PERIODIC MEDICAL EXAMINATIONS—Disease Detection and Health Promotion

The medical examination of persons who have no medical complaints is a procedure that has different purposes than the traditional diagnostic examination. These include not only the detection of incipient disease but the evaluation of the adjustment of the individual to his environment and an assessment of his personal hygiene. It should be concluded by a discussion of what has been found, and by positive, persuasive advice and education which will lead to better health.Interest in such work and competence for it are not found in every physician. Physicians who do not want to acquire such competences should recognize the fact and refer such work to others who are prepared to cope with it. Inept, incomplete health examinations disappoint the patient and make the physician uncomfortable; thorough, constructive examination and counseling is satisfying and profitable to both.     

Medical Care of the Alcoholic Patient

Alcoholism is an illness that constitutes a major health problem at all levels of society. The physician should accept his responsibility to prevent it and to care for the alcoholic. If he knows that one of his patients is drinking immoderately, he should warn him of the outlook. A patient''s acquired dependence on alcohol may be overt, or revealed only on examination for organic disease or emotional disturbance. The diagnosis may be accepted reluctantly, or denied despite positive evidence, but the patient should be persuaded to give up drinking. He may require psychiatric help or advice from a social worker. He may be so ill as to require treatment in hospital, and hospitals must recognize the urgency of such admissions. Discharge from hospital does not end treatment, for alcoholism is a chronic disease, requiring long-term planning, persistent follow-up and enduring sympathy by the physician, who must always be as available to his alcoholic patient as he is to his patient with diabetes, epilepsy or cardiac disease.     

The Educationally Handicapped Child—The Physician's Place in a Program to Overcome Learning Disability

Under California Assembly Bill 464, special classes may be provided by school districts for children designated as educationally handicapped. An educationally handicapped child is not mentally retarded or physically disabled. He may have neurological handicap or emotional disorder, but he must show impaired achievement in relation to his tested abilities.A physician may be asked to participate in the program, either as a specified member of the admissions committee of the school district or to provide a medical clearance for entrance of one of his own patients into the program.He does a thorough history and physical examination but adds special examination of attention, activity, coordination and attitudes.The educationally handicapped child is helped most by the physician who does not reject the idea of educational handicap even if the medical examination is negative; who treats his minor ills; who medicates, when it is indicated, for hyperactivity, distractibility or extreme anxiety; who cooperates with parents and school personnel.     

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.     

The clinical psychologist; his role in private medical practice

The independent diagnosis and treatment of mental and nervous disorders according to California law constitutes practicing medicine. By this yardstick, an increasing number of clinical psychologists are entering the private practice of medicine. The medical profession has not provided through its leadership the opportunity for clinical psychologists to utilize their skills in a legitimate and supervised way in the treatment of private patients, nor has the medical profession taken sufficient interest in modern methods of treating patients with psychogenic disorders. If the psychiatric team is a feasible and practical approach to spreading the base of psychiatric treatment in hospitals and clinics, it should be applicable to private practice settings too. In the team setting, the psychologist can render great assistance to the physician in the diagnosis and treatment of patients with psychogenic disorders without compromising the principle that the primary responsibility for the patient is the physician's. By virtue of his training and experience, it is the psychiatrist who is best qualified to supervise the work of the psychologist; and until such time as the medical profession is better acquainted with psychotherapeutic techniques, the employment of psychologist assistants should be (according to good medical practice) left to the psychiatrist. The need for some regulation of the use of the title "psychologist" is increasing in order to protect the public from quacks who pose as psychologists. However, any law which is directed toward elimination of the quack should specifically define psychotherapy and contain provisions for its use under adequate medical supervision. The medical profession is obligated to take its traditional role in providing the best possible treatment for patients who are in need of it, and psychotherapy is an inherent part of treatment.     

The role of routine serum testosterone testing: routine hormone analysis is not indicated as an initial screening test in the evaluation of erectile dysfunction

A 60-year-old male physician is self-referred to your office for evaluation of his erectile dysfunction, which has been worsening for 5 years. He reports his erections rarely achieve fullness for penetration, and he is unable to ejaculate. He has tried sildenafil citrate (Viagra(R); Pfizer Inc, New York, NY) with mild success in the past. He has a strong libido and feels healthy. He rarely exercises, but is on his feet most of the day at work. He has been healthy his whole life and never seeks a doctor's attention. He has no other medical problems. His only medication is a baby aspirin once a day. His physical examination, including genitalia, is normal. As part of his initial visit, should his serum testosterone level be checked by his urologist?     

Disability under social security; medical evaluation and decision as to rehabilitation

Recent amendments to the Social Security Act give privileges to persons who are found to be disabled. In California, the State Bureau of Vocational Rehabilitation has responsibility for determining whether or not an applicant is disabled within the meaning of the Act. Each applicant must submit medical evidence provided by his own physician or by a hospital. The evidence is reviewed by both a physician and a counselor, who determine not only whether disability exists but also whether rehabilitation services might be helpful. In the first 9,000 cases in which determinations were made, 49 per cent of applicants were found to be disabled and 51 per cent not; but in recent months the proportion found disabled has increased. Diseases of the circulatory system and nervous system, including late effects of cerebrovascular accidents, were the largest groups of conditions causing disability. Psychoneurotic conditions and orthopedic and respiratory disorders were next in order. Some 10 to 15 per cent of applicants were referred for rehabilitation services, but of these only about one in six is accepted for rehabilitation, and only half of those accepted actually receive the services. Thus, it appears that only one per cent of workers applying for disability benefits are getting the services made available through state and federal sources to restore them to productive employment. Physicians need to be alert to opportunities provided in programs such as these to utilize all facilities to round out the full cycle of medical care.     

DISABILITY UNDER SOCIAL SECURITY—Medical Evaluation and Decision as to Rehabilitation

Recent amendments to the Social Security Act give privileges to persons who are found to be disabled. In California, the State Bureau of Vocational Rehabilitation has responsibility for determining whether or not an applicant is disabled within the meaning of the Act. Each applicant must submit medical evidence provided by his own physician or by a hospital. The evidence is reviewed by both a physician and a counselor, who determine not only whether disability exists but also whether rehabilitation services might be helpful.In the first 9,000 cases in which determinations were made, 49 per cent of applicants were found to be disabled and 51 per cent not; but in recent months the proportion found disabled has increased. Diseases of the circulatory system and nervous system, including late effects of cerebrovascular accidents, were the largest groups of conditions causing disability. Psychoneurotic conditions and orthopedic and respiratory disorders were next in order.Some 10 to 15 per cent of applicants were referred for rehabilitation services, but of these only about one in six is accepted for rehabilitation, and only half of those accepted actually receive the services. Thus, it appears that only one per cent of workers applying for disability benefits are getting the services made available through state and federal sources to restore them to productive employment. Physicians need to be alert to opportunities provided in programs such as these to utilize all facilities to round out the full cycle of medical care.     

DOES PROFESSIONAL AUTONOMY PROTECT MEDICAL FUTILITY JUDGMENTS?

Despite substantial controversy, the use of futility judgments in medicine is quite common, and has been backed by the implementation of hospital policies and professional guidelines on medical futility. The controversy arises when health care professionals (HCPs) consider a treatment futile which patients or families believe to be worthwhile: should HCPs be free to refuse treatments in such a case, or be required to provide them? Most physicians seem convinced that professional autonomy protects them from being forced to provide treatments they judge medically futile, given the lack of patient benefit as well as the waste of medical resources involved. The argument from professional autonomy has been presented in a number of articles, but it has not been subjected to much critical scrutiny. In this paper I distinguish three versions of the argument: 1) that each physician should be free to exercise his or her own medical judgment; 2) that the medical profession as a whole may provide futility standards to govern the practice of its members; and 3) that the moral integrity of each physician serves as a limit to treatment demands. I maintain that none of these versions succeeds in overcoming the standard objection that futility determinations involve value judgments best left to the patients, their designated surrogates, or their families. Nor do resource considerations change this fact, since they should not influence the properly patient‐centered judgment about futility.     

Analysis of Your Professional Liability Insurance Policy

The most important lessons for the physician to learn in regard to his professional liability insurance coverage are the following:1. The physician should carefully read his professional liability policy and should secure the educated aid of his attorney and his insurance broker, if they are conversant with this field.2. He should particularly read the definition of coverage and carefully survey the exclusion clauses which may deny him coverage under certain circumstances.3. If the physician is in partnership or in a group, he should be certain that he has contingent partnership coverage.4. The physician should accept coverage only from an insurance carrier of sufficient size and stability that he can be sure his coverage will be guaranteed for “latent liability” claims as the years go along—certainly for his lifetime.5. The insurance carrier offering the professional liability policy should be prepared to offer coverages up to at least $100,000/$300,000.6. The physician should be assured that the insurance carrier has claims-handling personnel and legal counsel who are experienced and expert in the professional liability field and who are locally available for service.7. The physician is best protected by a local or state group program, next best by a national group program, and last, by individual coverage.8. The physician should look with suspicion on a cancellation clause in which his policy may be summarily cancelled on brief notice.9. The physician should not buy professional liability insurance on the basis of price alone; adequacy of coverage and service and a good insurance company for his protection should be the deciding factors.     

Housing,health, and illness.

Cases referred to a community physician in his role as medical adviser to a housing authority were reviewed. A new system of classifying health problems was devised because conventional diagnostic classification was found to be inappropriate. The effectiveness of medical intervention was apparently low, since only 29 out of 612 (4.7%) applications for rehousing on medical grounds were successful. The effectiveness of the community physician''s role was limited by the available resources and the number of cases he could take before the housing committee. It is proposed that the use of medical resources for intervention in such cases is acceptably efficient, though this proposal is based on value judgement rather than on economic grounds. Doctors should be concerned in improving housing conditions, which are still unacceptably poor in many parts of Britain, in the interests of improving general standards of public health.     

Acutely Suicidal Patients—Management in General Medical Practice

Suicidal crises are best understood as late stages in the progressive breakdown of adaptational behavior in emotionally exhausted patients. The premonitory symptoms of suicide include verbal communications, suicide attempts, symptomatic actions, depression, treatment failure, excessive emotional reactions to specific disease states and panic reactions.Of persons who committed suicide, 75 per cent had seen a physician within six months. To recognize and evaluate suicide danger the physician must not be afraid to question the patient directly about his suicidal plans. The average physician encounters half a dozen suicidal patients a year and will have 10 to 12 suicides in his practice during a long career.In treating suicidal patients, the physician should maintain his medical attitude. The patients need emergency medical care including appropriate drugs. Free communication between patient and physician is very important. This may take some extra time. Patients benefit from emergency psychological support and stimulation toward constructive action. Family, friends, and community agencies should be mobilized to aid the patient. For seriously suicidal patients, consultation is recommended and treatment in hospital is advisable.     

Waiting list already 7 months long at Toronto's new Environmental Health Clinic

Following the head set by Nova Scotia, Ontario now has a clinic devoted to the treatment of patients with "environmental illness." It opened in Toronto last year, and patients must be referred by their family physician and complete a 16-page previsit questionnaire. They receive a 3-hour assessment in which their medical history is explored, plus a full physical examination and blood and urine tests. Dr. Frank Foley, who heads the Toronto clinic, says his patients have seen from 8 to 10 health care professionals in the 2 years before their visit and most have been told the problem is "in your head." He says they need to "have their symptoms validated and their distress acknowledged."     

Informed Consent in California: Latent Liability Without `Negligence'

Informed consent is a legal obligation due from a physician to his patient, an obligation which may not be met by the physician''s skillful treatment of his patient. It may only be met by the treating physician obtaining from his patient knowing authorization for carrying out the intended medical procedure. The physician is required to disclose whatever would be material to his patient''s decision, including the nature and purpose of the procedure, and the risks and alternatives. The disclosures should be made by the physician to his patient, and not through use of consent forms which are not particular to individual patients. To minimize any subsequent claim by the patient that there was a lack of adequate disclosures, the physician should record in the patient''s chart the circumstances of the patient''s consent, and should not rely on the patient''s unreliable ability to recall those circumstances.     

Poetry, physiology, and puerperal fever: understanding the young Oliver Wendell Holmes

The 19th-century American physician Oliver Wendell Holmes (1809-1894) is known, internationally, more for his literary output than for his contributions to medical science. Yet a single paper he wrote in 1843--"The Contagiousness of Puerperal Fever"--has made him a hero in the eyes of many (especially in the United States) of the struggle against that scourge. Why that one article, written when Holmes was still in his thirties, should--even in its expanded 1855 version--so routinely be referred to as a "classic of medical literature", and why its author should have been raised on such a high pedestal that some grant him a position beside Ignác Semmelweis, are complicated questions. This present paper is an attempt to begin assessing what it is that makes someone a medical hero by looking at three different aspects of Holmes's early career. He was even as a young man a poet and a physiologist/anatomist as well as the author of this important essay. Whether and how those three features of Holmes's many-sides public persona are connected is discussed as a prelude to considering whether his work on puerperal fever legitimates his status as a medical hero.     

Privileged Communications—The Effect of California's New Evidence Code As It Concerns Physicians and Psychotherapists

A physician has an ethical duty to hold in confidence communications made to him by his patient. A legal recognition of this ethical duty is found in the concept of privilege, which is the subject of this article. January 1967 will bring to California physicians a new protection for patients'' communications. The physician-patient privilege has been redefined to include confidential communications made during diagnostic evaluation, those made to non-licensed physicians, interns and medical aides, and those overheard by eavesdroppers. There has been added a psychotherapist-patient privilege designed to facilitate communications required in psychotherapy as well as in behavioral research.This paper first presents a brief historical background and discusses the protections and limitations afforded by the new California Evidence Code. There follows a section on the psychotherapist-patient privilege with the recommendation that in the context of psychotherapy, patients of physicians who are not psychiatrists should be afforded the additional benefits of the psychotherapist-patient privilege. Lastly, advice is given concerning the physician''s conduct in relation to his duty to claim privilege under the new code.     

The Anxious Patient

Anxiety appears in many disguises and mimics most other afflictions. Once the anxious patient has been recognized as such and a proper diagnosis is made, management of him is easily carried out within the framework of the medical transaction. Lack of awareness of underlying anxiety in a patient who presents with somatic complaints can lead to poor results for the patient and frustration for the physician. It is not the physician''s role to remove all anxiety. Rather, it is his mission to manage the anxious patient so as to mediate the anxiety allowing for integrated adaptive function.     

Attainment of Optimum Health

The history of the worker in public health is reviewed, his present activities are assessed, and predictions are made concerning his future role. It is emphasized that the public health specialist is but one member of the total health team in the community. His interdependence with other disciplines must be accepted if optimal health care is to be provided.Although prepared specifically for public health workers, this article has direct relevance to the future of the medical profession as a whole. In view of the present intense interest in the future pattern of health care in Canada, the viewpoint of a physician with a dual background in public health and medical school administration and teaching is considered to be particularly pertinent.     

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A 65-year-old man undergoes a routine checkup before retiring. His wife has urged him to have his prostate examined, because she has read about testing for prostate cancer and a friend has just died of this disease. During the rectal examination, the man''s physician discovers some firmness in the right lobe of the prostate gland. The patient has had no urinary symptoms and is in excellent general health. Sexual function is normal. There is no history of prostate cancer; his father died of a stroke at age 86 years. Testing shows that the patient''s prostate-specific antigen level is 9.3 ng/mL, and he is referred to a urologist. Transrectal ultrasound-guided needle biopsy reveals adenocarcinoma with a Gleason score of 7 (intermediate grade). At a follow-up meeting with his physician, the patient says, "I have been doing some research, and it appears that I should have treatment. However, what is less clear to me is what form of therapy is best--surgery or radiation treatment. Please tell me what you can about the state of the art with respect to surgery."     

Psychiatric Programs: Their Medical Integration

The basic premise that psychiatry and medicine are one and the same discipline is advanced. Patients present with symptoms: sometimes largely the result of structural change, sometimes largely the result of emotional perturbation, but most frequently a mixture of both. The physician can never do his job satisfactorily without attention to the emotional problems of his patient, which is essentially the subject matter of psychiatry. He must have adequate training during his medical school years in order to recognize and handle emotional problems. The psychiatrically oriented general practitioner and the psychiatrist, who live in the community, are most valuable mental health resources and must have treatment facilities in the general hospital. Furthermore, hospital and medical insurance plans must be devised that will not penalize either doctor or patient when mental illness is recognized and dealt with in the most appropriate manner.