WORKMEN'S COMPENSATION ACT—Some Aspects of Interest to California Physicians

This article was prepared by Mr. William M. Whelan, Director of Special Services, California Medical Association, under the supervision of Dr. Francis J. Cox, Chairman of the Medical Services Commission of the Association, and Mr. Howard Hassard, the Association''s Legal Counsel. It is intended as a brief synopsis of the California Workmen''s Compensation Law as it applies to the physician in private practice. It is not an exhaustive treatment of the subject. A physician who desires to acquaint himself in detail with California industrial practice should consult the article entitled “The Physician''s Role in Workmen''s Compensation,” California Medicine, 82:352-362, April, 1955. Inquiries regarding industrial medicine should be addressed to Mr. William M. Whelan, California Medical Association, 450 Sutter St., San Francisco 8.     

The Physician and Workmen's Compensation—A New Paramedic to Help with Compensation Cases

The first social, no-fault, insurance legislation in California was the Workmen''s Compensation Act of 1911. It has been changed and modified in the years since, and is having an increasing impact on the practice of most California physicians. Many physicians consider caring for the occupationally ill or injured time-consuming and difficult. A newly emerging kind of paramedic, the workmen''s compensation benefit administrator, is available to assist the physician in overcoming difficulties encountered. A cooperative effort between the physician and the benefit administrator will expedite management of industrial patients.     

WHAT PSYCHIATRISTS THINK ABOUT ALCOHOLISM

The one approach most favored for alcoholism by psychiatrists in Southern California who answered a questionnaire is membership in Alcoholics Anonymous. Ninety-nine per cent of them approved Alcoholics Anonymous, and 80 per cent had referred patients to the organization. Yet they believed only 10 per cent of the persons who join A.A. remain sober for over two years. This against the claim of A.A. that 60 per cent or more of their fellowship are recovered emphasized the pessimism of the psychiatrists questioned.Ninety per cent of the psychiatrists who replied said they do not treat alcoholics or that they limit the number or the type they will accept for treatment. They obtain recovery, they said, of 10 per cent of patients, improvement of 50 per cent, and the rest are unchanged.The emphasis in psychiatry is on elimination of the anxieties leading to alcoholism; in Alcoholics Anonymous the emphasis is on the strength to bear these anxieties. Ninety per cent of the replies received were in favor of clinics for alcoholics, and the respondents felt that governmental agencies should support these clinics. Under such circumstances psychiatrists would combine their abilities with psychologists, social workers and Alcoholics Anonymous. Thirty-five per cent of psychiatrists said they are willing to work in a clinic, the majority without recompense.     

Occupational cancer: experience in Ontario.

This paper reviews the experience of the Workmen''s Compensation Board of Ontario in identifying cases of cancer that could be attributed to occupational hazards. Worker''s claims for compensation are allowed if there is reasonable medical evidence that their cancer was caused by exposure to risk factors associated with their occupation. Details of the types of cancer associated with specific carcinogens or fields of employment are discussed. About 50% of the cases were related to exposure in particular industrial operations that functioned for relatively brief periods. The number of deaths from cancer identified as being caused by occupational factors is compared with the total for cancer from all causes in Ontario during the period 1971 through 1975. Although all workers eligible for compensation may not have been identified, the data suggest that less than 1% of cancer is presently caused by occupational factors.     

Informed Consent — A Reappraisal of Patients' Reactions

In response to the November 1972 ruling of the California Supreme Court requiring complete, detailed disclosure of risks for procedures and treatments, a survey was made of the reactions of one hundred patients to this decision. A fictional man was described with a clinical diagnosis of brain tumor, and then the procedure for cerebral angiography and all of that procedure''s potential complications were described. The majority of the patients surveyed responded that this complete disclosure of risks helped them in making an intelligent decision about giving consent for the procedure. However, 50 percent of these patients would have withheld consent for the procedure on learning of the complications. Although physicians would have reacted differently, it is certainly the patients'' right to make the choices they did.     

Survey of general practitioners' attitudes to management of patients with heart attacks.

Out of 305 general practitioners sent a questionnaire asking how they would treat three hypothetical patients with heart attacks 231 (76%) replied. Of these, only 179 were prepared to make an unqualified choice of home or hospital treatment for a middle-aged man with an uncomplicated attack, 70 (39%) saying that they would keep the patient at home. Practitioners qualifying before 1960 were more likely to do this than those qualifying in 1960 or later. If a patient declined hospital treatment 161 (70%) of the practitioners would keep him in bed for a week or less, but the date of the practitioners'' qualification significantly affected the time they would advise him to remain off work. Faced with a patient acutely ill after a heart attack, 162 (70%) of the practitioners would arrange his immediate admission to hospital and 51 (22%) would send him to hospital after initial treatment at home. The numbers of partners in the practice, the nature of the premises, and the location of the practice in urban or rural areas affected the practitioners'' attitude to the management of severely ill patients but not to the management of patients with uncomplicated attacks.     

Opinions of general practitioners in Nottinghamshire about provision of intrapartum care.

OBJECTIVE--To examine the beliefs of general practitioners concerning intrapartum care. DESIGN--Postal questionnaire survey. SUBJECTS--All general practitioners with patients in Nottinghamshire Family Health Services Authority in September 1993. MAIN OUTCOME MEASURES--General practitioners'' current involvement in maternity care, and beliefs on intrapartum care. RESULTS--Of 694 general practitioners sent questionnaires, 550 (79.2%) replied. 529 of these were on the obstetric list; 437 had not attended a delivery in the past 12 months; 36 had attended two or more; 358 general practitioners did not wish to provide more intrapartum care; 349 did not feel competent to do so. Reasons for not wanting to provide intrapartum care included current workload (453), disruption to personal life (407), and the fear of litigation (377). General practitioners who already booked women for home delivery were more likely to wish to do more deliveries (62/42 v 61/316, chi 2 = 85.3; P < 0.0001) and to have more positive attitudes towards increasing women''s choice in maternity care (90/22 v 195/151, chi 2 = 227; P < 0.0001). CONCLUSIONS--The involvement of general practitioners in intrapartum care in Nottinghamshire is low, and most general practitioners are unwilling to increase their role. However, general practitioners who already book for home delivery are keen to do more.     

Community care service for diabetics in the Poole area.

Because of an increasing work load at the hospital diabetic clinic in Poole general practitioners were asked to help in a community care service for diabetics. In this, general practitioners typically care for non-ketotic patients with maturity onset diabetes who are well controlled on diet or diet and oral hypoglycaemic agents, while the clinic concentrates on more difficult cases and screens patients for long-term complications. The hospital laboratory''s work load has been eased because patients may attend for two-hour interval blood sugar estimations when they like; most patients appreciate this flexibility and prefer being looked after by their own doctor. The service has not increased the general practitioners'' work load unduly, but it has heightened their awareness of diabetes in the community, thus allowing the diabetic consultant to deal with the problems for which he has been trained. The service has thus provided improved care for all diabetics in the Poole area.     

Nurse Practitioner and Physician's Assistant Clinics in Rural California: Part II: A Survey

Twenty-six rural California clinics have employed nurse practitioners (NP''s) or physician''s assistants (PA''s) to meet the primary health care needs of local communities. Of the 24 NP''s and 5 PA''s involved, 11 were men and 18 were women. Their average age was 37, and all but five were trained in California. The clinics, with less than 50 percent on-site physician supervision, averaged 19 miles in distance from the nearest physician (ranging up to 63 miles). More than half the clinics were satellites of central, physician-staffed, nonprofit clinics, a third were community-administered and two were private. Half served a whole community, a quarter were established to serve Indians and a quarter to serve Chicanos. Each NP or PA saw an average of 13 patients a day. All nonprivate clinics received subsidies from a variety of local, state and federal funds. Four of the clinics had closed or had no medical staff at the time of our survey.NP/PA clinics are proving to be a feasible and valuable means of offering essential health care needs to remote communities.     

HIV testing in patients with end stage renal disease.

One hundred and twenty eight British and Irish nephrologists were questioned about their policy for HIV testing of patients with end stage renal failure being considered for renal replacement therapy. A total of 101 (79%) replied. In the case of candidates for dialysis roughly one third of respondents tested only people they considered at risk of infection with HIV and nearly one fifth considered testing unnecessary. In the case of candidates for transplantation routine HIV testing was carried out by 68 of 100 nephrologists; 22 tested only patients "at risk" and 10 did not test. A positive HIV test result was considered by most but not all respondents (63/86) to exclude patients from transplantation. Twenty four of 88 nephrologists considered that HIV positivity should exclude patients from haemodialysis, but only seven of 87 would exclude such patients from peritoneal dialysis. Similar attitudes pertained for patients with end stage renal failure who refused HIV testing. Testing with the patient''s knowledge and consent was the policy of two thirds of nephrologists, but a patient''s signature was obtained by only 24 of 88. There should be a consensus on practice for HIV testing of patients with end stage renal failure.     

The Physician Fee Index and Other Economic Indicators—Recent Changes and Outlook

Figures compiled by the Bureau of Research and Planning show that the California Physician Fee Index increased 3.0 percent in the last six months of 1969, compared with 2.5 percent in the first six months. Nationally, physicians'' fees increased at a slightly slower rate—2.9 percent during the last half of the year, according to the U. S. Bureau of Labor Statistics. This was the first time since 1965 that physicians'' fees increased faster in California than nationally. In the seven and a half years since the California Physician Fee Index was started, fees have shown an increase of 36.3 percent in the state and 42.9 percent for the whole country.The “all items” component of the Consumer Price Index published by the Bureau of Labor Statistics increased 6.1 percent in 1969, while the medical care component increased 6.0 percent. This, too marks the end of a trend which had showed more rapid increases in medical care costs than in the cost of all goods and services.     

Glasgow Women Medical Students: Some Facts and Figures

A questionaire was sent to 343 women medical undergraduates at the University of Glasgow, and 317 replied. Of the respondents, 36% had a member of their family in medicine and 15% had either one or both parents a doctor: 45% had a working mother. Half of all the students had doubts about medicine as a career, and the proportion of these rose with seniority. Doubts were mainly due to the length of the medical course but the girls also recognized the difficulty of combining a medical career with family life. There was a significant correlation between having doubts about a medical career and having a mother who worked.Half the girls said they would prefer to work in hospital after qualification—the favourite specialties being paediatrics and obstetrics; only a quarter said they would like to do general practice. The need for careers advice which links actual career openings and the wish of most women to combine medical work with marriage and child-rearing is emphasized. The majority of the students saw a doctor''s primary role as the giving of advice and reassurance.     

Containing Health Care Costs: A Critical Test of the Public-Private Joint Venture in Health

As the federal government shifted from its traditional roles in health to the payment for personal health care, the relationship between public and private sectors has deteriorated. Today federal and state revenue funds and trusts are the largest purchasers of services from a predominantly private health system. This financing or “gap-filling” role is essential; so too is the purchaser''s concern for the costs and prices it must meet. The cost per person for personal health care in 1980 is expected to average $950, triple for the aged. Hospital costs vary considerably and inexplicably among states; California residents, for example, spend 50 percent more per year for hospital care than do state of Washington residents. The failure of each sector to understand the other is potentially damaging to the parties and to patients. First, and most important, differences can and must be moderated through definite changes in the attitudes of the protagonists.     

Immediate health effects of an urban wildfire.

To document the immediate health effects of the urban wildfire that swept through parts of Alameda County, California, on October 20 and 21, 1991, we conducted a retrospective review of emergency department and coroner''s records. Nine hospitals (6 local and 3 outlying) were surveyed for the week beginning October 20, 1991. Coroner''s reports were reviewed for 25 identified fire-related deaths. A total of 241 fire-related emergency encounters, including 44 inpatient admissions, were recorded for 227 persons. Nearly a fourth of emergency department patients were seen for work-related injuries, more than half of which occurred among professional firefighters. Smoke-related disorders constituted more than half of all emergency department cases; of these, 61% had documented bronchospasm. Major trauma and burns contributed 1% and 4% of principal diagnoses, respectively; these were exceeded in number by corneal abrasions (13%), other medical problems (8%), and minor trauma (7%), among other diagnoses. All coroner''s cases involved extensive burns, many with documented smoke inhalation injury. While the Oakland-Berkeley fire storm resulted in a high case-fatality ratio among major burn cases (25/31), those who survived the initial fire storm did well clinically. Among emergency department patients, medical (particularly smoke-related) disorders outnumbered traumatic presentations by a ratio of more than 2 to 1.     

TAX-SUPPORTED MEDICAL CARE FOR CALIFORNIA'S CHILDREN—Where Should It Be Going?

The multiplication of separate governmental agencies providing health services to California''s children, the increasing difficulties in staffing tax-supported health agencies and the recent studies of the quality of care under these programs, have all pointed to an urgent need for prompt decisions on certain basic questions about the function of tax-supported medical care for children of dependent families.Fourteen separate kinds of health services are currently provided through public funds at an annual cost to California taxpayers of $52,000,000. These funds underwrite an uncoordinated, fragmented, patchwork quilt of medical care for some 500,000 children. Coordination and integration of these services through “one door” with uniform eligibility requirements and maximum utilization of private physicians'' services that meet appropriate standards is needed now. California physicians have an urgent responsibility to provide leadership in the development of more effective and more economical organization and distribution of higher quality medical care services for California''s children dependent on public support.     

Poem: the prophet in his own country

Although generalist physicians appear to be more likely than specialists to provide care for poor adult patients, they may still perceive financial and nonfinancial barriers to caring for these patients. We studied generalist physicians'' attitudes toward caring for poor patients using focus groups and used the results to design a survey that tested the generalizability of the focus group findings. The focus groups included a total of 24 physicians in 4 California communities; the survey was administered to a random sample of 177 California general internists, family physicians, and general practitioners. The response rate was 70%. Of respondents, 77% accepted new patients with private insurance; 31% accepted new Medicaid patients, and 43% accepted new uninsured patients. Nonwhite physicians were more likely to care for uninsured and Medicaid patients than were white physicians. In addition to reimbursement, nonfinancial factors played an important role in physicians'' decisions not to care for Medicaid or uninsured patients. The perception of an increased risk of being sued was cited by 57% of physicians as important in the decision not to care for Medicaid patients and by 49% for uninsured patients. Patient characteristics such as psychosocial problems, being ungrateful for care, and noncompliance were also important. Poor reimbursement was cited by 88% of physicians as an important reason not to care for Medicaid patients and by 77% for uninsured patients. Policy changes such as universal health insurance coverage and increasing the supply of generalist physicians may not adequately improve access to care unless accompanied by changes that address generalist physicians'' financial and nonfinancial concerns about providing care for poor patients.     

Withholding or Withdrawing Extraordinary Life Support—Optimizing Rights and Limiting Liability

For many years physicians, ethicists and members of the legal community have attempted to minimize ambiguity and unpredictability in making decisions to withhold or withdraw extraordinary life support. Recent developments in national and California law now afford medical care providers unparalleled protection from criminal and civil liability in surrogate decision-making situations. They also reinforce the concept of patient''s rights by providing medical care consumers with new and effective mechanisms for enforcing their “right to decide,” even after they have lost decision-making capacity. A case in point is California''s new Durable Power of Attorney for Health Care, which serves as a model for other jurisdictions that do not have such legislation. Thus, the medical and legal professions, working together, can contribute immeasurably to respectful medical decision making by educating the public about these developments and by adopting policies that reinforce these rights.     

Hospital bed utilisation in the NHS,Kaiser Permanente,and the US Medicare programme: analysis of routine data

Objective To compare the utilisation of hospital beds in the NHS in England, Kaiser Permanente in California, and the Medicare programme in the United States and California.Design Analysis of routinely available data from 2000 and 2001 on inpatient admissions, lengths of stay, and bed days in populations aged over 65 for 11 leading causes of use of acute beds.Setting Comparison of NHS data with data from Kaiser Permanente in California and the Medicare programme in California and the United States; interviews with Kaiser Permanente staff and visits to Kaiser facilities.Results Bed day use in the NHS for the 11 leading causes is three and a half times that of Kaiser''s standardised rate, almost twice that of the Medicare California''s standardised rate, and more than 50% higher than the standardised rate in Medicare in the United States. Kaiser achieves these results through a combination of low admission rates and relatively short stays. The lower use of bed days in Medicare in California compared with Medicare in the United States suggests there is a “California effect” as well as a “Kaiser effect” in hospital utilisation.Conclusion The NHS can learn from Kaiser''s integrated approach, the focus on chronic diseases and their effective management, the emphasis placed on self care, the role of intermediate care, and the leadership provided by doctors in developing and supporting this model of care.     

Nurse Practitioner and Physician's Assistant Clinics in Rural California: Part I: Issues

The primary health care needs of at least 26 rural California communities are being served by nurse practitioners (NP''s) or physician''s assistants (PA''s). All of these have physician supervision and support. NP''s and PA''s have proved to be acceptable and effective. With 230 rural areas in California identified as having unmet health care needs, this type of service is likely to increase and should be supported.NP/PA clinics serve total populations or concentrate on Indians, Chicanos or the poor. Many barriers have been overcome, especially over the past four years, to allow these clinics to flourish and increase in number. The availability of nurse practitioners and physician''s assistants has increased due to support to schools and to school policies. Clinic funding has greatly improved; federal funds for general rural clinics, Indians, migrants, family planning and maternalchild health have been greatly supplemented by California state funds. Beginning in 1978, rural NP and PA services can be reimbursed by Medicare and Medi-Cal (California''s Medicaid program).Since 1975 state laws have defined PA and NP roles broadly, and these roles are more precisely defined at the local level. Although nurse practitioners and physician''s assistants generally cannot prescribe or dispense drugs (a major problem in many clinics), demonstration legislation allows special pilot projects to do both. As remaining funding and legal problems are corrected, NP''s and PA''s will serve an even greater role in rural areas.     

Prevalence and intensity of avian malaria in a quail hybrid zone

Hybrid zones have been described as natural laboratories by researchers who study speciation and the various mechanisms that may affect gene flow. The evolutionary consequences of hybridization depend not only on reproductive compatibility between sympatric species, but also on factors like vulnerability to each other''s predators and parasites. We examined infection patterns of the blood parasite Haemoproteus lophortyx, a causative agent of avian malaria, at a site in the contact zone between California quail (Callipepla californica) and Gambel''s quail (C. gambelii). Controlling for the potential influence of sex and year, we tested whether species identity predicted infection status and intensity. We found that infection prevalence was lower in California and hybrid quail compared with Gambel''s quail. However, infected California and hybrid quail had higher infection intensities than Gambel''s quail. California and hybrid quail exhibited no significant differences in prevalence or intensity of infection. These findings suggest that infection by H. lophortyx has the potential to influence species barrier dynamics in this system; however, more work is necessary to determine the exact evolutionary consequences of this blood parasite on hybridization.