for “failure to thrive,” yet gains weight rapidly while away from his parents.The parents of both types of children are likely to be immature and inadequate, but much more study is required before the factors common to these parents are known, to say nothing of the means required for prevention and treatment.When the physician suspects that the parent is causing the difficulties manifested by the child, he should seek the help of a social worker in clarifying the situation and in contacting the appropriate social or legal agency. A greater awareness of the problems of these children should result in more rapid recognition of the condition, the establishment of well-defined methods of handling such cases, and ultimately better legislation to safeguard the child''s rights to a safe and healthy childhood.     

Prevention should be the preferred insurance program for all physicians.

Recent fee increases announced to the Canadian Medical Protective Association (CMPA) and the Ontario government''s plan to stop its CMPA rebate program for the province''s physicians have put the spotlight on medical liability insurance. In this examination of the role played by the CMPA, Ottawa lawyer Karen Capen notes that quality service and attention to physician-patient communication will in most cases ensure a litigation-free professional life.     

Evidence-based policymaking when evidence is incomplete: The case of HIV programme integration

Jan Hontelez and co-authors discuss the use of different types of evidence to inform HIV program integration.

Summary points

• Sustainable Development Goal 3 aims to “ensure healthy lives and promote well-being for all at all ages” and has set a target of achieving global universal health coverage, representing a major policy shift away from mostly disease-specific “vertical programmes”.
• While health service integration can be a promising strategy to improve healthcare coverage, health outcomes, and efficiency, the exact impact of integration in different settings is hard to predict, and policy makers need to choose from a large variety of integration strategies and opportunities with varying levels of scientific evidence.
• Using the case of health service integration for HIV in low- and middle-income countries, we outline implementation strategies for integration opportunities with lacking or scarce high-level causal evidence, based on existing frameworks and methodologies from within and beyond healthcare and implementation science.
• Proper use of scientific evidence in other contexts requires adequate and systematic assessments of the transportability of an intervention. Several methods exist that allow for judging transferability and comprehensively identifying key context-specific indicators across studies that can affect the reported impact of interventions.
• When (transferable) evidence is absent, we propose that by drawing on well-established design and implementation methodologies—underpinned by ongoing learning and iterative improvement of local service delivery strategies—countries could substantially improve decision-making even in the absence of scientific evidence.
• Reaching the goal of making the HIV response an integral part of a larger, universal, people-centred health system that meets the needs and requirements of citizens can be facilitated by applying lessons learned from implementation science and novel design methodologies.

     

Hospital Bills—What Portion Is Paid by Insurance?—Report of Bureau of Research and Planning

A two-year survey result—ending some 18 months ago and just released—reveals that 68 per cent of all short-stay hospital discharges had hospitalization coverage. Insurance paid three-fourths or more of the bill for over 75 per cent of those covered.One-half of the discharges in the 65+ age group were covered. Almost 60 per cent of this group had three-fourths or more of the hospital bill paid by voluntary health insurance.The 65+ group with family income under $4,000 had better protection than age groups under age 45.The highest per cent of coverage was in the 45 to 64 age group where over 75 per cent of the discharges had coverage, with insurance paying more than three-fourths of the bill. This is the group which is likely to retain coverage upon retirement.     

Insurance coverage and incentives for weight loss among adults with metabolic syndrome

Objective: To describe how insured adults with metabolic syndrome respond to various options for insurance coverage and financial incentives for weight management. Methods and Procedures: Insured adults meeting the criteria for the metabolic syndrome were randomly identified through automated medical records and invited to participate in a telephone‐based survey of the acceptability of various weight management programs—with different financial incentives and insurance coverage options—in a health maintenance organization. Multivariable logistic regression models were used to test the relationship between participant characteristics and the odds of being motivated by incentives. Results: One hundred and fifty‐three adults with the metabolic syndrome completed the survey (i.e., 79% of telephone contacts). A hypothetical increase in insurance coverage from 10 to 100% led to a threefold increase among women and a sevenfold increase among men in the proportion reporting they were “very interested” in enrolling in a weight management program within the next 30 days. Most participants (76% of women and 57% of men) supported a health plan–sponsored financial incentive program tied to weight loss, and 41% believed such a program would motivate them to lose weight. The mean financial incentive proposed for a 15‐pound weight loss was $591 (median: $125). Discussion: Although weight loss is an effective treatment for metabolic syndrome, standard health insurance rarely covers intensive behavioral treatment. The results of this study suggest that providing full insurance coverage and financial incentives for weight management increases the interest in participating in obesity treatment programs. Further research should determine how full coverage and incentives affect participation rates, long‐term body weight changes, and costs.     

Commentary: Personal Renewal

After John Gardner''s presentation on “Self-Renewal” to THE WESTERN JOURNAL OF MEDICINE Editors'' Meeting, ^* Joseph Murphy, MD, Special Editor for Wyoming, asked the former Secretary of Health, Education, and Welfare, “Where are you in your life''s cycle?” Dr Gardner, who is 80 years old, answered, “When Chief Justice Oliver Wendell Holmes, Jr, was in his 90s, he was asked a similar question and said, `I''m like a race horse cantering along after the race is over, cooling down.'' Well, I''m nowhere near cantering! I''m still in the race, pushing the world.” race, pushing the world.”John Gardner, who received his undergraduate degree from Stanford and PhD from the University of California, Berkeley, taught at the college level for several years before he joined the Carnegie Foundation. As president of Carnegie Corporation and Carnegie Foundation for the Advancement of Teaching, he began to “push the world” toward education and in 1964 received the country''s highest civilian honor, the Presidential Medal of Freedom. He has also pushed it toward political reform by founding Common Cause, toward grass-roots political action by founding the Urban Coalition, toward leadership training by founding the White House Fellows program, and toward volunteerism by founding the Independent Sector (a coalition of for-profit and not-for-profit organizations and foundations). His books, including Excellence, Self-Renewal, No Easy Victories, and On Leadership, have pushed readers to new understanding of themselves and of organizations to higher levels of creativity and energy to get important work done. His current research focuses on discovering and defining the characteristics of healthy, vital communities. His call to “keep on keeping on,” indeed, to push the world, leads to constructive change. Active people become effective people, infused with the energy and optimism that good hard work inspires. I think you will find this paper as invigorating to read as it was to hear.     

Dan Salah Tawfik (1955‐2021)—A giant of protein evolution

It was with great sorrow that we have learned of the untimely death of our friend, mentor, collaborator, and hero, Dan Tawfik. Danny was a true legend in the field of protein function and evolution. He had an incredibly creative mind and a breadth of knowledge—his interests spanned chemistry and engineering to genetics and evolution—that allowed him to see connections that the rest of us could not. More importantly, he made solving biochemical mysteries fun: He was passionate about his work, and his face lit up with joy whenever he talked about scientific topics that excited him (of which there were a lot). Conversations with Danny made us all smarter by osmosis.Danny’s own evolution in science began with physical organic chemistry and biochemistry. His PhD at the Weizmann Institute of Science, awarded in 1995, was on catalytic antibodies under the supervision of Zelig Eshhar and Michael Sela. It was followed by a highly productive period at the University of Cambridge’s Centre for Protein Engineering, first as a postdoctoral fellow with Alan Fersht and Tony Kirby, and then as a senior researcher. Among his many achievements during his time in Cambridge was the demonstration that off‐the‐shelf proteins—the serum albumins—could rival the best catalytic antibodies in accelerating the Kemp elimination reaction due to non‐specific medium effects. This work was an early example of unexpected catalytic promiscuity, and it sowed the seed for Danny’s later fascination with “esoteric, niche enzymology” that went far beyond convenient model systems.It was also in Cambridge where Danny first realized the power of the then new field of directed evolution, both for biotechnology and for elucidating evolutionary processes. He and Andrew Griffiths pioneered emulsion‐based in vitro compartmentalization. The idea of controlling biochemical reactions in separate aqueous droplets inspired emulsion PCR and next‐generation sequencing technologies, whereas Danny used it to solve a long‐standing problem in directed evolution; in vitro selection techniques had always been good at identifying ligand‐binding proteins, but compartmentalization finally enabled the directed evolution of ultra‐fast catalysts.Danny returned to Israel in 2001 to join the faculty of the Weizmann Institute of Science where his scientific trajectory further evolved, diverged, and even “drifted”. He developed new methods for enzyme engineering and applied his evolutionary insights into de novo protein design efforts. In this context, Danny’s interest was always focused on how proteins evolve, particularly the connection between promiscuity, conformational diversity, and evolvability. His depth of understanding underpinned both applied research, such as engineering enzymes to detoxify nerve agents, and fundamental research, such as the evolution of enzymes from non‐catalytic scaffolds.Through it all, Danny retained his sense of joy and wonder at the “beautiful aspects of Nature’s chemistry”. This includes his discovery of an exquisite molecular specificity mechanism mediated by a single, short H‐bond that enables microbes to scavenge phosphate in arsenate‐rich environments. In recent years, he deciphered the biosynthetic mechanism of dimethyl sulfide, “the smell of the sea”, and homed in on the interplay between the evolution of an enzyme, its host organism, and environmental complexity. His insights into how the first proteins emerged caused tremendous excitement in the field. He established the roots of two common enzyme lineages, the Rossmann and P‐loop NTPases, as simple polypeptides, and suggested ornithine as the first cationic amino acid. Prior to his death, he published the results of another tour de force: evidence that the first organisms to utilize oxygen may have appeared much earlier than thought.His work impacted many research fields, and he won many significant awards. Most recently, Danny was awarded the EMET Prize for Art, Science and Culture (2020), informally dubbed “Israel’s Nobel Prize”. He was an active and valued member of the EMBO community, having been elected in 2009, and, until his passing, served on the Editorial Advisory Board of EMBO Reports.Danny was also a superb science communicator. Both his research articles and reviews are a joy to read. What stood out just as much as his brilliance was his personality, as he embodied the Yiddish concept of being a true “mensch”. Danny was humble, was down‐to‐earth, and treated all his colleagues—including the most junior members of our research teams—as equals. He championed the careers of others, both those who worked directly for him and those who were lucky enough to be “just” his friends and collaborators. He believed in us even when we did not believe in ourselves, and he was always there to answer questions both scientific and professional. While he loved to share his own ideas, he would be just as excited about ours. Despite his own busy schedule, he always found the time to help others. He was also excellent company, with a great, very dry, sense of humor, and endless interesting stories, including from his own colorful life. In the days after his untimely death, an often‐repeated phrase was “he was my best friend”. Danny’s former group members have gone on to be highly successful in both industry and academia, including more than 15 former doctoral and postdoctoral researchers who are now faculty. The network of researchers Danny has trained, mentored, or influenced is broad, and this legacy is testament to his qualities as both a scientist and a person.Danny was born in Jerusalem to an Iraqi Jewish family, and his Arabic Jewish identity was important to him. He believed strongly in coexistence and peace, and very much valued the Arabic part of his heritage. In his own words: “I am an Israeli, a Jew, an Arab, but first and foremost a human being”. He would often speak of the achievements of his children with immense pride. Danny also had a passion for being outdoors, especially climbing and hiking—when the best discussions were often to be had (Fig ​(Fig1).1). One of the easiest ways to persuade him to come for a seminar, a collaborative visit, or a conference was to have access to high‐quality climbing in the area. He passed away in a tragic rock‐climbing accident, doing what he loved most outside of science. Our thoughts are with his partner Ita and his children, and we join the much broader community of friends, collaborators, and colleagues whose hearts are broken by his sudden loss.Open in a separate windowFigure 1Dan Salah Tawfik (1955–2021)Photo courtesy of Prof. Joel Mackay, The University of Sydney.     

BEYOND THE SURGEON'S SKILL

The scientific attainments of medical science have advanced greatly in this generation. The art of the practice of medicine has not kept pace. The kindly spirit, unselfish service, and spiritual uplift which were characteristic of most physicians in the “horse-and-buggy days” are needed more today than they were a generation ago. A combination of medical science and spiritual counseling will do much to relieve the sufferings of mind and body. The personal physician-patient relationship and the building up of the patient''s confidence in his physician are a most important aspect of the physician''s duty. A belief in God and a knowledge of the availability of help from above is of great benefit to both physician and patient.     

An Analysis of Costs and Health Co-Benefits for a U.S. Power Plant Carbon Standard

Reducing carbon dioxide (CO₂) emissions from power plants can have important “co-benefits” for public health by reducing emissions of air pollutants. Here, we examine the costs and health co-benefits, in monetary terms, for a policy that resembles the U.S. Environmental Protection Agency’s Clean Power Plan. We then examine the spatial distribution of the co-benefits and costs, and the implications of a range of cost assumptions in the implementation year of 2020. Nationwide, the total health co-benefits were $29 billion 2010 USD (95% CI: $2.3 to $68 billion), and net co-benefits under our central cost case were $12 billion (95% CI: -$15 billion to $51 billion). Net co-benefits for this case in the implementation year were positive in 10 of the 14 regions studied. The results for our central case suggest that all but one region should experience positive net benefits within 5 years after implementation.     

MEDICO-LEGAL ASPECTS OF TRAUMATIC EPILEPSY

The medico-legal problems of cranial injuries require a broad assessment of many factors, not always related to the nervous system, and a nicety of judgment in correctly evaluating the role of each factor in relation to all of them.Seizures in the period immediately after trauma are not necessarily precursors of later development of epileptic attacks. If such seizures do occur, it can be said in general, from statistical data, that the sooner they occur after injury the less the likelihood of disabling attacks later. It would seem a reasonable medical probability that if a patient has no neurological symptoms or deficit, has a normal electroencephalogram and has gone two years after injury without evidence of seizures, he will not have epilepsy.Putting a label of “post-traumatic epilepsy” on a patient, unless he is known to have had authentic seizures, may stigmatize him without warrant and lead to unjust settlement of litigation or to unreasonable compensation awards. In doubtful cases, perhaps an equitable solution of compensation for damage would be to award an insurance policy providing suitable payments if disabling seizures should develop later as a sequel of cranial injury.     

Multi-Sample Pooling and Illumina Genome Analyzer Sequencing Methods to Determine Gene Sequence Variation for Database Development

Determination of sequence variation within a genetic locus to develop clinically relevant databases is critical for molecular assay design and clinical test interpretation, so multisample pooling for Illumina genome analyzer (GA) sequencing was investigated using the RET proto-oncogene as a model. Samples were Sanger-sequenced for RET exons 10, 11, and 13–16. Ten samples with 13 known unique variants (“singleton variants” within the pool) and seven common changes were amplified and then equimolar-pooled before sequencing on a single flow cell lane, generating 36 base reads. For comparison, a single “control” sample was run in a different lane. After alignment, a 24-base quality score-screening threshold and 3` read end trimming of three bases yielded low background error rates with a 27% decrease in aligned read coverage. Sequencing data were evaluated using an established variant detection method (percent variant reads), by the presented subtractive correction method, and with SNPSeeker software. In total, 41 variants (of which 23 were singleton variants) were detected in the 10 pool data, which included all Sanger-identified variants. The 23 singleton variants were detected near the expected 5% allele frequency (average 5.17%±0.90% variant reads), well above the highest background error (1.25%). Based on background error rates, read coverage, simulated 30, 40, and 50 sample pool data, expected singleton allele frequencies within pools, and variant detection methods; ≥30 samples (which demonstrated a minimum 1% variant reads for singletons) could be pooled to reliably detect singleton variants by GA sequencing.     

Genetic Counseling—A Health Department Service to Physicians

Questions about inheritance in all kinds of diseases and defects are commonly asked of nearly all physicians. In attempting to answer these questions, however, the physician is often hampered by lack of formal instruction in clinical genetics.Since the health department, if it is to carry out its epidemiologic function, must be as concerned over the increasing identification of genetic agents in disease as it is and has been over environmental disease agents, it should come to represent a source of assistance not now generally available to the physician. In short, as it carries out those activities by which its store of general genetic information is increased, and until other sources of genetic consultation become reasonably available, the health department can be of real service to physicians as a resource to which they may turn for help when dealing with families wanting genetic information.Such a service has been provided experimentally for the last two years by the Contra Costa County Health Department.This program calls for the taking of family pedigrees by public health nurses on families with questions of a genetic nature who are health department clients and on families who are referred by their private physicians for this service. An interpretation of each pedigree is made by the department''s physician in charge of the program and submitted to the family''s physician for his use in counseling the family. Evidence to date suggests the process can be a highly useful service to the practitioner and his patient.