Relationships in consultation

The cause of medicine is advanced by the proper exchange of services between general practitioners and specialists. As a medical group and singly, physicians stand to benefit by strengthening their relationships; and the one to benefit most of all by this combination of services is the patient. Any physician of integrity admits that it is impossible for one physician to know all there is to know about every medical subject. The establishment of rules of conduct to be followed by those who get together to solve a medical problem will promote the use of advisory practice.     

Preventable diseases; the scope of public health

The purpose of a department of public health is to put into effect for the benefit of all the people of a community the practical lessons of preventive medicine. The scope of public health work is chiefly determined by our knowledge of the causes of the preventable diseases. We do not know how to prevent all diseases. We do, however, know effective ways to prevent or to reduce the occurrence of at least a dozen varieties of disease. Every health department ought to provide for a program and services which will prevent so far as possible the preventable diseases and the preventable hazards to health. To concentrate on prevention is to avoid diversion by specious arguments into the fields of medical care of the sick.     

PREVENTABLE DISEASES: THE SCOPE OF PUBLIC HEALTH

The purpose of a department of public health is to put into effect for the benefit of all the people of a community the practical lessons of preventive medicine. The scope of public health work is chiefly determined by our knowledge of the causes of the preventable diseases. We do not know how to prevent all diseases. We do, however, know effective ways to prevent or to reduce the occurrence of at least a dozen varieties of disease.Every health department ought to provide for a program and services which will prevent so far as possible the preventable diseases and the preventable hazards to health. To concentrate on prevention is to avoid diversion by specious arguments into the fields of medical care of the sick.     

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.     

A report from Japan: choices of Japanese patients in the face of disagreement

Background: Patients in different countries have different attitudes toward self-determination and medical information. Little is known how much respect Japanese patients feel should be given for their wishes about medical care and for medical information, and what choices they would make in the face of disagreement.
Methods: Ambulatory patients in six clinics of internal medicine at a university hospital were surveyed using a self-administered questionnaire.
Results: A total of 307 patients participated in our survey. Of the respondents, 47% would accept recommendations made by physicians, even if such recommendations were against their wishes; 25% would try to persuade their physician to change their recommendations; and 14% would leave their physician to find a new one.
Seventy-six percent of the respondents thought that physicians should routinely ask patients if they would want to know about a diagnosis of cancer, while 5% disagreed; 59% responded that physicians should inform them of the actual diagnosis, even against the request of their family not to do so, while 24% would want their physician to abide by their family's request and 14% could not decide. One-third of the respondents who initially said they would want to know the truth would yield to the desires of the family in a case of disagreement.
Interpretations: In the face of disagreement regarding medical care and disclosure, Japanese patients tend to respond in a diverse and unpredictable manner. Medical professionals should thus be prudent and ask their patients explicitly what they want regarding medical care and information.     

The Inability of the Consumer Price Index to Measure “Cost of Quality” of Medical Care,Report of the Bureau of Research and Planning

The Consumer Price Index (CPI) of the Bureau of Labor Statistics is an index which measures the price changes of 300 goods and services. Among these 300 items are several which reflect price changes for selected health care and medical care services. These comprise the medical care index and physician fee index, depending on what services are being measured.The Physician Fee Index is based upon charges for five procedures rendered by physicians: Appendectomy, tonsillectomy, obstetrical delivery, home visits and office visits.Although the CPI takes into account quality changes in the prices for various goods, it is unable to do so for services, particularly physicians'' services.The difficulty in measuring the “cost” of quality of medical care overstates price increases in the physician fee and medical care indexes.     

基于杜邦分析法的非营利性医院财务状况分析

随着我国医疗卫生事业的不断发展,医院管理者逐渐把重点转移到医院的经营管理上。针对这一现象,利用杜邦分析法将财务指标进行逐一分析,及早掌握医院的财务状况和经营状况,控制财务风险的发生。     

Medical direction and control of emergency medical services in Canada.

OBJECTIVE: To determine the level of physician involvement in prehospital emergency medical services (EMS) in Canada, as compared with published principles of medical control and direction. DESIGN: Mail and telephone survey by means of a questionnaire from March to November 1991. SETTING: All Canadian provinces and territories. PARTICIPANTS: Fifty-six key prehospital EMS physicians, senior government administrators and senior representatives of the agencies responsible for licensing physicians in each province or territory. MAIN OUTCOME MEASURES: Responses to questions regarding the legislation, organization, administration, practice and regulation of medical direction and control by physicians in each province or territory. RESULTS: EMS legislation describing medical direction and control was completely lacking in five provinces and both territories and was incomplete in the remainder. Provincial guidelines written by physicians for prehospital patient care were present in only four provinces. Formal organization of medical directors varied from none to partially remunerated networks. Regional medical-director systems were present in three provinces, and local medical directors were required for all communities in three. Most rural ambulance services were found to engage physicians only when there was local interest. CONCLUSIONS: The level of physician involvement in the medical direction and control of EMS appears to be inconsistent across Canada and insufficient in most jurisdictions, as compared with accepted principles.     

Profiles

The Canadian Medical Association (CMA) recognizes that there is justification for abortion on medical and nonmedical socioeconomic grounds and that such an elective surgical procedure should be decided upon by the patient and the physician(s) concerned. Ideally, the service should be available to all women on an equitable basis across Canada. CMA has recommended the removal of all references to hospital therapeutic abortion committees as outlined in the Criminal Code of Canada. The Criminal Code would then apply only to the performance of abortion by persons other than qualified physicians or in facilities other than approved or accredited hospitals. The Canadian Medical Association is opposed to abortion on demand or its use as a birth control method, emphasizing the importance of counselling services, family planning facilities and services, and access to contraceptive information.     

Medical home care services for the housebound elderly.

In our health jurisdiction the proportion of elderly people is more than double the national average, and there is a severe shortage of both home care services and long-term care beds. To help the many elderly housebound people without primary medical care we initiated a medical services home care program. The goals were patient identification, clinical assessment, medical and social stabilization, matching of the housebound patient with a nearby family physician willing and able to provide home care and provision of a backup service to the physician for consultation and help in arranging admission to hospital if necessary. In the program''s first 2 years 105 patients were enrolled; the average age was 78.9 years. More than 50% were widowed, single, separated or divorced, over 25% lived alone, and more than 40% had no children living in the city. In almost one-third of the cases there had never been a primary care physician, and in another third the physician refused to do home visits. Before becoming housebound 15% had been seeing only specialists. Each patient had an average of 3.2 active medical problems and was functionally quite dependent. Thirty-five of the patients were surveyed after 1 year: 24 (69%) were still at home, and only 1 (3%) was in a long-term care institution; 83% were satisfied with the care provided, and 79% felt secure that their health needs were being met. One-third of the patients or their families said that it was not easy to reach the physician when necessary. We recommend that programs similar to ours be set up in health jurisdictions with a high proportion of elderly people. To recruit and retain cooperative physicians hospital geriatric services must be willing to provide educational, consultative and administrative support.     

DISASTER MEDICAL CARE AND SHELTER—The Federal Program

The role of the physician in event of natural disaster or overwhelming (perhaps nuclear) attack by an enemy is:To assist the layman in preparing to meet his own health needs in a disaster situation until organized health services can reach him.To prepare and plan for the provision of organized medical care when conditions permit.To extend his own capability to render medical care outside his normal specialty.To assist in the training of allied and professional health workers and laymen for specific mobilization assignments in health services.     

DISASTER MEDICAL CARE AND SHELTER-The Federal Program

The role of the physician in event of natural disaster or overwhelming (perhaps nuclear) attack by an enemy is:To assist the layman in preparing to meet his own health needs in a disaster situation until organized health services can reach him. To prepare and plan for the provision of organized medical care when conditions permit. To extend his own capability to render medical care outside his normal specialty. To assist in the training of allied and professional health workers and laymen for specific mobilization assignments in health services.     

Hospital data management at the Graz University Ophthalmology Clinic]

In 1991, the eye hospital at the University of Graz initiated the development of a system for the documentation of patient data and services provided. The starting point of the hospital data management system was the surgical documentation system. This made it possible for the patient to be transferred to the ward accompanied by the completed and signed surgical report. In the subsequent steps we developed a complete client server system adapted to the different specific needs of all the various sections of the eye hospital. A further important feature is the fact that all the data are available for access at every part of the hospital. The current version has been in use since 1996, and will be discussed below. The main features of our hospital data management system are automated coding of medical services provided in the diagnostic, surgical and outpatient areas, and guaranteed authenticated data. Automatic generation of findings, reports, etc, allows the physician to concentrate fully on medical concerns. For a modern, service-oriented hospital, complete records of the services provided are indispensable. Complete recording of services is, however, possible only via automation. In our case, this means not only that the available data are always correct (up to date), but also that there is wide acceptance of and reliance on these data by the medical staff. Since the system is an in-house development, it is possible to react rapidly to suggestions for improvement and to eliminate possible errors immediately. The hospital data management system of the eye hospital at the University of Graz is a well-functioning example that makes it worthwhile discussing the greater use of subsystems.     

我国医药分开政策目的及其策略分析

目的 进一步明确医药分开政策目的及策略。方法 采用文献回顾性研究法,对医药利益链条及其形成原因,以及解决策略进行系统性地总结和分析。结果 现有研究一是认为医疗服务提供方拥有垄断地位造成利益链条存在,因而提出消除垄断;二是认为扭曲的“白色”或不良的“灰色”激励机制造成利益链条存在,因而提出完善“白色”或消除“灰色”激励机制的综合策略。结论 医药利益链条产生更深层次的原因是,非营利性的公立医疗机构不合理地追求经济利益,医生采用不合理方式追求部分合理经济利益。因此,医药分开目的应是让公立医疗机构真正成为非营利机构,使医生依靠技术获得合理的经济回报,让公立医疗机构、医生、政府、患者、药品企业及流通商间激励相容。建议采用外部补偿和内部薪酬制度为重点的综合改革策略,形成各利益相关方激励相容的良好局面,自然消除公立医疗机构、医生与药品销售间利益链条。     

The Primary Care Network: A New Type of HMO for Private Practice Physicians

A new type of health maintenance organization has been developed to encourage primary care physicians in private practice to become coordinators and financial managers for all medical care. Each patient chooses one internist, family or general physician, or pediatrician and must be referred by that physician for all hospital admissions and care by specialists. The primary care physician authorizes all payments from his own account for care provided to his patients. He shares any deficit or surplus remaining at the end of the year.Hospital admission rates and length of stay are lower than those of Blue Cross, with only one of three dollars paid to hospitals. The plan is providing care to 38,000 persons with 750 participating physicians in Northern California, Washington and Utah.This plan represents an attempt by physicians to control costs without government regulation.     

Focus: A Multifaceted Battle Against Cancer: The Cost of Cancer-Related Physician Services to Medicare

Although physician services represent a substantial portion of cancer care costs, little is known about trends in the costs of physician cancer services in the fee-for-service Medicare program. We analyzed aggregated data from all Part B Medicare claims for physician and supplier services attributed to cancer patients from 1999 to 2012 to characterize how billing and payments have changed over time for the most common cancer types. Billing and expenditure data are from the Medicare Statistical Supplement, and age-adjusted incidence data are from SEER. Physician services for cancer patients grew from $7.6 billion in 1999 to $12.3 billion in 2012 (60 percent increase). Reimbursements for physician and supplier services for cancer treatment in Medicare Part B beneficiaries steadily grew from 1999 to 2005 and then plateaued through 2012, led by a decrease in reimbursements for prostate cancer care. These trends may reflect shifts toward hospital-based care or changes in aggressiveness of care.     

Project Head Start—An Evaluation of the Medical Components in California

Half of 1,135 children medically examined as a part of Project Head Start in California had one or more conditions that warranted referral to a physician or dentist, and only one-fifth of these were under care. In the judgment of the examining physicians, one-third of the referable medical conditions were described as “major.” Follow-up procedures were variable and not very successful.Increased local medical society participation in planning the health services for these children is recommended as an especially important step in securing care for the problems that are identified.     

Cervical Cancer—Use of a Non-Physician Health Team for Screening Procedures

A team of non-physician personnel has been trained in cytologic screening for cervical cancer. In a county hospital clinic setting among low income women whose annual pelvic examinations were being by-passed by physicians, this three-person team has performed pelvic examinations and screening under physician supervision for one year.Results of the first year''s experience, measured in cancer detection and in recognition and referral of benign gynecological disease as well, would suggest that a non-physician team, with a registered nurse doing a pelvic examination of screening type, can screen for cervical cancer and other pelvic disease efficiently and without a significant lowering of the quality of medical care.The training and use of teams of allied health care personnel directed by physicians is suggested as a practical means of overcoming the increasing shortage of physician services in annual screening for cervical cancer among low income women.     

The medical aspects of civil defense in California

Medical care for persons injured in atomic bomb attack or other far-reaching enemy action occupies an important place in civil defense plans that have been set up in California. Preparations have been made on the basis of suppositions as to where attacks might occur and estimates of the number of casualties. State and federal funds have been allocated for aid station equipment, antibiotics, plasma, blankets and litters. In the table of organization, use of all physicians, nurses and hospitals in the state is contemplated. Communities at the center of attacks would borrow facilities and medical personnel from areas not directly affected.County medical societies in California have appointed civil defense committees to work out local plans. Each physician has a part in these plans. If he does not know what his assignment is, be ought to get in touch with his county medical society headquarters immediately.