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Your Basic Medical Plan

Would your basic medical plan carry you through a prolonged illness or serious injury? Would it carry you through the high cost of advancements in medical technology ; new procedures or specialized equipment? What about a longer than average hospital stay?

Probably not. That is why the Medical Society of Virginia is sponsoring an Excess Major Medical plan...to pick up where your basic medical plan leaves off.

Highlights

• Pays up to a Lifetime Maximum of

$1,000,000

• Pays up tol00% of eligible expenses after the deductible

# Choice of $50,000 or $100,000 cash deductibles

# Pays whether you are in or out of the hospital

# Broad coverage

# Family and employee coverage available

# Affordable rates

For more information, including terms and conditions of coverage, write the insurance administrator, John P. Pearl & Associates, Ltd., or call them at (804) 282-9600,

Virginia toll-free (800) 572-2211.

Administered By

John P. Pearl & Associates, Ltd.

6620 W. Broad St., Suite 300 Richmond, VA 23230-1720

Underwritten By

Insurance Company of North America

A CIGNA Company

Index to Volume 116

JANUARY-DECEMBER 1989

PAGES ACCORDING TO MONTHLY ISSUES

Pages

No.

Month

1-46

1

January

47-90

2

February

91-144

3

March

145-192

4

April

193-248

5

May

249-294

6

June

1-320

7

July

295-338

8

August

339-388

9

September

389-444

10

October

445-488

11

November

489-534

12

December

KEY TO ABBREVIATIONS

b — book review cr — committee report ed — editorial h — history in — interview le — letter to editor m — memoir

* — medical article

mb — medibytes

par — public affairs report

pv — point of view

s — speech

sa — special article

ww — who’s who

December 1989, Virginia Medical

531

SUBJECT INDEX

Abstracts.

Conference on gastroduodenal disease and Campylobacter pylori 512*

Student honors day at the Medical College of Virginia 373* Virginia Authors 182*

Virginia Chapter, American College of Physicians, and Vir- ginia Society of Internal Medicine 71*

Virginia Dermatological Society 125*

Virginia Society of Otolaryngology 322*

Virginia Surgical Society 224*

AIDS.

Consent forms for Virginia’s new AIDS law 392 How to report AIDS/HIV infections 78 Hilar adenopathy and positive HIV antibody test [Ingram et al] 122*

AIDS: Beware of buzzwords 198 Alcoholism. Beer potomania syndrome in an alcoholic [Harrow] 270*

Arteritis. Grand rounds: Takayasus’ arteritis [Roberts] 218*

Barney, William H. A tribute to President Barney [Wilson] 519-ed Books.

Hello, Friend by Wilson [Toone] 151 Hidden Illness in the White House by Crispell & Gomez [Grad] 151

Jury of My Peers by Snider [Kirkpatrick] 344 The Injured Athlete by Kulund [Pettrone] 151 White Rabbit by Morrison [Haun] 268 Damning the Innocent by Darmon [Conner] 479 Cancer.

New techniques for diagnosing malignancy: morphology and beyond [Komstein] 274*

Carbon monoxide poisoning in indoor ice-skating arenas [Miller et al] 74*

Cavitation. Pulmonary infarction with cavitation: case report [Becker et al] 215*

Chlamydial Infections.

Diagnostic methods for chlamydial infections in a high-risk population [Boese et al] 62*

Cochlear Implants. Current status of cochlear implants in adults, children [Lambert et al] 318*

Consultation patterns in an urban hospital setting [Bienia et al] 371*

Crohn’s disease presenting as a pelvic mass: case report [Lassere] 471 Editorials.

A true friend [Campell] 441

Addiction [Campell] 128

Bald [Campell] 520

Biomedical ethics [Kendig] 477

Commentary [Kendig] 441

Comprehensive health care [Kendig] 184

Contributions [Kendig] 477

Don’t bite the hand that feeds you [Block] 375

Drug war [Campell] 279

Education — or lack of it [Kendig] 227

Forgiving [Campell] 35

Fraud and abuse statutes [Kendig] 77

Horse, knife, wife [Campell] 227

Hospital notes [Campell] 129

Inner space [Campell] 325

Making a decision [Campell] 376

Medical practice restrictions [Kendig] 128

Medical students [Kendig] 375

More on smoking bans [Kendig] 279

MSV progress [Kendig] 35

On being politic [Campell] 324

Pain management [Lawrence] 183

President Barney [Wilson] 519-ed

President Hulvey [McCue] 34

Self-pity [Campell] 77

The work ethic [Kendig] 324

Too fat [Campell] 477

VMAPP [Kendig] 324

War and anger [Campell] 183

Welcome [Kendig] 520

Wiser? [Campell] 376

Endoscopic injection therapy for acute upper GI bleeding [Valenzuela et al] 507*

Ethics. Decisions to forego life-sustaining treatment [Fletcher] 462-sa

From the Rostrum. “The best there is anywhere, and the credit is ours!” [Grayson] 326-s Guest Speaker. Fifty years of change [Monroe] 281 High School Athletes.

New medical standards for Virginia’s high school athletes [Perriello et al] 359*

Physical fitness and the high school athlete [Kendig] 358-sa Physician’s kit for the new VHSL physical exam 362 Questions use of new VHSL exam for Eastern Shore ath- letes [Koenig] 494-le

Hirsutism. Evaluation and treatment of the hirsute woman [Nestler] 310*

Historical Notes. George Tebault: Renaissance man [Barrow] 478

HMOs. Hoist by an HMO’s fine print [Peay] 466-pv Hulvey, J. Thomas. President Hulvey [McCue] 34-ed Impaired Physicians Program.

Portrait of an impaired physician [Fluharty] 266-sa New post underscores program’s success 267 Injured Infants Act.

Study assesses definition, newborn records [Brown & Faulknier] 1 14-sa

Birth-injured infants: legal definitions, claims frequency in Virginia [Brown] 473-sa Insurance.

Before you join a risk retention group, read this 247, 298 Ensuring a healthy liability insurance system [Terry] 53 Legal aspects of risk retention groups [Kramer] 16 What to do about soaring health plan rates [Godwin] 3 Letters.

Advocates sending editorial to “every legislator and lawyer” [Fiveash] 94

Cites role of psychiatrists in impaired physicians program [Scavullo] 298

Letter on complication secondary to ACE inhibitors prompts a query [Baird] 256 “Light at end of smoke-filled tunnel”: Va Med’s text on smoking in hospitals [Koziol ] 49 Long-time nursing school teacher favors both diploma, de- gree programs [Lynch] 298

Offers treatment plan for “the most dangerous drug” [Smith] 452

532 Virginia Medical, December 1989

Proposes taping/distributing conversations with third parties [Sporn] 94

Questions use of new VHSL exam for Eastern Shore ath- letes [Koenig] 494

Questions views expressed in article on health insurance [Gueriera] 252

Report angioedema secondary to hypertension medications [Bama et al] 147

Research and rabid dogs concern former health commis- sioner [Shanholtz] 148

Smoking: more wrapped in emotion than scientific truth? [Ragland] 452

Somehow the word got out without our help [Stein- gaszner] 452

The Directory: perfection is elusive 342

Wants action to get rid of “unfair and unjust bill” [Termini] 94 Medibytes. 57, 259, 451

Medicare. What you should know about the proposed “safe” harbors [Grad & Logan] 211 Mettauer, John Peter. In rural Virginia, world-class medicine: John Peter Mettauer, 1787-1878 [Kight] 66-h M marinum infections in a Chesapeake Bay community [Hoyt et al] 467*

Natural Death Act. Physician’s guide to the Natural Death Act and patient form 334-335 Nuckolls, James H. 90-ww Pain Management.

Analgesics: the physician’s partner in effective pain manage- ment [Rogers] 164*

Neurosurgical concepts of pain control [Young] 173*

Patient-controlled analgesia [Kane] 171*

Psychological aspects of pain management [Klinger & Levenson] 177*

Payment Reform. “I have changed my mind” [Rich- ards] 120-pv

Renal Trauma. Twenty-five years of renal trauma at a teaching hospital [Osborne et al] 504*

THE MEDICAL SOCIETY OF VIRGINIA

Actions of Council 57, 259, 451 Annual Meeting 1988

Actions of House of Delegates 19 Address of the Governor 28 Holland wins community service award 22 Budget 1988-1989 32 Officers elected 18 Presidential address [Updike] 36 President Hulvey 34 Annual Meeting 1989

Hotel reservation form 305 Preliminary program 409 President Barney [Wilson] 519 Annual reports of committees 409 MSV officers 49, 231 MSV phone book 92 Physicians Opinion Survey Council hears survey data 259 Comments from Physicians Opinion Survey 402 We asked what you thought — and you told us!

[Hulvey] 197 Unification.

Unification, dues abraid survey respondents 259-mb Council recommends deunification 451 -mb Members vote to rescind unification 491 -mb VaMPAC entertains state legislators 100

Sonography. Venous sonography for pregnancy-related thrombosis: case report [Abbitt & Thiagarajah] 277* Urinary calculus: high-tech changes in a urology practice [Kramolowsky et al] 368*

Wellness [Zakaib] 321-pv

AUTHOR INDEX

Abbitt, P.L. 277*

Abedi, E. 147-le Arnold, W.P. 432-cr Baird, C.L., Jr. 256-le Baliles, G.L. 28-s Bama, J.S. 147-le Barrow, M.R. 478-h Bates, H.C., Jr. 328-m Becker, D.M. 215*

Benjamin, J.T. 359*

Bienia, C. 371*

Bienia, R. 371*

Bilowus, P. 74*

Block, L.I. 375-ed, 419-cr Boese, K.F. 61*

Boling, P.A. 185-pv Brown, B.S. 114-sa, 473-sa Bryant, J.E. 467*

Burke, J.O.

329-m

Caldwell, J.B

.H. 359-m

Campell, H.

S. 35-ed, 77-ed,

129-ed,

183-ed, 227-ed,

324-ed,

325-ed, 376-ed,

477-ed; 520-ed

Caravati, C.M., Jr. 423-cr

Carroll, G.J.

522-m

Carter, H.G.

330-m

Cartin, I.M.

436-cr

Clancy, C.M. 185-pv Collins, K. 504*

Conner, A.E. 479-b Cook, C.B. 420-cr Cook, W.A., Jr. 186-m Crowder, C.H., Jr. 435-cr Dagostino, M.R. 215* David, R.K. 433-cr Davis, T., Jr. 507* Dicicco, B. 122*

Dickens, M.D. 359* Dodson, A. I. 368*

128-ed, Eagles, W.M. 329-m

279-ed, Edwards, N.R. 424-cr

441-ed, Faulconer, R.J. 421-cr

Faulknier, T.E. 114-sa

Fiveash, J.G., Jr. 94-le Fluharty, D.G., Jr. 266-sa Ford, R.F. 359*

Frable, M.A.S. 147-le

Franco, A.P. 467* Ghaphery, J.L. 426-cr

Gleason, C.H. 359* Glessner, S.F. 467* Godwin, I.D. 3-sa, 428-cr Grad, J.D. 151-b, 211-sa Grayson, R.J. 326-s Gueriera, C.J. 256-le Hagy, J.A. 421-cr Halpin, C. 318*

December 1989, Virginia Medical 533

Harrow, A.S. 270*

Pettrone, F.A. 151-b

Ferry, A.M. 328

Haun, E.C. 268-b

Phillips, R.M. 329-m

Field, B.E. 480

Hawkes, D.L. 359*

Pizzani, E. 507*

Foster, W.L. 522

Heuser, G. 371*

Pope, T.L., Jr. 215*

Gamble, J.H. 78

Hodges, A. V. 318*

Ragland, S., Jr. 452-le

Gardner, J.E., Sr. 130

Hotchkiss, W.S. 229-pv

Rein, M.F. 62*

Gardner, S.DeW. 130

Howell, H.R. 130-m

Reynolds, D.R. 359*

Grinnan, B.R., Jr. 186

Hoyt, R.E. 467*

Richards, N.G. 120-pv

Grove, P.T. 186

Hulvey, J.T. 197-sa

Roberts, W.N. 218*

Hardy, R.G. 130

Ingram, C.W. 122*

Robinson, B.E. 215*

Harper, F.G. 328

Jacobson, A. 130-m

Rogers, A.G. 164*

Harris, A.E., Jr. 39

Johnson, G.W. 130-m

Ruth, R. A. 318*

Hedrick, R.B. 130

Kane, N.E. 171*

Ryan, M.C. 74*

Hranowsky, N.P. 480

Katchinoff, B.L. 130-m

Scavullo, B.C. 298-le

Kazakis, T.R. 480

Keeley, R.L.A. 420-cr

Schildwachter T. 359*

Kitterman, J.A. 231, 330

Kell, J.F., Jr. 329-m

Shanholtz, M.I. 147-le

Landes, R.R. 522

Kendig, E.L., Jr. 35-ed, 77-ed, 128- ed,

Shapiro, C.S. 425-cr, 432-cr

Latimer, R.A.W., Sr. 78

184-ed, 227-ed, 279-ed, 324-ed,

Shield , J . A . , Jr . 430-cr

Lynch, J.P. 328

375-ed, 421-cr, 441-ed, 477-ed;

Sipe, W.H. 430-cr

Mandanis, J.P. 522

520-ed

Smith, C.G. 452-le

McCollum, D.C. 231

Kight, J.R. 66-h, 330-m

Smith, M.J.V. 504*

McCoy, C.M. 522

Kirkpatrick, B.V. 344-b

Smith, M.P. 379-m

Miller, E.I. 522

Klein, F. 504*

Spom, I.N. 94-le

Mills, J.D., Jr. 328

Klinger, R.L. 177*

Stein, J. 330-ed

O’Brien, D.C. 480

Koenig, C.L. 494-le

Steingaszner, L.C. 452-le

O’Brien, T.E. 186

Koontz, W.W. 504*

Suslick, R.H. 378-m

Pastore, P.N. 480

Komstein, M.J. 274*

Talbert, J.R. 428-cr

Pennington, M.A. 130

Koziol, I. 49-le

Teja, K. 215*

Pole, W.C. 480

Kramer, S.L. 16-sa

Termini, J.E. 94-le

Redding, G.J. 522

Kramolowsky, E.V. 368*

Terry, M.S. 53

Robinson, J.A. 480

Kravitz, P. 122*

Thiagarajah, S. 277*

Saunders, J.R. 78, 186

Lambert, P.R. 318*

Thomas, J.F. 318*

Sheppard, L.B. 231, 379

Lassere, M.W. 471*

Tingle, N.R., Jr. 467*

Sloop, F.B., Jr. 480

Lawrence, W., Jr. 183-ed

Toone, E. 344-b

Spaar, A. 282

Levenson, J.L. 177*

Tuck, K.D. 438-cr

Stephenson, J.A. 328, 480

Littleton, F.C.N., Jr. 467*

Updike, G.H., Jr. 36-s

Strickler, F.A. 522

Logan, M.P. 211-sa

Valenzuela, G.A. 507*

Surhio, G.H. 78

Lynch, J.P. 298-le

White, G.H., Jr. 425-cr

Sutton, C.E. 78

Machen, C.W. 359*

Wilson, J.W. 504-ed

Tompkins, G.R. 231

McAllister, R.G. 329-m

Wolcott, J.M., Jr. 330-m

Troland, C.E. 231, 329

McCausland, A. 435-cr

Wootton, P. 440-cr

Victor, F.E. 78

McCue, F.C., III 34-ed, 436-cr

Young, H.F. 173*

Warren, J.E. 328

McGroarty, D. 507*

Zakaib, E.A. 321-pv

Warshauer, S. 38, 330

McLeod, S. 62*

Weaver, E.N. 480

Mella, B.A. 439-cr

Williams, A.T. 186

Miller, R.K. 74*

Wingfield, W.L. 328

Mitchell, R.E., Jr. 424-cr

Yates, M.R. 230

Monroe, W.M. 281-s

Obituary /Memoirs

Moore, E.W. 358-m

Angell, R.L. 186

Moore, J.L., Jr. 414

Archer, R.A. 328

Morris, R.C. 480-m

Atkinson, G.W. 130

Nelson, C.M.K. 368*

Beck, W.C. 78

Nestler, J.E. 310*

Birdsong, G.G. 378, 522

Newman, R.J. 467*

Blades, J.F. 480

Nichols, D.B. 467*

Boyd, J.O. 78

Nold, R.J. 330-m

Braxton, H.H., Sr. 78, 378

O’Bannon, J.M. Ill 440-cr

Brown, T.McP. 328

Ooghe, R.B. 343 -le

Burk, L.B. 231,328

Osborne, B. 504*

Clark, L.L. 231, 329

Owen, J.A., Jr. 419-cr

Coleman, H.R. 480

Pastore, L. 122*

Cooper, C.E. 522

Patterson, J.L., Jr. 429-cr, 439-cr

Davis, W.A. 480

Peay, C.L. 466-pv

Dunman, L.E. 78

Perriello, V.A. 359*

Farano, L. Ill 480

534 Virginia Medical, December 1989

VIRGINIA

MEDICAL

January 1989, Volume 116, Number 1

© 1989 — The Medical Society of Virginia

AT THE ANNUAL MEETING

18 New Medical Society of Virginia Officers

Actions of the House of Delegates, an Illustrated Report

19 Reference Committee One

25 Reference Committee Two

30 Reference Committee Three

22 Winners: Clancy Holland wins Community Service Award 28 “We must constantly reach for agreement” Gerald L. Baliles 36 Presidential Address Glen B. Updike, Jr.

UP FRONT

3 What to Do about Soaring Health Plan Rates Ira D. Godwin 16 Legal Aspects of Risk Retention Groups Sandra L. Kramer

EDITORIALS

34 President Hulvey Frank C. McCue III

35 MSV Progress E. L. Kendig, Jr.

35 Forgiving Henry S. Campell

14 Meetings about Medicine

39 Obituary

40 New Members

43 Classified Advertisements

Editor Associate Editors Editorial Board

Executive Editor Business Manager

Edwin L. Kendig, Jr., MD

Richard G. Lester, MD; Duncan S. Owen, Jr., MD; John A. Owen, Jr., MD H. C. Alexander III, MD; Raymond S. Brown, MD; Henry S. Campell, MD; C. Barrie Cook, MD; Eloise C. Haun, MD; Walter Lawrence, Jr., MD; Lockhart B. McGuire, MD; Robert Edgar Mitchell, Jr., MD Ann Gray

James L. Moore, Jr.

Virginia Medical (ISSN 0146-3616) is the monthly publication of The Medical Society of Virginia. Second-class postage paid at Richmond, Virginia. Yearly subscription rate: $24 domestic, $30 foreign; single copies, $3. Virginia Medical does not hold itself responsible for statements made by any contributor. Although all advertising is expected to conform to ethical medical standards, acceptance does not imply endorsement by this journal, and the publisher reserves the right to reject any advertisement. For information on the preparation of articles, write to the Executive Editor for “Advice to Authors", or call (804) 353-2721. POSTMASTER: Send address changes to Virginia Medical, 4205 Dover Road, Richmond VA 23221.

Y

MEDICAL COLLEGE OF VIRGINIA/VIRGINIA COMMONWEALTH UNIVERSITY OFFICE OF CONTINUING EDUCATION IN MEDICINE AND ALLIED HEALTH PROFESSIONS CALENDAR OF CONTINUING MEDICAL EDUCATION CONFERENCES

APRIL THROUGH AUGUST 1989

OPHTHALMOLOGY: UVEITIS

DATES: April 7-9, 1989 LOCATION: The Williamsburg Royce Hotel, Williamsburg, Virginia DESIGNED FOR: Ophthalmologists

CLINICAL CONCERNS IN PRIMARY CARE: Geriatrics, Psychiatry & Selected Topics

DATES: April 14-16, 1989 LOCATION: The Williamsburg Royce Hotel, Williamsburg, Virginia DESIGNED FOR: Primary care physicians

EMERGENCY MEDICINE FOR THE PRIMARY CARE PHYSICIAN

DATES: April 14-16, 1989 LOCATION: The Williamsburg Hilton and National Conference Center DESIGNED FOR: Primary care and emergency medicine physicians

NEUROLOGY FOR INTERESTED PHYSICIANS

DATES: April 28-30, 1989 LOCATION: The Williamsburg Hilton and National Conference Center DESIGNED FOR: Psychiatrists, neurologists, and other interested physicians

THE MCV CARDIOLOGY CONFERENCE

DATES: May 4-6, 1989 LOCATION: Williamsburg Royce Hotel, Williamsburg, Virginia DESIGNED FOR: Interventional cardiologists

UROGYNECOLOGY & PELVIC SURGERY

DATES: May 27-29, 1989 LOCATION: The Williamsburg Royce Hotel, Williamsburg, Virginia DESIGNED FOR: Gynecologists and urologists

HOW TO BUILD AND MAINTAIN THE VALUE OF YOUR PRACTICE

DATES: July 14-16, 1989 LOCATION: Virginia Beach Resort and Conference Center DESIGNED FOR: Physicians in private /group practice

PRACTICAL INTERNAL MEDICINE

DATES: July 14-16, 1989 LOCATION: The Ramada Oceanside Tower Resort, Virginia Beach, VA DESIGNED FOR: Internists and interested primary care physicians

PEDIATRICS AT THE BEACH

DATES: July 21-23, 1989 LOCATION: The Ramada Oceanside Tower Resort, Virginia Beach, VA DESIGNED FOR: Pediatricians and Primary Care Physicians

SUMMER RETREAT: PRACTICAL ISSUES IN PRIMARY CARE

DATES: August 17-20, 1989 LOCATION: The Virginia Beach Resort and Conference Center DESIGNED FOR: Primary care physicians

PRIMARY CARE OF THE FEMALE PATIENT

DATES: August 25-27, 1989 LOCATION: Virginia Beach Resort and Conference Center DESIGNED FOR: Physicians who provide primary care to women

The Virginia Hospital Television Network (VHTN): In cooperation with Hospital Satellite Network (HSN) the Office of Continuing Education (OCE) has developed the VHTN to provide a broad based program of continuing medical education. Using a communication satellite, programs produced nationally and at MCV are transmitted to VHTN and national subscriber hospitals across the United States. OCE develops and coordinates satellite pro- grams of particular interest to Virginia Hospitals, provides audio-conferencing to allow immediate interactive discussion between health care professionals and consultants at MCV as well as at other major medical centers. For more information, please contact Carol Hampton, Assistant Director Community Hospital Programs, at 786-0494.

FOR MORE INFORMATION ON ANY OF THESE PROGRAMS, PLEASE CALL (804) 786-0494, or write to:

CME BROCHURE REQUEST, Box 48, MCV Station, Richmond, VA 23298-0048. WE WILL BE GLAD TO SEND YOU ANY AVAILABLE COURSE BROCHURES, OR PLACE YOU ON A MAILING LIST TO RECEIVE A BROCHURE AS SOON AS ONE IS AVAILABLE.

Medical College of Virginia

Virginia Commonwealth University

INSURANCE

Why’s, Wherefore’s, and What to Do

about

Soaring Health Plan Rates

Ira D. Godwin, MD, Chairman, Insurance Committee

For over 25 years, the Medical Society of Virginia has endorsed a Virginia Blue Cross/Blue Shield health insurance plan for its members and their fam- ilies and staff. The currently endorsed plan is known as the Virginia Physician’s Plan. It is a full-service health insurance plan. In addition to MSV members, partici- pating physicians of Virginia BC/BS and their families and staff are also covered.

The plan’s premiums increased in 1988 by only 8.7%, of which 1.5% was due to improving outpatient mental health coverage from 50/50 copay to 80/20. Most subscribers were not unhappy with that increase.

Unfortunately, the plan experienced heavy usage in the period 9/1/87-8/31/88, with incurred claims ($9,720,119) greater than premiums ($9,251,199). When Virginia BC/BS projected the increasing costs of the plan, including pooling of excess claims, state premium tax, and administration/contingencies, they proposed a rate increase for 1989 of 46.4%. This proposal shocked the Insurance Committee and Council.

After exhaustive discussions with Virginia BC/BS, it was decided to increase certain deductibles in an effort to hold the premium increases down. The Comp Care 100 plan has been changed to Comp Care 200 to reflect the individual calendar year deductible increase to $200; also, the individual out-of-pocket limit has been increased from $1,000 to $1,500.

For both Comp Care 200 and Comp Care 500 (also individual calendar year deductible of $200), the in- hospital deductible has been increased from $100 to $200 per confinement and the PRN drug card deduct- ible per prescription has been increased from $2.50 to $3.50 for a generic drug and from $4.50 to $7 for a brand name prescription.

With these changes, the Comp Care 200 premium will be 37% greater than the 1988 Comp Care 100 premium, and the Comp Care 500 premium will in- crease by 44%. The Insurance Committee regrets that it could not keep the premium increases lower, but these are the best rates that Virginia BC/BS would give

us. Most health insurance plans are having large increases at this time, although ours is more than most.

At its November 2, 1988, meeting. Council accepted the Insurance Committee’s recommendation that the Society accept these premium increases in its en- dorsed plan. The Council was distressed at the size of the premium but felt that it must offer this plan to members who cannot get other acceptable health insurance.

The new rates became effective on January 1, 1989.

WHY is this plan so expensive in comparison with other plans? First, because this plan has excel- lent coverage. When compared item by item with other plans, coverage of this plan is usually better.

Second, because its issue is guaranteed. It has been Medical Society of Virginia policy that its sponsored health insurance plan must be available to all mem- bers, regardless of their health. This means those who cannot get health insurance elsewhere can buy into this plan.

Third, because excellent coverage and guaranteed issue lead to much higher usage and cost than for other kinds of plans. Also, this plan’s subscribers probably are the most sophisticated users of medical care in the entire state.

Fourth, because of adverse selection. Although the survey the Insurance Committee did last year showed that good coverage was generally more important to the plan's subscribers than cost, many physicians and their staffs are more interested in lower premiums. This is particularly true if they are in good health. Therefore, more and more of them opt out of this plan. This in turn causes the premiums to continue to rise at a faster than average rate.

WHAT can be done to decrease the costs of this plan? We could increase the deductibles even more, decrease some of the benefits, or go to a “managed care’’ plan. Adoption of managed care for

January 1989, Virginia Medical 3

this plan would have reduced the premium by 5.2%. Your Insurance Committee intends to explore these options in the coming year.

What should MSV members do? If this plan is best for your particular circumstances, buy it. If you have some hesitancy, shop around. You may be able to find another Virginia BC/BS plan; you may qualify for their healthy Virginian plan. The Medical Society of Virgin- ia has endorsed a health insurance plan with Pearl & Associates which has deductibles of $1,000 and $2,000; this plan is not truly comparable in benefits with the Virginia Physician’s Plan, but you may prefer it.

Address correspondence to Dr. Godwin at PO Box 188, Fairfax VA 22030. These members serve with him on the Insurance Committee: Dr. Lawrence E. Blanchard III and Dr. Owen W. Brodie, both of Richmond; Dr. Williams S. Burton, Nassawadox; Dr. John L. Dobson, Virginia Beach, and Dr. J. William Giesen, Radford.

SAFE DRIVERS

If one of your patients persists in driving despite your warnings not to, ask Dr. Howard M. McCue, Jr., for help. He is staff physician at the Department of Motor Vehicles, where there is a Medical Control Unit to handle these cases. A state law now protects you from 1) disclosure and 2) legal action. Dr. McCue’s address is PO Box 27412, Richmond VA 23229. His telephone number is (804) 367-6639.

Eighteen years of devoted service to The Medical Society of Virginia ended this year when John Nash (left above) retired from his post as maintenance man and general assistant.

“He did anything that was needed, and he always did it well and cheerfully,” Executive Vice President Jim Moore (right above) told the MSV Council. As the councilors applauded, Nash accepted a check, then stayed one more time to super- vise the serving of lunch.

4 Virginia Medical, January 1989

Specify Adjunctive.

&

<c »ts«_

■

J J c’

t>A*

Each capsule contains 5 mg chlordiazepoxide HCLand 2.5 mg clidinium bromide.

Please consult complete prescribing information, a summary of which follows:

* Indications: Based on a review of this drug by the National Academy of Sciences— National Research Council and/or other information, FDA has classified the indications as follows:

"Possibly” effective: as adjunctive therapy in the treatment of peptic ulcer and in the treatment of the irritable bowel syndrome (irritable colon, spastic colon, mucous colitis) and acute enterocolitis.

Final classification of the less-than-effective indications requires further investigation.

Contraindications: Glaucoma; prostatic hypertrophy, benign bladder neck obstruction; hyper sensitivity to chlordiazepoxide HC1 and/or clidinium Br. Warnings: Caution patients about possible combined effects with alcohol and other CNS depressants, and against hazardous occupations requiring complete mental alertness (e g., operating machinery, driving).

Usage in Pregnancy: Use of minor tranquilizers during first trimester should almost always be avoided because of increased risk of congeni- tal malformations as suggested in several studies. Consider possibility of pregnancy when instituting therapy. Advise patients to discuss therapy if they intend to or do become pregnant.

As with all anticholinergics, inhibition of lactation may occur.

Withdrawal symptoms of the barbiturate type have occurred after discontinuation of benzodiazepines (see Drug Abuse and Dependence).

Precautions: In elderly and debilitated, limit dosage to smallest effective amount to preclude ataxia, oversedation, confusion (no more than 2 capsules/day initially; increase gradually as needed and tolerated) . Though generally not recommended, if combination therapy with other psychotropics seems indicated, carefully con- sider pharmacology of agents, particularly potentiating drugs such as MAO inhib- itors, phenothiazines. Observe usual precautions in presence of impaired renal or hepatic function. Paradoxical reactions reported in psychiatric patients. Employ usual precautions in treating anxiety states with evidence of impending depres- sion; suicidal tendencies may be present and protective measures necessary. Variable effects on blood coagulation reported very rarely in patients receiving the drug and oral anticoagulants; causal relationship not established. Inform patients to consult physician before increasing dose or abruptly discontinuing this drug. Adverse Reactions: No side effects or manifestations not seen with either com- pound alone reported with Librax. When chlordiazepoxide HC1 is used alone, drowsiness, ataxia, confusion may occur, especially in elderly and debilitated; avoidable in most cases by proper dosage adjustment, but also occasionally observed at lower dosage ranges. Syncope reported in a few instances. Also encountered: isolated instances of skin eruptions, edema, minor menstrual irreg- ularities, nausea and constipation, extrapyramidal symptoms, increased and decreased libido— all infrequent, generally controlled with dosage reduction; changes in EEG patterns may appear during and after treatment; blood dyscrasias (including agranulocytosis), jaundice, hepatic dysfunction reported occasionally with chlordiazepoxide HC1, making periodic blood counts and liver function tests advisable during protracted therapy. Adverse effects reported with Librax typical of anticholinergic agents, i.e., dryness of mouth, blurring of vision, urinary hesi- tancy, constipation. Constipation has occurred most often when Librax therapy is combined with other spasmolytics and/or low residue diets.

Drug Abuse and Dependence: Withdrawal symptoms similar to those noted with barbiturates and alcohol have occurred following abrupt discontinuance of chlor- diazepoxide; more severe seen after excessive doses over extended periods; milder after taking continuously at therapeutic levels for several months. After extended therapy, avoid abrupt discontinuation and taper dosage. Carefully supervise addiction-prone individuals because of predisposition to habituation and dependence.

P.l. 0288

Roche Products

Roche Products Inc. Manati, Puerto Rico 00701

141st Annual Meeting

Summarized in these pages are actions taken by the House of Delegates during its second session on November 5 during The Medical Society of Virginia’s annual meeting in Williamsburg. Dr. Glenn B. Updike, Jr., was the presiding officer. Conducting the deliberations of the House were Dr. William H. Barney, Speaker, and Dr. George E. Broman, Vice Speaker.

REFERENCE COMMITTEE ONE: Education and Interprofessional Relations

Eugene R. Lareau, MD, Chairman,

Louis D. Parham, Jr., MD, James P. Baker, MD,

Sam Barton, MD, Henry D. Patterson, MD,

Jack C. Turner, MD, Daniel N. Mohler, Jr., MD,

Carol S. Shapiro, MD, Frank Blanton, Jr., MD,

Catherine S. Casey, MD, and Deborah Irr

Thomas L. Williams photographed the annual meeting.

Executive Editor Ann Gray wrote the report of the delegates’ actions.

Address of the President The chairman reported that Refer- ence Committee One urged adoption of the following recommendation made by Dr. Updike in his Presiden- tial Address (see page 36): That VaMPAC ensure that the Society’s councilors and vice councilors, mem- bers of the MSV State Legislative Committee from the pertinent dis- tricts, and the Society’s lobbyists are consulted before making candidate- support decisions. The House adopted President Updike’s recom- mendation.

On the recommendation of the Committee, the House then elected Dr. Updike to honorary active mem- bership in The Medical Society of Virginia.

Aging

Agreeing with the Reference Com- mittee’s endorsement, the House adopted the following three recom- mendations from the Report of the Committee on Aging:

1) Encourage component medical societies to develop plans for volun- tary programs for acceptance of

Medicare assignments based on finan- cial need; 2) designate the Committee on Aging and the MSV staff as re- sources for the programs; and 3) set January 1, 1990, as deadline for im- plementation of the programs.

Cancer

Reference Committee One asked for adoption of this amended version of a recommendation from the Re- port of the Cancer Committee:

“That The Medical Society of Vir- ginia recommend to the General As- sembly of Virginia the creation of programs of cytotechnology in appro- priate health education centers, to be supported with adequate faculty, space and funding.” The House so adopted.

Resolution C on mammography, introduced by the Alexandria Medi- cal Society, called for The Medical Society of Virginia to encourage the General Assembly of Virginia to en- act legislation mandating that health insurance cover screening mammog- raphy. A Supplemental Report from

January 1989, Virginia Medical

19

the Cancer Committee described the proposed legislation.

Dr. Lareau reported to the House that Reference Committee One had heard testimony describing the ad- vantages and disadvantages of man- datory insurance coverage of mam- mography. There was general accord, he related, as to the impor- tance of mammography as a screen- ing procedure and as to the need for improving the quality of the proce- dure and of archiving the results. There was concern, however, about the costs associated with mandating

Dr. Sidney W. Tiesenga, Chesapeake

insurance coverage.

The Committee had also heard testimony, Dr. Lareau continued, that a member of the General As- sembly, Delegate Bernard Cohen, was drafting legislation for introduc- tion in the 1989 session that would mandate health insurance coverage of mammography.

Reference Committee One recom- mended that the Cancer Committee work with the General Assembly in drafting legislation to ensure that it is responsive to the goals articulated in the report of the Task Force on Screening Mammography created by The Medical Society of Virginia in 1988, and recommended accordingly that Resolution C be referred to the Cancer Committee.

Dr. C. M. Kinloch Nelson rose to suggest that the resolution be re- ferred to Council, where it could be given more authoritative action, and offered an amendment to implement that suggestion. His amendment found favor and the amended recom- mendation to refer Resolution C to the MSV Council was adopted.

Highway Safety

The Highway Safety Committee’s Report recommended that riders of bicycles, mopeds and “off-road” mo- torcycles be encouraged to use safety helmets. Reference Committee One

recommended adoption and the House unanimously endorsed the recommendation.

Peer Review

On the Reference Committee’s recommendation, the House adopted the following amended version of a recommendation from the Medical Society of Virginia Review Organiza- tion Oversight Committee:

That Medical Society of Virginia members of the MSVRO Board be instructed to institute the following procedures:

1) In Severity I Level cases, at least one physician of the specialty in ques- tion and of the same type of practice review the case where there is a ques- tion of quality of care.

2) In cases potentially of Severity II/III Level, two physicians of the specialty in question and of the same type of practice register unanimous agreement prior to referral to the Regional Review Committee.

3) The Quality Assurance Commit- tee include three ad hoc members of the same specialty and type of prac- tice as the physician or provider un- der investigation.

Reference Committee One recom- mended against adoption of Resolu- tion O submitted by the MSVRO and calling for a change in the name of the organization, and the House fol- lowed the committee’s lead. “The current name appropriately ex- presses the relationship between the two organizations,’’ said the Com- mittee’s report as read by the chair- man.

Rural Health

From the Rural Health Committee came a recommendation calling for The Medical Society of Virginia to continue to support efforts to equalize payments by third-party payors to rural and urban hospitals and physi- cians. Reference Committee One fa- vored adoption of the recommenda- tion, reported Dr. Lareau, but Dr. Richard L. Fields rose to ask that the recommendation be referred to Council for action. The recommen- dation was amended to include that

Left to right, Dr. Alexander T. Ocampo, Fairfax, Dr. Andrew J. Sheridan, Arlington, and Dr. Rolando J. Santos, Springfield

20 Virginia Medical, January 1989

referral and was then adopted unan- imously by the House.

Sheriffs Advisory Two recommendations from the Report of the Sheriffs Advisory Committee were endorsed by the Reference Committee:

Resolution One called for the dis- continuation of the committee and formation in its place of a statewide organization of jail physicians. Reso- lution Two provided for the appoint- ment by the President of The Medical Society of Virginia of a liaison com- mittee from the new organization.

Both recommendations were adopt- ed by the House.

Sports Medicine Three recommendations from the Sports Medicine Committee and Resolution D on Anabolic Steroids from the Fairfax County Medical So- ciety were next considered in the report of Reference Committee One.

The first recommendation, as amended by the Reference Commit- tee, read as follows: resolved, that The Medical Society of Virginia sup- port efforts of the special state legis- lative subcommittee studying the use of anabolic steroids and endorse send- ing to schools in Virginia a survey regarding the use of anabolic steroids.

On behalf of the 10th district del- egation (Arlington and Fairfax), Dr. William J. Purkert rose to add to the end of the recommendation, “and to keep studying this situation, espe- cially in Virginia’s high schools.” Af- ter voting in favor of Dr. Purkert’s addition, the House then adopted the recommendation as amended.

The committee recommended re- ferral to the Society’s State Legisla- tive Committee of the second recom- mendation from the Sports Medicine Committee. This recommendation called for The Medical Society of Virginia to support legislation that would permit physicians to supervise licensed physical therapy assistants.

“The Legislative Committee is now engaged in discussions with the physical therapists regarding areas of responsibility,” Dr. Lareau read

from the Reference Committee’s re- port; hence the referral recommen- dation. The House voted so to refer.

The third recommendation from the Sports Medicine Committee had been amended by the Reference Com- mittee. As presented to the House by Dr. Lareau, it read, resolved, that The Medical Society of Virginia sup- port certification of athletic trainers in Virginia. The recommendation as pre- sented was adopted.

Resolution D asked for MSV liai- son with state high school athletic associations to address the issues of anabolic steroids. The Reference Committee did not feel the resolu- tion warranted adoption, reported the chairman, because “the first rec- ommendation of the Sports Medi- cine Committee deals adequately with the subject.”

Mental Health

As introduced by the Norfolk Academy of Medicine, Resolution B called for The Medical Society of Virginia to endorse legislation man- dating reimbursement for an in- creased minimum of mental health services. “Your Reference Commit- tee is concerned that this and other requests for increased insurance coverage could have a material im- pact on the cost of insurance and the willingness of employers to provide

Dr. Jeffrey W. Wilson, Roanoke, Chairman, Rules Committee

Dr. Vito A. Perriello, Jr., Charlottesville

Left to right, Dr. Timothy L. Kelly, Jr., Dr. Lawrence A. Gaydos, and Dr. Catherine S. Casey, all of Arlington

January 1989, Virginia Medical 21

insurance coverage for their employ- ees,” said Dr. Lareau in presenting the committee’s recommendation not to adopt. The House agreed and the resolution was lost.

Fraud/Abuse Clauses From the Northern Neck Medical Society came Resolution V, dealing with third-party payor “fraud and abuse” clauses aimed at physicians. Reference Committee One had shortened the resolution as follows and recommended that the House adopt it: resolved, that The Medical Society of Virginia establish a physi- cian/patient advocacy clearing house or respository for complaints, ques-

tions and concerns regarding third- party payors. The House adopted the resolution as amended.

Death and Dying Not recommended for adoption by Reference Committee One was Res- olution W submitted by the Rich- mond Academy of Medicine; it was directed toward formation of an MSV committee to “study the issues of death and dying.” The Reference Committee had heard testimony, said Dr. Lareau, that the Society’s Ethics Committee is dealing with the important issues addressed in this resolution. The House did not adopt.

Consent Calendar

Recommended for filing by Refer- ence Committee One were the re- ports of these committees: Educa- tion, Federal Legislative/Activities, Maternal Health, Mental Health, Public Relations and Rehabilitation; the Hospital Medical Staff Section; and commentary from the Report of Council on the MSVRO, the Aging Committee, and the nursing short- age.

Recommended for adoption:

1) Council’s rejection of Resolution S on Newborn Circumcision, referred to it by the 1987 House of Delegates, on the grounds that “it is not the role

WINNERS

Delegate Clancy Holland sits with his 2nd district peers during the first session of the House. Behind him at right is Dr. Harry G. Plunkett, Norfolk.

As a page in the Virginia senate 44 years ago, Clarence Adrian Holland found his boyhood role model in the late Dr. James D. Hagood, whom he watched legislate effectively as a senator from Halifax County while continuing his general practice of medicine.'

Today Dr. Holland has an established general prac- tice of his own and is entering his fifth year as state senator from Virginia Beach.

In 1968 Dr. Hagood received The Medical Society of Virginia’s highest honor, the Physician Award for Community Service.

Twenty years later Clancy Holland became the 26th recipient of that same award, at ceremonies during the Society’s annual meeting in Williamsburg.

Watching Dr. Hagood whetted Clancy Holland’s appetite for public office, but it was his father who really got him started: The late Shirley T. Holland, an Isle of Wight Banker, served for 20 years in Virginia’s House of Delegates. One of Clancy’s two brothers, Richard J. Holland, is today the senator from the Isle of Wight. The other brother joined Clancy in medicine; he is Dr. William E. Holland, Richmond cardiologist. (Not related to the three brothers is another state senator, Edward M. Holland of Arlington.)

For 12 years Clancy Holland was a member of the city council of Virginia Beach (during the same period he was president of the Virginia Beach Medical Socie- ty), and in 1976 he was elected the city’s mayor. In a highly effective two-year term, Mayor Holland insti- tuted a tourist and industrial development department, gave strong support to education, including Eastern Virginia Medical School, and developed volunteer

22 Virginia Medical, January 1989

of the Society to rule whether or not a certain medical procedure is ap- propriate."

2) Resolution I on the Good Sa- maritan Law, introduced by the Vir- ginia Chapter, American Academy of Pediatrics, and the Virginia Pedi- atric Society, as follows: resolved, that The Medical Society of Virginia support passage by the Virginia Gen- eral Assembly of legislation, such as has been enacted in Ohio, Kansas, Missouri and Tennessee, to expand our present Good Samaritan Law to include protection for volunteer med- ical personnel at scholastic and com- munity athletic events.

3) Resolution on Dissemination of Information Regarding Healthcare Costs, introduced by the Richmond Academy of Medicine, as follows:

resolved, that The Medical Society of Virginia, in consultation with rep- resentatives of the insurance indus- try, government and business, de- velop educational programs to keep physicians informed regarding details of various healthcare plans developed by these institutions; and . . . con- tinue to maintain an active role in representing physicians and patients of the Commonwealth in the develop- ment of healthcare plans and pro- grams.

4) Resolution T on Proposed In- formation Requirement for "Life- Threatening” Findings, introduced by the Virginia Beach Medical Soci- ety, as follows: resolved, that The Medical Society of Virginia oppose HB1036, which would require that radiologists inform patients of “life- threatening” findings; and . . . that members of the House Committee on Health, Welfare and Institutions be informed of the opposition of the So- ciety to this bill; and . . . that the MSV State Legislative Committee be directed to use its best efforts in op- posing this bill.

emergency medical services. In 1981 he was chosen King Neptune of the Virginia Beach Neptune Festival, a title honoring civic achievement within the Tidewa- ter community.

Dr. Holland also supports the arts in his hometown; he currently serves on the executive committee of the Virginia Beach Arts Center and the board of trustees of the Virginia Marine Science Museum.

At the state legislature in Richmond, his appoint- ments include the Senate Committees on Education and Health, on Rehabilitation and Social Services, and on Privileges and Elections.

Carefully even-handed in an arena redolent of self- interest, Senator Holland nevertheless manages to be a cogent ally of The Medical Society of Virginia's lobbying efforts while the General Assembly is in session. He keeps an eye on the bills in progress, sharing information with the lobbyists so that they can "go out and touch everybody," as one legislator described it.2 During the 1987 session he steered the Vaccine-Related Injury Act through both Senate and House so adroitly that there wasn't a dissenting vote.

Long a supporter of the Virginia Medical Political Action Committee, Clancy is now VaMPAC’s vice chairman. He is a working member of the Society’s Federal Legislative and Activities Committee, special advisor to the State Legislative Committee, and is on call to attend meetings of other committees grappling with legislative concerns. Typically, he sits attentively in these meetings until asked to speak, then deferen- tially offers information or suggestions.

On the hustings, he’s an ebullient man with a big, big

smile, accessible to all sorts and conditions of men, hospitable to all shades of opinion, susceptible to human frailty and distress.

"I believe we are put on this earth to help each other," he has said, "and I like to feel I’m doing a service.’’1 MSV President Glenn B. Updike, Jr., con- firmed Dr. Holland in that feeling as he presented him with the Community Service Award.

Clancy Holland, said Dr. Updike, is "a physician who has given not just 100% but 1 10%, to his patients, his community, and most of all. to us, his fellow physicians."

To Dr. William A. Shaver, Roanoke, went the blue ribbon for the scientific exhibit adjudged best of show; his topic, "Gastrostomy, a Simple and Effective Tech- nique for Decompression and Feeding." Second place went to the American Cancer Society, Virginia Divi- sion, for its exhibit on the manifestations of oral cancer. The yellow ribbon for third was pinned on the exhibit displayed by Dr. Ted Dupuy, Chesapeake, whose text and pictures elucidated "A New Semi- Supine Oblique Radiographic View of the Hook of the Hamate."

In the golf tourney, Dr. C. B. Courtney, Jr., New- port News, tallied the lowest gross score for the 18- hole round and took home the Challenge Cup. Not enough players signed up to make a tennis tourney.

Dr. George R. Smith, Jr., Shawsville, and Dr. Harvey D. Smallwood, Charlottesville, won the copies of Borland' s Illustrated Medical Dictionary contribut- ed by the W. B. Saunders Company.

January 1989, Virginia Medical 23

Crisis in black and white.

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REFERENCE COMMITTEE TWO: Legislation and Regulation

Antonio M. Longo, MD, Chairman,

Robert T. Davis, MD, Russell D. Evett, MD,

Lawrence C. Zacharias, MD, George J. Carroll, MD, Henry S. Campell, MD, William E. Painter, MD,

Joel R. Poole, MD, Beryl H. Owens, MD,

Richard E. Linde, MD, and Tracy Iezzi

Animal Research

The chairman reported that Refer- ence Committee Two recommended for adoption an expanded version of Resolution G on the Use of Pound Animals for Research Purposes in Virginia Medical Institutions, intro- duced by the Virginia Chapter, American Academy of Pediatrics. The text was revised and endorsed by the Committee: resolved, that The Medical Soci- ety of Virginia support enactment of legislation by the Virginia General Assembly that would require making available animals from pounds, after they have not been claimed by own- ers, for research purposes in medical schools in the Commonwealth of Vir- ginia; and be it further

resolved, that The Medical Soci- ety of Virginia adopt a policy encour- aging voluntary health organizations, such as the state component associa- tions of the American Cancer Society and the American Heart Association, to endorse publicly a position sup- porting the use of pound animals for research purposes in Virginia’s med- ical schools; and be it further

resolved, that The Medical Soci- ety of Virginia encourage methods of identifying and retrieving lost pets, such as registration and the use of tattoos, so as to facilitate their early identification and safe return.

Dr. Longo told the delegates that Reference Committee Two heard testimony relating to legislation in- troduced in the last session of the Virginia General Assembly intended to severely restrict the use of pound

animals for medical research. This legislation was carried over for con- sideration in the 1989 session, he noted, and in the interim was the subject of a legislative study and a source of public debate.

The Committee believes that ani- mal research is essential to continue to find and improve methods of treating debilitating and deadly hu- man disease, Dr. Longo continued, and heard testimony indicating that voluntary health organizations are in a good position to communicate the good that is derived from animal research in saving and improving the quality of human life. Accordingly, the Reference Committee added to the resolution the second resolved clause asking the Society to encour- age such support.

But the Committee is sensitive to the concerns of pet owners that their pets not be the subject of such re- search, Dr. Longo emphasized, and for that reason its members added the third resolved clause to facilitate the early identification and safe re- turn of lost pets.

The Speaker opened the subject for discussion, drawing negative comments from the floor on the use of the word “pets.” The objections subsided, however, when the chair- man reiterated the Committee’s spe- cific purpose in that part of the res- olution— to indicate expressly that physicians do not want pets used in research.

After that point had been clarified. Dr. Donald S. Thorn rose to request the addition of another clause, namely, “that The Medical Society of

Virginia urge its members to contact their legislators and representatives in the Virginia legislature to urge their support of the Society’s posi- tion.”

The House approved the adden- dum and then adopted the entire four-part resolution.

Information Sharing by BC/BS

The next recommendation made by Dr. Longo on behalf of Reference Committee Two arose out of the Committee’s “extreme concern about the implications" of certain aspects of Blue Cross and Blue Shield of Virginia's use of its new insurance claim form. The Commit- tee received at its hearing copies of a document entitled “Health Manage- ment Corporation — HMC Informa- tion Services for Hospitals,” the chairman related, and also heard tes- timony expressing concern because the document seemed to indicate that BC/BS intends to share propri- etary physician information with its affiliate, Health Management Corpo- ration, without the knowledge or consent of physicians. Additional testimony, said Dr. Longo. indicated that HMC apparently intends to de- velop individual physician profiles from such information, which it in- tends to sell or otherwise make available to hospitals and other em- ployers. The Reference Committee was disturbed by the implications of such data collection and dissemina- tion, Dr. Longo said, particularly “the prospect of such activity with- out the knowledge or consent of physicians, who intend merely to provide information to Blue Cross and Blue Shield so as to obtain pay- ment for services performed." Ac- cordingly, he concluded, the Com- mittee offered the following recommendation:

resolved, that the House of Dele- gates instruct Council to investigate and take appropriate and prompt ac- tion responding to the apparent inten- tion of Blue Cross and Blue Shield of Virginia to share physician claims in-

January 1989, Virginia Medical 25

Dr. Warren W. Koontz, Jr. (left), Richmond, and Dr. Robert F. Baxter, Grundy

From left, Dr. John R. Hogg, Newport News, Dr. Robert T. Mosby, Virginia Beach, and Dr. Jefferson D. Beale, Jr., Danville

formation with its affiliate, Health Management Corporation, thus en- abling Health Management Corpora- tion to develop and release individual physician profile data to hospitals and employers.

The House swiftly adopted the recommendation, and on the motion of Dr. Charles M. Caravati, Jr., the MSV staff was instructed to send to all the delegates copies of the docu- ment referred to by Dr. Longo.

Professional Liability

Observing that “your Committee feels that physicians have behaved responsibly by helping to get the Injured Infant Program started through their contributions during its first two years of operation,” Dr. Longo submitted Reference Com- mittee Two’s endorsement of these two recommendations:

1) That The Medical Society of Vir- ginia propose legislation to remove the $250 assessment from the Injured Infant Act. This recommendation came from the Professional Liability Committee.

2) That The Medical Society of Vir- ginia urge the amendment of the mechanism of funding for the Vir- ginia Birth-Related Neurological In- jury Compensation Act to reflect con- tributions by all citizens of the Commonwealth of Virginia. This rec- ommendation was introduced by the Alexandria Medical Society.

Both recommendations were adopted unanimously.

Also endorsed by Reference Com- mittee Two and unanimously adopted by the House were three other recommendations from the Professional Liability Committee, as follows:

1) That The Medical Society of Vir- ginia support efforts to study the In- jured Infant Act and continue to look for alternatives to the tort system for settling liability disputes.

2) That The Medical Society of Vir- ginia monitor closely and intercede where appropriate in the judicial de- termination of the constitutionality of the cap on medical liability awards.

26 Virginia Medical, January 1989

3) That The Medical Society of Vir- ginia oppose current efforts to liber- alize the Statute of Limitations and standards of care. Of this third rec- ommendation, Dr. Longo said, “Your Committee wishes to note that it considers the Society’s Ex- pert Witness Program an appropriate way to respond to the concerns of plaintiffs’ attorneys regarding the availability of medical experts who are familiar with the statewide stan- dards of care, and wishes to encour- age the Society to continue to look for ways to enhance the effective- ness of this program.”

Therapeutics and Devices

Testimony at Reference Commit- tee Two’s hearing about patients or- dering prescription medications by mail in order to receive discounts triggered the next recommendation submitted to the House by the chair- man.

The Committee recommended

that the Therapeutics and Devices Committee be directed to consider any patient care or other problems arising from the practice of ordering prescription medications through the mail.

“While the Committee is sympa- thetic to the interests of patients who wish to cut their health care costs,” Dr. Longo explained, “it heard suf- ficient testimony regarding the po- tential for adverse quality of care to warrant further investigation by the Society.”

“Your Committee also wishes to affirm the actions of the Therapeu- tics and Devices Committee,” he added, “in its work with the Board of Pharmacy in seeking to ensure that physicians will continue to be allowed to administer medications in their offices without regulation by this Board.”

Respiratory Therapy

From the Richmond Academy of Medicine came Resolution P on Mandatory Certification of Respira- tory Therapists, which noted that the current program of voluntary

Dr. Jorge A. Naranjo, (left), Boykins, and Dr. Irwin H. McNeely, Franklin

From left, Dr. James P. Baker, Norfolk, Dr. Randall S. Suslick, Chase City, and Dr. Arthur S. Gear, South Hill

January 1989, Virginia Medical 27

certification for respiratory thera- pists has elicited “poor enrollment" and asked The Medical Society of Virginia to support legislation to make certification mandatory.

Basing its conclusions on testi- mony at its hearing. Chairman Longo said, Reference Committee Two came to the conclusion that some different form of regulation may be in order to ensure that respi- ratory therapists are appropriately trained. The Committee felt, how- ever, that mandatory certification might in effect be licensure and that would not be appropriate. Accord- ingly, the Committee offered the fol- lowing modification of the resolution and recommended its adoption: resolved, that The Medical Soci-

ety of Virginia support legislation to create appropriate regulation of res- piratory therapists in Virginia.

The House adopted the Commit- tee’s version of the resolution.

Highway Safety Taking up Resolution Q on Alco- hol-Related Motor Vehicle Acci- dents, introduced by the Virginia Chapter, American College of Sur- geons, Reference Committee Two recommended that the House adopt a slightly edited version as follows: resolved, that The Medical Soci- ety of Virginia’s Highway Safety Committee pursue expansion of the Norfolk Intoxicated Driver Study to all Level I Trauma Centers within the Commonwealth; and be it further

RESOLVED, that The Medical Soci- ety of Virginia support legislation fa- cilitating the prosecution and removal of alcohol and/or drug-impaired driv- ers from the roadways of the Com- monwealth; and be it further

resolved, that a copy of this reso- lution be sent to the Governor of the Commonwealth.

There was a request from the floor that copies of an article titled “Al- cohol and the Motor Vehicle: a So- cial and Economic Dilemma,’’ which was offered as supplemental information with Resolution Q, be sent to members of the General As- sembly. This stipulation was in- serted in the resolution’s second clause, and the House then voted unanimously for adoption.

“We must constantly reach for agreement”

The Hon. Gerald L. Baliles, Governor of Virginia

My childhood impression of doctors was formed in the days of my growing up in Patrick County. They were people of integrity, decency and principle. And while so much else has changed, that has not. In fact, I hold to the view that the type of person drawn to the practice of medicine is driven far less by financial gain than by the desire to heal and to be independent.

The opportunity to heal remains — and the high quality of American medicine reflects that individual commitment. But, the aspiration for personal indepen- dence— a very American trait — is, for those who enter the medical professions, less easy to achieve. And for you, that may represent the greatest change of all.

In fact, I remember a few years ago, when a physician/crusader came to Richmond to lecture doc- tors on the benefits of forming a union. When I heard that he filled the main hall of the Richmond Hyatt Hotel with Virginia doctors to talk about unionism, I said to myself, “Something has changed here.’’

Well, I do not expect to see the union label show up in the local clinic anytime soon, but I do recognize your anxieties over the future, and as someone who

Excerpted from Governor Baliles’ address at the VaMPAC banquet honoring the memory of Dr. Leonard Weyl on No- vember 3 in Williamsburg during The Medical Society of Virginia’s annual meeting.

has spent a lifetime in public service, I can appreciate your feelings.

Things are changing very quickly. Even in Virginia, a prosperous state, we see the Medicaid budget in- creasing at twice the rate of the state budget. In fact, Medicaid — now approaching expenditures of $1 billion annually — is already the second largest single line in the state budget, yet Virginia is regarded by some as one of the more parsimonious states in its allocations to the program. So, just as Congress has taken a great interest in your profession, so, too, must Virginia.

Generally, one of the more common declarations in politics is the call to work together. Given the diversity of our country, it is a call heard often. But in the case of health care, it could not be more true — because, in the past, there have been times when doctors and government worked at odds.

It comes down to a matter of perspective. Do you take the long view or the short view? If influential physicians simply say “No’’ to every proposal — as many doctors did when faced with Social Security, Medicare, Medicaid, and DRGs — then, after a while, that influence will diminish. It is not an enviable position — but it is the inevitable result of a nation that paradoxically believes that high quality, low cost healthcare is a natural right.

So, again, we must work together. In fact — and this is my commercial for the evening — Virginia has a

28 Virginia Medical, January 1989

Conflicts of Interest Recommended for referral to the State Legislative Committee was Resolution S on Conflicts of Interest in the General Assembly, introduced by Dr. Robert P. Nirschl.

Dr. William W. Regan, MSV councilor for the 3rd district, rose to express the opinion that the Council could better deal with such matters. The House agreed with him, voting to change the referral accordingly.

Freedom to Choose Physicians Concerned about a recent memo to retirees in which state officials encouraged them to choose a physi- cian participating in Medicare, the Lynchburg Academy of Medicine drafted Resolution Z about State Re-

tirees and Their Choice of Physi- cians. Reference Committee Two deleted one clause and added some language to the other, endorsing the following amended resolution for af- firmative House action:

resolved, that The Medical Soci- ety of Virginia encourage the Com- monwealth of Virginia to develop a health insurance package for its retir- ees that includes benefits for physi- cians’ services and which allows free- dom of choice of physician.

From the floor came a request that the resolution be referred to Council for action and that the Council re- port back to the House at the 1989 annual meeting.

The House voted to amend the resolution to specify referral to

Council and then adopted the mea- sure as amended.

Consent Calendar

Recommended for filing were all or parts of the reports of these com- mittees: AIDS, Animal Research, Insurance, State Legislation, Thera- peutics and Devices, and VaMPAC, and items from the Report of Coun- cil dealing with animal research, on Medicare’s ‘ 'medically unnecessary” program, and on activities of the Leg- islative Committee.

Recommended for adoption:

1) Resolution F on Health Insur- ance Claims, introduced by the Richmond Academy of Medicine, which stated:

resolved, that The Medical Soci-

splendid opportunity for you to do so.

As you may know, Virginia’s rate of infant mortality has reached a new low — and that is very satisfying. Still, the rate remains too high. It exceeds the national average. So Virginia has launched the “BabyCare” program, which is Medicaid coverage for labor, deliv- ery and prenatal care for all those women at or below the poverty level. With this program we believe we can reduce costs over the long haul, but Virginia needs widespread physician participation for the program to work, so I urge you to take part.

End of commercial.

I have enjoyed this evening — and I hope you will take my remarks in the spirit in which they are offered. America holds its doctors in high esteem. You are accorded great respect. You are influential and af- fluent. But America also subjects its doctors to enor- mous stresses and demands, and I cannot see where it is going to get any easier.

Despite the well-established American preference for individuality, our nation is still premised on our ability to draw our resources and our people together. We must constantly reach for that point at which we agree — for it is then that we achieve consensus and move ahead.

By the dedication of a lifetime to his profession and his Commonwealth, Dr. Weyl offers us an example. It is one that we would do well to remember.

Governor Baliles (right) is escorted through the crowd at the reception preceding the VaMPAC banquet by Dr. Clancy Holland.

January 1989, Virginia Medical 29

ety of Virginia request the State In- surance Commissioner to study the feasibility of developing a standard claim form for the Commonwealth of Virginia; and be it further

resolved, that The Medical Soci- ety of Virginia encourage the Virginia General Assembly to enact legislation requiring insurers to pay interest at a competitive rate on those insurance claims that have been properly sub- mitted and not paid within 25 days.

2) Resolution R on All-Terrain Ve- hicles, introduced by the Virginia Chapter, American Academy of Pe- diatrics, and the Virginia Pediatric

Alternative Delivery Systems Chairman Krueger began with a recommendation from the Commit- tee on Alternative Delivery Sys- tems, which asked for legislation to create a state health maintenance organization guaranty association. The Reference Committee believed the problem might be adequately ad- dressed by the rules and regulations of the State Bureau of Insurance, Dr. Kreuger said, and amended the recommendation to read as follows: resolved, that The Medical Soci- ety of Virginia investigate the need for a state HMO guaranty association.

The Committee recommended that the House adopt the amended version, and the delegates did so.

Ethics

Reference Committee Three had reordered and amended the recom- mendations in the Report of the Eth- ics Committee, said Dr. Kreuger, and with some minor adjustments of

Society, concluding as follows: resolved, that The Medical Soci- ety of Virginia support 1) a ban on the sale of all ATVs to, and use by, indi- viduals under 16 years of age; 2) a ban on the recreational use of these vehicles on public land or on private land without the written consent of the property owner; and 3) a require- ment for helmet use by all ATV rid- ers; and be it further

resolved, that The Medical Soci- ety of Virginia recommend passage of legislation by the Virginia General Assembly to require routine licensing of all ATV drivers above age 16.

language from the floor they were adopted by the House as follows:

1. That every medical and hospital staff should have written policy re- garding No Code/Do Not Resuscitate orders using the following guidelines:

a) That every medical and hospital staff use a standard No Code/DNR order when it is intended that no CPR be given to a patient. Synonyms such as no heroics, comfort care only, chemical or pharmacological code, etc., should not imply No Code or DNR.

b) It should be clearly understood that the No Code/DNR order does not imply per se a lower or less aggressive standard of medical care of the pa- tient, and the attending physician must write the order in the chart and give an adequate, though not neces- sarily lengthy, account in the progress notes regarding the reasons which led to the order.

c) That it is the physician’s respon- sibility to eliminate any confusion

among the nursing staff regarding the No Code/DNR order.

d) That the attending physician should always take pains to make sure that any No Code/DNR decision is in the best overall interest of the patient, and that both the decision and the reasons for it are clearly communi- cated to those who have a vital need to know.

2. That medical staff, hospital staff, and attending physicians familiarize themselves with the requirements of the Natural Death Act of Virginia and the significance of the Living Will (Code of Virginia 54-325.8:1) so as to be able to take advantage of the im- munity from liability it provides in connection with the writing of No Code/Do Not Resuscitate orders.

Finances

The Reference Committee next recommended that the proposed budget for 1988-1989 be adopted as presented. It was so adopted and is published on page 32.

V entilator-Dependent Patients

After considering the Richmond Academy of Medicine’s Resolution A on Funding for Chronically Venti- lator-Dependent Patients, the Refer- ence Committee made some revi- sions, Dr. Kreuger reported. He offered these two clauses for adop- tion:

resolved, that The Medical Soci- ety of Virginia work to encourage the Commonwealth of Virginia to provide sufficient funding in the Medicaid program to make home care and nursing home care financially possible for ventilator-dependent patients; and be it further

resolved, that The Medical Soci- ety of Virginia encourage other insur- ance carriers to make similar cover- age available.

The House adopted Resolution A as amended.

Child Health

As introduced by the Virginia Chapter, American Academy of Pe- diatrics, and the Virginia Pediatric

REFERENCE COMMITTEE THREE: Internal Affairs

John J. Krueger, MD, Chairman,

T. Eugene Temple, MD, C. M. Kinloch Nelson, MD,

Anthony J. Munoz, MD, Arthur W. Whitehurst, MD,

Robert L. Keeley, MD, Harvey D. Smallwood, MD,

Joseph V. Puglise, MD, William R. Deal, MD,

Barbara A. Mella, MD, and John Prahinski

30 Virginia Medical, January 1989

At the reception for new 50- Year Club members, Dr. Glenn B. Updike, Jr. (left), presents his certificate

to Dr. DuPont Guerry III, Richmond.

Society, Resolution E on a Child Health Assurance Plan called for The Medical Society of Virginia to support legislation mandating a package of preventive health care services for children in every health insurance policy written in Virginia. Reference Committee Three en- dorsed the general intent of the res- olution, but the Committee’s mem- bers changed the specified package to an option and deleted a clause stipulating physician reimbursement at UCR levels; the changes were made, Dr. Kreuger stated, because the Committee was “concerned about cost and other implications of mandating such coverage.”

Dr. Nicholas G. Colletti rose to advocate an alternative to the legis-

lative route: Why not ask the Soci- ety simply to encourage all insurers to offer the package as an option? His motion so to amend was sec- onded and passed, and the resolu- tion that follows was then adopted by the House:

resolved, that The Medical Soci- ety of Virginia encourage all medical insurers conducting business in the Commonwealth to offer as an option in every policy written a package of preventive healthcare services for children for at least the minimum of such care recommended by the Amer- ican Academy of Pediatrics.

Dues Reduction

The chairman announced that Ref- erence Committee Three did not rec-

ommend adoption of Resolution J on MSV Dues Reduction, introduced by the Lynchburg Academy of Med- icine, because, explained Dr. Kreu- ger, the Society’s President and the Finance Committee had concluded such a step was not feasible. The resolution was lost.

RBRV Scale

“Your Reference Committee heard conflicting testimony on the concept of a cost- and resource- based relative value scale for physi- cians,” said Dr. Kreuger, “and be- lieves it has merit, as compared with other suggested alternatives, and that continued study and evaluation of this system would be appropri- ate.” The Committee therefore rec-

January 1989, Virginia Medical 31

MEDICAL SOCIETY OF VIRGINIA BUDGET 1987-1988

Salaries $470,000

Stationery and Supplies 18,000

Office Equipment: Repairs and Replacement 10,500

Building Expense 5,000

Telephone 18,000

Postage 24,500

Convention Expense 40,000

Council and Committee Expense 28,000

Delegates to American Medical Association 54,000

Staff Travel— AMA 3,700

President’s Expense 14,000

Presidential Expense Allowance 15,000

President Elect Expense Allowance 3,000

Staff Travel Expense

Preparation and Distribution of Virginia Medical 122,500

Editor, Virginia Medical 2,400

Legal Expense 110,000

Legislative Program 40,000

Walter Reed Commission 1,000

MSV Auxiliary 7,000

Membership Dues, Affiliated Agencies 1,200

Special Appropriations

AMA/ERA 1,000

Scholarships

Medical College of Virginia 1,000

University of Virginia 1,000

Eastern Virginia Medical School 1,000

Rural Health 1,000

Student Medical Societies

Medical College of Virginia 3,500

University of Virginia 3,500

Eastern Virginia Medical School 3,500

Virginia Health Council 1,000

Hospital Resident Section 1,500

Other Special Appropriations 10,500

Insurance Premiums 14,500

Professional Liability and Tort Reform 60,000

Newsletter 6,000

Employee Benefits

Retirement Fund 110,000

Blue Cross/Blue Shield, Life, and Disability 22,000

Payroll Taxes 34,000

Continuing Medical Education 18,000

Consulting Services

Legislative and Public Relations 60,000

Insurance Actuary 10,000

Physicians’ Health and Effectiveness Program 16,000

Miscellaneous 5,000

Computer Operation and Maintenance 6,000

Audit 8,000

TOTAL $1,441,800

ommended adoption by the House of an amended version of Resolution K from the Virginia Society of Internal Medicine as follows: resolved, that The Medical Soci- ety of Virginia support the continuing study and evaluation of a cost- and resource-based relative value scale for physician reimbursement.

The House adopted the resolu- tion.

Medicaid

Dr. Kreuger described some revi- sions made by Reference Committee Three in Resolution M on Medicaid Reimbursement for Child Health Services, introduced by the Virginia Chapter, American Academy of Pe- diatrics, and the Virginia Pediatric Society.

He urged the adoption of the amended version as follows:

resolved, that The Medical Soci- ety of Virginia urge the Virginia Gen- eral Assembly to enact legislation to improve access to child health serv- ices by increasing reimbursement for all such services.

Resolution U, introduced by the Norfolk Academy of Medicine, also related to Medicaid. It referred to the Virginia Medicaid program as “a poorly run, inefficient bureaucracy with anachronistic fee schedules, punitive audit policies, and unneces- sarily complex, often obscure, regu- lations.” The program has been ranked 48th out of the 50 states in terms of delivering health care, the resolution continued, and is being sued by the American Hospital As- sociation for inadequate reimburse- ment. The resolution concluded by calling for “a complete and thorough investigation of the Medicaid system in Virginia” by the General Assem- bly.

Dr. Krueger pointed out to the delegates that a study of the Medi- caid program is in progress and is being monitored by the Society’s State Legislative Committee, and to that committee the resolution should be referred. The House adopted the recommendation so to refer.

32 Virginia Medical, January 1989

Consent Calendar

Expressing its “sincere thanks and appreciation for the Auxiliary's invaluable assistance and support,” the Reference Committee recom- mended for filing the Report of the Auxiliary Advisory.

The Committee recommended for filing the Report of the Executive Vice President and expressed its “sincere appreciation to Mr. Moore and the staff for their continued service.”

With the Reference Committee's commendation for his “many years of dedicated service,” the Remarks of Speaker William H. Barney were recommended for filing.

Also recommended for filing by Reference Committee Three were all or parts of the Reports of the Alter- native Delivery Systems and Emer- gency Medicine Committees; the Reports of the AMA Delegates and the Editorial Board; and six items

Dr. Clifford A. Nottingham, Roanoke, at the scientific exhibit on the paleopathology of pre-Columbian mummies presented by Dr. Enrique Berszten et al, Richmond

from the Report of Council relating to the Scholarship. Finance, and Physicians' Health/Effectiveness Com- mittees, the annual meeting format/ site.

Dr. John A. Martin, Roanoke, on the driving tee

and MSV/AMA unification.

Recommended for adoption by the Committee were the Reports of the Bylaws, Membership, and Physi- cians’ Health and Effectiveness Com- mittees, and these two resolutions:

1) Resolution AA on Quality of Care Denials, introduced by Dr. Ira J. Green, which read, resolved, that The Medical Society of Virginia sup- port the Medical Society of Virginia Review Organization in its efforts to exclude the provisions regarding no- tification of beneficiaries of quality of care payment denial decisions from the Social Security Act and related regulations.

2) Resolution H on Health Insur- ance for Motorcyclists, introduced by the Norfolk Academy of Medi- cine, which stated, resolved, that The Medical Society of Virginia en- courage the General Assembly of Vir- ginia to enact legislation to require that all persons licensed by the Com- monwealth of Virginia to ride in tw o- wheeled vehicles demonstrate a level of health care insurance sufficient to cover accidental vehicular injuries.

Dr. Michael W. Russell rose to voice his opinion that it would be appropriate to refer the second res- olution to the Highway Safety Com- mittee and he so moved to make that referral. The House agreed and voted to refer. ■

January 1989, Virginia Medical 33

VIRGINIA MEDICAL

President Hulvey

It is a genuine privilege to introduce the President of The Medical Society of Virginia for 1988-1989, Dr. J. Thomas Hulvey, whose distinguished service to the practice of medicine, to the Society and to his com- munity eminently equip him to foster the continued development of The Medical Society of Virginia in this rapidly evolving time.

Tom Hulvey was born in Staunton, Virginia, on November 15, 1935. Following graduation in 1962 from the University of Virginia School of Medicine, Dr. Hulvey completed his surgical internship at The University of Florida. He then saw duty as a medical officer in the United States Navy from 1963-1965. Re- turning to the University of Virginia, he completed his residency in orthopedics and entered private practice in Abingdon, Virginia, in 1969.

He is a diplomate of the American Board of Ortho- paedic Surgery and a fellow of the American Academy of Orthopaedic Surgeons and the American College of Surgeons. Tom Hulvey is a member of the Washington County Medical Society,

Southwestern Virginia Med- ical Society, American Med- ical Association, Southern Medical Association, Vir- ginia Orthopaedic Society,

Orthopaedic Society for Sports Medicine, Eastern Orthopaedic Association, Southern Orthopaedic As- sociation, and the Sports Medicine Committees of The Medical Society of Virginia and the Virginia Orthopae- dic Society.

A former President of both the Washington County Medical Society and the Southwestern Virginia Med- ical Society, Tom Hulvey served in the House of Delegates for The Medical Society of Virginia and was chairman of the Membership Committee and the Van- guard Committee. As 9th District councilor, he served

from 1979 to 1985. He was elected as an alternate MSV delegate to the American Medical Association. In 1985, he was elected Second Vice President and the fol- lowing year, First Vice Pres- ident. In 1987, he became President Elect.

For the University of Vir- ginia and its School of Med- icine, he has been vice chair- man and chairman of the Medical Alumni Advisory Committee. He is a consult- ant in hand surgery and sports medicine and a mem- ber of the University of Vir- ginia Student Aid Founda- tion.

Dr. Hulvey is a staff or- thopaedic surgeon and mem- ber of the board of trustees, Johnston Memorial Hospi-

President Hulvey

34 Virginia Medical, January 1989

tal, Abingdon, Virginia; orthopaedic consultant, Vir- ginia Bureau of Crippled Children; consulting ortho- paedic surgeon, Southwestern State Hospital, Marion, Virginia; and clinical assistant professor. Department of Orthopedic Surgery, Medical College of Virginia, Richmond.

In Abingdon, he has served for many years as a member of the Barter Foundation, which operates the state theater of Virginia. He has been a member of the advisory board of Central Fidelity Bank and the Wash- ington County School Board and actively worked in sports medicine in Southwest Virginia with Emory and Henry athletic teams, as well as area high school teams and Little League programs.

It gives me great personal satisfaction that he was presented the Second Annual Award given by the Virginia High School Coaches Association to the individual who has given the most to the medical care of the high school athletes.

Dr. Hulvey married Elizabeth Lewis Kelsey, a native of Blacksburg, Virginia. They have two daugh- ters and a son.

Tom Hulvey will diagnose and treat the problems of The Medical Society of Virginia in the same decisive, wise and honest way that he handles his patients — practical in his approach, but fair to all in recognition of their just and proper needs.

His ability to cut through the extraneous material to expose the vital crux of any issue is clearly apparent to all in contact with him.

Dr. Hulvey has the ability to accomplish any task imparted to this office. He will perform his duties with vigor and a steadfast and stalwart manner. Please join me in wishing him well.

Frank C. McCue III, MD

University of Virginia Health Sciences Center Charlottesville, Virginia 22908

MSV Progress

Since the unfortunate division of opinion over the American Medical Association/Medical Society of Virginia unification, with the resultant loss of MSV members, the Society has buckled down and contin- ued to go forward. But progress has not been easy.

During the past year, the Society has been fortunate in having as president Dr. Glenn Updike, an industri- ous and innovative leader. His good judgement and thoughtful evaluation of complex problems have

served the Society well. We are grateful for his leader- ship.

Now, in Dr. J. Thomas Hulvey, the Society has another outstanding leader and prospects are bright for a continuation of this progress. But we must actively support Dr. Hulvey and the other MSV leaders. Medi- cine in Virginia needs MSV support; non-members certainly don’t supply it.

E.L.K., Jr.

Forgiving

Most patients are far more forgiving and tolerant of our errors and foibles than we think. Over the years far more patients have overlooked my oversights than have nitpicked and found fault when I was faultless. Even when I have erred, many a patient has made excuses for me.

Yes, rapport with the patient is almost everything. If the patient likes you, trusts you, and knows that you are sincerely interested in the problem, even major gaffes are overlooked.

I am in the habit of telling patients entering my examining lane to have a seat in the big chair so that they will sit in the examination chair rather than in the chairs for relatives. Several years ago I called a lady’s name, and when she arose, I noticed she was very obese, with most of her excess weight in her hips and thighs. Her shape was so unusual as to be almost grotesque. With my mind wandering over thoughts about her large hips perhaps being the result of some

metabolic or endocrine problem, I told her, ‘‘Please have a big seat in the chair.”

She looked at me, and I mortifiedly returned her gaze and gasped, ‘‘I don’t believe that I just heard what Ijust heard come out of my mouth.” I smiled my best smile, and smitten with my obvious charm and sincerity she laughed. I laughed. We laughed and chuckled and made friends.

I finished her examination, explained her problem, and gave her a prescription. She left with the firm conviction that my medication would help because we had rapport. I had charmed her in spite of my initial Freudian slip. Another instance of honesty, charm and sincerity winning over a patient who could have been very hostile. Yes, I was proud of how I had handled my error.

I never saw her again.

Henry S. Campell, MD

January 1989, Virginia Medical 35

FROM THE ROSTRUM

The President Addresses Some Chief Concerns

Glenn B. Updike, Jr., MD, President 1987-1988, The Medical Society of Virginia

When I assumed office as your President one year ago, I touched in my remarks on some of the plans and objectives I believed needed our attention in the forthcoming year. You will not be surprised to learn that many of our problems remain with us, nor will you be further surprised to learn that some other little challenges arose during the course of the year.

At this time I will address the chief concerns of our members as judged by our mail and by reactions I have encountered in speaking to component societies. The actual work of the Society is covered in the committee reports and in the report of Council. I commend them to you for a complete report on Society activities.

In the spring we began to receive complaints from members about Blue Cross/Blue Shield charges for electronic claims submission and the introduction of a new paper claim form. As directed by Council, we engaged a data processing consultant to advise us in an approach to these problems. We have met with BC/BS top management on a number of occasions as re- ported. The net result of our conversations is that BC/ BS stands fast on its business decision to charge for electronic claims submission but did agree to postpone charging until 1 November. They had previously indi- cated that HCFA 1500 forms would receive the same processing attention as in the past for paper claims. We urge members to keep documented records of claims difficulties and report them to Medical Society of Virginia headquarters as well as to BC/BS, so that the situation can be properly monitored.

Presented before the House of Delegates at the annual meeting of The Medical Society of Virginia on November 5, 1988, at the Williamsburg Conference Center.

Membership loss has remained a problem. The decrease creates fiscal problems, but in my judgment loss of members per se is more significant. I believe that The Medical Society of Virginia should be just that, a society composed of most if not all of the physicians in the commonwealth.

For this reason, it is essential for the welfare of our Society that we have under constant review our major policy decisions and their ongoing effect. The record shows that following our decision to unify in 1985, we lost approximately 1400 members and the American Medical Association gained 1600 new members in Virginia. In addressing properly my responsibilities as your President, I therefore felt concern over the AMA dues increases recommended by the AMA Board of Trustees for 1989 and 1990. That is, I did not want to wind up “head flea on a dead dog.” I am aware that each of us often fritters away $23.00 without a thought. I am also aware that we and our professional brethren have used less weighty straws than this to break the back of a camel received with only marginal enthusi- asm by some.

Therefore, on behalf of the Virginia delegation at the annual AMA meeting in Chicago in June, I proposed at the Unified Societies Advisory Committee meeting and at the appropriate reference committee that the six unified states be granted an exemption from the dues increase. The reference committee did not recommend nor did the House of Delegates grant the exemption.

I have given careful thought to the possibility of recommending an equal decrease in MSV dues to offset this increase, but in view of our ongoing ex- penses, particularly in the legislative and lobbying field, I cannot in good fiscal conscience recommend a decrease.

36 Virginia Medical, January 1989

My concern, of course, is that of further member- ship loss. Council addressed this problem in Septem- ber through the following resolution: "... that the President appoint an ad hoc committee to look into the problems associated with unification and deunification and to conduct a survey including groups they deem fit and report to Council with their findings at the earliest possible time.”

I have appointed this committee, chaired by Dr. Jim Patterson, who will be membership chairman next year. We have met with membership representatives from the AMA, and they are preparing surveys to be directed to members we have lost and to other physi- cians as well who are not MSV/AMA members. These are to be submitted to us for review. Also plans for a membership recruitment effort have been submitted and are being evaluated. The AMA proposed a “bonus recruitment” plan directed at the employment of phy- sicians no longer in practice as “recruiters.” I believe that monetary rewards should more appropriately ac- crue to the Society than to individuals. I proposed that they present a plan that would accomplish this objec- tive and if done, I would appeal to the leadership — officers, councilors, vice councilors, MSV delegates and alternates and AMA delegates and alternates — to accept the challenge in a true peer-to-peer effort in recruitment. The AMA has responded with a plan with greater monetary incentives and with membership goals that deserve intense effort on our part. I there- fore call on all of our leadership to join in this effort and accept specific assignments.

To summarize my appraisal of the present unifica- tion/deunification situation: I do not consider it an issue at this annual meeting, constitutionally or other- wise. Council has directed an approach that we are following. With information from the surveys and with membership recruitment results in hand, we can make informed decisions. I believe it to be less than reason- able not to keep our minds open on this question. It is essential that our conclusions be reached with the best interests of The Medical Society of Virginia in mind. This, of course, is the primary responsibility with which we are charged. We must maintain the strength of our convictions on behalf of medicine in Virginia. We also must fortify the strength of these convictions with strength in numbers, particularly in our dealings with the legislature.

There is no doubt that we have lost members because of the $250 assessment levied by the General Assembly as part of the financing of the Injured Infant Act. Diligent efforts have been made to inform all physicians about the act, its potential benefits and the necessity for the assessment. Judging from certain responses, we have not been totally successful in our objective. However, we now have prepared amend- ments to the act to be proposed to the General Assembly in January. If passed, the assessment would be curtailed, though it is not likely that it would

become effective in 1989. I do believe that if support of the proposal is accompanied by only a portion of the vigor, imaginative eloquence and energy we have seen in opposition to the assessment, it cannot help but pass. Please be prepared to mount an intense legisla- tive effort in support of this proposal.

VaMPAC and The Medical Society of Virginia can have more effective legislative impact with closer and broader cooperation in evaluating legislators and their positions. The Legislative Committee has established a grass roots legislative task force. In conjunction with this, I propose that Council take steps to ensure that the VaMPAC directors receive input from councilors, vice councilors, and the legislative committee member from each district, as well as our lobbyists, before making any decisions on candidate support. We will also have information available from Virginia care, a service that provides records of each legislator's vote in committee and on the floor. I ask that the House adopt and approve this proposal.

The shortage of bedside care for patients was ad- dressed by the AMA through the concept of pilot programs to train registered care technicians to help fill the gap. Your delegation to the AMA supported this concept. It may not be the final solution to the problem of bedside care, but it has brought forth a great deal of reaction which I hope will translate into positive cooperation among all concerned with patient care. We have reactivated the Joint Care Committee to represent us in this field.

We have continued to work toward higher levels of physician reimbursement, particularly in the field of primary care. Some success has been obtained, but funding is still not adequate. The recently released Resource Based Relative Value Study will offer sup- port for readjustments in the “cognitive” fields. The Society will be represented at the AMA/RVS confer- ence in Chicago.

The Auxiliary, under the leadership of its energetic and peripatetic President, Carole Lougheed. has con- tinued with its indispensable activities in medicine's behalf. Again, quite simply, we could not do without them.

Most organization work is done through its commit- tees. I particularly wish to commend Ken Tuck of the Legislative Committee, Ron Davis of the Professional Liability Committee, Jim Ghaphery of the Injured Infant Task Force, Hayden Hollingsworth of the Membership Committee and Ira Godwin of the Insur- ance Committee. The Executive Committee and Council have labored willingly and faithfully on the Society’s behalf. There are many others who also deserve the thanks of the Society: these will become apparent as you study the committee reports.

There are many to whom I and the Society owe thanks. I do not believe that anyone who has not occupied the position I have this year can fully appre- ciate the role that Jim Moore plays in our organization.

January 1989, Virginia Medical 37

The term “dedicated” is used often and rather freely, but I know firsthand that Jim’s dedication and devo- tion to the Society are total. The joys of the presidency do not come unaccompanied by certain moments of challenge, if not despair, and it has been most reassur- ing to have the Executive Vice President to smooth out and insulate one from some of the bumps along the way. I submit that Jim Moore is a worthy successor to his honored mentor, Bob Howard.

The Society’s staff members “behind the scenes” have performed smoothly and efficiently. I have been well supported by my own office staff. I am grateful to my colleagues, Drs. Richard Patterson, William Broach, and DeWitt Ellis, for their generous coverage for me when Eve been on the road.

Most important to me personally, I extend to my wife, Betty, my everlasting thanks for the added measure of patience and support . . . above and be- yond . . . that she has given me in the past year.

Now, permit me a bit of a homily as I conclude.

Medicine as the profession we know can survive only if we adhere to the basic traditions sacred to our predecessors. Concern and caring devotion in each of the two million to four million patient visits a day in America must be maintained to ensure patient trust and confidence. To do this, we must develop our skills though continuing medical education, adopt firm quali- ty assurance procedures, and through our own peer review process assure that our profession is kept free of those who are incompetent or unfit. Unless we do this we can not properly claim that the health care system of which we are a part is the best in the world.

On the other hand, we are beset by forces that would dictate how health care will be delivered. We must not let the almighty bottom line, corporate or governmental, create guidelines that impair quality of care. Rationing of health care is now a reality: who will have the liver transplant? how many coronary bypass- es can we afford? how many carotid endarterectomies equal how many lens implants? A prudent concern for fiscal reality is necessary but the basic decisions must remain in physicians’ hands. Unfortunately, the doc- tor no longer sits alone in the consultation room with the patient. Somewhere nearby, as “close as your telephone”, sits a “patient treatment manage- ment coordinator” or some such, armed with a recipe book and a computer screen ready to tell you that you must do with the patient and how long you may take doing it.

We must make our influence felt. From a position firmly based on public trust and confidence, we must approach government through organized medicine: our component societies at the local level, The Medi- cal Society of Virginia at the state level, and AMA at the national level. Just as important we must constant- ly reach our legislators as individuals. Success is not guaranteed but we shall surely lose by default if we do

not persevere in all of the above.

If you don’t believe me, let me refer to an authority, Chairman Dan Rostenkowski of the House Ways and Means committee. When asked at the AMA National Leadership Conference what doctors could do to be heard he said (and I paraphrase), “Doctor, over here in Washington we read the Washington Post and the New York Times and we believe what we read so if you want to be heard you had better get hold of your representatives and senators and tell them what you think.” Therefore, if we do provide the best health care in the world we must be prepared to work for its survival; otherwise it will be merely a thing of the past.

As I have said, I have many to whom I am grateful for support, aid and comfort this past year. I happen to believe that for a Virginia physician, particularly one born a Virginian, there is no higher honor than the privilege of serving as President of The Medical Society of Virginia. Therefore, my deepest thanks are extended to you, my friends and colleagues, who gave me this opportunity for service in our beloved Commonwealth. For this, I will be always and truly grateful.

A TRIBUTE TO

SANFORD WARSHAUER, M.D.

(1935 - 1988)

We have suffered a deep loss and mourn the untimely death of a true leader of Alexandria Hospital and our Medical Staff. He served as a guiding force at the Hospital, particularly in the development of the com- prehensive family-centered maternity services we offer today. He infused a spirit of compassion and profes- sionalism that will be tremendously missed. But, in his absence, we will carry on his tradition of excellence.

We are grateful for having had the opportunity to work with someone as caring and progressive as Dr. Warshauer, someone who always pushed us to be the best we could be. He truly made a difference at Alexan- dria Hospital.

A ALEXANDRIA HOSPITAL

38 Virginia Medical, January 1989

OBITUARY

A. Epes Harris, Jr., MD 1925-1988

Dr. Andrew Epes Harris, Jr., for 36 years a family physician in Blackstone, Virginia, died unexpectedly on November 13, 1988, in Winston-Salem, North Carolina. He was 63 years old. Dr. Harris had gone to North Carolina to see his second grandson, born November 9 to his daughter, Amanda, and her hus- band, George Woolen.

Only six weeks before his death, in a ceremony at the State Capitol in Richmond, Dr. Harris had been

named a Virginia Cultural Laureate for his pivotal role in the establishment, in 1970, of Virginia’s family practice residency program, which encourages young physicians to serve rural areas. He founded the Black- stone Family Practice Center with his brother, Dr. James Selden Harris, who survives him, and Dr. Stuart Bruce White, and it became the rural arm of the Medical College of Virginia’s family practice depart- ment, with all three physicians serving on the MCV faculty.

Deeply rooted in Virginia, Dr. Harris could trace his ancestry to an Englishman who came to Virginia in 1611, Thomas Harris, and to Francis Epes, who set- tled in Virginia in 1623. Plantations figure in the family’s history, among them “Norwood” and “Mill-

wood” in Powhatan County and “Appomattox Man- or” (now called “Epes Manor”) near Hopewell. Ulys- ses S. Grant made the latter his headquarters during the seige of Richmond, and the estate is now a federal historical park. Epes Harris lived in Blackstone in a house his grandfather built; his bedroom was the room in which he was born. He had roots in Virginia medicine, too: His great-grandfather, Dr. William Jor- dan Harris, was a member of the first Virginia State Board of Medical Examiners, created in 1884.

Educated at Hampden-Sydney College and the Medical College of Virginia (M-51), where he also performed his residency, Epes Harris from early on in his practice was committed to organized medicine. He had been president of the Southside Medical Society and a delegate to Medical Society of Virginia meet- ings, and he had also led as president the Virginia Academy of Family Practice. For the American Acad- emy of Family Physicians, he was a longtime delegate to the Congress of Delegates. His contribution to The Medical Society of Virginia centered chiefly on the Virginia Medical Political Action Committee, for he was convinced that the profession of medicine should make itself heard in legislative chambers, and he was a veteran VaMPAC board member. Clinical superiority was his, too; he was a charter diplomate of the American Board of Family Physicians and a fellow of the American Academy of Family Physicians. For these and many more professional organizations he had served in numerous advisory capacities and on countless boards and committees.

At his death he was chairman elect of the Medical Division, Medical College of Virginia Alumni Associa- tion. In his native community, the Blackstone Cham- ber of Commerce saluted him in 1976 with its service award, he had been president of the Blackstone Rotary Club, and he was an elder of the Blackstone Presby- terian Church.

An editorial in the Blackstone Courier-Record said this of him in part:

“When it came to serving his fellow man, Epes Harris never ran out of energy. Through his efforts Blackstone became the site of the first Family Practice Center in Virginia. Dozens of physicians have been trained here in how best to provide family health care. He helped establish other such centers around the nation. The world is a better place because Epes Harris lived and served . . .

“Little Travis Edward never got to know his grand- father, but as he grows up he will hear much about the man we all loved and so greatly mourn."

Dr. Harris’ wife, Arline Raney Harris, also survives him, as do another daughter, Elizabeth Selden Harris, Newport News; a son, Andrew Epes Harris III, Mo- bile, Alabama; and two sisters, Lunette Harris Beale and Katherine Harris Coleburn, both of Blackstone.

January 1989, Virginia Medical 39

YOCON'

YOHIMBINE HCI

Description: Yohimbine is a 3a-15a-20B-17a-hydroxy Yohimbine-1 6a-car- boxyiic acid methyl ester. The alkaloid is found in Rubaceae and related trees. Also in Rauwolfia Serpentina (L) Benth. Yohimbine is an indolalkylamine alkaloid with chemical similarity to reserpine. It is a crystalline powder, odorless. Each compressed tablet contains (1/12 gr.) 5.4 mg of Yohimbine Hydrochloride.

Action: Yohimbine blocks presynaptic alpha-2 adrenergic receptors. Its action on peripheral blood vessels resembles that of reserpine, though it is weaker and of short duration. Yohimbine’s peripheral autonomic nervous system effect is to increase parasympathetic (cholinergic) and decrease sympathetic (adrenergic) activity. It is to be noted that in male sexual performance, erection is linked to cholinergic activity and to alpha-2 ad- renergic blockade which may theoretically result in increased penile inflow, decreased penile outflow or both.

Yohimbine exerts a stimulating action on the mood and may increase anxiety. Such actions have not been adequately studied or related to dosage although they appear to require high doses of the drug . Yohimbine has a mild anti-diuretic action, probably via stimulation of hypothalmic centers and release of posterior pituitary hormone.

Reportedly, Yohimbine exerts no significant influence on cardiac stimula- tion and other effects mediated by B- adrenergic receptors, its effect on blood pressure, if any, would be to lower it; however no adequate studies are at hand to quantitate this effect in terms of Yohimbine dosage.

Indications: Yocon® is indicated as a sympathicolytic and mydriatric. ft may have activity as an aphrodisiac.

Contraindications: Renal diseases, and patient’s sensitive to the drug, in view of the limited and inadequate information at hand, no precise tabulation can be offered of additional contraindications.

Warning: Generally, this drug is not proposed for use in females and certainly must not be used during pregnancy. Neither is this drug proposed for use in pediatric, geriatric or cardio-renal patients with gastric or duodenal ulcer history. Nor should it be used in conjunction with mood-modifying drugs such as antidepressants, or in psychiatric patients in general.

Adverse Reactions: Yohimbine readily penetrates the (CNS) and produces a complex pattern of responses in lower doses than required to produce periph- eral a-adrenergic blockade. These include, anti-diuresis, a general picture of central excitation including elevation of blood pressure and heart rate, in- creased motor activity, irritability and tremor. Sweating, nausea and vomiting are common after parenteral administration of the drug.12 Also dizziness, headache, skin flushing reported when used orally.1-3 Dosage and Administration: Experimental dosage reported in treatment of erectile impotence. 1 -3-4 1 tablet (5.4 mg) 3 times a day, to adult males taken orally. Occasional side effects reported with this dosage are nausea, dizziness or nervousness. In the event of side effects dosage to be reduced to Vz tablet 3 times a day, followed by gradual increases to 1 tablet 3 times a day. Reported therapy not more than 10 weeks.3 How Supplied: Oral tablets of Yocon® 1/12 gr. 5.4 mg in

AVAILABLE EXCLUSIVELY FROM

bottles of 100’s NDC 53159-001-01 and 1000’s Nnn

References:

1. A. Morales et al.. New England Journal of Medi- cine: 1221 . November 12, 1981 .

2. Goodman, Gilman — The Pharmacological basis of Therapeutics 6th ed., p. 176-188.

McMillan December Rev. 1/85.

3. Weekly Urological Clinical letter, 27:2, July 4, 1983.

4. A. Morales etal., The Journal of Urology 128: 45-47, 1982.

PALISADES

PHARMACEUTICALS, INC.

219 County Road Tenafly, New Jersey 07670

(201) 569-8502 Outside NJ 1-800-237-9083

NEW MEMBERS

Alexandria Medical Society

William D. Trainor, MD, Pulmonary Medicine, 5216 Dawes Avenue, Alexandria VA 22311

Peter J. Verdin, Jr., MD, Orthopedic Surgery, 2805 Duke Street, Alexandria VA 22314

Augusta-Highland Counties Medical Society

David Q. Massey, MD, Family Practice, 113 First Street, Stuarts Draft VA 24477

Bradley M. Tipler, MD, Diagnostic Radiology, 110-D Mac- Tanly Place, Staunton VA 24401

Fairfax County Medical Society

Donald G. Hope, MD, Neurosurgery, 3016 Williams Drive, Fairfax VA 22031

Patrick F. A. Magee, MD, Cardiology, 5510 Alma Lane, Springfield V A 22151

Lynchburg Academy of Medicine

Robert N. Headley, Jr., MD, Oncology, 1509 Lexington Drive, Lynchburg VA 24503

Wade A. Neiman, MD, Obstetrics/Gynecology, 1300 Cren- shaw Court, Lynchburg VA 24503

Newport News Medical Society

James W. Reid, Jr., MD, Internal Medicine, 1401 Washing- ton Avenue, Newport News VA 23607

Richmond Academy of Medicine

Hugh H. Hemsley, Jr., MD, Emergency Medicine, 5712 Oak Knoll Road, Midlothian VA 23112

C. Foster Jennings, Jr., MD, Internal Medicine, 7702 Parham Road, Richmond VA 23229

Edward M. Leaton, MD, Neurology, 7131 Jahnke Road, Richmond VA 23225

Roanoke Academy of Medicine

Laurie A. Flint, MD, Family Practice, 3104-F Honeywood Lane, Roanoke VA 24014

Southside Virginia Medical Society

Wallace J. Horne, MD, Family Practice, PO Box 416, Alberta VA 23821

Virginia Beach Medical Society

Robert E. Davis, MD, Occupational Medicine, Occupational Health Service, Virginia Beach VA 23456

Pamela G. Pyle, MD, Obstetrics/Gynecology, 913 First Colo- nial Road, Virginia Beach VA 23454

York E. Winston, MD, Obstetrics/Gynecology, 915 First Colonial Road, Virginia Beach VA 23454

'Williamsburg- James City County Medical Society

Diem D. Nguyen, MD, Family Practice, 3810 Staffordshire Road, Williamsburg VA 23185

40 Virginia Medical, January 1989

HEALTH SCIENCES LIBRARY UNIVERSITY OF MARYLAND BALTIMORE

Up Front

Insuring a Healthy Medical Liability

Insurance System

Mary Sue Terry Medibytes: MSV Council Meets

History

In Rural Virginia, World-Class Medicine

John Peter Mettauer, 1787-1878

John R. Right

Editorials

Medicine

Diagnostic Methods for Chlamydial Infections

in a High Risk Population

Kathrine F. Boese, Susan McLeod, and Michael F. Rein Abstracts for the Regional Meeting,

Virginia Chapter, American College of Physicians, and Virginia Society

of Internal Medicine

Carbon Monoxide Poisoning in Indoor

Ice Skating Arenas

Richard K. Miller, Mary C. Ryan, and Paul Bilowus

Fraud and Abuse Statutes E. L. Kendig, Jr. Self-Pity

H. C. Campell

Letters to the Editor

How to Report AIDS/HIV Infections

Obituary .

Guide to the Natural Death Act

Meetings about Medicine

Classified Advertisements

Who’s Who: Dr. James G. Nuckolls

dume 116

L

February 1989

Number 2

Your Basic Medical Plan

May

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The

Way

W’ ould your basic medical plan carry you through a prolonged illness or serious injury? Would it carry you through the high cost of advancements in medical technology, new procedures or specialized equipment? What about a longer than average hospital stay?

Probably not. That is why the Medical Society of Virginia is sponsoring an Excess Major Medical plan.. .to pick up where your basic medical plan leaves off.

Highlights

• Pays up to a Lifetime Maximum of

$1,000,000

• Pays up tol00% of eligible expenses after the deductible

• Choice of $50,000 or $100,000 cash deductibles

• Pays whether you are in or out of the hospital

• Broad coverage

• Family and employee coverage available

• Affordable rates

For more information , including terms and conditions of coverage, write the insurance administrator, John P. Pearl & Associates, Ltd., or call them at (804) 282-9600,

Virginia toll-free (800) 572-2211.

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‘ ‘Light at end of smoke-filled tunnel”:

Va Med’s text on smoking in hospitals

After reading the November 1988 issue of Virginia Medical, I saw light at the end of the smoke-filled tunnel. I am very encouraged by the articles on smoking in hospitals1,2 and the letter of Delegate George W. Grayson.1 2 3

About a year ago, I started pushing a local hospital to institute a restrictive smoking policy. Fortunately, the administration was very receptive and a smoking committee was formed. It was important to have both smokers and nonsmokers represented on the commit- tee. After a long deliberation and research, we have finally come up with a smoking policy. This will severely restrict visitors and staff and will be gradually phased in. Public buildings of this sort were not built with smoking policies in mind.

One of our obstacles was and still is how to tell the handful of physicians they cannot smoke in the physi- cians’ lounges, dressing rooms, and dining areas. Some of them are hostile towards this smoking policy, and we all understand change does cause some uneas- iness. On the other hand, many smokers understand that smoking is an environmental pollutant, and they have been very cooperative.

The global issue of smoking in our society is a difficult problem. I hope that physicians will be at the forefront of helping our society achieve a smokeless state at some point in the future. The economics of smoking and health care will certainly help change our ways. It will be extremely expensive for our society to continue to provide health care for those individuals who have been harmed by their long history of smok- ing.

Once again my congratulations. Keep up the good work.

Isaac Koziol, MD

5855 Bremo Road Richmond VA 23226

1. Gray A, Kendig ELjr. Smoking in Virginia’s hospitals. Va Med 1988;1 15:526-527, 530

2. Davy N. Witness: “We could watch our patients and smoke a couple of cigarettes.” Va Med 1988:1 15:528-529

3. Grayson GW. Delegate Grayson to seek no-smoking areas in hospitals (letter). Va Med 1988;! 15:508

MEDICAL SOCIETY OF VIRGINIA

President

J. Thomas Hulvey, MD, Abingdon President Elect

William H. Barney, MD, Lynchburg

Immediate Past President

Glenn B. Updike, Jr., MD, Danville

First Vice President

John A. Owen, Jr., MD, Charlottesville

Second Vice President

Leon I. Block, MD, Falls Church

Third Vice President

James P. Baker, MD, Norfolk

Speaker

George E. Broman, MD, Culpeper Vice Speaker

Lawrence K. Monahan, MD, Roanoke

Councilors by District 1st: William H. Sipe, MD, Newport News

2nd: Russell D. Evett, MD, Norfolk 3rd: William W. Regan, MD, Richmond

4th: John W. Hollowed, MD, Portsmouth

5th: Edwin J. Harvie, MD, Danville

6th: Jeffrey W. Wilson, MD, Lynchburg

7th: H. George White, Jr., MD, Winchester

8th: Ira J. Green, MD, Alexandria

9th: James L. Patterson, Jr., MD, Pulaski

10th: Ira D. Godwin, MD, Fairfax

AMA Delegates

H. C. Alexander III, MD, Roanoke Raymond S. Brown, MD, Gloucester Charles M. Caravati, Jr., MD, Richmond C. Barrie Cook, MD, Falls Church Richard L. Fields, MD, Fairfax William J. Hagood, Jr., MD, Clover John A. Martin, MD, Roanoke Glenn B. Updike, Jr., MD, Danville Percy Wootton, MD, Richmond Harold L. Williams, MD, Newport News

Executive Vice President James L. Moore, Jr.

February 1989, Virginia Medical 49

Crisis in black and white.

Your personal crisis may be waiting in the morning mail. If so, you’ll want the best professional help. You’ll want a Medical Protective General Agent.

Professional liability coverage is our only business. And we’ve been providing it for almost 100 years. Our agents live in the territories they serve so they understand the local legal climate. And with the extensive resources of the home office Law Department to draw from, they’re always ready to answer your questions or give advice.

Someday it may be you against a negligence charge. When that day comes and your professional reputation is on the line, you’re going to want all the help you can get. To make sure you have it, contact your Medical Protective General Agent today.

Ted J. Pandak, 4205 Dover Road Richmond, Virginia 23221, (804) 359-0036

FROM THE CAPITOL

Insuring a Healthy Medical Liability Insurance System

Mary Sue Terry, Attorney General of Virginia

Medical malpractice insurance is as important to a smoothly functioning health care system as anesthesia in a surgical suite: you just can’t operate without it.

I am concerned that persistent problems with medi- cal malpractice insurance might result in Virginia’s citizens being denied adequate health care. The tort reparations system for compensating victims of medi- cal malpractice is not simply a financial mechanism. It affects victims of malpractice, doctors and hospitals, consumers, lawyers, insurers, businesses and govern- ment.

While these groups may have goals that often con- flict, it is generally agreed that a good tort system should encourage quality medical care; provide fair and humane treatment of victims; encourage economic efficiency; and provide for predictability of victims’ compensation and insurers’ costs.

No simple approach can accomplish all these goals. Our response in Virginia has been multi-fold, including close regulatory scrutiny, limited tort reform, estab- lishment of the Virginia Birth-Related Neurological Injury Compensation Program, and authorization of a Joint Underwriting Association for medical malprac- tice insurance. Despite these efforts, there are still imbalances in the tort system in Virginia.

We can get some idea of the complexity and subtlety of the medical malpractice issue by looking at the situation in our state’s hospitals that have associated medical schools, and that treat many of the Common- wealth’s indigent patients.

Medical faculty members often have private prac- tices that complement their work as state employees. The State pays for their medical malpractice insurance in their capacity as employees of the Commonwealth, but they are on their own in purchasing malpractice insurance for their private practice associated with the

The Attorney General’s Office is in the Supreme Court Building, 101 North Eighth Street, Richmond VA 23219.

institution. Some doctors report that their malpractice insurance premiums take as much as half of their state salary.

If this insurance situation is not resolved, our medi- cal schools may eventually be unable to recruit faculty members — especially in “high risk” specialties. And the people who will be hurt most are Virginia’s needi- est citizens. Thus, we are faced here with an important issue of public policy. We need to find an approach that will keep in balance the needs of the doctors, the state institutions, and the patients they serve.

The search for solutions to the problems with medi- cal malpractice insurance is complicated by the fact that medical malpractice insurance is “a land of many contrasts.” What appears to be a solution in one place may not help — and, indeed, may hurt — in another place. Our first challenge, then, is to develop a road map of medical malpractice insurance, to see where we have come from, where we are today, and what routes we might take to get to where we want to go. Here are some of the approaches that have been tried or proposed for Virginia.

• Under insurance regulatory reforms drafted by my Office and unanimously adopted by the General As- sembly in 1987, the State Corporation Commission annually reviews Virginia’s commercial liability insur- ance market and designates those lines it has reason to believe are potentially noncompetitive.

In November 1987 the SCC designated medical malpractice insurance as a potentially noncompetitive line of insurance. Last July the Commission found that it is in fact noncompetitive, subjecting rate requests to prior review.

Since 1987 my Office has made a commitment to monitor requests by insurers for rate increases. For example, when St. Paul asked for a 29.5% medical malpractice rate increase in 1988 (after receiving a 15% increase in 1987), we hired an insurance consultant and actuary to review that rate request.

Regulatory scrutiny can help keep medical malprac- tice insurance rates from becoming excessive within

February 1989, Virginia Medical 53

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the meaning of the Code of Virginia, but it does little to address problems of unavailability. And clearly, regu- latory effectiveness is enhanced when the medical profession becomes its own best advocate, as when The Medical Society of Virginia hires an actuary to evaluate proposed rate increases and provides input to the regulators.

• The Joint Underwriting Association deals with the availability problem but does not help much with affordability. The JUA’s premiums are usually higher than ordinary-risk premiums, and the size of the JUA’s risk-sharing pool is limited, although that has improved somewhat as more doctors have joined the JUA.

• The Birth-Related Neurological Injury Compensa- tion Program removes a category of serious injuries from the tort system, but since no claims have been filed thus far, the effectiveness of the fund in compen- sating victims has not yet been tested, and no signifi- cant reductions in medical malpractice insurance rates have resulted to date.

• While at first glance shared risk pools, or risk retention groups, would appear to solve both afford- ability and availability problems, there are practical concerns that make this apparently simple solution difficult to achieve.

We in the Office of the Attorney General are con- cerned about the health of medical malpractice insur- ance in Virginia. We know that good insurance princi- ples and sound underwriting practices are central to any kind of risk management strategy, whether by a commercial insurer or through some pooling arrange- ment. We recognize that the inventory of an insurance company — or a shared risk pool — consists primarily of the money it holds in trust to meet obligations incurred under the policy contract. The insurance product is not fully delivered until all claims are paid and all policies have expired. If an insurance company fails, its customers and many other people will be hurt. We don’t want that to happen in Virginia, any more than we want Virginia’s insurance consumers to pay more than they should for the protection they need.

We need to hear from Virginia’s physicians, so that we have a clear picture of the medical malpractice insurance situation in Virginia and can decide how best to allocate our resources to meet the many needs of our citizens. I encourage Medical Society of Virgin- ia members to let my office know of any specific problems and concerns.

Our goal is an insurance environment in which individuals, businesses and professionals can obtain the protection they need at a price they can afford; in which our citizens can enjoy the benefits of quality health care and protection for injured workers; in which businesses and entrepreneurs can take the nec- essary risks to develop and market products; and ultimately, in which our citizens can achieve their fullest potential. ■

54 Virginia Medical, February 1989

MBVTES

MARY SUE IN THE CARRIERS' DEN

Elsewhere in this issue Virginia's Attorney General, Mary Sue Terry, asks Virginia physicians to write to her. She wants to know your experienced problems with the medical liability insurance situation and your concerns about it. Ms. Terry has been challenging the insurance industry, a formidable adversary, and seems to be feeling the need for help. That's not surprising, since a legislative subcommittee failed to support her key initiative, a recommendation to restrict the ability of insurance companies to use certain data collected by rating bureaus. The insurance industry's lobbyist told the subcommi ttee the Attorney General's proposal would lead to higher costs for many small companies and thus to higher rates for consumers. The subcommittee came down 9-1 on the carriers' side; the lone supporting vote came from Del. Thomas W. Moss,

Jr., the subcommittee's chairman. Answer Ms. Terry's plea. Write! Her office is at 101 North Eighth Street, Richmond V A 23219.

STATE COURT'S RULING ON CAP TAKES COUNCIL SPOTLIGHT

News of the Virginia Supreme Court's decision upholding the constitutionality of the cap on medical liability awards dominated the meeting of The Medical Society of Virginia's Council on January 14 at headquarters. MSV President J. Thomas Hu Ivey conducted the meeting.

"It's a good decision, carefully written," observed counsel Allen C. Goolsby III, "and it is very important substantively and PR-wise, but the issue will not be over until the 4th Circuit Court case is decided." The case before the U.S. Court of Appeals, 4th Circuit, is an amicus curiae brief filed by Goolsby on the Society's behalf to test the legality of the cap. "We'll have a decision there in a couple of months," the attorney predicted. "If the decision is not favorable, we can go to the [U.S.] Supreme Court with it. I think there's a good chance the justices would be willing to hear it."

Virginia's law limiting med i ca 1 1 i ab i 1 i ty

awards to $750,000 was passed in 1976, and the state's trial lawyers have been trying to discredit it ever since. The action that brought the ruling by the state justices was

FEBRUARY 1 989/V I RG I N I A MEDICAL 57

MEQBVTES

filed on behalf of a Virginia Beach mother of three who suffered brain damage in a 1980 operation and sued the hospital; she won her suit and the jury awarded her $2.75 million, but the judge applied the cap to the award.

The judge's action, said the four- just i ce majority opinion, was in compl iance with the law and should be affirmed.

Another state law, the much-discussed Birth-Related Neurological

Injury Compensation Act, is under scrutiny by an MSV task force, and the group's chairman.

Dr. James L. Ghaphery, had news for the councilors. The Williamson Institute for Health Studies at the Medical College of Virginia, he announced, has completed a pilot study of all infants born at the MCV Hospitals 1984-1987 in an effort to predict how many injured babies might qualify annually under the act's provisions as written. The study cost $10,000 and was underwritten by the Virginia Insurance Reciprocal and the Medical Protective Company.

Now, continued Dr. Ghaphery, the authors of that study want to move into a second phase, an analysis of the act's probable cost. Virginia's obstetricians have contributed $5,000 to fund this second phase, he reported, and he asked the councilors to allocate $3,500 to complete the funding. Promptly and unanimously, the councilors did so. (Scheduled for Virginia Medical's March issue are the data from the first-phase pilot study.)

Turning to a report on the Joint Underwriting Association, Dr. Ghaphery revealed that as of September 1 last, 315 physicians had joined the JUA. Of these, 56 are obstetricians, or 107* of the obs in Virginia. As of December 1988, 17 claims were pending, and four had

been settled before trial.

The MSV Federal Legislative Committee, seeking support from

Council for federal funding of biomedical research, got that support and more in a motion from Dr. Jeffrey W. Wilson. It not only advocated general support but asked for two specifics: first, that Dr. Hu Ivey discuss the issue when he speaks to Virginia's legislators at the Society's Congressional Luncheon May 3 on Capitol Hill, and second, that "correspondence to our appropriate congressmen be encouraged as directed by the committee.” The councilors passed the mot i on .

At its meeting in Williamsburg last November, the Society's House of Delegates referred five measures to the Council for action (Va Med 1989;116:19-33:

58 VIRGINIA MEDICAL/FEBRUARY 1989

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MEDJBVTES

1. A resolution asking for state legislation requiring insurance carriers to cover screening mammography had given the reference committee pause because of the costs involved. The councilors were concerned about costs , too, their discussion revealed, yet they didn't want to say anything negative about this valuable procedure. Finally,

Dr. Russell D. Evett framed, and the Council adopted, this position on the issue: "That The Medical Society of Virginia supports insurance coverage for appropriate screening mammography . "

2. Conflicts of interest at the General Assembly proved too hot a potato for the councilors to handle, and they were unanimous that no action should be taken on the resolution that called

for the imposition of voting strictures.

3. Another tough decision involved the resolution generated by a memorandum sent by state officials

to retired state employees urging them to select for the i r hea 1 th care phys i c i ans who part i c i pate in Medicare. "Just the beginning of restricting access to care," commented Dr. Stephen M. Ayres. "The state's trying to keep costs down,” observed Health Commissioner C.M.G. Buttery, "and the choices are difficult." One of the councilors noted that action in postdate of the memo was as fruitless as shutting the barn door after the horse is gone. Fruitless or not, the Council shut the door by passing a motion offered by Dr. John A. Owen,

Jr. The measure asked that letters be written to the proper officials asserting that it is "inappropriate for you to regulate the health care choices of your ex-employees solely on the basis of Medicare participation."

3. The recommendations from the MSV Review Organization Oversight Committee had been dealt with affirmatively, reported Dr. Eugene F. Poutasse, MSVRO medical director. Notably, the makeup of

the Quality Assurance Committee will henceforth include three ad hoc members of the same specialty or type of practice as the physician under investigation. As for changes in the review of certain severity cases. Dr. Nelson G. Richards noted that these did not exactly paraphrase the Oversight Committee's requests, and they were sent back to the MSVRO board for minor alterations.

4. Also referred by the House was a recommendation of the Rural Health Committee that the Society continue to support efforts to equalize rural

and urban payments by third parties to hospitals and physicians. On the motion of Dr. William H. Barney, the councilors voted to research what equalizing measures are being considered at the AMA and to check out any pertinencies in the Physicians Payment Review Commission report due March 1. — A.G.

60 VIRGINIA MEDICAL/FEBRUARY 1989

A HEALTHY NEW SIGN IN WEST VIRGINIA

The road to recovery runs both ways. Proof of that is the new 120-bed Women and Children's Hospital of West Virginia. A healthy new sign for us all.

Women and Children's is a tertiary and special- ized care facility of Charleston Area Medical Center devoted exclusively to the physical and emotional needs of women and children. And a new referral source for you, the doctors who care for them.

State-of-the-art technology combines with special- ists and sub-specialists in fields such as:

• Infertility • Perinatology • Neonatology • Pediatric cardiology hematology oncology nephrology

We value your referrals for consultation or tertiary services. And we invite you to take a tour of our hospital. To arrange a tour, or for more information, call our administrator, Shirley Perry at (304) 347-9233.

Women and Children's Hospital

Division of Charleston Area Medical Center

VIRGINIA

MEDICAL

FEBRUARY 1989

Diagnostic Methods for Chlamydial Infections

In a High-Risk Population

Kathrine F. Boese, BS, Susan McLeod, MD, and Michael F. Rein, MD,

Charlottesville, Virginia

An enzymeimmunoassay test performed well in comparison with cell culture in detecting chlamydial infections among 209 women at a public health clinic, detecting 73% of the infected patients. Clinical and epidemiological criteria alone identified only 52%. The authors consider the test an essential supplement to other criteria when looking for chlamydial infection in a high risk population.

One of the major causes of sexually transmitted disease in the United States, Chlamydia trachomatis ,l can lead to a host of clinically important conditions, including mucopurulent cervicitis, ure- thritis, acute pelvic inflammatory disease, ectopic pregnancy and infertility in women; nongonococcal urethritis, proctitis and epididymitis in men; and inclu- sion conjunctivitis and pneumonia in infants, who acquire the infection passing through an infected birth canal. ^ Thus there is a need for early diagnosis and treatment of infected individuals, but one of the most disturbing aspects of chlamydial infections is their relatively asymptomatic nature in women.5

Until recently, diagnosis of chlamydial infections depended on recognition of clinical features or epide- miological suspicion and required confirmation using the time-consuming and expensive cell culture method. Although cell culture techniques have been modified and improved,6 7 recent advances have made available several rapid detection systems.8 9 Chlamyd- iazyme (Abbott Laboratories, North Chicago IL) is an

From the Division of Infectious Diseases, Department of Internal Medicine, University of Virginia School of Medi- cine (Ms. Boese and Dr. Rein) and the Thomas Jefferson District Health Department, Charlottesville. Address corre- spondence to Kathrine Boese at Box 385, University of Virginia Medical Center, Charlottesville VA 22908. Submitted 3-31-88.

enzymeimmunoassay (EIA) method which is offered by the state laboratory in Richmond for use among women attending the Health Department’s sexually transmitted disease (STD) clinics. While treating pa- tients attending the clinic at the Thomas Jefferson District Health Department in Charlottesville, we had the opportunity to compare the results obtained from the test offered by the state with 1) clinical diagnosis and 2) the tissue culture method performed in our laboratory at the University of Virginia.

Materials and Methods

Patient Population. Clinical information was ob- tained from 290 consecutive women attending the Health Department’s STD clinic in Charlottesville. Each patient was examined for Chlamydia trachoma- tis using the Chlamydiazyme test performed by the state laboratory and by cell culture.

Clinical Diagnosis. Patients who presented as the sexual partners of men with gonorrhea or nongono- coccal urethritis or who manifested mucopurulent cervicitis (a purulent or mucopurulent cervical dis- charge) were treated at their first clinic visit with a regimen active against Chlamydia. 1 All other women were asked to call the clinic in seven days to obtain their test results and to return if treatment was indi- cated.

Specimen Collection. Prior to specimen collection.

62 Virginia Medical, February 1989

excess cervical mucus was cleared away with a large cotton swab. Routine endocervical cultures for Neis- seria gonorrhoeae were obtained, followed by dupli- cate swabs of the endocervical canal for the detection of Chlamydia. The Chlamydiazyme test kit (std-eze for women) included a cotton tipped swab with which the physician collected the endocervical specimen. The swab was snapped at midshaft and inserted into the cap so that its tip was held firmly inside a vial containing transport medium (0.2M sucrose-phosphate buffer with 10% fetal bovine serum). The vials were labeled, packed inside mailing tubes, and immediately refrigerated until they were transported to the state laboratory in Richmond. The turnaround time for results was approximately seven to ten days.

A second cotton swab obtained from the endocer- vical canal was used to inoculate a vial containing 2 ml of 2SP transport medium (0.2M sucrose-phosphate, 10 |xg/ml gentamicin, and 25 |xg/ml nystatin, pH 7.0). Within three hours of collection, these samples were frozen at -70°C until the isolation procedure for Chlamydia by cell culture could be performed.

Enzymeimmunoassay . std-eze tubes inoculated with cervical specimens for the Chlamydiazyme assay were held at 4°C and processed within 72 hours according to the instructions provided by the manu- facturer.

Cell Culture. Inoculation and culture of confluent McCoy cell monolayers with cervical specimens were performed according to the procedure described by Bird and Forrester.10 Chlamydial infection of the cells was facilitated by the addition of 1.0 mg/ml of cyclo- heximide to the growth medium. Each specimen was tested in triplicate. After a 48-72 hour incubation period at 35°C, two monolayers of each triplicate were fixed and stained with Microtrak C trachomatis cul- ture confirmation reagent (Syva Co., Palo Alto CA), a fluorescein conjugated antibody specific for the outer membrane protein of C trachomatis. Positive controls, obtained from the Centers for Disease Control and negative controls of uninoculated transport media were stained with each run. Positive or negative cultures were determined by the presence or absence of typical, bright green inclusion bodies within individ- ual McCoy cells. The third monolayer of an apparently negative specimen was passed to a fourth McCoy cell monolayer. After incubation for an additional 24-48 hours at 35°C, it was fixed and evaluated as above.

Results

Results of the two supplementary diagnostic meth- ods are compared in Table 1. Using culture as the standard, the prevalence of infection was 10.3% (30/ 290). The sensitivity and specificity of the Chlamyd- iazyme method were 73.3% (22/30) and 94.6% (246/ 260) respectively. The predictive value was 61.1% (22/ 36) for a positive test and 96.8% (246/254) for a negative test. If, however, Chlamydiazyme is consid-

ered to be 100% specific, then Chlamydia trachomatis was identified by either Chlamydiazyme or cell culture in a total 44 of the 290 patients (15.2%). Primary cell culture identified 28 of the 44 cases (63.6%), and blind passage of negative cultures identified two additional cases for a total of 30 positive cases (68.2%). The Chlamydiazyme test identified 36 Chlamydia cases (81.8%). Eight cases were identified by cell culture alone, while 14 cases were positive by Chlamydiazyme alone (McNemar Chi square = 1.136, p = 0.29). The two cases identified as positive by cell culture only after blind passage were also positive by Chlamyd- iazyme.

Mucopurulent cervicitis or epidemiological data (i.e., contact to gonococcal or nongonococcal ure- thritis) were used as clinical indicators of chlamydial infection. Only 13 of the 30 (43%) infections diagnosed by culture were recognized on clinical or epidemiolog- ical grounds. Twenty-one of the 44 (47.7%) women with either test positive were treated initially on the basis of clinical evidence of infection or epidemiolog- ical risk. Among these 21 clinically recognized Chla- mydia cases, six (28.6%) also had bacterial vaginosis, five (23.8%) had trichomoniasis, two (9.5%) had gon- orrhea, and one (4.8%) had candidiasis.

The remaining 23 (52.3%) did not have mucopuru- lent cervicitis, although they were frequently sympto- matic from other urogenital infections. Among these women, identified only by laboratory tests, ten (43.5%) had trichomoniasis, six (26.1%) had bacterial vaginosis, two (8.7%) each had candidiasis and urinary tract infections. Three were completely asymptomatic and had no other genital infection.

The prevalence of coexisting or multiple infections among the clinically recognized Chlamydia cases was 67% (14/21) compared to 87% (20/23) for the Chla- mydia cases identified by laboratory tests alone (Chi square = 1.5, p = .2). Among the 14 women whose chlamydial infections were detected by the Chlamyd- iazyme test alone, 57.1% (8/14) were identified on the basis of clinical and epidemiological evidence, and 71.4% (10/14) of these women were coinfected. In comparison, 43.3% (13/30) of the women identified by cell culture had clinical or epidemiological evidence of chlamydial infection, and 76.7% (23/30) had coexisting infections.

Discussion

This study confirms other work showing that, when

Table 1. Comparison of the Results of Chlamydiazyme and Cell Culture for the Detection of Chlamydia trachomatis in 290 Women Attending a Sexually Transmitted Disease Clinic.

Cell Culture

Chlamydiazyme

Positive

Negative

Total

Positive

22

14

36

Negative

8

246

254

Total

30

260

290

February 1989, Virginia Medical 63

FOR YOUR OFFICE:

NEW CHLAMYDIAL TEST

A new enzymeimmunoassay test for chlamydial infection suitable for performance in physicians’ offices was released in October 1988 by Abbott Laboratories, Abbott Park, Illinois. Its name: Testpack® Chlamydial. Based on data from about 1400 women attending private gynecologi- cal practices (a low-risk population), the new test had a sensitivity of 90.0% and a specificity of 98.6% compared to Chalmydiazyme®. Personal experience with the test confirms its ease of performance. — M.F.R.

dealing with patients at high risk for chlamydial infec- tion, it is essential to supplement clinical and epidemi- ological criteria for diagnosis with a laboratory test.11 This was clearly evidenced by the 52.3% of our infected patients who were identified as having chla- mydial infections only by the laboratory tests. In fact, two patients with clinically unrecognized chlamydial infection received appropriate treatment only because CDC guidelines call for the use of supplementary tetracycline HC1 in the treatment of gonorrhea. 1

Our evaluation of the Chlamydiazyme test in com- parison to cell culture showed that the quicker EIA based method performed well in detecting the chla- mydial infections of women attending an STD clinic. The 73.3% sensitivity and 94.6% specificity of the test for this particular sampling of women fell within the range of values determined by other investigators in similar studies12-16 for which the sensitivities and spec- ificities were 63.6 to 100% and 93.0 to 98.1%, respec- tively.

Many of our patients who were positive by EIA but negative by culture may have been truly infected. They did not differ from the culture-positive group in the frequency with which they had clinical or epide- miological evidence of chlamydial infection [8/14 (57.1%) vs 13/30 (43.3%), Chi square = .281, p = .6] nor did they differ in the prevalence of coexisting infections [10/14 (71.4%) vs. 23/30 (76.6%)].

The cell culture, dependent as it is on the presence of viable organisms in the specimen, may be falsely negative if organisms die in transit to the laboratory. Even though we processed specimens promptly, our cultures may have been subject to destruction of the McCoy cell monolayers by other organisms, including Trichomonas vaginalis and herpes simplex virus, which are prevalent in sexually active populations and which are unaffected by the antibiotics included in the collection and growth media. Indeed, one recent study suggests that the growth of T vaginalis may be en- hanced by the presence of McCoy cells.17 Interestingly enough, four of the cases of chlamydial infections detected by Chlamydiazyme but not by cell culture occurred in patients also infected with T vaginalis.

Chlamydiazyme, which is somewhat less sensitive and only slightly less specific than cell culture, is an obvious alternative for clinicians with limited access to laboratory facilities. The test itself involves detection of chlamydial antigen present in a specimen. It is not dependent on the viability of the infectious agent at the time of collection, nor is it dependent on the integrity of the cell culture system. Once inoculated, specimens can be refrigerated and then mailed within 72 hours to a central laboratory for testing, thus offering a rela- tively rapid, inexpensive and technically less demand- ing method for the detection of Chlamydia trachoma- tis. In a high-prevalence population such as that attending an STD clinic, the ability to detect otherwise unrecognized cases appears to outweigh the risk of false positive reactions (if they are indeed false posi- tives) that may be seen with use of the EIA. The physician in private practice may see a somewhat lower risk population, but the ease of usage and the possible consequences of undetected infection make the EIA a highly useful test in this setting as well.

With EIA alone, 82% of those infected in this population would have been detected, and the infec- tion rate would have been identified as 12.4% (36/290). This differs little from the 13.8% infection rate found by EIA alone in a group of 298 family planning patients tested in a Virginia clinic in 198618 or the 10.7% infection rate in a Wisconsin family planning clinic study.19 For this reason, access to this type of testing should not be limited to STD clinic patients alone.

In 1985 the Virginia Division of Consolidated Lab- oratory Services first made the enzymeimmunoassay available to public health STD clinics and certain public health maternity and family planning patients. However, in the fall of 1986, the high rate of use and budgetary constraints forced a significant restriction on testing and, later, complete elimination of the test. In mid- 1987 the test was once again made available but was restricted to asymptomatic women in STD clinics, leaving out high risk asymptomatic maternity patients and all family planning patients. Funds are expected in mid- 1988 to broaden test availability to cover these public health clinic patients. Clearly the medical and economic consequences of untreated chlamydial infec- tions in the medically indigent population served by public health clinics makes the provision of this test a sound policy for state government.

References

1. CDC. Chlamydia trachomatis infections. Policy Guide- lines for Prevention and Control. MMWR 1985; 34:53s- 74s

2. Schachter J. Chlamydial infections. New Engl J Med 1978; 298:428-435, 490-495, 540-548

3. Stamm WE, Koutsky LA, Benedetti JL et al. Chlamydia trachomatis urethral infections in men. Prevalence, risk factors, and clinical manifestations. Ann Int Med 1984; 100:47-51

4. Harrison HR, Alexander ER. Chlamydia trachomatis infections of the infant. In Holmes KK, Mardh PA.

64 Virginia Medical, February 1989

Sparling PF et al. Sexually Transmitted Diseases. New York, McGraw Hill International Book Co., 1984, pp 270-28

5. McCormack WM, Alpert S, McComb DE et al. Fifteen month follow-up study of women infected with Chla- mydia trachomatis. New Engl J Med 1979; 300:123-125

6. Yoder BL, Stamm WE, Koester CM, Alexander ER. Microtest procedure for isolation of Chlamydia tracho- matis. J Clin Microbiol 1981; 12:1036-1039

7. McComb DE, Puzniak Cl. Micro cell culture method for isolation of Chlamydia trachomatis. Appl Microbiol 1974; 28:727-729

8. Tam MR, Stamm WE, Handsfield HH et al. Culture- independent diagnosis of Chlamydia trachomatis using monoclonal antibodies. N Engl J Med 1984; 310:1146

9. Stamm WE, Harrison HR, Alexander ER et al. Diagno- sis of Chlamydia trachomatis infections by direct immu- nofluorescence staining of genital secretions. Ann Int Med 1984; 101:638-641

10. Bird BR, Forrester FT. Laboratory diagnosis of Chla- mydia trachomatis infections. Atlanta, Centers for Dis- ease Control, 1981, pp 42-45, 68-70

11. Handsfield HH, Jasman LL, Roberts PL et al. Criteria for selective screening for Chlamydia trachomatis infec- tion in women attending family planning clinics. JAMA 1986; 255:1730-1734

12. Tjiam KH, van Heijst BYM, van Zuuren A et al.

Evaluation of an enzyme immunoassay for the diagnosis of chlamydial infections in urogenital specimens. J Clin Microbiol 1986; 23:752-775

13. Ryan RW, Kwasnik I, Steingrimsson O et al. Rapid detection of Chlamydia trachomatis by an enzyme im- munoassay method. Diag Microbiol Inf Dis 1986; 5:225- 234

14. Amortegui AJ, Meyer MP. Enzyme immunoassay for detection of Chlamydia trachomatis from the cervix. Obstet Gynecol 1985; 65:523-526

15. Chernesky MA, Mahony JB, Castriciano S et al. Detec- tion of Chlamydia trachomatis antigens by enzyme immunoassay and immunofluorescence in genital speci- mens from symptomatic and asymptomatic men and women. J Infect Dis 1986; 154:141-148

16. Smith JW, Rogers RE, Katz BP et al. Diagnosis of chlamydial infection in women attending antenatal and gynecological clinics. J Clin Microbiol 1987; 25:868-872

17. Garber GE, Sibau L, Ma R et al. Cell culture compared with broth for detection of Trichomonas vaginalis. J Clin Microbiol 1987; 25:1275-1279

18. McLeod SL. Unpublished data from the Thomas Jef- ferson District Health Department, Charlottesville

19. Addiss DG, Vaughn ML, Holzhueter MA et al. Selec- tive screening for Chlamydia trachomatis infection in nonurban family planning clinics in Wisconsin. Family Planning Perspectives. 1988; 19:252-256

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Your voice and membership is needed. Join with those who realize that medicine is a constituency. VaMPAC is the political action committee of The Medical Society of Virginia. Enclosed is a check for:

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February 1989, Virginia Medical 65

In Rural Virginia, World-Class Medicine: John Peter Mettauer, 1787-1878

John R. Kight, MD, Virginia Beach, Virginia

When he devised a method for repairing vesico- vaginal fistulas, the great Marion Sims took notice and did likewise. For his original work in congenital deformities he was called America’s first plastic surgeon. “A genius of his time,” summed up an article describing his innovations in ophthalmology. He was Peter Mettauer of Prince Edward Courthouse, Virginia.

In Prince Edward County, Mettauer is pronounced mortar. In France, where Peter Mettauer’s father was born, it is pronounced Meftower.

Although the contributions of John Peter Met- tauer to many areas of medicine have been extolled by leaders in the profession, he has never received the recognition he rightly deserves. For his accomplishments, his name should be ranked along with another great Virginian, Dr. Walter Reed.

Among those who have appreciated Dr. Mettauer’s contributions to the extent they have found reason to publish facts about his life are some outstanding members of the academic and medical world. All have been especially qualified to do so, but none more than three of the first; Dr. George Ben Johnston, Dr. Joseph Eggleston, and Dr. M. Pierce Rucker. Dr. Johnston, who as chairman of the Department of Surgery at the Medical College of Virginia, where the school amphi- theater bears his name, lived within the lifetime of Dr. Mettauer and had the advantage of being intimately aware of his prolific achievements. For his presidential

This text was abstracted from a lecture given by Dr. Kight before the Virginia Obstetrical and Gynecological Society on April 10, 1987, in Norfolk. Address correspondence to him at 4308 Sandy Bay drive, Virginia Beach VA 23455.

address before the American Surgical Association in 1905, his theme was “A Sketch of John Peter Mettauer of Virginia.”1

Twenty-five years after Dr. Johnston’s presentation, Dr. Eggleston, then president of Hampden-Sydney College and for whom the school library is named, paid tribute by placing in the prestigious William and Mary Quarterly some known facts of the Mettauer family. This act by Dr. Eggleston for the benefit of future generations is extremely significant, because Dr. Eggleston spent nearly his entire life in the com- munity where Dr. Mettauer had practiced medicine and established a reputation that extended into many states and abroad. Dr. Eggleston’s family and the families of many of his associates had been patients of the doctor; from them he learned firsthand of Dr. Mettauer’s remarkable accomplishments, his compas- sion, and his dedication to the profession.2

A decade later, Dr. Rucker, who as Editor of the Virginia Medical Monthly guided that journal into national prominence and whose extensive knowledge of the world medical literature distinguished him among his contemporaries, extolled Dr. Mettauer’s accomplishments in a factual and scholarly article. In closing his biographical report, Dr. Rucker touched on the relationship between the work of Dr. Mettauer and that of Dr. J. Marion Sims, who erroneously is recog-

66 Virginia Medical, February 1989

nized as being the first to have successfully repaired a vesico-vaginal fistula.3

John Peter Mettauer was born on April 10, 1787, in rural Prince Edward County, Virginia.4 All biographical reports state that John Peter’s fa- ther, Francis Joseph Mettauer, a French surgeon born and reared in Soultzbach-les-Bains, Alsace, served with Fafayette in the Battle of Yorktown. Off and on over a period of 20 years, Adolf Michaelis, a descen- dant of the Mettauer family now living in Bonn, West Germany, and the author have researched military records on both sides of the Atlantic to determine in what capacity he served during the conflict. Many French military records were destroyed during the French Revolution, as were American records when buildings were burned in Washington in the war of 1812, and it is an established fact that Revolutionary War records are incomplete. It can be stated that no reason has ever been found to arouse doubt that Francis Joseph, the father, served with the French forces.5,6

It is well established that Mettauer pere arrived in Kingsville, in Prince Edward County, Virginia, in 1781, soon after the Yorktown surrender, with a detach- ment of French troops proceeding south under orders of General Washington to reinforce the troops of Gen. Nathaniel Greene, since there was no assurance that all hostilities had ceased. En route some of the troops encamped at Charlotte Courthouse and others at nearby Kingsville. Those quartered at Kingsville were stricken by an epidemic of smallpox and were forced to remain in the area a prolonged period of time. Afterward, when the detachment departed, Dr. Joseph Mettauer (as he was known in this country) was persuaded by some of the prominent citizens to re- main, and he thus became the first physician known to have practiced in Prince Edward.7 In 1783 he became a naturalized citizen of the new nation, and within one year he purchased land, since divided by a highway between Farmville and old Prince Edward Court- house, now Worsham. His first son, John Peter, was born on that parcel of land only six years after this country had won its independence and in the same year the Constitution of the United States was adopted.

On May 6, 1791, when John Peter was four years old, his father, Francis Joseph, married Jemima Gaulding, a widow from Henrico County, whose maiden name was Crump.2 Most accounts imply that Jemima was the mother of Peter and his brother, also named Francis Joseph. Efforts to find conclusive evi- dence to support a belief that there was a previous marriage have resulted in only one positive piece of supportive evidence. William Fett Harris, President of The Medical Society of Virginia in 1926, tells us, “. . . his father built a Methodist church just across the road from the old home site, as a memorial to his

wife. . . .”8 This memorial, if it did exist, was not to Jemima; she was ejected from the home soon after the marriage and for a decade Francis Joseph tried to petition the General Assembly for annulment of the marriage. A deed recorded in Prince Edward Court- house in 1813 confirms that Jemima outlived her estranged husband.

Fittle is known of Peter Mettauer’ s early life. Even his birth date has been questioned.2 His early educa- tion was obtained at the nearby Prince Edward Acad- emy. In 1804 he matriculated at the then well-estab- lished Hampden-Sydney College, within walking distance of his home; he attended for only two years, departing in 1806 before receiving a baccalaureate degree. By choosing medicine for his life work, he was following in the footsteps of his father and a distin- guished line of ancestors.5,9 His uncle, Karl Franz Naegle, an obstetrician and gynecologist, whose con- tributions continue to bear his name, was one of the 18 known to have been doctors. John Peter attended the University of Pennsylvania, where he received his degree in medicine in 1809. 10 While there, he studied under one of the most distinguished medical faculties ever assembled, notably Benjamin Rush, William Shippen, Casper Wistar, and Phillip Syng Physick.

After obtaining his degree, he worked in the Phila- delphia Dispensary for one year before returning home to practice medicine with his father. This association lasted until the time of his father’s death, on the last day of 1811 or the first day of 1812.

We do not know how long Peter remained in the area after his father died. Some authors would have us believe he went to Norfolk for military duty in the War of 1812, that he arrived at the onset of the conflict, and remained there for a period of two years. During that time, we are told, he served as a surgeon in the United States Army, gaining valuable professional experience by treating casualties resulting from military engage- ments.11,13 Dr. Johnston said that Mettauer “once made a settlement, which proved to be a brief one in Norfolk,” but no evidence has been found to indicate that he was in the military service at that time. An announcement in the Norfolk Gazette on January 4, 1815, however, tells of his association with his brother, Francis Joseph, in the practice of medicine. This was not the first newspaper notice of one of the Mettauers in that city; six months before, on July 27, 1814, Francis Joseph had married Mary Ann Eliza Marsden, and on January 26, 1815, there was an announcement of John Peter Mettauer’ s marriage to Mary Woodward. Both brides were of prominent Norfolk families; their fathers were members of the town council. Peter and Mary’s first child, Sarah Eliza, was born in Norfolk in 1816, and Francis Joseph, their first son, in 1818.

When and why the two brothers left Norfolk, we were not absolutely certain. Francis Joseph is listed in the 1820 United States census as residing in Peters-

February 1989, Virginia Medical 67

Doctors J. P. k l\ J. METTAUER,

HAVING associated themselves together in the Prac- tice of Medicine, make a respectful tender of their professional aery ices to the inhabitant’* of Norfolk and its vicinity. They have taken for their stand the house formerly occupied by Dr. Hodge a, on Main-street, near- ly opposite to Mr*. Davis's boarding house, where they will be constantly found. y

JC7* Thty will take ar tkret Pupils.

January 4* 181 5.

Announcement in the Norfolk Gazette tells of Met- tauer’s association in practice with his brother.

MBvH

■

ilSSi

Above, Mettauer wears the high silk hat that was his trademark. Courtesy Virginia State Library and Archives. In the watermarked photograph below, taken when Mettauer was 83, he appears to be wearing a wig. From the author’s collection.

In 1986 Mayor G. Antony of Soultzbach-les-Bains took this photograph of the house built in 1771 by John Peter Mettauer’s grandfather.

burg; John Peter is not listed, arousing speculation that he may still have been living in Norfolk, maybe residing with Mary’s parents. Documents confirm that the family returned to Prince Edward by 1823. In that year Peter’s beloved Mary died. Her body was returned to Norfolk, where on December 27, 1823, an announcement in the American Beacon informed that a funeral service for Mary Woodward Mettauer was preached in the Methodist church. Although Peter married three more times, in his will he acknowledged endearment to Mary by requesting -hat her letters to him be placed in his grave.

In choosing to return to Prince Edward County, the young doctor was emulating his father, who with his superior medical education and cultural back- ground4,914 had appreciated the uniqueness of the rural community. When the father settled in Kings- ville, the nearby Prince Edward Courthouse was a crossroads where travellers going north and south, east and west, came to a well-known meeting place; among them were such statesmen as John Randolph and Patrick Henry, who became patients of Dr. Joseph Mettauer.

Following his return home, Peter Mettauer ex- perimented with the use of metallic sutures, reporting a case of successful repair of a recto- vaginal septum. Here we see Peter furthering the work of Professor Physick.16 During that time he also pre- pared a manuscript on typhus fever.17 His reputation spread beyond the local community, and he was offered the chairmanship of the Department of Surgery at Washington University School of Medicine in Bal- timore, which he accepted in 1835. 18 After two years he resigned and returned to rural Prince Edward County, where, along with maintaining a large medical practice, he organized and served as professor and administrator of a medical school, the Prince Edward Medical Institute, which later became affiliated with Randolph-Macon College.19

Manuscripts now available portray his broad knowl- edge of the then current diagnostic and therapeutic principles, his scientific enthusiasm, and profound ingenuity. His literary contributions included these medical subjects: epilepsy, scarlet fever, cholera in children, puerpera, menorrhagia, dysentery.20-25 ‘"He was, also, the original suggestor of employment of iodine in the treatment of scrofula,” said Johnston, his first physician biographer.1

His surgical accomplishments have been even more highly esteemed. In the days before there were trained assistants, knowledge of antisepsis, and the benefit of general anesthesia, Dr. Mettauer performed many surgical procedures, some by techniques of his own design, others by accepted techniques that he im- proved upon. He was a pioneer in many technically difficult surgical endeavors while working alone in a rural environment. Furthermore, he prepared manu-

scripts describing in detail his procedures. He is said to have published 55 scientific articles.

Of all his accomplishments, none did more to relieve human suffering than the method he devised to repair a vesico-vaginal fistula. Now almost unheard of, in those days it was a frequent debilitating complication of childbirth that destroyed the normal life of an untold number of young mothers. In the very early days of modern medicine, in this country and abroad, one of the most constantly sought goals by leading gynecol- ogists was a means of correcting this life-threatening condition. In 1838 Dr. Mettauer, utilizing techniques he devised and instruments he designed, accomplished the first successful repair reported in the United States.26 He also reported his method in detail, af- fording others a means of repeating his success. Among them was the renowned J. Marion Sims. ‘‘That he influenced the great Sims, as I believe he must have done, is sufficient glory for a country surgeon,” ob- serves Dr. Rucker.

For his original work in congenital deformities, including cleft palate27 and hypo- and epi-spadias,28 Mettauer has been acclaimed “America’s First Plastic Surgeon.”12 In an article depicting his work in oph- thalmology he was described as “a genius of his time.”29 Among the innumerable other operative pro- cedures performed by him are: correction of urethral stricture, removal of stones from the urinary tract, and removal of the parotid gland.30-32 He was one of the first to ligate a carotid artery33 and resect a maxilla/’4

More than 100 years have passed since his death in 1875, yet Dr. Mettauer continues to be known by the citizens of Prince Edward County. He is best remembered as the good doctor who always wore the high silk hat. One daughter is reported to have said she never saw her father without his hat on.3" A photograph taken of him when he was 83 years old showing him without the high hat but certainly wearing a wig was given to the author by Mrs. Marguerite Campbell Bacon of Norfolk, whose grandfather as a boy often drove Dr. Mettauer on his rounds. By requesting in his will that he be buried with his tall hat on, he not only created problems during his last rites, as he was over six feet tall, but it served as a stimulus to more legendary tales.

Of his children, three sons and three daughters lived to adulthood. Descendants survive today. Dr. Edward Mumford, the youngest son to reach adulthood, moved to Florida, where the name was spelled several different ways, including Mettair.36 All three sons became physicians; the two older, Francis Joseph and Henry Archer, assisted their father in teaching at the medical school he organized.

Peter Mettauer continued to practice medicine until several days before his death at 88 years on November 22, 1878. He was a man of integrity and culture with much dignity of manner. He was made an honorary

February 1989, Virginia Medical 69

member of several medical societies, served as a delegate to the American Medical Association, and was given an honorary master of science degree by his alma mater, Hampden-Sydney College.

Probably his greatest tribute, greater because it was paid during his lifetime, was made by one of America’s most brilliant surgeons, Thomas Dent Mutter, who declared him, “Facile princeps [easily the first] of the medical and surgical profession of the world.” On his death it was written in the American Journal of Medical Science , “He is accredited with more im- provements in operations and inventions of instru- ments to date than any other man.” One hundred years later Dr. Benjamin Sheppard wrote, “A genius of his time, he gave Virginia and America a dynamic chapter in advancing medicine.”29

References

1. Johnston GB. A sketch of John Peter Mettauer of Virginia. Transactions of the American Surgical Associ- ation, 1905.

2. Eggleston JD. Francis Joseph and John Peter Mettauer, a sketch. William and Mary Quarterly 1928 ;8:96.

3. Rucker MP. Dr. John Peter Mettauer: an early Southern gynecologist. Ann Med Hist 1938 ; 10:36.

4. Holladay WM. Letter to Dr. E. Jordan. 1-23-1911. University of Pennsylvania Library.

5. Michaelis A. Personal communications. Bonn, West Germany, May 1974 to July 1980.

6. Villaneuva M. Personal communication. Orange, New Jersey, April 1975.

7. Bradshaw HC. History of Prince Edward County, Vir- ginia. Richmond, Dietz Press, 1955.

8. Harris WL. John Peter Mettauer, a country surgeon. Va Med Mon 1926;53:485.

9. Hofmeister JA. Personal communications. Soultzbach- les-Bains, France, 1975.

10. Bell WH. John Peter Mettauer’s notes on clinical lec- tures by Benjamin Rush. Va Med Mon 1938;65:354.

11. Blanton WBsr. Today and yesterday in the heart of Virginia. Farmville Virginia Herald, bound volume 1935.

12. Horton CE. John Peter Mettauer — America’s first plas- tic surgeon. Plastic Reconstr Surg 1 961 ;27:268.

13. Altaffer LF. John Peter Mettauer (1787-1875). Invest Urol 1980; 18: 185.

14. Antony G. Personal communication. Soultzbach-les- Bains, France, 1986.

15. Mettauer JP. Letters and ledgers. Hampden-Sydney College Library.

16. Mettauer JP. Laceration of recto-vaginal septum suc- cessfully treated with metallic sutures. Am J Med Sci 1833,13: 1 13.

17. Mettauer JP. Note on typhus or congestive fever ( 1 826— 1827). College of Physicians Library, Philadelphia.

18. Blanton WBsr. Medicine in Virginia in the 19th Century. Richmond, Garrett and Massie, 1933.

19. Minutes of board of trustees, Randolph-Macon College, March 13, 1847, p. 375.

20. Mettauer JP. Crusta genu equinae in epilepsy. Boston Med Surg J 1835;8: 1 17.

21. Mettauer JPM. Practical observations on scarlet fever. Stethoscope 185 1 ; 1 :8 1 .

22. Mettauer JPM. On cholera infantum. Va Med Surg J 1856;7: 191 .

23. Mettauer JPM. Practical observations on puerpera. Am J Med Sci 1846;1 1:379.

24. Mettauer JPM. Practical observations on menorrhagia. Am J Med Sci 1842;3:298.

25. Mettauer JPM. Contributions to practical medicine — dysentery. Va Med Surg J 1851; 1:452.

26. Right JR. The first successful closure of vesicovaginal fistula in the United States. Am J Ob Gyn 1967;885:99.

27. Mettauer JPM. On staphylorrhaphy. Am J Med Sci 1837 ;21 :309.

28. Mettauer JPM. Practical observations on those malfor- mations of the male urethra. Am J Med Sci 1842;4:43.

29. Sheppard LB. John Peter Mettauer (1787-1875). Va Med 1977,104:1.

30. Mettauer JP. A memoir of stricture of the urethra. Farmville, Virginia, Saunders and Cowan, 1849.

31. Mettauer JP. Lithotomy. Manuscript, College of Physi- cians Library, Philadelphia.

32. Mettauer JP. Extirpation of the parotid gland. Va Med Surg J 1854;3:189.

33. Mettauer JP. Ligature of the common carotid artery. Am J Med Sci 1849;18:348.

34. Mettauer JP. Exostosis of the left superior maxillary bone requiring resection. VA Med Surg J 1853; 1:455.

35. Scheer GF Jr. Doctor high hat. Richmond Times-Dis- patch, April 26, 1936.

36. Peters T. Personal communications. Miami, Florida, 1972-1973.

Help for a troubled friend is only a phone call away.

If you suspect a colleague is experiencing problems with alcohol or drug abuse, don't contribute to the "conspiracy of silence," call The Medical Society of Virginia's Physicians' Health and Effectiveness Committee. A non-punitive approach through rehabilitation is an alternative. Your report will be kept confidential. Ask for Jeanne Douglas at MSV headquarters, (804) 353-2721.

70 Virginia Medical, February 1989

ABSTRACTS

These are abstracts of papers to be presented at the 1989 regional meeting of the Virginia Chapter, American College of Physicians, in conjunction with the Virginia Society of Internal Medicine on March 4 in Williamsburg. Dr. Oscar E. Edwards is program chairman.

Dynamic Respiration Dependent Pseudostenosis of a Coronary Artery Bypass Graft. Charles Vaughan, MD, and Joseph Robbins, MD, Norfolk.

A 47-year-old gentleman with evidence of coronary ischemia underwent coronary angiography which re- vealed a proximal tight stenosis of a saphenous vein bypass graft. However, the following day, angiogra- phy prior to angioplasty of the lesion revealed full patency of the vessel during full expiration and tight stenosis of the vessel during full inspiration. Simulta- neous pressure tracings proximal and distal to the lesion failed to demonstrate any significant change in the translesional pressure gradient during respiration indicating that the lesion was probably hemodynami- cally insignificant. The implication of this finding how- ever is significant in that it represents yet another possible pitfall in the interpretation of coronary angi- ography films.

The Role of Platelets in Myocardial Ischemia. G.

Stouffer, MD, M. E. Williams, MD, and R. S. Gibson, MD, Charlottesville.

Coronary artery occlusion is a dynamic process involving atheroma, platelets and vascular endothe- lium. Clinical evidence of the importance of platelets can be seen in the trials of the thrombolytic agents, in the data supporting the use of platelet inhibitors after coronary artery bypass grafting or angioplasty, and in the recent U.S. and Canadian trials demonstrating a decreased incidence of myocardial infarction in pa- tients taking aspirin. Other studies have revealed increased platelet aggregability and breakdown prod- ucts in patients with unstable angina, and that intra- coronary infusion of platelet activators (e.g., ADP or epinephrine) can precipitate myocardial infarction.

We describe a 63-yo man with stable angina who was admitted for elective splenectomy for refractory ITP diagnosed four months earlier. His initial platelet count was 3000/mm3 but rose steadily with IV Gamma Globulin 400 mg/kg/day for 4 days. He subsequently developed unstable angina at a platelet count of 111,000/mm3; cardiac catheterization showed a high grade LAD lesion. Thus, this patient’s profound thrombocytopenia appeared to have protected him from unstable anginal symptoms.

Detection of Plasma DNA by Counterimmunoelectro- phoresis (CIE), a Rapid Screening Test for Pulmonary Emboli (PE). Jill S. Vargo, MD, Daniel M. Becker,

MD, John S. Davis IV, MD, et al, Charlottesville.

Previously we reported that plasma DNA was found in 83% of patients with PE using a rapid, simple and inexpensive method, CIE. Since the workup of PE involves time-consuming and expensive tests, a rapid specific blood test would be desirable. As part of a prospective study of all suspected PE patients at our institution, we reexamined the diagnostic value of plasma DNA. As part of a study of lung scans in PE, we obtained plasma samples from 121 out of 148 entries. CIE was performed on each sample against anti-DNA from a patient with systemic lupus erythem- atosus. The CIE gave consistent well-defined precip- itin lines at 0.75 fxg/ml; in all plasma tested, no lines developed after treatment with DNase or blocking of the anti-DNA with standard DNA. When done, pul- monary angiography was the standard test for compar- ison; otherwise high probability (HPLS) and normal (NLS) lung scans were used. This data was used to calculate the sensitivity (sens) of the test.

+

Plasma DNA

If patients with > 3 days of PE symptoms are excluded the sens, increases to 90%. This data supports our previous observation that in patients who present with acute symptoms suggestive of PE, the detection of DNA increases the likelihood that a PE has occurred.

Henoch-Schonlein Purpura Following Influenza Vacci- nation: Successful Treatment of Progressive Renal In- sufficiency with High-Dose Pulse Steroids and Cyclo- phosphamide. Alan Rolfe, MD, and David Dresner, MD, Portsmouth.

Henoch-Schonlein purpura (HSP), a systemic ne- crotizing vasculitis characterized by the syndrome of nonthrombocytopenic purpura, arthralgias, abdominal pain, gastrointestinal bleeding, and glomerulonephri- tis, has been temporally associated and is a rare complication of influenza, cholera, yellow fever, para- typhoid A and B, and smallpox vaccination. We report the first case of a young adult who developed all the classic manifestations of HSP after split-dose influenza vaccination.

HPLS/ + PA

NLS/ -PA

18

4

4

22

sens. = 82% spec. = 85%

February 1989, Virginia Medical 71

The patient presented with palpable purpura, pete- chiae, and arthralgias. He rapidly developed colicky abdominal pain, intractable nausea and vomiting, fe- ver, and Brcinhamellci catarhalis sepsis. Skin biopsy showed perivascular and vessel wall IgA by immuno- fluorescence. Endoscopy demonstrated diffuse severe gastritis and duodenitis. Moderate renal insufficiency developed rapidly. A renal biopsy disclosed focal proliferative and exudative glomerulonephritis. Immu- nofluorescence confirmed the presence of 3+ mesan- gial IgA deposits and trace IgM, IgG, and C3 consis- tent with HSP renal disease. After treatment with high dose pulse steroids and cyclophosphamide the patient experienced rapid clinical improvement with the res- olution of proteinuria and normalization of the serum creatinine.

Familial Terminal Complement Deficiency and Recur- rent Meningococcemia. R. Duncan Hite, MD, Gerald R. Donowitz, MD, and W. Michael Scheld, MD, Charlottesville.

Deficiencies of serum complement are extremely uncommon (.03%) in general practice. However, in patients with systemic Neisseria infection, terminal complement deficiencies are noted to be as frequent as 10-15%. We report a characteristic and illustrative case of terminal complement deficiency.

The patient was a 19-year-old Oriental female who presented with fever, myalgias, stiff neck and pete- chiae with positive blood and CSF cultures for N meningitidis. The patient had a similar episode 30 months prior, and a sibling had recently died from fulminant meningococcemia. Our patient was success- fully treated with penicillin. Complement analysis re- vealed a C8(3 deficiency. Two siblings were found to have a similar deficiency. C8 deficiency is the most common of the terminal complement deficiencies. C8(3 deficiency is typified by recurrent N meningitidis infections and is most commonly seen in Caucasians. Overwhelming disease and mortality as seen with this patient’s sister is uncommon. The mild course demon- strated in our patient is more typical.

As a result of this patient and our review of the literature, we suggest that patients with N meningitidis infection warrant evaluation for complement defi- ciency.

Ehrlichiosis, a Diagnosis to Be Considered in Virginia. D. Alec Lindley, MD, and C. J. Schleupner, MD, Roanoke/ Salem.

Ehrlichia canis, an intraleukocytic parasite of wild and domestic animals in the family Rickettsiaceae, has recently been found to be a human pathogen. Clini- cally, it causes an illness similar to Rocky Mountain spotted fever (RMSF), but usually without a rash. The diagnosis is confirmed by finding intraleukocytic bac- teria on a stain of peripheral blood and by serology. We describe a case of a 44-year-old white male who presented with fever of two weeks duration accompa-

72 Virginia Medical, February 1989

nied by headache, arthalgias, malaise, cough, leuko- penia, and mild elevations of liver enzymes. The patient had a history of tick exposure approximately 2 weeks prior to onset of symptoms. The patient’s fever and clinical illness responded promptly to doxycy- cline; a convalescent serum specimen demonstrated a rise in specific E canis antibody to a titer of 1:40,000.

E canis represents another tick-transmitted infec- tion and should be considered in patients with a febrile illness and documented or possible tick exposure which is otherwise unexplained, especially in patients without a rash or serologic evidence of Rocky Moun- tain spotted fever.

Cunninghamella Bertholetiae in a 62- Year-Old Immuno- competent Male. Stuart Zeilender, MD, and Dave Drenning, MD, Richmond.

Cunninghamella bertholletiae is a saprophytic fun- gus usually associated with severe life threatening infections in immunocompromised hosts. There are 11 previous cases reported in the literature, with all patients having underlying diseases that were likely to compromise immune defenses. Patients typically have invasion blood vessel wall invasion by the organism with subsequent infarction of the tissue perfused by the involved vessels. We report the first case of Cunninghamella associated with an apparently immu- nocompetent patient. A 62-year white man was admit- ted with a right upper lobe abscess cavity, diffuse interstitial lung disease and a right pleural effusion. Cunninghamella bertholletiae was repeatedly grown from the pleural effusion, bronchial washings, sputums and at autopsy cultures of the lung parenchyma and abscess cavity were also growing the organism. No malignancy or other immunocompromised state was revealed at autopsy.

An Unusual Presentation of Limited Wegener’s Granu- lomatosis. Scott Yagel, MD, and Neil Duval, MD, Portsmouth.

We report a case of biopsy-proven Wegener’s gran- ulomatosis in a 19-year-old otherwise healthy male. The patient presented with a nonproductive cough and fever, and was found to have multiple cavitary pulmo- nary lesions, from which anaerobic bacteria were cultured. The patient eventually developed Raynaud’s phenomenon and leukocytoclastic vasculitis. He had no evidence of upper airway involvement, clinically or by extensive diagnostic evaluation. Aside from brief microscopic hematuria which spontaneously resolved, renal involvement was absent. Biopsies of skin, mus- cle and sural nerve were nonspecific. Review of open lung biopsy by the AFIP yielded the diagnosis.

It is felt that to establish a diagnosis of Wegener’s granulomatosis, disease must be present in two of the following: upper respiratory tract, lower respiratory tract, kidney. Biopsy must confirm the diagnosis in at least one site. Further, it has been noted that lower respiratory tract disease is unusual without upper tract

involvement. Our patient defies both these maxims.

A Chyloma Presenting as a Posterior Mediastinal Mass: Previously Unreported Complication of Cardiopulmo- nary Resuscitation. William D. Frazier, MD, Char- lottesville.

A chyloma is an extrapleural mediastinal collection of lymph resulting from disruption of the thoracic duct. To my knowledge, this is the first reported case of a chyloma with an associated chylothorax second- ary to cardiopulmonary resuscitation (CPR). A 75 y/o man had a cardiac arrest at home. He required CPR for 12 minutes before a countershock restored a sponta- neous pulse. On admission, a head CT revealed a large left subdural hematoma. Despite operative drainage, the patients’ neurologic status remained very poor. Chest x-rays obtained during the first 19 days of hospitalization were normal except for left rib frac- tures. However, on hospital day 22, a follow-up chest x-ray showed a large, left posterior mediastinal mass and a left pleural effusion. Thoracentesis revealed clear, straw-colored exudative fluid with a lymphocyte count of 137,640/mm3. Cultures and cytology were negative. A pleural fluid triglyceride level was 134 mg/ dl and a sudan red stain was positive for fat globules. The patient was maintained on parenteral hyperali- mentation, which was begun on hospital day 8, for a total of 6 weeks. His chyloma and chylothorax re- solved. This case illustrates 4 salient points: (1) a chyloma may present as a posterior mediastinal mass,

(2) chylous fluid does not necessarily have a milky appearance, especially in the patient who is not eating,

(3) a chylothorax may have an extremely high lympho- cyte count. This case represents the highest lympho- cyte count yet reported in a chylothorax. (4) Cardio- pulmonary resuscitation can cause thoracic duct disruption.

Tums-Alkali Syndrome: Severe Symptomatic Hypercal- cemia from Excessive Turns Ingestion, a Report of Two Cases. Ramon Matawaran, MD, and Herschel Estep, MD, Norfolk.

Milk-alkali syndrome was first described in 1923 by Hardt and Rivers as a complication of the use of the Sippy regimen for the treatment of acid-peptic disease. Since the introduction of H2 blockers, they have become the mainstay in the treatment of peptic-ulcer disease. As a result, milk-alkali syndrome has become an uncommon cause for hypercalcemia.

We present two cases of severe hypercalcemia in two female patients. These patients were both seen within a 6-week period and gave a history of ingestion of an average of 5-6 g CaC03/d in the form of Turns. They both presented with an acute change in mental status. A detailed work up failed to reveal any other cause for the hypercalcemia. Correction of their hy- percalcemic states resulted in marked clinical im- provement in both.

How to Report AIDS and HIV Infection in Virginia

Who should report? Every Virginia phy- sician is required by law to report any case or suspected case of AIDS under his or her care. HIV infection is reportable by law in Virginia when the physician needs the local health department's support in patient coun- seling and epidemiologic tracking. Reports are kept confidential, as the law specifies.

What should be reported? The presence of a reliably diagnosed disease at least moderately indicative of an underlying cellular immune deficiency, with no other known underlying cause of cellular im- mune deficiency nor any other cause of reduced resistance associated with that disease, should be reported as AIDS.

Only patients who have positive blood tests for HIV antibodies as demonstrated by at least two enzyme-linked immuno- sorbent assays (done in duplicate at the same time or singly at different times) and another testing procedure, such as the Western blot, should be reported as having HIV infection.

When should I report? As soon as pos- sible after you first provide care for the patient.

Where should I report? To the local health department serving the jurisdiction in which your practice is located.

Prepared for VIRGINIA MEDICAL by the Virginia Department of Health

February 1989, Virginia Medical 73

Carbon Monoxide Poisoning in Indoor Ice Skating Arenas

Richard K. Miller, MD, Mary C. Ryan, MD, and Paul Bilowus, BA,

Fairfax, Virginia

Exposure to fumes from a gasoline powered ice resurfacer in an indoor ice skating arena in Fair- fax, Virginia, resulted in at least one documented case of moderate carbon monoxide poisoning in an em- ployee as well as symptoms of carbon monoxide toxicity in patrons using the ice skating rink. The circumstances surrounding this occurrence and the corrective measures taken are described in this report.

While elevated ambient carbon monoxide levels due to these resurfacers have been reported previously in Massachusetts, Pennsylvania and Colorado, individ- ual case reports of poisoning were not described.1-3 Intensive maintenance procedures, increased ventila- tion and close followup for compliance at indoor ice arenas with gasoline powered ice resurfacers has been advised. However, the introduction of an electric powered ice resurfacer at the ice arena in Fairfax resulted in permanent elimination of the hazard.

Case Report

Shortly after midnight, a 16-year-old male employee in an indoor ice skating arena developed severe head- ache and dizziness. Difficulty concentrating gradually increased to the point where he was barely able to count to ten. He became extremely fatigued and was unable to walk. He had been doing janitorial work at the arena almost continuously for ten hours that day. The employee had been in good health previously, was a nonsmoker, and did not have a history of frequent or severe headaches.

A diagnosis of carbon monoxide poisoning was established that night at a local emergency room. While the employee did not have the typical cherry red color of the lips, the diagnosis was suspected because of a coworker’s prior experience at a different ice rink and a report of malodorous fumes at the arena indicat- ing exhaust accumulation. The patient’s carboxyhe- moglobin (COHb) level was 30%; the blood specimen was obtained about one-half hour after the employee left the ice arena. After treatment with 100% oxygen

From the Air Pollution Control Division, Fairfax County Health Department, Virginia State Department of Health. Address correspondence to Dr. Miller at 10777 Main Street, Suite 203, Fairfax VA 22030.

Submitted 6-27-88.

inhalation for an hour, he became asymptomatic and was sent home.

For several days after this incident, the employee experienced problems concentrating in school and found himself unable to perform some language exer- cises in English class which he had done previously. No long-term sequelae were reported after a period of several months. These findings are based on a conver- sation with the patient and a telephone contact with his mother. Formal testing was not performed. The pa- tient continued to attend high school, remained with the high school orchestra, and returned to his job at the ice arena.

Upon diagnosis of this case, the emergency room staff contacted the Fire Department, the Fairfax County Health Department’s Air Pollution Control Division which had jurisdiction in this case, and the city’s mechanical inspector. Carbon monoxide levels above 100 ppm were found throughout the arena that night by an air pollution control engineer from the Health Department using an Ecolyzer Model 2100 portable carbon monoxide analyzer. The peak capac- ity for measurement with this standard screening de- vice is 100 ppm, and that peak was always reached — and presumably exceeded — in the environment. The Occupational Safety and Health Administration (OSHA) has set a limit of 50 ppm maximum eight-hour exposure average to protect workers in at-risk environments.4

The elevated carbon monoxide levels at the ice arena were attributed to two problems. First, the gasoline powered ice resurfacer, which is driven over the ice routinely every one to two hours between 5 am and 11 pm, was emitting excessive carbon monoxide. Second, there was insufficient ventilation at the ice arena, which allowed the carbon monoxide to accu- mulate.

Headaches had been a relatively frequent complaint at this ice arena for months prior to the above episode. Several children developed gastrointestinal distress on the day the employee became ill, and many skaters and nonskating employees experienced severe head- aches. An outbreak of flu was initially suspected, but, as learned through discussions with skaters at the arena, those with symptoms became well within hours after leaving the arena. In retrospect, these complaints were viewed as probable indicators of lower levels of carbon monoxide toxicity.

Corrective measures at the ice arena were recom- mended by the Air Pollution Control Division and instituted immediately. Maintenance work on the re- surfacer was done that day, and a new catalytic converter was installed. A faulty ventilating pipe for the heating system was replaced, the air exchange rate increased, and, in addition, a new ventilation system was designed for the arena. The ice resurfacer was scheduled to be warmed up 8-10 minutes prior to use, and the exhaust pipe was vented to the outside through an exhaust hose during warm-up. A continuous sam-

74 Virginia Medical, February 1989

pling analyzer (MSA-LIRA-2025) was left at the arena for monitoring. Over a period of weeks, the level of ambient carbon monoxide dropped to a mean of 23 ppm.

Because of the technical and cost problems involved with increased ventilation at the arena, as well as a desire to lower ambient carbon monoxide levels even further, the owners of the arena purchased a nonpol- luting electric powered ice resurfacer.5 With this re- surfacer, ambient carbon monoxide levels dropped to an average of 1 ppm, typical of outside air.

While no complaints had been received from pa- trons or employees, a second ice arena in Fairfax County was tested for ambient carbon monoxide lev- els because of the problem previously encountered. (These are the only ice arenas in the county.) A gasoline powered ice resurfacer was in use at this arena, and again significantly elevated levels of carbon monoxide were detected. Structural ventilation de- fects were not noted. Conversion of the gasoline powered resurfacer to propane was in progress at the time. With subsequent use of the propane powered resurfacer and provision of a faster rate of air ex- change, ambient carbon monoxide levels decreased from a mean of 48 ppm to 12 ppm. Continued moni- toring was instituted.

Discussion

Carbon monoxide is naturally present in the blood due to catabolic processes, producing carboxyhemo- globin (COHb) concentrations up to 0.8%. Smokers have higher levels of COHb than the general popula- tion; values of 5% to 10% have been reported. Toxicity is due to the fact that hemoglobin has a higher affinity (240X) for carbon monoxide than oxygen. Because the resulting COHb is incapable of carrying oxygen, many organ systems are affected by hypoxia.

Additional mechanisms of toxicity may involve binding of carbon monoxide to such hemoproteins as cytochrome oxidase, myoglobin, tryptophan deoxyge- nase, and tryptophan catalase.6 Since the cytochrome oxidase systems are also the site of great metabolic activity, the organs with the highest metabolic rates (e.g., the heart and central nervous system) are af- fected the most by carbon monoxide. Thus, carbon monoxide affects the body in three ways:

1) inhibition of oxygen transport;

2) reduction of oxygen delivery to the tissues;

3) impairment of oxygen utilization by the tissues.

Complications of carbon monoxide toxicity affect

almost all organ systems. The heart is involved early, since extra effort is required to deliver an increased volume of blood to poorly oxygenated tissues. This problem is exacerbated by direct effects of carbon monoxide on myoglobin. At carboxyhemoglobin lev- els of 10%, shortness of breath on vigorous exertion may be noted. Other cardiac manifestations of carbon monoxide over-exposure are sinus tachycardia, atrial

and ventricular dysrhythmias and conduction defects. The mechanisms for these abnormalities are not en- tirely understood but may include acidosis, anoxia and hemorrhage in the conduction system.

The neurologic effects of carbon monoxide toxicity are among the initial symptoms and follow a fairly well-defined pattern. Impairment of perception may begin at carboxyhemoglobin levels as low as 5%. Coordination is affected at levels between 15% and 20%. Headaches develop at 20% and fatigue, distur- bances of judgment, dizziness, and visual problems occur at COHb levels of 30%.

Confusion, muscle weakness, and fainting are re- ported at carboxyhemoglobin levels of 40% to 50%. Loss of consciousness, convulsions, and death after long exposure occur at 60% to 70% COHb levels. A level of 80% can be immediately fatal. Death at much lower levels has been reported with prolonged expo- sures and in particularly sensitive individuals.7 Neuro- logic relapse and deterioration have been reported to occur in some patients 2-9 days after exposure. Late and potentially severe neuropsychiatric symptoms have also been reported following apparent recover- ies.

Development of symptoms of carbon monoxide poisoning varies based on the concentration of carbon monoxide to which the individual is exposed and the duration of exposure. The Environmental Protection Agency (EPA) has set a standard for outdoor air at 9 ppm maximum 8-hour exposure average and 35 ppm maximum 1-hour exposure, neither to be exceeded more than once a year. Based on exposure analysis, this standard is estimated to keep 99% or more of the sensitive population below a 2. 1% COHb level. Recent review of research concerning the medical effects of carbon monoxide exposure resulted in retention of this standard by the EPA.6 8

Levels of carboxyhemoglobin rise over exposure time until an equilibration is reached between blood COHb and the concentration of carbon monoxide in the air. About three hours are needed at rest for COHb to reach 50% of the equilibrium value. Exposure to an ambient carbon monoxide level of 100 ppm may result in a COHb level of 4% after one hour and 16% when equilibrium is reached. Exercise and smoking de- crease the time required to reach equilibrium.8

Carbon monoxide toxicity is a gradually reversible process with time. When removed from an environ- ment with high carbon monoxide levels, a patient may eliminate half of his absorbed carbon monoxide in about five hours and 20 minutes in fresh air. This half-time can be decreased to 1 hr 20 min with admin- istration of 100% oxygen by mask.9

Increased susceptibility to the effects of carbon monoxide exposure is present in certain individuals and under special circumstances. Children and teen- agers appear to develop toxicity at lower exposure concentrations than do adults. They may experience gastrointestinal symptoms more frequently. 10 Expo-

February 1989, Virginia Medical 75

sure during pregnancy can result in fetal death, while the mother may recover.11 (The effects of maternal smoking on fetal growth and development are consid- ered to be related to carbon monoxide exposure in utero.) Patients with a history of angina pectoris may develop severe and prolonged chest pains at low exposure levels.6 The presence of chronic obstructive pulmonary disease also exacerbates the effects of carbon monoxide.12

The clinical presentation at low levels of exposure is nonspecific, with complaints such as headache, nau- sea, vomiting and sometimes exertional dyspnea. The symptoms are often of several days’ or even weeks’ duration, which makes an occupational or environ- mental etiology less likely to be considered. Several family members may be affected, resulting in a diag- nosis of “viral syndrome’’. Failure to diagnose carbon monoxide poisoning may allow the patient to return to the exposure, sometimes with very serious conse- quences. Therefore, carbon monoxide poisoning should be included in the differential diagnosis of patients presenting to the emergency department with headache, dyspnea, nausea or altered levels of con- sciousness. Questions should be asked about car ex- haust leaks, home heating systems and other voca- tional or avocational activities that may be associated with high carbon monoxide levels.

Multiple factors are present in indoor ice skating arenas which increase the toxic effects of elevated ambient carbon monoxide levels. Children and adoles- cents constitute the majority of ice arena patrons. They are performing vigorous exercise and are in- volved in an activity requiring excellent coordination to prevent serious injury to themselves and others. A study of ice hockey players at Harvard demonstrated that exercising athletes can develop levels of carboxy- hemoglobin associated with impaired perception and coordination when performing in ambient air concen- trations of carbon monoxide of about 22.5 ppm after a playing time of only 93 minutes.13

Because ice skating arenas are frequently open 18 hours daily and skaters and employees spend many hours at them, often more than eight hours at a time, duration of exposure is regularly prolonged. Many employees and most ice skaters are not aware of the risk of carbon monoxide exposure and/or toxicity. Therefore, early warning signs are ignored, mild cases not diagnosed, and persons with special risk factors exposed. Pregnant women not only ice skate but may be employed as instructors.

Recommendations

The following measures are recommended to pre- vent carbon monoxide toxicity in indoor ice skating arenas.

1) Standards for indoor air quality, including carbon monoxide levels, should be established nationally for the general public.

2) When there is a risk of exposure to levels of carbon monoxide above those recommended by the Environmental Protection Agency, employees and the general public should be warned by a clearly visible warning sign posted at the entrance to the arena by the management.

3) All indoor ice skating arenas using gasoline pow- ered ice resurfacers and other gasoline powered ma- chines should be monitored regularly. Carbon monox- ide monitors may be placed at the arena by the management for daily review with a plan established for frequent notification of and spot checks by the local regulatory authority.

4) Introduction of electric powered ice resurfacers should be encouraged. Propane powered resurfacers may provide a less costly, acceptable but preferably interim option.

The authors gratefully acknowledge the assistance of Dr. Cecile Rose.

The assistance of Edgar M. Chase, director, and the staff of the Fairfax County Air Pollution Control Division in the conduct of the study and preparation of this report is appreciated.

References

1. Centers for Disease Control (CDC). Carbon monoxide intoxication — a preventable environmental health haz- ard. MMWR 1982;31:529-531

2. CDC. Carbon monoxide intoxication associated with use of a gasoline powered resurfacing machine at an ice skating rink — Pennsylvania. MMWR 1984;33:49-51

3. CDC. Carbon monoxide exposures at an ice skating rink — Colorado. MMWR 1986;35:435-441

4. National Institute for Safety and Health. Occupational Diseases — A Guide to Their Recognition. Washington DC, Department of Health, Education and Welfare, Centers for Disease Control, June 1977, pp 417-419

5. Zamboni F. Zamboni ice resurfacers, Paramont, Califor- nia. Personal communication

6. Office of Air Quality Planning and Standards, US Envi- ronmental Protection Agency. Review of the NAAQS for carbon monoxide: reassessment of scientific and technical information, July 1984

7. Zimmerman S, Truxal B. Carbon monoxide poisoning. Pediatrics 1981;68:215-224

8. Lippmann M, Schlesinger RB. Chemical Contamination in the Human Environment. New York, Oxford Univer- sity Press, 1979, pp 41-43

9. Zenz C. Occupational Medicine. Chicago, Year Book Medical Publishers Inc, 1975, pp 605-612

10. Gemelli F, Cattani R. Carbon monoxide poisoning in childhood. Br Med J 1986; 1 34: 1 197

11. Cramer CR. Fetal death due to accidental maternal carbon monoxide poisoning. J Toxicol Clin Toxicol 1982;19:297-301

12. Grumbeck CH. Preplanning allows prompt action on workplace respiratory distress. Occup Health Safety 1984;53:25-29

13. Spengler JD, Stone KR, Lilly FW. High carbon monox- ide levels measured in enclosed skating rinks. J Air Pollut Control Assoc 1978;28:776-779

76 Virginia Medical, February 1989

VIRGINIA MEDICAL

Fraud and Abuse Statutes

For those practitioners of medicine who deal with Medicare and Medicaid a new regulation seems to be promulgated each month. Obviously that is not really the case, but new interpretations and new regulations do appear with alarming frequency. Fur- ther, these changes seem to be frequently nebulous and always more constrictive. Consider the draft copy of the proposed regulations concerning the anti-kick- back provisions of the Medicare and Medicaid fraud and abuse statutes.

Under the Social Security Act, it is a crime for a physician to offer, pay, solicit or receive kick-backs or rebates under certain circumstances, such as financial relationships which may be linked to patient referrals. Congress has directed the Secretary of the United

States Department of Health and Human Services to specify payment practices that will not be treated as a criminal offense under the Social Security Act. The proposed regulations concerning the anti-kickback provisions are being developed in response.

According to Ms. Julia Krebs-Markrich, a former Assistant Attorney General of Virginia, the “safe harbors” included in the draft of the proposed regula- tions are quite narrow; careful analysis of payment practices not covered by the regulations will be nec- essary in order to ensure compliance with the law.

To the practitioner: Submit comments as to the appropriateness of the proposed regulations when they are published in the Federal Register ; if you are in doubt, consult your attorney. E. L. K., Jr.

Self Pity

It had been a busy Saturday morning in the office, my two partners were out of town, I had both nasal congestion and pounding sinuses with my URI, my cough was slightly better because I had practiced all night, and now I had to see a patient at a nursing home.

I dread seeing patients at nursing homes. As an ophthalmologist, I feel naked and inadequate without my ton of equipment, without my big chair, without my gizmos. Bare hands and just an ophthalmoscope do not security give.

Also, almost nothing depresses me more than seeing so many physically and mentally incapacitated people in the last stages of their lives. I admire people who can work in nursing homes because I do not have that kind of mental stamina.

But there was no way out. Mr. Smith had a sore red eye and was in no shape to be bought to our office. I puttered about the office, dictated a letter or two, then

could procrastinate no longer. How I wished that it was my weekend off so that I could be in the moun- tains, that my cold was gone, that I felt good, that I did not have to go to the nursing home.

Mr. Smith had severe dementia from Alzheimer’s disease, but this time he was not combative, so I quickly saw that he had a mild bacterial conjunctivitis. I wrote some orders for antibiotic eye drops, put on my coat against the cold fall drizzle, stuck my black bag under my arm, and slowly walked down the long hall toward the exit. My frontal sinuses were killing me. I was going home and get in bed and skip lunch.

In the door of the room next to the exit stood a very old, frail, man with a terribly twisted spine. He looked up at me with obvious envy and said, “I wish I felt half as good as you look.”

Henry S. Campell, MD

February 1989, Virginia Medical 77

OBITUARY

• John Richard Saunders, MD, retired Lynchburg ob- stetrician/gynecologist; Medical College of Virginia, 1935; age 78; died November 26, 1988. He had been president of the Lynchburg Academy of Medicine and the Virginia Obstetrical and Gynecological Society.

• James H. Gamble, MD, longtime family physician in Lovingston; University of Virginia School of Medi- cine, 1953; age 71; died July 11, 1988.

• Robert A. W. Latimer, Sr., MD, Manassas; George- town University School of Medicine, 1949; age 62; died July 10, 1988. He was a general practitioner.

• Herman Harrison Braxton, Sr., MD, for 55 years a general practitioner in Chase City; Johns Hopkins University School of Medicine, 1932; age 82; died November 18, 1988.

• Ghulam Hussain Surhio, MD, Blacksburg ophthal- mologist; Liquat, Pakistan, Medical School; age 50; died of a massive coronary on October 2, 1988.

• John Otto Boyd, MD, Roanoke; Medical College of Virginia, 1941; age 74; died September 2, 1988. His specialty was emergency medicine.

• Fen’n Ernest Victor, MD, family physician in Roa- noke; School of Medicine and Pharmacy of the Uni- versity of Haiti, Port au Prince, 1950; age 64; died September 6, 1988.

• Charles Edward Sutton, MD, Richmond; Howard University College of Medicine; age 63; died May 16, 1988. He was a general practitioner.

• Lester Edwin Dunman, MD, longtime Pearisburg internist; Medical College of Virginia, 1935; age 76; died September 16, 1988, in Atlanta.

• Walter C. Beck, MD, retired pathologist; George Washington University Medical School, 1947; age 67; died October 18, 1988, in Vienna, Austria. From 1957- 1966 he was associate pathologist at Roanoke Memori- al Hospital. A brother, Ralph E. Beck, MD, practices pathology in Richmond.

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78 Virginia Medical, February 1989

Physician’s Guide to the Natural Death Act

From the time it became effective in 1983, the Natural Death Act (Virginia Code §54-325.8:1) has offered a statutory “safe harbor" for the Virginia physican who complies in good faith with its provi- sions.

The Act defines “terminal condition" as “a condi- tion caused by injury, disease or illness from which, to a reasonable degree of medical certainty, (i) there can be no recovery and (ii) death is imminent."

“Life-prolonging procedure" is defined by the Act as “any medical procedure, treatment or intervention which (i) utilizes mechanical or other artificial means to sustain, restore or supplant a spontaneous vital function or is otherwise of such a nature as to afford a patient no reasonable expectation of recovery from a terminal condition and (ii) when applied to a patient in a terminal condition, would serve only to prolong the dying process; however, nothing in this act shall prohibit the administration of medication or the per- formance of any medical procedure deemed necessary to provide comfort care or to alleviate pain."

These are the steps the law requires:

1. A patient makes a declaration directing the with- holding or withdrawing of life-prolonging procedures in the event of a terminal condition. If the declaration is written, it must be signed by the patient and two witnesses, neither of which may be the patient's spouse or blood relative but one of which may be the physician.

If the declaration is oral, it is valid only (i) if made after the patient has been diagnosed as having a terminal condition and (ii) if it is made in the presence of a physician and two witnesses, neither of which may be the patient’s spouse or blood relative.

2. If the patient has made a valid declaration and is competent, the attending physician must then certify in writing that the patient has a terminal condition before withholding or withdrawing a life-prolonging procedure.

3. If the patient has made a valid declaration but is “comatose, incompetent, or otherwise physically or mentally incapable of communication,” the attending physician must certify in writing that the patient has a terminal condition and must also have one other physician examine the patient and do likewise before withholding or withdrawing a life-prolonging proce- dure.

4. In the case of a patient who is comatose, incom- petent or otherwise physically or mentally incapable of communication and who has not made a written or oral declaration, the Act designates these persons, listed in order of priority, with whom the attending physician must consult and agree prior to withholding or with- drawing a life-prolonging procedure:

1) any guardian or committee judicially appointed on behalf of the patient;

2) anyone designated in writing by the patient to make the treatment decision;

3) the patient’s spouse;

4) an adult child of the patient or a majority of the children who are reasonably available for consulta- tion;

5) the parents of the patient;

6) the nearest living relative of the patient.

If no one in the first category is “reasonably avail- able, willing and competent to act,” the physician may go to the next priority, and then the next, until an appropriate person is located.

But when the physician must turn to any of the family members in the last four categories, the physi- cian (i) must insure that there are two witnesses present when the treatment decision is made with those family members, and the patient's spouse and blood relatives may not serve as either of these witnesses, and (ii) must get consent from two persons in any of the last four categories if two are reasonably available.

Two points should be emphasized. First, the Act does not apply to patients who are under 18 years of age. Second, if a physician does not want to direct the withholding or withdrawing of life-prolonging proce- dures as authorized by this Act. he has no obligation to do so; he must, however, offer to transfer the patient to another physician.

The Act does not eliminate any immunity a physi- cian already may have under the common law.

Attorneys Sandra Kramer and Allen C. Goolsby III developed this legal information for the June 1983 issue of Virginia Medical. It has been slightly revised for subsequent reprintings.

IE

Still available at Virginia Medical is the patient brochure with the declaration that implements the Natural Death Act. To receive up to 100 copies free of charge, send your order to the Executive Editor. 4205 Dover Road. Richmond VA 23221.

February 1989, Virginia Medical 79

Imagine a machine

THAT CAN DO THIS TO

We're proud to announce the introduction of Extra- corporeal Shock Wave Lithotripsy as a new feature of our kidney stone treatment program. This new device makes it possible to pulverize and eliminate kidney stones with- out invasive surgery Now you have the opportunity to participate in this state-of-the-art procedure at CAMC's High Tech Center here in Charleston, West Virginia.

The Lithotripter uses shock waves to bombard kid- ney stones into sand-like particles inside the body. The residue is then easily passed. Although the theory behind Lithotripsy is simple, the process is precise. The stone is pinpointed inside the body with fluoroscopy and shock wave firing is synchronized with the patient's heartbeat by electrocardiogram. Usually, the entire pro- cess takes about an hour.

As you can imagine, Lithotripsy offers many benefits to kidney stone patients. The process is less painful, entails fewer side effects, and recuperation is quicker than with conventional surgery. It's even less expensive than surgery.

We're encouraging all area urologists to apply for privileges in Extracorporeal Shock Wave Lithotripsy. We invite you to visit CAMC and see the lithotripter in action. Come and learn about this revolutionary therapy. We will happily provide you with a brochure for your use as well as brochures for your patients.

For your brochures or other information about Lithotripsy and our kidney stone treatment program, call CAMC: in West Virginia at 1-800-654-0159; from out of state, call 304-340-7315.

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The new president of the American Society of Internal Medicine likes to call himself a mountain boy. He is Dr. James G. Nuckolls of Galax, Vir- ginia. “There’s an old saying in the mountains of Virginia,” he told ASIM members in accepting the presidency, “If you see a turtle sit- ting on a fence post, you can bet it didn’t get there by itself.” At 49, Dr. Nuckolls is believed by the Society to be its youngest president ever. He is definitely the first Virginian to lead the 23,000-member national spe- cialty society.

Jim Nuckolls spent his undergrad- uate years as a basketball scholar at Davidson College. He earned his medical degree at Duke University School of Medicine, where he also served his residency. At Duke he was one of the first Carnegie-Com- monwealth Clinical Scholars (now the Robert Wood Johnson Clinical Scholar program) and was named chief resident in 1971. (Now, as an associate professor of clinical medi- cine, he heads up the Duke outreach

President Nuckolls in his lab

program in Galax.) After his resi- dency at Duke, he enlisted with the United States Public Health Service and was assigned to the Center for Disease Control in Atlanta, where he and three colleagues examined an epidemic in Pontiac, Michigan. They turned out five research papers that described what was then known as Pontiac fever and contributed six years later to the identification of Legionella pneumophila.

His colleagues thought he was crazy when he decided to set up shop in Galax, a rustic community 90 miles southwest of Roanoke. With a population of just over 6,000, it is not the place one would expect to find a hotshot doctor from Duke, but Dr. Nuckolls is a sixth-genera- tion Galaxian and still has the sad- dlebag his physician great-grandfa- ther took on house calls. When asked why he went back, Dr. Nuck- olls deadpans, “I almost had to.” He started in 1972 with a solo prac- tice in the basement of an abandoned Baptist church, but now has three associates, Drs. Len B. and Linda T. Lastinger and Dr. Allen M. Laws, who practice with him as Blue Ridge Health Associates.

In 1977 he was named ASIM’s Young Internist of the Year, and he has been a member of the Society’s board of trustees since 1982. He has also served for ten years on the board of directors of the Robert Wood Johnson Clinical Scholars program. His organizational creden- tials include the Southwestern Vir- ginia Medical Society, The Medical Society of Virginia and the Ameri- can Medical Association. At the AMA meeting in Chicago in Decem- ber, he caucussed with the MSV delegation every morning at 7 am and was “well-informed and articu- late,” according to delegation chair- man Percy Wooton, on that hot acronymn, the RBRVS.

He is the director of the intensive care unit at the 149-bed Twin County Community Hospital, which adjoins his office building, and is a founder and president of the Blue Ridge Highlands Nursing Home of Galax.

With its mountains and lakes, Ga- lax is the perfect place for an athletic doctor such as James Nuckolls. Tall (6'6") and lanky, he still plays a mean game of basketball, with a local men’s team, and begins his day three times a week with 6 am aerobics. Every Tuesday is a ski day, snow permitting.

Dr. Nuckolls met his wife Mary Lily while he was at Davidson and she at Duke. Mary Lily is office manager for Blue Ridge Associates and the founder of what will be the first licensed daycare center in Ga- lax, Apple Pie Kids, slated to open in spring 1989. They live on a farm at the foot of the mountains beside the New River where Dr. Nuckolls fishes for pike, rock bass and catfish; in earlier years he was often joined by one or the other of his three children, but now they are all in college.

As president of the ASIM he is scheduled for a speech about twice a month. He says he doesn’t like pub- lic speaking but admits, “The more I do it, the bigger a ham I get.”

He looks serious when he talks about his goals for ASIM, especially physician payment reform. He says physicians must establish their own payment guidelines before the gov- ernment steps in (“If we don’t do it, someone else will”). Dr. Nuckolls believes specialty differentials and geographic variation of fees have caused the demise of the primary care physician in particular and the country doctor in specific. “We need to make those fields more at- tractive,” he says, “because that's what the public needs.”

— Sandra McKinnon

90 Virginia Medical, February 1989

VIRGINIA

MEDICAL

© 1989 — The Medical Society of Virginia

March 1989, Volume 115, Number 3

ON THE COVER

114 Injured Infants Act: Study Compares Definition, Newborn Data Barbara S. Brown and Tamara E. Faulknier

119 Legislators to Study Act’s Definition, Funding

UP FRONT

94 Letters Joseph G. Fiveash, Jr., I. N. Sporn, and John E. Termini 100 Popular Party: VaMPAC Entertains State Legislators

109 Who’s Who

POINT OF VIEW

120 Payment Reform: “I have changed my mind” Nelson G. Richards MEDICINE

122 Hilar Adenopathy and Positive HIV Antibody Test: Case Report Christopher W. Ingram, Barry Dicicco, Lucia Pastore, and Paul Kravitz

125 Abstracts from the Virginia Dermatological Society EDITORIALS

128 Medical Practice Restriction E. L. Kendig, Jr.

128 Addiction H. S. Campell

129 Hospital Notes H. S. Campell

129 Medical Society of Virginia Officers

130 Obituary

133 New Members

135 Meetings about Medicine

142 Classified Advertisements

Editor Associate Editors Editorial Board

Executive Editor Business Manager

Edwin L. Kendig. Jr., MD

Richard G. Lester. MD; Duncan S. Owen. Jr., MD; John A. Owen, Jr., MD H. C. Alexander III. MD: Raymond S. Brown. MD: Henry S. Campell. MD; C. Barrie Cook. MD: Eloise C. Haun. MD; Walter Lawrence. Jr., MD; Lockhart B. McGuire. MD; Robert Edgar Mitchell, Jr., MD Ann Gray

James L. Moore. Jr.

Virginia Medical (ISSN 0146-3616) is the monthly publication of The Medical Society of Virginia. Second-class postage paid at Richmond, Virginia. Yearly subscription rate: $24 domestic, $30 foreign: single copies. $3. Virginia Medical does not hold itself responsible for statements made by any contributor. Although all advertising is expected to conform to ethical medical standards, acceptance does not imply endorsement by this journal, and the publisher reserves the right to reject any advertisement. For information on the preparation of articles, write to the Executive Editor for "Advice to Authors ’, or call (804) 353-2721. POSTMASTER: Send address changes to Virginia Medical, 4205 Dover Road. Richmond VA 23221.

92 Virginia Medical, March 1989

THE SECRET IS OUT

“I am very impressed with the SMA’s Annual Meetings. I had not anticipated the diversity of the meetings and the specialties available as well as the postgraduate programs. I’ve participated in two courses and have been extremely impressed with the organization and content of the programs.”

Nancy E. Pace, M.D.

Internal Medicine

Honolulu, Hawaii

Since 1906, the Southern Medical Association has been the best kept secret in the South. No longer! The word is out and everybody’s talking.

They’re talking about the educational benefits of belonging to the largest regional multi- specialty association in the U.S. and the diversity of the Annual Scientific Assembly.

They’re talking about a non-political associa- tion whose only mission is to provide the best educational and financial benefits available anywhere.

They’re also talking about unrivaled member benefits including the SMA Insurance Program, the Physicians’ Purchasing Program, the SMA Retirement Program, SMA Travel Services, Dial Access, the Southern Medical Journal and many, many more.

But most of all, they’re talking about how SMA can offer so much at such a low cost.

Call the SMA for more information and a membership application. Find out why more and more physicians are joining the SMA every day.

Join the SMA today . . . You’ll be talking about us too!

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IN THIS ISSUE:

No sooner had the “Injured Infants Act,” as it is familiarly known, passed the General Assembly in 1987 than it began to generate discussion, and the discussion continues to date. On page 96 you will find another in a long line of Letters to the Editor protesting the act’s funding mechanism. On page 1 19 you will find a report of a legislative subcommittee to study both the funding mechanism and the act’s articulation of birth-related neurological injury. In between, beginning on page 114, you will find the results of a study of the act’s potential efficacy as a compensatory device and deterrent to liability suits; this is the first such research, and the two young women who conducted it have already moved into a second phase, an analysis of the act’s probable cost.

No one takes a keener interest in all this discussion and study than attorney Sandra L. Kramer, who was there when the Injured Infants Act was passed. For almost a decade Ms. Kramer helped Allen C. Goolsby 3rd run the MSV lobbying team; she negotiated with lawmakers, wrote many of the bills the Society introduced, was party to countless MSV committee meetings on matters legal/legislative. Now she has been appointed to succeed Goolsby as The Medical Society of Virginia’s chief counsel and head lobbyist, although Goolsby will continue to serve the Society as “outside” counsel. Previous MSV counsels have operated on a consulting basis. It is a sign of the times that Sandra Kramer will be a fulltime, inhouse attorney, with offices in downtown Richmond and at MSV headquarters.

Counsel Kramer with Del. John C. Brown (left) and Dr. Kenneth W. Tuck, chairman, MSV State Legislative Committee

The Medical Society of Virginia

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American Medical Association

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Medicaid Provider Relations

800-552-8627 Richmond 786-6273

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Virginia Department of Health

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MSV Review Organization

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March 1989, Virginia Medical 93

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LETTERS

Advocates sending editorial to “every legislator and lawyer”

The editorial on the profession of medicine in the December issue of Virginia Medical1 is the most outstanding piece of writing I have ever seen concern- ing the problems that confront us in the practice of medicine.

The solution concerning the changing of the tort system so that malpractice litigation can be limited to avoidable personal injury is also absolutely essential if the high cost of medicine can be controlled. The editorial should be forcibly nailed to the forehead of every legislator and lawyer in the country.

My congratulations for such a brilliant and succinct piece of writing.

Joseph G. Fiveash, Jr., MD

400 West Brambleton Avenue Norfolk VA 23510

1. Kendig ELjr. The profession of medicine. Va Med

1988;115:588-9

Proposes taping, distributing conversations with third parties

Like most doctors I am increasingly disturbed by intrusions into medical practice, in the name of “cost- containment,” by representatives of the insurance companies and other third parties to the doctor-patient relationship. By contract they have arrogated to them- selves the “right” to peruse patients’ charts and otherwise to obtain detailed and privileged clinical information about them. Armed with this information, they then decide who is to be admitted to the hospital, what tests and treatment they will receive, and how long they will stay in the hospital. They are exerting increasing pressure on us to cut corners in ordering tests and treatment and to discharge patients prema- turely. In short, they have thrust themselves into the role of uninvited and unqualified participants in the care of our patients.

In the vast majority of cases, patients have no idea what is happening behind the scenes, and if things go wrong it is the doctor and the hospital they blame. Indeed, the decisions made by the third parties are presented to the public as “quality assurance” and the doctors and hospitals are portrayed as villains who must be watched to prevent dishonest and greedy behavior. Moreover, the business executives who

Continued page 96

94 Virginia Medical, March 1989

A single-entity muscle relaxant for prescribing flexibility

RltRAFON FORTE DSC

DOUBLE STRENGTH CHLORZOXAZONE

Works alone. . .

■ Now with 500 mg chlorzoxazone per caplet — double the muscle relaxant of a PARAFON FORTE® (chlorzoxazone and acetaminophen) tablet, and no analgesic.

■ Just one easy-to-s wallow caplet q.i.d. may encourage compliance.

■ Prompt, effective relief with minimal drowsiness.* Clinical studies have shown that patients respond by the end of 24 hours following initiation of therapy.

Or with an analgesic

■ Formulated without an analgesic, for maximum treatment flexibility

■ Can be used with the analgesic of your choice, according to the patient’s need for pain relief.

■ Scored caplet permits greater dosing flexibility for patients requiring lower daily doses.

"Clinical studies have shown that most patients remain alert when chlorzoxazone-containing products are administered at recommended doses, although drowsiness sometimes occurs.

Please see following page for brief summary of Prescribing Information.

(C) McNEILAB, INC., 1988

The following is a brief summary only. Before prescribing, see complete prescribing information in PARAFON FORTE DSC labeling. CONTRAINDICATIONS: PARAFON FORTE DSC chlorzoxazone is contraindicated in patients with known intolerance to the drug.

WARNINGS: The concomitant use of alcohol or other central nervous system depressants may have an additive effect. Usage in Pregnancy. The safe use of PARAFON FORTE DSC chlorzoxazone has not been established with respect to the possible adverse effects upon fetal development. Therefore, it should be used in women of childbearing potential only when, in the judgment of the physician, the potential benefits outweigh the possible risks.

PRECAUTIONS: PARAFON FORTE DSC chlorzoxazone should be used with caution in patients with known allergies or with a history of allergic reactions to drugs. If a sensitivity reaction occurs such as urticaria, redness, or itching of the skin, the drug should be stopped. If any symptoms suggestive of liver dysfunction are observed, the drug should be discontinued.

ADVERSE REACTIONS: After more than twenty-six years of extensive clinical use of chlorzoxazone-contain- ing products in an estimated thirty-two million patients, it is apparent that the drug is well tolerated and seldom pro- duces undesirable side effects. Occasional patients may develop gastrointestinal disturbances. It is possible in rare instances that chlorzoxazone may have been associated with gastrointestinal bleeding. Drowsiness, dizziness, lightheadedness, malaise, or overstimulation may be noted by an occasional patient. Rarely allergic-type skin rashes, petechiae, or ecchymoses may develop during treatment. Angioneurotic edema or anaphylactic reac- tions are extremely rare. There is no evidence that the drug will cause renal damage. Rarely, a patient may note discoloration of the urine resulting from a phenolic metab- olite of chlorzoxazone. This finding is of no known clinical significance. Approximately thirty-six patients have been reported in whom the administration of chlorzoxazone- containing products was suspected as being the cause of liver damage. In one case, the jaundice was subse- quently considered to be due to a carcinoma of the head of the pancreas rather than to the drug. In a second case, there was no jaundice but an elevated alkaline phospha- tase and BSP retention. In this patient there was a malig- nancy with bony and liver metastases. The role of the drug was difficult to determine. A third and fourth case had cholelithiasis. Diagnosis in a fifth case was submas- sive hepatic necrosis possibly due to abusive use of the drug for approximately one year The remaining cases had a clinical picture compatible with either a viral hepati- tis or a drug-induced hepatitis. In all these latter cases, the drug was stopped, and with one exception, the patients recovered. It is not possible to state that the hep- atitis in these patients was or was not drug-induced.

Full directions for use should be read before adminis- tering or prescribing.

For information on symptoms and treatment of over- dosage, see full prescribing information.

12/16/87

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select the plans to be offered to their employees often have no real knowledge of how the plans will affect the quality of the health care they and their employees will receive. Ultimately, they may not care as long as the bottom line is favorably influenced.

It is important to be sure that our patients know and that their employers know. It is time to get the word out to the public at large. Only we can do it, and it is our duty to inform them in unmistakable terms. It seems to me the only way to accomplish this is to get these procedures into the fresh air of public scrutiny.

With that in mind, I have bought a tape recorder and a telephone pickup device so I can record my conver- sations with third parties. I inform them at the begin- ning of the conversation that it is being recorded and that it is my plan to send a copy of the tape-recorded conversation to the patient and to the employer who selected the health insurance plan. I plan eventually also to release a number of these tapes to the media.

I have obtained a written legal opinion from the Attorney General of the State of Virginia that it is lawful to obtain such tapes and to use them as I describe. My purpose in writing is to urge every practitioner in the state to begin taping these conver- sations, too. It seems to me if enough of us do this, it cannot be long before there is a public outcry to return control of medical care to the doctors, where it belongs.

I.N. Sporn, MD

Suite 302, 1400 Westwood Avenue Richmond VA 23227

Wants action to get rid of “unfair and unjust bill”

Once again we have been billed for the second annual assessment of $250 levied on Virginia physicians to fund the Birth-Related Neurological Injury Compen- sation Act. Once again our noses are rubbed into this malodorous and obnoxious “no fault” bill. How long must we in the medical profession remain in the indecent “Sim’s position” for this annual proctosco- pic exercise?

This bill is a legislative gargoyle which should be put out of its misery. This “assessment” is blackmail in designer clothing.

Ridding physicians of this unfair and unjust bill demands only a modicum of imagination. Funds should be drawn from state revenues or welfare re- sources. The state enjoyed a budgetary surplus last year and introduced a state lottery during calender ’88.

With each year this tax will become a more en- trenched, ossified addiction. Currently, payment can be made only with maximum protest. Action is needed now, this year!

John E. Termini, MD

1440 Emerson Avenue at Chain Bridge Road McLean VA 22101

96 Virginia Medical, March 1989

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Dr. Henry C. Cambell, Martinsville (left), and Speaker of the House A. L. Philpott

The annual VaMPAC re- ception on the eve of the General Assembly’s open- ing session has become a popular party with state legislators, their aides, and other people with clout at Virginia’s Capitol. For this year’s event, the seventh in the series, an estimated 350 persons piled into the ballroom of the Common- wealth Club in Richmond. Some of the 99 legislators who came appear in these pictures and all are listed at the right.

From the Senate

Hunter B. Andrews (D-Hampton)

W. Onico Barker (R-Danville)

Joseph B. Benedetti (R-Richmond)

Daniel W. Bird, Jr.

(D-Wytheville)

Robert L. Calhoun (R-Alexandria)

Edwina P. Dalton ( R-Richmond )

Mark L. Earley (R-Chesapeake)

Joseph V. Gartlan, Jr.

(D-Mason Neck )

Virgil H. Goode, Jr.

(D-Rocky Mount ) Clarence A. Holland (D-Virginia Beach ) Edward M. Holland (D-Arlington)

Richard J. Holland (D-Windsor)

R. Edward Houck (D-Spotsylvania)

Johnny S. Joannou (D-Portsmouth)

Benjamin J. Lambert III (D-Richmond)

J. Granger Macfarlane (D-Roanoke)

Thomas J. Michie, Jr.

(D-Charlottesville)

Emilie Miller (D-Fairfax)

Kevin G. Miller

( R-Harrisonburg )

Yvonne B. Miller (D-Norfolk)

Frank W. Nolen ( D-New Hope )

Robert E. Russell (R-Bon Air)

Richard L. Saslaw (D-Springfield)

Elliot S. Schewel (D-Lynchburg)

Robert C. Scott (D-Newport News)

William A. Truban (R-Woodstock)

Charles L. Waddell (D-Sterling)

Stanley C. Walker (D- Norfolk)

William C. Wampler, Jr. (R-Bristol)

From the House

A. L. Philpott, Speaker (D-Bassett)

Watkins M. Abbitt, Jr.

(D- Appomattox)

Robert W. Ackerman (D-Fredericksburg)

G. Steven Agee (R-Roanoke)

George F. Allen (R-Charlottesville)

James F. Almand (D-Arlington)

Robert T. Andrews (R-McLean)

Robert S. Bloxom (R-Mappsville)

Vincent F. Callahan, Jr.

(R-McLean)

Mary T. Christian (D-Hampton)

Whittington W. Clement (D-Danville)

Shirley F. Cooper (D-Yorktown)

Howard E. Copeland (D-Norfolk)

J. Paul Councill, Jr.

( D- Franklin )

Frederick H. Creekmore (D-Chesapeake)

E. Hatcher Crenshaw, Jr.

(R-Richmond)

Glenn R. Croshaw (D-Virginia Beach)

Jean W. Cunningham (D-Richmond)

Robert K. Cunningham, Sr (R-Springfield)

Jay W. DeBoer (D-Petersburg)

Alan A. Diamonstein (D-Newport News)

V. Earl Dickinson (D-Mineral)

John G. Dicks III (D-Chesterfield)

James H. Dillard II (R-Fairfax)

J. Robert Dobyns (D-Dublin)

Willard R. Finney (D-Rocky Mount)

V. Thomas Forehand, Jr.

( D-Chesapeake )

Arthur R. Giesen, Jr.

(R-Waynesboro)

Raymond R. Guest, Jr.

(R-Front Royal)

Mark W. Hagood (R- Halifax)

Franklin P. Hall (D-Richmond)

Emmett W. Hanger, Jr. (R-Mt. Solon)

100 Virginia Medical, March 1989

Sen. Daniel W. Bird, Jr., and Health Commissioner C. M. G. Buttery

Del. Gladys B. Keating (left) with Dr. and Mrs. Anthony M. Longo, Alexandria

Dr. C. Barrie Cook, Falls Church, and Del. Dorothy S. McDiarmid

Photographs by Taylor Dabney

March 1989, Virginia Medical 101

Or do you know someone who is?

Saint Albans Psychiatric Hospital in Radford, Virginia has been helping people deal with life since 1916. We offer comprehen- sive programs for adults and adolescents in chemi- cal dependency, eating disorders, depression, out- of-control behavior and other life problems —all supervised by a skillful and compassionate staff.

When you know someone in need of psychiatric help, call Saint Albans.

We build real smiles.

In Virginia: 1-800-572-3120 Outside Virginia: 1-800-368-3468 P.O. Box 3608 Radford , Va., 24143

A

Radford.Virgima

Saint Albans ftychiatric Hospital

When the winner of the Louise Obici Memorial Hospital’s annual award is presented next month, an internist/hematologist will step for- ward to receive it. He is Dr. G. Watson James 3rd, who has been hanging round the Medical College of Virginia in Richmond since his student days in the Class of ’43. He is the 25th recipient of the award, given “for outstanding contributions to the medical profession.” The pre- sentation is to occur at the hospital’s clinical conference on April 5 in Suf- folk.

Dr. James’ reputation as a top- notch clinician and researcher knows no geographical boundaries. He has been on the national commit- tee of the American Federation for Clinical Research, is a fellow of the International Society of Hematolo- gy, and is at home in the rarified proceedings of the American Society for Clinical Investigation. For his alma mater he has been chairman of the Division of Hematology (1958— 1983), and he holds full professor- ships in both medicine and patholo- gy. As author or coauthor, he has published 41 articles, most of them in journals with worldwide reader- ships.

But above all, emphasizes a col- league, “Watson James takes great care of his patients.”

Gov. Gerald L. Baliles has ap- pointed Dr. Charles W. Crowder, Jr., South Hill, to the Governor’s Advisory Board on Medicare and Medicaid, and Dr. Lee Richard Brock, Fredericksburg, to the Medi- cal Advisory Board for the Depart- ment of Motor Vehicles.

Dr. Fran DuRocher, Springfield internist, has been elected president of the Metropolitan Washington area branch, American Medical Women’s Association.

March ushers in the championship bicycling season, and in Williams- burg Dr. Camilla M. Buchanan and her racing bike are reaching a peak of training. This year there’s a spe- cial urgency to the 30 high-speed hours per week they spend together: in Pensacola, Florida, last year, Dr. Buchanan won first in the Women’s Criterion Master’s Cycling Champi- onship in the 40+ age category, and she’ll be defending her title this year. She has won other races, but the national first was particularly grati- fying.

In training for a major competi- tion, Dr. Buchanan cycles about 250

miles a week. Last summer she trav- eled every Thursday to the Afton Mountain area in preparation for mountain competition in Idaho. It’s important for a serious biker to rep- resent a racing club in the national events; she rides for the Tidewater Cycling Association. Her associate in obstetrics/gynecology, Dr. Mary Kay Dineen, covers for her when she’s out of town for a race.

Camilla Buchanan was active in intercollegiate athletics in her under- graduate days at William and Mary. She married, went into teaching, reared two children, decided to enter medicine, earned an MD degree at the Medical College of Virginia, Class of 1976, then also trained at MCV. She began running in the late 1960s and ran for 16 years, working up to marathon distance. Entering the Sandman Triathlon in Virginia Beach, she found she enjoyed cy-

Cycling Champ Buchanan

March 1989, Virginia Medical 109

New Officers for Component Societies

These Virginia physicians have been elected to leadership posts by their component medical societies. All but three of them are members of The Medical Society of Virginia.

Alexandria Medical Societry , Dr. William M. Stone, president; Dr. Merrill F. Prugh, secretary.

Augusta-Highland County Medical Society: Dr. Davis S. Klein, president; Dr. Brian Kennedy, secretary.

Danville-Pittsylvania Academy of Medicine: Dr. Arthur W. White- hurst, president; Dr. Douglas W. Shiftlett, secretary.

Fredericksburg Area Medical Society: Dr. J. D. Brock, president; Dr. Robert B. Vranian, secretary.

Loudoun County Medical Society: Dr. Randall L. Harrington, president; Dr. Flinton Callahan II, secretary.

Northern Virginia Medical Society: Dr. Stephen H. Martenson, president; Dr. John H. Armstrong, secretary.

Patrick-Henry Medical Society: Dr. W. Daniel Price 3rd, president; Dr. G. Samuel Hurt, secretary.

Prince William County Medical Society: Dr. Frederick W. Parker 3rd, president; Dr. Stephen L. Ferlazzo, secretary.

Richmond Academy of Medicine: Dr. Warren W. Koontz, Jr., president; Dr. John M. Daniel 3rd, secretary.

Roanoke Valley Academy of Medicine: Dr. Richard J. Grayson, Jr., president; Dr. William J. Dichtel, Jr., secretary.

Rockingham County Medical Society: Dr. T. Keith Vest, president; Dr. C. Newkirk Sheap, secretary.

Virginia Beach Medical Society: Dr. Ramnath Nayak, president; Dr. Bruce C. Dundon, secretary.

cling more than running. In only her third season of competition biking she won the national title.

Her athletic regimen helps her keep her work as physician in per- spective, she told Wilford Kale, who interviewed her for the Richmond Times-Dispatch. “The job is impor- tant and I want to be the best doctor, but I also realize other things are important.”

Such as being the best biker.

Dr. Harry I. Johnson, Jr., Roa- noke, has been appointed by Gov. Gerald Baliles to a four-year term on the board of visitors of Virginia Commonwealth University.

Dr. Paul B. Underwood, Jr., pro- fessor and chairman of obstetrics and gynecology at the University of Virginia, has been named one of the 107 best doctors for women, ac- cording to a nationwide survey con- ducted by Good Housekeeping magazine. The survey polled 250 de-

partment heads and other leaders of ob/gyn at major medical centers.

Named fellows of the American College of Radiology during ceremo- nies at the annual meeting in Cincin- nati were Dr. Hans O. Riddervold, Charlottesville, and Dr. Anas M. El- Mahdi, Portsmouth.

Dr. William E. Broach III, Dan- ville, has been named a fellow of the American College of Obstetricians and Gynecologists.

For his contributions to the educa- tional programs of the American Academy of Ophthalmology, Dr. Earl R. Crouch, Jr., Norfolk, has received the academy’s Honor Award. Dr. Crouch is professor and chairman of the ophthalmology de- partment at Eastern Virginia Medi- cal School.

For his 21 years of service as team physician to the Alleghany High School football team, Dr. Charles F.

Ballou III, Clifton Forge, was given a plaque and a round of applause prior to the start of the big Allegh- any-Covington game. Kenny Hig- gins, AHS coach, and Ben Hicks, president of the Mountaineer Ath- letic Club, conducted the ceremony honoring the physician. The team celebrated the occasion by winning the game.

Dr. Alvin J. Ciccone, Norfolk, was named 1988 Family Physician of the Year by the Virginia Academy of Family Physicians.

At Warren Memorial Hospital in Front Royal, Dr. Elizabeth B. Sher- man and Dr. Edwin M. Eastham were honored recently for their “loyal and valuable service to the hospital and the citizens of Front Royal and Warren County.”

Dr. Sherman, a native of Luray, earned her MD at the University of Maryland, graduating in 1926 and then completing training for general practice, including a residency in pediatrics at Bellevue Hospital in New York. She joined the medical staff of Warren Memorial in 1942 and was named to the emeritus medical staff in 1983.

Born in Flint Hill, Dr. Eastham was awarded his MD degree in 1943 by George Washington University, where he also served his internship. After service overseas with the Army Medical Corps during World War II, he joined Warren Memori- al’s medical staff in 1946, with privi- leges in general medicine and obstet- rics, and was appointed emeritus in 1984. He also served as medical ex- aminer and coroner for Warren County.

To Dr. Thomas K. Hunter, former dean of the University of Virginia’s School of Medicine, went the 1988 Abraham Flexner Award of the As- sociation of American Medical Col- leges. The award is given for “signif- icant lifelong contribution to medicine,” a criterion admirably met by Dr. Hunter’s 27 years in key administrative posts on the Char- lottesville campus and his world

110 Virginia Medical, March 1989

leadership in the field of biomedical ethics. Officially retired as of 1980, he continues to keep what he de- scribes as “a little office’ ’ at the university and lives in Cismont in the 170-year-old house he and his wife bought 35 years ago.

Elected to fellowship at the annual clinical congress of the American College of Surgeons were Dr. Martin A. Thiel, Williamsburg, and Dr. Wil- liam A. Liston, Farmville.

Dr. Leo Goldhammer, Arlington, is to present a paper at the annual meeting of the American Academy of Neurology in Chicago. His title: “Apraxic and Parietal Hand and Their Localizing Value: Tonic, Mo- tor and Visuokinetic Phenomena in Parietal Lob Syndromes.”

The Radiological Society of North America’s highest honor, the Gold Medal Award, was given to Dr. Richard G. Lester, Norfolk, at the society’s annual meeting. Dr. Les- ter, dean and vice president for aca- demic affairs at Eastern Virginia Medical School, is a past president of the society.

Dr. Robert P. Singer, Richmond, was there when the mountain climb- ers of the 1988 Northwest American Everest Expedition made it all the way to the top of the 29,000-foot peak last October. He was a member of the support system, serving as a doctor at a base camp 11,500 ft above sea level while the climbers pushed on to the ultimate heights.

Dr. Singer had been training for three years for the Everest venture; a dedicated fitness man, he had only to beef up his workouts at the swim and racquet club to which he be- longs. In early August he left his Henrico County practice to join the climbers in Katmandu, Nepal, and hike 120 mi to the peak. On October 22, while still on the mountain, he celebrated his 59th birthday. No cake, no candles, but oh my, the view!

BUOY THE PRESTIGE OF THE MSVGOU)

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WITH A M.88% APR.

As a member of the Medical Society of Virginia, you’re eligible for a very attractive rate on the MSV Gold Master- Card issued through Central Fidelity Bank.

With a fixed Annual Percentage Rate of just 14.88% and a reduced first year annual fee of only $15, you’ll be able to pay off other cards and save on interest payments. That’s an exciting prospect in itself. And when you add other preferred benefits like 24-Hour Travel Service and travel discounts, travel accident insurance and a package of medical, legal, car rental and pre-trip travel services . . . all at no additional cost, it’s an offer you can’t afford to pass up.

And, everytime you use the MSV Gold MasterCard, you’re actually making a donation to the Society’s Medical Student Loan Foundation.

So why not take advantage of this attractive membership service today. You’ll enjoy the prestige it brings to you and the support it provides to Virginia’s medical students.

Central

Medical Society of Virginia

March 1989, Virginia Medical 111

Imagine a machine

THAT CAN DO THIS TO

We're proud to announce the introduction of Extra- corporeal Shock Wave Lithotripsy as a new feature of our kidney stone treatment program. This new device makes it possible to pulverize and eliminate kidney stones with- out invasive surgery Now you have the opportunity to participate in this state-of-the-art procedure at CAMC's High Tech Center here in Charleston, West Virginia.

The Lithotripter uses shock waves to bombard kid- ney stones into sand-like particles inside the body. The residue is then easily passed. Although the theory behind Lithotripsy is simple, the process is precise. The stone is pinpointed inside the body with fluoroscopy and shock wave firing is synchronized with the patient's heartbeat by electrocardiogram. Usually, the entire pro- cess takes about an hour.

As you can imagine, Lithotripsy offers many benefits to kidney stone patients. The process is less painful, entails fewer side effects, and recuperation is quicker than with conventional surgery. It's even less expensive than surgery.

We're encouraging all area urologists to apply for privileges in Extracorporeal Shock Wave Lithotripsy. We invite you to visit CAMC and see the lithotripter in action. Come and learn about this revolutionary therapy. We will happily provide you with a brochure for your use as well as brochures for your patients.

For your brochures or other information about Lithotripsy and our kidney stone treatment program, call CAMC: in West Virginia at 1-800-654-0159; from out of state, call 304-340-7315.

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VIRGINIA

MEDICAL

MARCH 1989

Injured Infants Act:

Study Compares Definition, Newborn Records

Barbara S. Brown, PhD, and Tamara E. Faulknier, BS,

Richmond, Virginia

In a study of a teaching hospital’s newborn records 1986-1987, the definition of severe neurological injury in Virginia’s Injured Infants Act was found to be associated with neonatal death, prematurity, and a preexisting maternal condition likely to contribute to poor outcome. The incidence of severe neurologic injury did not approach the prevalence of severe mental retardation and cerebral palsy. Thus the ability of the Act to preempt litigation substantially is questionable, the authors state, and they recommend a broader definition.

When the Virginia General Assembly passed the Birth-Related Neurological Injury Compensation Act in 1987, 1 several questions about the mea- sure’s effectiveness were unan- swered because of lack of informa- tion about the number of infants born each year who would meet the Act’s definition of neurologically in- jured. Practitioners criticized the definition as being too restrictive to deter litigation. Some even ques- tioned if any infants could be found to meet the explicit eligibility crite- ria. On the other side, policy makers wanted to begin with a conservative definition so that excessive financial burden on the trust fund would be avoided at the outset. Until the ef- fects of broadening the definition

were known, it was unlikely that the legal definition could be revised.

To address these issues, the Medi- cal Society of Virginia contracted with the Williamson Institute for Health Studies at the Medical Col- lege of Virginia, Virginia Common- wealth University, to conduct a study on the incidence of severely neurologically injured infants and

From the David G. Williamson Insti- tute for Health Studies, Department of Health Administration, Medical College of Virginia/ Virginia Commonwealth Uni- versity, where Barbara Brown is assist- ant professor and coordinator of the Health Care Financing Administration Research Center. Address correspon- dence to her at Box 206, MCV Station, Richmond VA 23298-0206.

Submitted 1-25-89.

the effect of broadening the defini- tion.

Materials and Methods

The records of infants born at a university medical center between January 1, 1986, and December 31, 1987, and having anoxia at birth were abstracted to identify infants fitting the Act’s definition and three alternative definitions of severe neu- rologic birth injury. Figure 1 shows the enacted and proposed definitions tested. A select task force of the Medical Society chose the three al- ternatives. Each definition captures different eligibility factors.

Virginia’s definition is explicit (only those children who are “per- manently nonambulatory, aphasic, incontinent, and in need of assist-

114 Virginia Medical, March 1989

Fig. 1. Enacted, Proposed Definitions of Birth-Related Neurological Injury.

Virginia Definition

“Birth-related neurological injury” means injury to the brain or spinal cord of an infant caused by oxygen deprivation or mechanical injury occurring in the course of labor, delivery, or resuscitation in the immediate post-delivery period in a hospital, which renders the infant permanently nonambulatory, asphasic, incontinent, and in need of assistance in all phases of daily living. This definition shall apply in live births only.

Florida Definition

“Birth-related neurological injury” means injury to the brain or spinal cord of an infant of term gestation caused by oxygen deprivation or mechanical injury occurring in the course of labor, delivery, or resuscitation in the immediate post-delivery period in a hospital, which renders the infant permanently and substantially mentally and physically impaired. This definition shall apply to live births only and shall not include disability or death caused by genetic or congenital abnormality.

Medical Society of Virginia Alternative Definition I

“Birth-related neurological injury” means injury to the brain, spinal cord, or peripheral nervous system of an infant caused by oxygen deprivation or mechanical injury occurring in the course of labor, delivery, or resuscitation in the immediate post-delivery period in a hospital, which renders the infant permanently or substantially mentally or physically impaired. This definition shall apply to live births only and shall not include disability or death caused by genetic or congenital abnormality.

Medical Society of Virginia Alternative Definition II

“Birth-related neurological injury” means injury to the brain or spinal cord of an infant caused by oxygen deprivation or mechanical injury occurring in the course of labor, delivery, or resuscitation in the immediate post-delivery period in a hospital, which renders the infant permanently and substantially mentally and physically impaired. This definition shall apply to live births only and shall not include disability or death caused by genetic or congenital abnormality.

ance in all phases of daily living” are eligible); while the other three are not.

The Florida definition, enacted by the Florida legislature when it passed a similar law in 1988, differs from the Virginia definition in two ways. It broadens the definition of disability by stating the infant is ren- dered “permanently and substantial- ly mentally and physically im- paired” without requiring explicit disabilities. However, it narrows eli- gibility by excluding preterm infants. The Virginia definition accepts pre- mature infants.

The third definition proposed by the task force, termed Medical Soci- ety of Virginia Alternative Definition I (MS VI), is the least restrictive of the definitions. It extends coverage to peripheral nerve damage and eliminates the requirements that im- pairment be both mental and physi- cal as well as permanent. Like the Virginia definition, it includes pre- mature infants. The definition was proposed after much debate on the effect of maturation on an injury sustained at birth. The expert physi- cians felt it inequitable to deny as- sistance to a child for whom the permanency of the severity of injury could not be confirmed until the pre- school years. In addition, their clini- cal experience indicated children could sustain permanent or substan- tial injury to peripheral nerves with- out being mentally impaired.

The fourth definition, listed as Medical Society of Virginia Alterna- tive Definition II (MS VII), is the Florida definition with the restric- tion on premature birth removed.

In all definitions, the cause of inju- ry remained the same as stated in the Virginia Act, “oxygen deprivation or mechanical injury occurring in the course of labor, delivery, or resusci- tation in the immediate post-delivery period in a hospital.”

The sample was composed of in- fants meeting oxygen deprivation criteria. The criteria were having Apgar scores consistent with as- phyxia neonatorum, i.e., scores less than 4 at 1 minute and less than 6 at 5 minutes.2 The Apgar scores were set

at these levels for two reasons. First, case studies of severely neurologi- cally impaired infants born at the facility from 1982 to 1985 indicated the most predictive variables were low Apgar scores at 1 and 5 minutes within this range. This finding was consistent with the literature.3 Sec- ond, it provided a method for identi- fying the population of infants, as Apgar scores are included on birth certificates filed with the state.

The Virginia Bureau of Vital Sta- tistics provided a list of infants meet- ing the Apgar criteria who were born between January 1, 1986, and De- cember 31, 1987, at the medical cen- ter. Each child’s birthweight was also given. Children weighing under 1000 grams (gms) were eliminated from the record review because it

was felt that they did not pose a serious malpractice litigation threat. Medical charts and/or discharge summaries of the remaining infants were abstracted by the principal in- vestigator (BSB).

To characterize the infants and gain insight to predisposing or ac- companying events associated with severe neurologic damage, the fol- lowing information was collected on each infant: Apgar score, sex, race, survival, length of hospital stay, di- agnoses, mother’s age, history of antepartal care, type of delivery, presentation, history of obstetric or delivery complications, positive findings on admission and discharge (either physical examination or diag- nostic studies) and hospital charges. Any subsequent hospital or ambula-

March 1989, Virginia Medical 115

Figure 2. Infants by Case for 1986 Meeting Definitions of Neurologically Injured

Case Number

86-1

86-2

86-3

86-4

History

APGAR at 1

0,0

1,2

1,0

1,3

min

Dx in addition to Asphyxia

SGA

RDS

Convulsions

Seizures

SGA

Mec aspir

Survival

Deceased

Deceased

Deceased

Deceased

(day 1)

(day 2)

(day 2)

(day 5)

Birth Weight

3 lbs 5 oz

5 lbs 1 oz

7 lbs 2 oz

5 lbs 2 oz

Mother’s Age

22

23

19

Missing

(in years)

Ante Care

No

Unknown

Yes

Yes

Obst/delv

comp

Footling breech PROM Sepsis

None

Mom admitted 2 day **PTD in ketoacidosis

Post term

Type Delivery Definitions (see

C-section

Fig. 1)

Vag

C-section for fetal distress

C-section when ROM W mec

VA

X

X

X

X

FLA

0

X

X

X

HSV I

X

X

X

X

MSV II

X

X

X

X

Notes

Uterine con-

Intubated x 20

“Persistent

“Hypoxic

tractios on head

for mec.

acidosis.”

encephalop-

made extraction

Urine output

Urine output

athy.”

difficult

down secondary

down.

Intubated x 7

On admis cyanot, floppy foul odor

to hypoxic in- sult to kidneys

No moro, no grasp, no spont move

for mec

* Meconium ** Prior to delivery

86-5

86-6

86-7

86-8

Totals

1,4

1,4

1,4

2,5

*Mec aspiration

Disseminated intravasc hem

Mec in trach

Seizures Mec in trach IGR

Deceased (day 1)

Deceased (day 1)

Deceased (day 1)

Living

7 lbs 10 oz

3 lbs 5 oz

6 lbs 15 oz

5 lbs 1 oz

17

16

21

23

Yes

Yes

Unknown

Yes

Mom being tx

G4P3 (note

Fever 102.3 F

Hypertension

for Group B strep

mom’s age)

Nuchal cord xl

Infarcted pla- centa

C-section for fetal distress

“C-section sec- ondary to se vere bradycar dia lasting 10 min & prob longer”

C-section

C-section

X

X

X

X

8

X

0

X

X

6

X

X

X

X

8

X

X

X

X

8

Intubated x 9

“Child severely

“Unable to

At 22 mos oper-

for mec.

asphyxiated at

maintain p02

ates on 3-5 mos

On admis no suck, no grasp, no moro

birth and never responded ade- quately to vent support”

compatible with life”

level

Figure 3. Infants by Case for 1986 With Pending Definitions of Neurologically Injured.

Case Number History

P-86-1

P-86-2

P-86-3

P-86-4

APGAR at 1

1,5

2,3

1,5

1,4

min and 5 min

Dx in addition

RDS

Convulsions

Hypovolemic

Convulsions

to Asphyx that contr to assign

Sepsis

Perinatal

infec

shock

Fx clavicle Cerebral hem RDS

Hydroceph

Survival

Living

Living

Living

Living

Birth Weight

3 lbs 4 oz

4 lbs 8 oz

5 lbs 5 oz

2 lbs 13 oz

Mother’s Age

28

24

Missing

22

(in years)

Ante Care

Missing

Yes

Missing

Yes

Obst/delv

comp

Prolapse cord Premature labor

None

Abruptio

Breech

Premature

labor

Type Delivery C-section for

fetal distress

Definitions (see Fig. 1)

Precep in bed

C-section

Vag

VA

0

0

X

X

FLA

0

0

X

0

MSV 1

X

X

X

X

MSV II

X

X

X

X

Notes

No D/C exam: does say tone normal No info on neuro

On admis hy- potonic, no suck or grasp D/C exam WNL

On admis pink, unresponsive to stim, flaccid No D/C exam

At 9 wks muse tone very hy- potonic Feeding prob on D/C (d 107) No D/C sum- mary exam

P-86-5

P-86-6

P-86-7

P-86-8

P-86-9

2,2

1,1

0,5

1,5

1,5

Intracereb

hem

RDS

Hydroceph

Severe

BPD*

Premature Intraventric & Periventric hem BPD

Mec in trach Sepsis

Premature Cerebral hem

Living 3 lbs 8 oz

Living 3 lbs 5 oz

Living 5 lbs 5 oz

Living 7 lbs 0 oz

Living 3 lbs 15 oz

24

33

24

17

Missing

Yes

Abruptio

Yes

Fever

PROM

Yes Twins Premature labor Resp dist

Missing

ROM**

2.5 days PTD

Missing

ROM

2.5 days PTD

C-section

C-section

C-section after forceps delv of Twin A

Missing

C-section for fetal distress

X

0

0

0

0

0

0

X

X

0

X

X

X

X

X

X

X

X

X

X

Intracran hem, bilat grade III Shunt insert On vent for 1 mo

Fair tone on D/C

Infantile re- flexes WNL Shunt insert

Hypotoniclit- tle spon activ on admis Weaned to RA in 48 hrs

Limp at birth Weaned to RA on d 3

No D/C exam

Mech vent un- til d 10

No D/C exam

* Bronchopulmonary dysplasia ** Room air

Totals

3

3

9

9

116 Virginia Medical, March 1989

tory care records available were re- viewed to confirm the assignment of infants to one or more of the categories.

Because the third definition in- cludes peripheral nerve injury, 54 cases occurring at the facility in the last five years were requested for review on the basis of this diagnosis alone. Forty-six of the 54 charts were found and reviewed.

Results

In 1986, 141 infants were born at the center who met the Apgar crite- ria. Of these, 66 were eliminated from the record review because they weighed less than 1000 gms. Of the 75 babies meeting the weight crite- ria, 69 cases were reviewed. For the remaining six, no records were avail- able.

In 1987, 130 infants had Apgar scores within the study range. Of the 93 cases meeting both the Apgar and birth weight criteria, 85 were re- viewed. No records were available for eight infants.

Of the 69 cases for 1986, 52 infants had no documented neurologic inju- ry; eight infants met one or more of the definitions and nine infants were designated as “pending.” The pend- ing category was added because in- formation in some charts was indica- tive of severe neurologic injury, but not complete enough to allow defini- tive assignment to one or more of the definitions. Figure 2 arrays the his-

tory and assignment of 1986 infants fitting one or more of the four cate- gories. The infants fitting the catego- ries represent 0.17% of the births at hospital and 0.01% of the Virginia births in 1986. Figure 3 arrays the history of 1986 infants with pending assignments. The notes at the bot- tom of each figure give chart infor- mation that assisted in categorizing the infants.

As can be seen from Figure 3, eight infants met the Virginia defini- tion as well as the two alternative definitions proposed by The Medical Society of Virginia. Prematurity ex- cluded two of the eight from the Florida definition. Only one of the infants is living. Two infants were premature, but of the remaining six term infants, half were diagnosed as being small for gestational age. Only one infant was a vaginal delivery of an uncomplicated pregnancy.

All infants in the 1986 pending group survived. Six of the nine in- fants were premature. All but one were products of complicated preg- nancies. Of the nine infants, four were designated as pending for Vir- ginia’s definition, three were consid- ered pending for Florida’s definition, and all nine met the alternative defi- nitions.

In 1987, of the 85 cases reviewed, 78 infants had no documented inju- ry. Three infants fit one or more of the definitions. Another four were placed in the pending category. Fig-

ure 4 arrays the 1987 infants fitting one or more of the definitions and Figure 5 arrays the 1987 pending cases. The infants fitting the Virginia definition represent 0.07% of the hospital's births and 0.003% of the births for 1987 in Virginia.

Infants fitting definitions in 1987 were products of complicated preg- nancies and delivered by cesarean section. Two of the three are still living. Only one infant met the Flori- da definition because the others were premature by dates. All three infants met the Virginia definition as well as the alternative definitions.

All four infants shown in Figure 5 were pending placement in the alter- native definitions only and are liv- ing. None of the infants had docu- mented injuries severe enough to be placed in the pending Virginia cate- gory. Prematurity made three of the four children ineligible for the Flori- da definition. All were cesarean sec- tion deliveries of mothers with com- plicated pregnancies.

Of the number of infants born who were likely to have severe neurolog- ic sequelae, very few actually did. The quality of care children at risk for injury receive from their physi- cians and the hospital in which they are born is a major factor in prevent- ing long-term disability.4 The hospi- tal attributed the decrease in sample size from 1986 to 1987 to clinical innovations that occurred during the study period, such as administering

Figure 4. Infants by Case for 1987 Meeting Definitions of Neurologically Injured

Case Number History

87-1

87-2

87-3

Totals

APGAR at 1 min

1,5

0,2

1,0

Dx in addition to Asphyx that contr to assign

Intraventric hem

Feeding prblm Lower nephron nephrosis Hypocalcemia Seizures

Seizures

Premat

Survival

Deceased (day 1)

Living

Living

Birth Weight

3 lbs 7 oz

8 lbs 5 oz

5 lbs 0 oz

Mother’s Age (in years)

23

25

33

Ante Care

Yes

Yes

Yes

Obst/delv comp

PROM

CMV exposure Progesterone exposure

Placenta previa

Type Delivery Definitions (see Fig. 1.)

C-section for fetal distress

C-section

C-section

VA

X

X

X

3

FLA

0

X

0

1

MSV I

X

X

X

3

MSV II

X

X

X

3

Unable to maintain p02 1 umbil artery

Central deafness Central blind N/G fed until 3 wks because of poor suck At 3 mo-marked head lag

“Pt remained severely neurologically impaired with hypertonic ex- tremities abnormal auditory potentials minimal visual evoked po- tential pattern.”

Mostly N/G fed secondary to poor suck & gag

March 1989, Virginia Medical 117

Figure 5. Infants by Case for 1987 With Pending Definitions of Neurologically Injured

Case Number History

P-87-1

P-87-2

APGAR at 1 min and 5 min

1,4

1,5

Dx in addition to Asphyx that contr to assign

Periventric hem

Post term SGA

Survival

Living

Living

Birth Weight

2 lbs 5 oz

4 lbs 12 oz

Mother’s Age (in years)

33

24

Ante Care

Yes

Missing

Obst/delv comp

PIH*

PIH

Obesity

Type Delivery Definitions (see Fig. 1)

C-section

C-section for fetal distress

VA

0

0

FLA

0

X

MSV I

X

X

MSV 11 Notes

X

Weaned from vent on d 5 D/C exam: “neuro nonfo- cal but questionab im- proved tone.”

Did well on oral feedgs. No enlarg of ventricle w bleed

X

Poor suck when feedg started. D/C exam: neck tone still decreased

P-87-3

P-87-4

Totals

2,5

1,1

Acidosis

Sepsis

Hyperglycemic

Hypopotassemia..

Hyperosmolarity

Acidosis

Living

Living

3 lbs 8 oz

4 lbs 13 oz

21

29

Yes

Yes

Partial abruptio 3rd trimester bleed Premat labor

PIH

Abruptio

C-section

C-section

0

0

0

0

0

1

X

X

4

X

X

4

D/C exam: “infant remains very letharg.”

On admiss tone in UE > LE.

Head ultras WNL. Feeding well on D/C

* Pregnancy-induced hypertension

surfactant to premature infants in the delivery room.5

The trend at the hospital was mir- rored statewide. Within the two years, the number of infants born with Apgar scores within the study range in Virginia dropped by 9%, while the total number of live births increased by 3%.

The incidence of severe neurolog- ic injury was low. If both the current and pending cases (17 cases) are combined for 1986 for the most le- nient definitions (MSVI and MS VII), the incidence is four per 1000 live births. The prevalence of severe mental retardation and cere- bral palsy documented in the litera- ture is five per 1000. 3 For 1987, the incidence for the current and pend- ing cases (seven cases) is even lower at two per 1000.

Associated Factors

The proposed function of the Vir- ginia Injured Infants Act, as it is called, is to capture those circum- stances that lead to malpractice liti- gation as a result of uncontrollable events at delivery. Two predisposing factors apart from birthing influ-

enced the incidence of injured in- fants in this study.

The first of these was prematurity. As can be seen by Figures 2 through 5, the least number of infants fit the Florida definition because preterm infants were ineligible.

Prematurity predisposes an infant to severe neurologic damage and is difficult to isolate as its sole cause when accompanied by low Apgar scores. For example, is intraventric- ular bleeding in a low birthweight infant caused by premature systems or birth trauma? The answer is not discernible from medical chart data.

Successful outcomes for preterm infants are related to the degree of prematurity. The risk of cerebral palsy for infants weighing 1500 gms (3 pounds 3 ounces) or less is 22 times that of normal birth weight infants.3 It is estimated that for ev- ery 100 infants less than 1500 gms 16% will be seriously or moderately disabled.4 This rate has not changed despite more neonatal intensive care facilities because very sick new- borns who previously would have died now survive.4 Infants weighing less than 1500 gms made up 63% of

the 1986 sample and 50% of the 1987 group.

The second factor associated with infants’ neurologic injuries was a maternal preexisting condition. Chil- dren in the categories were likely to be born of mothers with placenta abruptio, placenta previa, sepsis and/or hypertension. It is unknown if injured infants delivered of moth- ers with these obstetric conditions represent typical malpractice cases.

The alternative definitions capture the larger number of infants because they do not exclude prematurity or designate explicit permanent disabil- ities. Extending eligibility to chil- dren with peripheral nerve injury did not increase the number of cases. The children would have been in- cluded because of additional prob- lems caused by asphyxia. However, a larger sample may identify children without mental impairment but hav- ing residual facial and brachial pal- sies.

Discussion

From these findings, the ability of the Act as written to preempt litiga- tion is suspect. Since the Virginia definition was associated with death in the neonatal period in 1986-87, it is unlikely to be currently covering a group of living, disabled infants whose families sue because of finan-

118 Virginia Medical, March 1989

cial need to meet their children’s health and welfare needs. The chil- dren identified as neurologically damaged represented population- based health care problems (prema- turity, maternal complications) rath- er than problems specific to treatment by a physician or in a hospital.

Children falling into the alterna- tive definitions are more likely to survive. The nonspecific nature of the term “substantially mentally and physically impaired” allows for the influence of maturation — but it makes it difficult to establish clear criteria for exclusion from the fund,

i.e., what criteria will be used for borderline cases. Requiring only physical impairment or mental im- pairment did not increase the num- ber of cases because we were unable to identify an infant who was sub- stantially impaired physically and was not also severely handicapped mentally, as indicated by achieve- ment of developmental milestones. This finding is influenced, however, by the age of our sample as well as the limited number of peripheral nerve injuries. Overall, the broaden- ing of the definition did not greatly increase the incidence of neurologic injury even when the pending and current categories were combined.

Our need for a pending category represents an issue for the commis- sioners of the Injured Infants Act’s fund. At present there is no method for dealing with infants for whom the probability of severe neurologic inju- ry is high but the degree of injury unconfirmed or for whom the degree of disability lessens, yet these in- fants are the survivors. Should crite- ria be developed to allow placement for a limited time until further evalu- ation and continued coverage by the fund is decided? If a child is aphasic, incontinent, and in need of assist- ance in all phases of daily living but starts to walk at 4 years of age, how shall the case be handled?

Within the state a system exists for early case finding of infants likely to have neurologic sequelae after birth. Apgar scores, birth weights, and birth hospital are part of the

database maintained by the Bureau of Vital Statistics. The overseers of the Injured Infants Act’s Commis- sion can receive names of infants likely to fall into the fund, based on Apgar scores, and can follow these infants through hospital discharge summaries, which further narrow the field of candidates. Further fol- lowup could then occur through pe- diatric neurologists’ office records or state agencies providing infant stim- ulation services. The provider of posthospital care was listed in all the summaries reviewed.

Summary

For this sample of infants, assign- ment to the Virginia Injured Infants Act’s definition of severely neuro- logically injured was associated with neonatal death, prematurity and a preexisting maternal condition likely to contribute to a poor outcome. The incidence of severe neurologic injury for confirmable cases did not ap- proach the prevalence of severe mental retardation and cerebral pal- sy for either year. For these reasons, the ability of the Act to substantially preempt litigation is questionable. Expanding the definition to include broader language, i.e., “substantial- ly mentally and physically im-

paired” was more likely to capture infants surviving the neonatal period and those in the “pending” catego- ry. Including peripheral nerve injury in the definition did not significantly increase the number of cases. Flori- da’s definition was most restrictive because it required infants to be term births.

The authors acknowledge the clerical assistance and support provided by Bev- erly DeShazo and Sharon Anckaitis in the preparation of this paper.

1. Framme LH. The story of House Bill 1216. Va Med 1987;114:284-90

2. US Center for Health Statistics Inter- national Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). Ann Arbor, Commis- sion on Profession and Hospital Ac- tivities, 1978

3. Pameth N, Start RI. Cerebral palsy and mental retardation in relation to indicators of perinatal asphyxia: an epidemiology overview. Am J Ob/ Gyn 1983; 147(8): 960-6.

4. US Congress, Office of Technology Assessment. Neonatal Intensive Care for Low Birthweight Infants: Costs and Effectiveness. Washington DC, December 1987

5. Personal communication, December 1, 1988

Subcommittee to Study Act’s Definition, Funding

As this issue of Virginia Medical progressed toward the presses, Del. Clifton A. (Chip) Woodrum (D-Roanoke) was successfully shepherding through the General Assembly his resolution to establish a joint sub- committee to study the definition of a compensable injury and the existing funding mechanism of the Virginia Birth-Related Neurological Injury Compensation Act. The subcommittee’s goal, Woodrum’s reso- lution read, would be “to determine whether any modification is necessary or desirable.” The measure calls for ten subcommittee members: four delegates, two senators, one citizen, and one repre- sentative from each of the following: The Medical Society of Virginia, Virginia Hospital Association, and Virginia Society of Ob/Gyn. It calls for the subcommittee to submit its findings and recommendations to the Governor and to the 1990 session of the General Assembly.

Woodrum introduced the Injured Infants Act at the 1987 Assembly and fought hard for its passage (Va Med, May 1987, pp 291-2).

March 1989, Virginia Medical 119

POINT OF VIEW

Payment Reform:

“I have changed my mind”

Three years ago the conservative Reagan adminis- tration recognized a need for reform of medicine’s fee-driven system of physician payment. The Secre- tary of Health and Human Services, through the Health Care Financing Administration, contracted with the Harvard School of Public Health to establish a resource-based, relative-value system (RBRVS) of payment. Organized medicine, through the American Medical Association and specialty societies, supplied the individuals for the study. A second phase is now in research.

Initial reaction to the process by both sides, those who were studied and those who did the studying, was not smooth, but subsequent efforts have improved this work relationship. It is the only study of the econom- ics of medicine that approaches the cost of delivery of care as a basis for reimbursement to the provider.

The primary investigators, William Hsiao, PhD, and Peter Braun, MD, had three questions: 1) What are the relative costs of physician services? 2) Can resource costs be measured? 3) Do the final results conform to reality?1

The formula RBRVS = (TW) (1 + RPC) (1 + AST) was developed. TW denotes total work, which in- cludes time and complexity of work. Six variables constitute work: time, mental effort, knowledge and diagnostic acumen, technical skill, physical effort and psychological stress. Each of these factors may be different for a given situation, procedure or diagnostic problem. Each may vary between physicians and specialty orientation. RPS represents the relative spe- cialty practice costs. AST is an amortized value for the costs of specialized training.

The data to insert into this formula were obtained from specialty physicians by the investigators, who selected 200 physicians from the AM A masterfile. This is a file of all doctors, and it identifies special interests. Half of this group were to be board certified in the specialty surveyed. The investigation was done by a professional phone-interviewing group. The data ob- tained from the approximately 60% respondents were evaluated by a panel of peers in the specialty. Cross- specialty correlation was obtained from a panel of

consultants.

Vignettes of hypothetical common situations, both cognitive and procedural, were developed by the phy- sicians for an identified specialty, and used as bases for projecting data. They included such vignettes as management and admission of acute pulmonary ede- ma, lumbar puncture of a 5-year-old child with menin- gitis, emergency surgical consultation for possible bowel obstruction, and uncomplicated, indirect ingui- nal hernia repair.

The interviewed specialists were asked to estimate the total work according to the six variables given above. Their answers were reviewed by technical consulting groups made up of physicians from special- ty societies. Cross-specialty comparisons were made. An extrapolation of measures of work for survey services to other services was developed. (It should be noted that this is an abbreviated overview of a very complex project.)

The Harvard group’s report to HCFA, 2,000 pages long, has been summarized in JAMA.1 The report has been under very careful review by many, and there have been criticisms of the study’s methodology and conclusions. Statistical, factual, practical, realistic analysis continues to be performed by the AMA, specialty societies, and various lay organizations. No one has accepted the report as final, but some new system of physician payment is likely to ensue shortly.

About the same time the Administration estab- lished the RBRVS, Congress appointed the Phy- sician Payment Reform Commission. The Commission is totally separate from the Harvard study. Indeed, the Commission studied the Harvard report as it prepared to present to Congress this month its own recommen- dations for physician payment reform.

The Commission is composed of 13 members, eight of them representing economics (2), public health policy-making (2), insurance (1), registered nurses (1), the American Association of Retired Persons (1), and medical center administration (1). Five physicians, two of them office-based, complete the Commission; they are Dr. Philip R. Lee, San Francisco, the Corn-

120 Virginia Medical, March 1989

mission’s chairman; Dr. Robert N. Butler, New York; Dr. P. William Curreri, Mobile, Alabama; Dr. John M. Eisenberg, Philadelphia; and Dr. Thomas Reardon, Portland, Oregon. The Commission has held hearings over the past two years.

When testifying for my specialty before the Com- mission in November, I was impressed at the depth of the questions to the various specialty society physi- cians and the Harvard study investigators. The Com- mission members seem to understand the magnitude of the program of payment reform. They are studying the RBRVS system as one of the methods for reform, but they have not accepted the plan and may devise a totally different approach to present to Congress this month.

A PPRC meeting in December included suggestions for how to determine the relative value of visits on a fee schedule and a full report on global services, including a definition of a global package. Log diaries regarding physician office visits and a survey of prac- tice costs and assignment were also on the agenda.

For a meeting last month, the Commission listed these topics for discussion:2

Fee Schedule Issues: review and evaluation, RBRVS; coding of visits; standardizing coding for surgical global fees; Commission revision of relative values for work; training costs; specialty differentials; practice costs; geographic multipliers; assignment; transition; updating.

Issues Related to Influencing Volume, Composition and Quality of Services: utilization and quality reivew; clinical research and practice guidelines; physician education and dissemination of practice guidelines; expenditure targets.

Data Issues: data requirements for the fee schedule, practice guidelines and expenditure targets; monitor- ing access under a fee schedule.

Capitation: Physician risk-sharing arrangements.

Initially I was a strong critic of the Harvard project, but as a consultant to the study over the past two and a half years my opinion has changed. It now appears to me that the investigators are seriously

interested in improving the system and are trying to use sensible methods to look at our overall cost of operation in order to help us determine some econom- ic principles for the determination of fees.

Certainly there is in Washington a serious mood for a restructuring of medicine’s fee system, and there is a very good probability that both Congress and the Administration will write legislation this summer that will attempt to bring some business-like rationale to our present system. It is plain that a new, sensible system is needed by all — by the patient, the employer, the third-party payer, and the physician. And the RBRVS is not the only system under study. Congress and the Administration are also intent on health care cost containment.

Virginia physicians must be responsive to the rapid changes to come. We must communicate with our constituent representatives in the coming months. We must be ready to assist them in understanding the very difficult legislation that will probably be written this summer. No one really knows what will be developed for physician payment reform, but there will be change. Medicine must respond in a unified, intelli- gent, reasonable, patient-advocate fashion.

Nelson G. Richards, MD

1. Resource-based relative-value study. JAMA 1988: 260:2347-2446

2. Ginsburg PB, executive director, Physician Payment Re- form Commission. Notice dated January 5, 1989, of public hearing for February 8, 1989

Dr. Richards is in the private practice of neurology. He is a past president of the American Academy of Neurology; an alternate delegate from the Academy to the American Medi- cal Association’s meetings, where he caucuses with The Medical Society of Virginia’s delegation; and technical con- sultant for the Academy on the Harvard RBRVS project. Address correspondence to him at 1459 Johnston-Willis Drive, Richmond VA 23235.

March 1989, Virginia Medical 121

Hilar Adenopathy and Positive HTV Antibody Test: Case Report

Christopher W. Ingram, MD,

Barry Dicicco, MD, Lucia Pas tore, MD, and Paul Kravitz, MD,

Falls Church, Virginia

The clinical manifestations of infection with the human immunodeficiency virus (HIV) in patients are protean, e.g. rashes, pneumonitis, diarrhea, and dementia. Any symptom or sign may herald the pro- gression from an asymptomatic state to the clinically defined syndrome of the acquired immunodeficiency syndrome (AIDS). This may involve any one of the various opportunistic infections or neoplastic compli- cations associated with defects in cell mediated and humoral immunity.12 Finding either hilar adenopathy or a skin rash in such a patient would raise concern about one of these opportunistic infections or tumors. However, we report an HIV antibody positive patient with both hilar adenopathy and a rash who later was found to have active sarcoidosis. Also discussed are the similar and contrasting clinical and immunological findings between AIDS and sarcoidosis.

Case Report

A 25-year-old bisexual black male was first seen at the Fairfax Hospital in March 1986 after one week of pleuritic chest pain, nonproductive cough, chills and night sweats. He was afebrile. Decreased breath sounds in the right lung field were noted. A chest roentgenogram revealed a 30% right pneumothorax and increased interstitial markings in the upper lung field. Even after the pneumothorax was relieved by chest tube drainage the chest roentgenogram demon- strated a diffuse interstitial infiltrate. A room air arte- rial blood gas revealed mild hypoxia and an increased A-a gradient (p02, 78 mm Hg; pC02, 37 mm Hg; pH, 7.40). An HIV antibody test was positive. A fiberoptic bronchoscopy with lavage and biopsy was negative for

From the Departments of Medicine at Fairfax Hospital Falls Church, Virginia, and the Georgetown University School of Medicine, Washington DC (Drs. Ingram, Dicicco, and Kravitz), and the Department of Pathology, Fairfax Hospital (Dr. Pastore).

When this article was written, Dr. Ingram was chief medical resident at the Georgetown University School of Medicine. He is now at Duke University, where correspon- dence should be addressed to him at Box 3538, Division of Infectious Diseases, Duke University Medical Center, Dur- ham NC 27710.

Submitted 6-24-88.

Fig. 1. Acquired ichthyosis on the lower extremities.

mycobacteria, fungi and Pneumocystis carinii. Oral trimethoprim-sulfamethoxazole was administered, his symptoms improved, and he was discharged.

He was lost to followup until March 1987, when he returned to the Fairfax Hospital with a diffuse pruritic rash over the extremities and chest. He denied dysp- nea, cough or fever. On physical examination he was found to have a blood pressure of 130/80 mm Hg, pulse of 84 beats/minute, respiratory rate of 16/minute, and oral temperature of 99° F. The heart, lung and abdom- inal examination were normal. The most prominent finding was a rash on both lower extremities covering the anterior pretibial surface and extending around the leg to the calf. The rash was hyperpigmented with flat, large, “stuck on” irregular scales. Ankle and pedal edema was also present. Clinically, this was “acquired ichthyosis” (Fig. 1).

A white blood cell count was 4,800/mm3 with 35% lymphocytes and 10% eosinophils. Other studies in- cluded a calcium of 8.4 mg/dl, a total protein of 7.4 grams/dl (albumin, 3.0 grams/dl; globulin, 4.4 grams/ dl), and a sedimentation rate of 18 mm/hour. A repeat HIV antibody test was positive for both p24 and gp41 antibodies. The T helper/suppressor cell ratio was 0.59 and the absolute T helper cell count was 329/mm3. The chest roentgenogram (Fig. 2) revealed bilateral hilar

122 Virginia Medical, March 1989

adenopathy, confirmed by computerized tomography of the chest. A fiberoptic bronchoscopy with trans- bronchial biopsy demonstrated only a chronic inflam- matory process without evidence of P carinii, myco- bacteria or fungi. A skin biopsy (Fig. 3), in addition to showing epidermal changes of ichthyosis, revealed numerous noncaseating granulomas in the superficial and deep dermis. This extensive involvement of the

Fig. 2. Chest roentgenogram revealing bilateral hilar ade- nopathy.

Fig. 3. Skin biopsy with noncaseating granulomas in superfi- cial and reticular dermis (H & E x250).

dermis probably was responsible for the peripheral edema. A serum angiotensin converting enzyme was 175 units per liter (normal, 21-69). A mediastinoscopy with lymph node sampling was performed which dem- onstrated a noncaseating granulomatous lymphade- nitis (Fig. 4) without evidence of an opportunistic lung infection or malignancy. Special stains and cultures of skin biopsy and mediastinal lymph nodes for bacteria, mycobacteria, and fungi were negative. The patient was treated with topical steroids and discharged. The rash improved and seven months after discharge he remained asymtomatic.

Discussion

The differential diagnosis of symmetrical hilar ade- nopathy in most individuals includes sarcoidosis, tuber- culosis, histoplasmosis, toxoplasmosis and lymphoma. Other less common causes of this roentgenographic presentation would include nonspecific inflammatory lymphadenitis, metastatic carcinoma, other fungal dis- eases, or mononucleosis secondary to cytomegalovirus or Ebstein-Barr virus. However, in patients infected with HIV, the differential diagnoses expands to include intrathoracic lymphoma, visceral Kaposi’s sarcoma, typical and atypical mycobacterial infections, and dis- seminated cryptococcosis or histoplasmosis.

In some patients infection with HIV progresses to acquired immunodeficiency syndrome (AIDS), pre-

Fig. 4. Mediastinal lymph node biopsy with noncaseating granulomas (H & E x250).

March 1989, Virginia Medical 123

senting with severe infections such as Pneumocystis carinii pneumonia or disseminated atypical tuberculo- sis, while others present with diffuse malignancies such as Kaposi’s sarcoma or intrathoracic or intra- cranial lymphomas. There is usually a prodrome of anorexia, weight loss, lymphadenopathy and a periph- eral lymphopenia. In our patient the skin lesions initially were thought to represent a cutaneous mani- festation of a thoracic tumor, either lymphoma or Kaposi’s sarcoma. Only after the biopsies of the skin and lymph node were obtained was the diagnosis of sarcoidosis made.

Sarcoidosis, a multisystem disease, affects not only the lungs and the reticuloendothelial system, but also the eyes, skin and liver. Intrathoracic involvement is found in over 90% of patients and bilateral hilar adenopathy is the most frequent finding. Acquired ichthyosis is one of the many skin manifestations seen in sarcoidosis. The classic pathological finding in all affected tissues is noncaseating granulomatous in- flammation.

In sarcoidosis, both T helper and suppressor lym- phocyte counts are elevated in the peripheral blood.3-4 However, the T helper lymphocytes are sequestered in areas of disease, attracting monocytes and macro- phages, leading to the formation of the noncaseating granulomas. Cutaneous skin anergy from the excess T suppressor lymphocytes in the peripheral circulation and a polyclonal gammopathy are other manifestations of this disease.5

The immunologic abnormalities occurring in AIDS are well described.6 Classically low levels of helper T cells and an inverted T helper to suppressor cell ratio are seen. As in sarcoidosis, a polyclonal hypergamma- globulinemia may be seen. Quantitated lymphocyte subsets in bronchoalveolar lavage lymphocytes may reveal a depressed T-4/T-8 ratio in AIDS patients while those with sarcoidosis generally have a pre- served T-4/T-8 ratio.4

In one prior report,5 AIDS developed in a patient who had had sarcoidosis ten years previously but was currently asymptomatic and not on corticosteroids. On presentation, that patient had the characteristic immunologic deficiencies noted with acquired immu- nodeficiency syndrome. In our patient, the peripheral T helper/suppressor ratio was depressed with a low normal absolute T helper cell count consistent with either HIV infection or sarcoidosis. However, the development of sarcoidosis would suggest that suffi- cient numbers of helper T cells and normal pathways of activation of monocytes and macrophages were present in order to initiate the formation of noncaseat- ing granulomas within the skin as well as hilar lymph nodes.

A positive HIV antibody titer in an individual need not imply an immunodeficiency state. Indeed, com- mon problems have been described in AIDS patients, such as pneumococcal pneumonia7 and tuberculosis.8 Hilar adenopathy in an HIV antibody positive patient may suggest an opportunistic infection and/or occult malignancy. Similarly, the skin lesions could easily have represented a cutaneous manifestation of either lymphoma or Kaposi’s sarcoma or a disseminated fungal or mycobacterial infection. However, it must be recognized that other common problems such as sar- coidosis may be responsible for either finding. There- fore, a tissue diagnosis should be pursued, especially in view of the implications of treatment of sarcoid with corticosteroids, which can further alter immune function.9

References

1. Armstrong D, Gold JWM, Dryjanski J, Whimbey E, Polsky B, Hawkins C, Brown AE, Bernard E, Kien TE. Treatment of infections in patients with the acquired immunodeficiency syndrome. Ann Intern Med 1985; 103: 738-745

2. Centers for Disease Control. Revision of the CDC sur- veillance case definition for acquired immunodeficiency syndrome. MMWR 1987; 36 (suppl no. IS)

3. Hunninghake GW, Crystal RG. Pulmonary sarcoidosis a disorder mediated by excess helper T lymphocyte activity at sites of disease activity. N Engl J Med 1981; 305: 429-434

4. Baughman RP, Solinger A, Hurtubise P, Dohn MN, Walker PD, Rashkin MC, Dortin D. Bronchoalveolar lavage in patients with the acquired immunodeficiency syndrome (AIDS). AIDS Research 1984; 1:91-97

5. Kalter S, Lopez-Berestein G. Acquired immunodefi- ciency syndrome in a patient with prior sarcoidosis: case report with monocyte function studies. Tex Med 1985; 81(9):44-46

6. Seligmann M, Pinching AJ, Rosen FS, Fahey JL, Khaitov RM, Klatzmann D, Koenig S, Luo N, Ngu J, Reithmuller G, Spira TJ. Immunology of human immunodeficiency virus infection and acquired immunodeficiency syn- drome. Ann Intern Med 1987; 107:234-242

7. Polsky B, Gold JWM, Whimbey E, Dryjanski J, Brown AE, Schiffman G, Armstrong D. Bacterial pneumonia in patients with the acquired immunodeficiency syndrome. Ann Intern Med 1986; 104:38-41

8. Pitchenik AE, Burr J, Suarez M, Fertel D, Gonzalez G, Moas C. Human T-cell lymphotropic virus-III (HTLV- III) seropositivity and related disease among 71 consec- utive patients in whom tuberculosis was diagnosed. Am Rev Respir Dis 1987; 135:875-878

9. Burmester GR, Gramatzki M, von Gernler J, Bartels O, Kalden JR. Pulmonary sarcoidosis associated with ac- quired humoral and cellular immunodeficiency. Clin Im- munol Immunopathol 1985; 37:406-412

124 Virginia Medical, March 1989

ABSTRACTS

These are abstracts from the scientific session of the Virginia Dermatological Society’s annual meeting on November 6, 1988, in Williamsburg. Dr. James W. Patterson was moderator.

Fabry’s Disease. Grace A. Newton, MD, Charlottes- ville.

A 35-year-old man first noted the development of skin lesions (angiokeratomas) at age 14. About one year later, he developed attacks of pain and paresthe- sias in his hands and feet, which over the years worsened in frequency and severity. The pain could be elicited by hard work or changes in temperature. Two maternal cousins had similar abnormalities. In July 1988 he was begun on amitryptyline with good control of pain crises and possible improvement in the asso- ciated hypohidrosis. Cutaneous examination revealed several deep red, 1-3 mm non-blanching macules clustered in the umbilical and genital regions. These findings indicated the diagnosis of Fabry’s disease (galactosidase A deficiency), an X-linked recessive disorder. Other abnormalities can include myocardial ischemia, congestive heart failure, neurological signs and symptoms, and azotemia. Many of the changes are due to a deficiency of alpha-galactosidase A, which results in the accumulation of glycosphingolipids in lysosomes of various tissues. In addition to sympto- matic management, treatment includes various means of enzyme replacement and substrate depletion. Amitryptyline was helpful in pain management in this case.

Linear IgA Bullous Dermatosis. Joy Gittin-Boyne, MD, Charlottesville.

A 54-year-old man presented with a generalized vesiculobullous eruption of three weeks’ duration. Physical examination reveled generalized erythema- tous papules, tense bullae, and grouped herpetiform vesicles. Target-like lesions were present on the palms. Mucous membranes were spared. Biopsy showed a subepidermal blister with a predominance of neutrophils. Direct immunofluorescence showed lin- ear deposits of IgA at the dermal-epidermal junction, and indirect immunofluorescence studies were nega- tive. The findings confirmed the diagnosis of linear IgA bullous dermatosis. The patient was unresponsive to prednisone, but once the diagnosis was established he was placed on dapsone, which resulted in cessation of new blister formation. Linear IgA disease is consid- ered by some to be a variant form of dermatitis herpetiformis, but others prefer to list it as a separate disease entity, since patients may have large, tense blisters, be HLA-B8 negative, and lack evidence for

gluten sensitive enteropathy. Chronic bullous derma- tosis of childhood also shows linear IgA deposits along the epidermal basement membrane, but unlike the adult disease, the childhood disorder shows predomi- nantly perioral and perineal lesions and has a high spontaneous remission rate.

Graft Versus Host-Like Reaction Associated with 5- Fluorouracil Chemotherapy. Estelle Young, MD, and Donna Fukumoto, MD, Petersburg, and James W. Patterson, Richmond.

Three patients presented with Duke’s D adenocar- cinoma of the colon and a history of intravenous infusion chemotherapy with 5-fluorouracil. None had received blood products or had undergone bone mar- row transplantation. Shortly after initiation of therapy, each patient noted a dusky erythema involving the palms and soles. Other findings encountered in varying degrees included sclerodactyly, flexion contractures, thinning of the nails, and white patches with lacy configurations on the buccal mucosae. Lesions seemed to persist despite reductions in dosage, al- though temporary discontinuation of therapy was ac- companied by improvement in two cases. Biopsies of affected skin showed vacuolar degeneration of the basilar layer, sometimes accompanied by a band-like dermal lymphocytic infiltrate and accumulations of lymphocytes in lower portions of the epidermis. A distinctive acral erythema similar to that described here has been reported in association with cyclophos- phamide, cytarabine and/or doxorubicin therapy, but because those patients had also received blood prod- ucts or bone marrow transplants, it was unclear whether the changes represented drug reactions or graft versus host disease. The findings in our cases suggest that 5-fluorouracil chemotherapy alone may produce cutaneous changes closely mimicking graft versus host disease.

Exuberant Secondary Syphilis in a Patient with HIV Positivity. David M. Pariser, MD, Harry Pariser, MD, Robert Pariser, MD, and Ann Wry, Norfolk.

This case involves a 46-year-old homosexual man with HIV seropositivity and unusual manifestations of secondary syphilis. The patient presented with annu- lar, nodular lesions that had elevated erythematous borders and central clearing with hyperpigmentation. The appearance resembled annular dermatitis or early mycosis fungoides. Nontreponemal (VDRL) test for syphilis showed reactivity with a titer of 1:256. A biopsy specimen was suggestive of secondary syphilis. The lesions cleared after the second intramuscular injection of 2.4 million units of benzathine penicillin. This case illustrates one of several recent cases of abnormal presentation of syphilis in an HIV-positive individual. Secondary syphilis usually manifests itself as a maculopapular erythematous rash involving the trunk and extremities including the palms and soles.

March 1989, Virginia Medical 125

This rash usually follows a primary chancre of the genitalia or oral mucosa by 2-10 weeks. If untreated, tertiary syphilis may ensue, which may produce a vast array of clinical pictures, including that of annular, nodular, elevated erythematous lesions as were seen in this case. Our case suggests that HIV seropositivity may alter and/or accelerate the course of infection with Treponema pallidum.

Erythema Chronicum Migrans of Lyme Disease. Bon- nie F. Straka, MD, Charlottesville.

A 21 -year-old woman presented in the 19th week of her first pregnancy with a one-day history of an enlarging red lesion on her right thigh. The lesion began as a small red bump one day after playing with her dogs in tall grass in Aroda, Virginia. Other symp- toms included headache, arthralgias, myalgias, and nausea. Physical examination revealed a 2 cm erythe- matous plaque with papular border and suggestion of central clearing on the right thigh. Five days later, the plaque had expanded to a three centimeter target-like lesion with two concentric rings, central clearing, and a distinct red border. Biopsy was consistent with a figurate erythema such as erythema chronicum mi- grans. A diagnosis of Lyme disease was made, and treatment was begun with penicillin VK 500 mg four times daily for 21 days. Lyme disease is transmitted by the bite of a tick, and the causative organism is a spirochete, Borrelia burgdorferi. It has been reported in a number of states in the United States, including Virginia. The disease may progress through three stages. Erythema chronicum migrans, the characteris- tic skin lesion, occurs in the first stage. The second stage features neurologic or cardiac involvement, and stage three is characterized by a monoarticular or oligoarticular arthritis. Early treatment with tetracy- cline or penicillin is effective.

Mild and Self-Limited Dominant Dystrophic Epider- molysis Bullosa. Robert J. Pariser, MD, Norfolk.

A newborn boy was seen in August 1987 because of congenital erosions. They were large, sharply defined, clean-based erosions located around the ankles. The right great toenail was partly detached. The family history supported an autosomal dominant transmis- sion of the disorder. Erosions gradually healed with the use of moist dressings. Similar lesions occurred occasionally on the lower extremities for the first few months of life, but they gradually became less fre- quent. At 1 year of age, the child seemed to be developing no new blisters or erosions, and he was beginning to walk without problems. Several clinical variants have been described with features similar to Bart’s syndrome, in which there is congenital absence of skin of the lower extremities along with trauma- induced blisters of skin or mucous membranes and nail changes. This case report indicates that the dominant dystrophic form of epidermolysis bullosa is one such

variant and that it can have a relatively benign clinical course.

Exfoliative Erythroderma with Histologic Features of Erythema Multiforme. Allen D. Berry, MD, Beverly S. Darwin, MD, Eileen C. Kitces, MD, James W. Patter- son, MD, and W. Kenneth Blaylock, MD, Richmond.

Five patients were recently encountered who pre- sented with superficial exfoliative dermatitis but on biopsy showed typical changes of erythema multi- forme. Clinically, each of the patients showed ery- thema with relatively superficial desquamation, while biopsy findings showed scattered necrotic kerati- nocytes, vacuolar degeneration of the basilar layer, and an upper dermal lymphocytic infiltrate, features characteristic of erythema multiforme. Treatments in- cluded topical and systemic corticosteroids and man- agement of the underlying disorders, with variable results. Causes of exfoliative dermatitis include drug, lymphoma or leukemia, and a variety of primary skin disorders including atopic dermatitis, seborrheic der- matitis, psoriasis, lichen planus, and pityriasis rubra pilaris. A large number of cases are idiopathic. Biopsy usually shows either changes of dermatitis or specific features of the underlying dermatosis. Erythema mul- tiforme typically produces papules, target lesions, bullae, or full thickness, sheet-like exfoliation of the epidermis (toxic epidermal necrolysis), but exfoliative dermatitis of the superficial type has not been de- scribed. Our results suggest that erythema multiforme should now be added to the list of dermatoses that can produce the clinical picture of exfoliative dermatitis.

Metastatic Eccrine Carcinoma (Malignant Acrospi- roma). Ricardo G. Mora, MD, Norfolk.

Two patients are presented with forms of metastatic eccrine carcinoma. A 67-year-old man was referred for evaluation of a lesion of the left lateral eyebrow of six months duration. Examination also revealed a 1.0 cm cervical lymph node palpable in the left anterior trian- gle. CT scan of the orbit was unremarkable except for the soft tissue mass. Histopathology revealed a malig- nant eccrine acrospiroma with skeletal muscle inva- sion and lymphatic permeation. The patient underwent Mohs micrographic surgery and was referred to an otolaryngologist, where biopsy of the left neck node showed metastatic disease. At that point a left paroti- dectomy and left modified radical neck procedure were performed, followed by irradiation to the left temple, parotid bed, and left neck. There was no evidence of disease upon followup one year later. A 64-year-old man had developed a lesion on the left medial foot that upon surgical excision showed eccrine carcinoma. Six months later he was referred for eval- uation of new lesions adjacent to the surgical scar. In addition to the skin lesions, physical examination revealed a fixed, enlarged lymph node in the left femoral triangle. The patient was referred to a surgical

126 Virginia Medical, March 1989

oncologist for wide excision and lymphadenectomy, followed by irradiation to the groin and foot, and there was no evidence of disease upon followup at one year. Eccrine carcinomas are potentially aggressive tumors that are being encountered with increasing frequency. Mohs micrographic surgery in conjunction with other surgical approaches appears to be an effective means of managing these difficult tumors.

Transient Acantholytic Dermatosis. Cynthia Hall Dent, MD, Charlottesville.

A 79-year-old man had a three-week history of a pruritic eruption of the chest, back, and upper extrem- ities. He reported having had a similar but less severe eruption one year previously which resolved after several weeks. Physical examination revealed numer- ous papulovesicular lesions on the chest, back and upper extremities with erythema and excoriations. The face was spared but revealed marked actinic damage and two basal cell carcinomas, one each on the nose and right earlobe. Biopsy confirmed the diagnosis of transient acantholytic dermatosis, and isotretinoin was begun at a dose of 40 mg daily. Transient acantholytic dermatosis is an acquired dis- order usually encountered in older adults. Despite its designation as “transient,” it can persist for several years. Microscopically, lesions show small foci of acantholysis that can have patterns mimicking those of Darier’s disease, Hailey-Hailey disease, pemphigus vulgaris, pemphigus foliaceus, or spongiotic derma- titis. Isotretinoin has been reported to produce dra- matic remissions in some patients with this disorder.

Subepidermal Bullous Dermatosis with Features of Epi- dermolysis Bullosa Acquisita. Chauncey A. McHargue, MD, Charlottesville.

A 37-year-old woman presented with a six month history of spontaneous noninflammatory bullous le- sions limited to the hands and feet. They were mod- estly tender but otherwise asymptomatic and tended to run their course over several weeks, healing with superficial scarring. Medications included both re- placement estrogen and iron. She did not use alcohol and there was no family history of similar disease. Physical examination confirmed the presence of non- erythematous vesicles and bullae on the dorsal and volar aspects of the hands and feet. Superficial scar-

ring was present at the sites of previous lesions. Urine porphyrin studies showed slight elevations in uro- porphyrin and coproporphyrin. Biopsy findings were consistent with epidermolysis bullosa acquisita or por- phyria cutanea tarda, and direct immunofluorescence revealed a strong IgG band at the dermoepidermal junction and in vessel walls. However, immunofluo- rescent studies on salt-split skin preparations were negative. The differential diagnosis of noninflamma- tory subepidermal bullous eruptions is extensive and includes porphyria cutanea tarda and variants, epider- molysis bullosa acquisita, bullous drug eruptions, and bullosis diabeticorum. Direct and indirect immunoflu- orescence and porphyrin studies are useful in deter- mining the correct diagnosis in these cases.

Aplasia Cutis Congenita. Audrey Gottlieb, MD, James W. Patterson, MD, and Allen D. Berry, MD, Rich- mond.

A dermatologic consultation was requested for a newborn infant with multiple cutaneous defects. The patient was the product of a full-term, otherwise uncomplicated, nonconsanguineous pregnancy. There was no family history of cutaneous disease. Upon physical examination, the newborn boy appeared to be healthy except for symmetrical, sharply marginated lesions on the trunk, back, thighs and scalp that showed complete absence of skin and subcutaneous tissue. Biopsy showed absence of epidermis and of cutaneous appendages in the underlying connective tissue. Unusual findings included bizarre vacuolated basal cells in the epidermis adjacent to an ulcer, and a dermal infiltrate that included numerous eosinophils. Affected sites have been granulating in well during treatment with Burows compresses and bacitracin ointment, and thus far no other developmental abnor- malities have been noted. Aplasia cutis congenita is commonly recognized as a focal lesion on the scalp, and more extensive involvement such as reported here is unusual. Theories of development have included failure of neural tube closure (for scalp lesions), am- niotic adhesions, or passage of thromboplastic mate- rial leading to placental and/or cutaneous infarctions. True congenital absence of skin can be distinguished from the junctional form of epidermolysis bullosa by clinical and microscopic studies.

March 1989, Virginia Medical 127

VIRGINIA MEDICAL

Medical Practice Restriction

As Jimmy Durante was wont to say, “Everybody wants to get in on the act.” Today it seems that everyone wants to be involved in the practice of medicine. Physicians are becoming accustomed, albeit not happily, to the self-serving paramedical groups, but there are others who would change the entire system. A recent report by the American Council on Science and Health1 cites four such organizations:

• The National Health Federation (NHF) states that it promotes freedom of choice, but it really advocates questionable health methods. For NHF, no scientific proof of efficacy is necessary; marketing of an un- proved treatment or product should not be restricted. This organization is very active in the political arena. • The Health Alternatives Fegal Foundation (HAFF) claims to be a “non-profit public interest law center.” Actually, it was founded to defend “alternative”

health care practitioners and to initiate antitrust litiga- tion challenging medical practice laws.

• The American Quack Organization (AQA) is a mu- tual support group of “holistic” practitioners. AQA strives to provide emotional support for its members by stimulating positive public feeling toward unortho- dox practitioners.

• The Coalition for Alternatives in Nutrition and Health Care (CANAH) is primarily a lobbying effort. The main goal of this organization is enactment of a “Health Care Rights Amendment” which would allow any individual to choose and practice any desired type of health care.

Physician, beware. E.F.K., Jr.

1. Barrett S. The Unhealthy Alliance. New York, American Council on Science and Health, 1988

Addiction

Drug addiction is big news, big problem, and big money. You see it, read about it, hear about it. It’s bad, dirty, destructive. It creates crime and de- stroys lives. It’s big money. “Saying no” is not stopping the profit. The heads of governments, under- lings, the CIA, law officers, rich men, poor men, doctors, lawyers, Indian chiefs are involved in this dirty, very profitable business.

The profits of the drug business buy people, planes, guns, tanks, bullets, lives. The enormity of the cash flow and profit makes money laundering a major pro- blem. Fosing a transport plane is ordinary overhead.

If you made $30,000 a year, is it conceivable that a $100,000 bribe might tempt you? $500,000? $1 million? While everyone may not have a price, I suspect that many of us do.

I propose that we make illegal drugs legal, which action will lower the price and deliver a death blow to

the financial empire of the drug trade. At the same time we reenact prohibition, making all alcoholic beverages illegal. Obviously this is a variation of the fact that forbidden fruits are the sweetest, initially proved by the snake in the Garden of Eden.

These simultaneous actions will unleash American ingenuity and a new wave of illicit entrepreneurs, now to make and distribute alcoholic beverages. These people will be relatively poor and driven to establish their empires quickly before the drug trade can realign itself into alcohol.

Mom and Pop moonshine operations will develop into big business, pauperizing the Asian and South American drug kingdoms. Foreign competion will wither quickly. Made in America will no longer be just a slogan, but a reality.

At this point creative American legislative genius comes to the fore, but timing will be crucial. After

128 Virginia Medical, March 1989

Alcohol Illegal Big Business (AIBB) drives out Drug Illegal Big Business (DIBB), we simultaneously make alcohol again legal and make tobacco illegal. An entire new wave of Mom and Pop operations, literally a grass root movement, replaces AIBB. Every little hidden valley will be green again. We may even see a resur- gence of the mule and wagon in Tobaccoland, USA, since initially these nouveau riche will want to hide their sudden surge of wealth.

This great land of ours has innumerable addictive substances and activities. We can continue this illegal- ize/legalize ploy for decades without repetition. After drugs, alcohol and tobacco, we illegalize and later legalize chocolate candy, ice cream, nouvelle cuisine, Cajun cooking, professional wrestling, professional football and the Superbowl, soap operas, professional basketball, baseball, golf, tennis, sports cars, etc., etc. The list is literally endless.

Americans arise! Write your legislators now! They will never be this creative on their own.

H.S. Campell, MD

Hospital Notes

Sometimes a very unhappy experience can give insight. After spending many weeks with sick relatives in hospitals, I slowly began to realize why patients and their relatives can get out of sorts “for no obvious reason.” The reason is simple: they are unhappy because they are extremely uncomfortable.

Have you sat for long in your waiting room chairs or in the hospital room chairs? Would you be caught dead with one in your house? Do you see these same Uncomfortable Chairs in the offices of the administra- tors, procurement officers or physicians? In their homes?

The Institute for Uncomfortable Chairs must be the design center for most chairs in hospital rooms, clinic waiting areas and physician’s offices. Look at them carefully. Sit in one for an hour or two, and then try to walk without a limp, without a grimace of pain, without gently rubbing your buttocks.

Do any of these Uncomfortable Chairs look less than 100 years old? How do they make new chairs look so realistically worn before they leave the chair fac- tory?

My research is valid and conclusive: You cannot be pleasant when your rear end is dead. If you doubt it, try it.

H. S. Campell, MD

MEDICAL SOCIETY OF VIRGINIA

President

J. Thomas Hulvey, MD, Abingdon President Elect

William H. Barney, MD, Lynchburg

Immediate Past President

Glenn B. Updike, Jr., MD, Danville

First Vice President

John A. Owen, Jr., MD, Charlottesville

Second Vice President

Leon I. Block, MD, Falls Church

Third Vice President

James P. Baker, MD, Norfolk

Speaker

George E. Broman, MD, Culpeper Vice Speaker

Lawrence K. Monahan, MD, Roanoke

Councilors by District 1st: William H. Sipe, MD, Newport News

2nd: Russell D. Evett, MD, Norfolk 3rd: William W. Regan, MD, Richmond 4th: John W. Hollowell, MD, Portsmouth

5th: Edwin J. Harvie, MD, Danville

6th: Jeffrey W. Wilson, MD, Lynchburg

7th: H. George White, Jr., MD, Winchester

8th: Ira J. Green, MD, Alexandria

9th: James L. Patterson, Jr., MD, Pulaski

10th: Ira D. Godwin, MD, Fairfax

AMA Delegates

H. C. Alexander III, MD, Roanoke Raymond S. Brown, MD, Gloucester Charles M. Caravati, Jr., MD, Richmond C. Barrie Cook, MD, Falls Church Richard L. Fields, MD, Fairfax William J. Hagood, Jr., MD, Clover John A. Martin, MD, Roanoke Glenn B. Updike, Jr., MD, Danville Percy Wootton, MD, Richmond Harold L. Williams, MD, Newport News

Executive Vice President James L. Moore, Jr.

March 1989, Virginia Medical 129

OBITUARY

• Thomas Bowles Hedrick, MD, general practitioner and former city councilman in Buena Vista; Medical College of Virginia, 1950; age 62; died December 28, 1988.

• Margaret Allen Pennington, MD, who before her retirement in 1984 practiced medicine in Buckingham County with her husband, William A. Pennington; Medical College of Virginia, 1937; age 79; died January 5 in Richmond after a lengthy illness. A gifted artist, Margaret Pennington recorded with pen and ink Buck- ingham County’s architectural landmarks; many of these drawings were reproduced in Virginia Medi- cal, and in 1977 they appeared in a book titled “The Courthouse Burned —

• Shockley DeWitt Gardner, MD, former assistant state director of rural health who also had a private practice in Varina; Medical College of Virginia, 1930; age 84; died January 16.

• Thomas G. Hardy, MD, Columbus, Ohio, surgeon; Johns Hopkins University School of Medicine, 1950; age 61; died December 26, 1988.

Memoir of J.E. Gardner, Sr. 1903-1987

By Abraham Jacobson, MD

Dr. John Everette Gardner, Sr., age 84, passed away on September 7, 1987. He was born on April 9, 1903, in Hillsville, Virginia. He received his under- graduate degree from Roanoke College in 1925 and his MD from Johns Hopkins in 1928.

He interned at Jefferson Hospital from 1928 to 1929 and was an associate on the medical service from 1929-1931. He did postgraduate work in advanced cardiology at Massachusetts General Hospital, cardio- vascular roentgenology at Temple University and in- ternal medicine in London, England. He had staff appointments in internal medicine and cardiology at the former Jefferson Hospital (now Community Hos- pital of Roanoke Valley), at Lewis-Gale Hospital, and at Roanoke Memorial Hospital, where he was chief of cardiology from 1940-42, chairman of the electrocar- diographic service and chief of medicine from 1950-51 . He was certified by the American Board of Internal Medicine on October 31, 1946.

He served in the US Navy and Naval Reserve during World War II, attaining the rank of captain.

Dr. Gardner was a member of the American Tho- racic Society, American College of Chest Physicians, American Medical Association, The Medical Society of Virginia, and the Roanoke Academy of Medicine, of which he was president in 1952-53.

His hobby was golf and he was a member of the Shenandoah Club and the Roanoke Country Club.

Dr. Gardner is survived by his wife, Nell S. Gardner, two sons, one stepdaughter and one stepson.

He deserves the highest praise for his loyalty, dedication, consideration and kindness to his patients throughout his practice.

Memoir of G. W. Atkinson 1931-1988

By Barry L. Katchinoff, MD,

H. R. Howell, MD, and G. W. Johnson, MD

Dr. Gerald W. Atkinson died of a heart attack on March 20, 1988, at the age of 57.

Dr. Atkinson was born in Kingston, Tennessee, the son of a Methodist minister. He graduated from Lin- coln Memorial University in 1952 and attended the Medical College of Virginia. Following an internship at DePaul Hospital in Norfolk he served in the US Army. After completing his military obligations he entered the private practice of family medicine in Jonesboro, Tennessee. He returned to Richmond in 1963 to enter the neurology residency program at the Medical Col- lege of Virginia and from 1966 onward was in the private practice of neurology in Richmond.

Dr. Atkinson served as the chief of neurology at Chippenham and Johnston-Willis Hospitals, where he was also medical director of the Special Procedures Laboratory. He also was president of the board of directors at the Richmond Headache Center.

His professional memberships included the Ameri- can Medical Association, the Virginia Neurological Society, the Richmond Academy of Medicine, The Medical Society of Virginia, the National Association for Diagnosis and Treatment of Headaches, the South- ern Medical Association, and the American EEG Society.

Jerry Atkinson was a gifted neurologist whose kind- ness and warmth touched his colleagues and patients alike. He provided a blend of professional competence and integrity that was admired by all. His personality was characterized by calm strength and quiet charm. He will be sorely missed by his family and friends.

He is survived by his wife, Joann, and four sons: Jonathan G. Atkinson and Timothy G. Atkinson of Richmond, Theodore J. Atkinson of Glen Allen, and S. Jeffrey Atkinson of Mechanicsville.

130 Virginia Medical, March 1989

STACKS

Health sciences ubsaw Universe of maRVLAND

BALTIMORE

APR ?R 1989

fiECU

WOT 10 CIRC.

Pain Management

Analagesics: The Physician’s Partner in

Effective Pain Management 164

Ada G. Rogers

Patient-Controlled Analgesia 171

Nancy E. Kane

Neurosurgical Concepts of Pain Control 173

Harold F. Young

Psychological Aspects of Pain Management 177

Rochelle L. Klinger and James L. Levenson

Point of View

More for Less 185

Carolyn M. Clancy and Peter A. Boling

Editorials

Pain Management 183

Walter Lawrence, Jr.

War and Anger 183

Henry S. Campell

Comprehensive Health Care 184

E.L. Kendig, Jr.

Letters to the Editor 147

Books 151

Meetings about Medicine 154

Virginia Authors 182

Obituary 186

Classified Advertisements 189

Who’s Who 192

Volume 116

April 1989

Number 4

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Report angioedema secondary to hypertension medications

Enalopril is a relatively new angiotensin converting enzyme (ACE) inhibitor that has become increasingly popular as a first-line drug in the treatment of hyper- tension at the Medical College of Virginia/ Virginia Commonwealth University. Captopril, another ACE inhibitor, is also used frequently in the treatment of hypertension. The authors report four cases of angio- edema associated with the use of enalopril and two cases associated with the use of captopril between June 1986 and June 1988. One patient required an emergency tracheostomy for airway obstruction.

These six cases of angioedema represent 20% of all adult patients admitted to the Medical College of Virginia Hospitals with upper airway obstruction dur- ing this two-year period. Angioedema resulting from ACE inhibitors is unlikely to be mediated by IgE, therefore, the mainstay of therapy, such as epineph- rine, antihistamines and steroids, may not be success- ful in the treatment of this complication. Surgical intervention may be needed in patients with airway obstruction secondary to ACE inhibitor medications.

James S. Barna, MD Mary Ann Smith Frable, MD Esrafil Abedi, MD

Department of Otolaryngology

Medical College of Virginia/VCU

Box 115, MCV Station, Richmond VA 23298

Research and rabid dogs concern former health commissioner

The following is an edited version of a letter sent earlier to committee members in the Virginia General Assembly in regard to a bill restricting the use of animals for research:

Dog pounds have been described by some as “havens for pets.” Actually, dog pounds were estab- lished for the purpose of confining — or eliminating — unlicensed, loose, stray dogs.

When rabies became rampant, the licensure law was amended to require proof that the dog had been vaccinated against this disease. This requirement es- sentially eliminated rabies in all dogs except the unli- censed stray ones.

!When it became evident that the unvaccinated ani- mals were not only the main cause of rabies but also the major source of human bites by rabid animals, the push was on for their elimination. Of course, there were other reasons for eliminating stray dogs, for

VIRGINIA

MEDICAL

Journal of The Medical Society of Virginia 4205 Dover Road, Richmond VA 23221 (804) 353-2721

Editor

Edwin L. Kendig, Jr., MD, Richmond

Associate Editors

Richard G. Lester, MD, Norfolk Duncan S. Owen, Jr., MD, Richmond John A. Owen, Jr., MD, Charlottesville

Editorial Board

H. C. Alexander III, MD, Roanoke Raymond S. Brown, MD, Gloucester Henry S. Campell, MD, Martinsville C. Barrie Cook, MD, Fairfax Eloise C. Haun, MD, Woodstock Walter Lawrence, Jr., MD, Richmond Lockhart B. McGuire, MD, Charlottesville Robert Edgar Mitchell, Jr., MD, Richmond

Executive Editor Ann Gray

Business Manager James L. Moore, Jr.

Virginia Medical (ISSN 0146-3616) is the month- ly publication of The Medical Society of Virginia. Second-class postage paid at Richmond, Virginia. Yearly subscription rate: $24 domestic, $30 foreign; single copies, $3. Virginia Medical does not hold itself responsible for statements made by any con- tributor. Although all advertising is expected to conform to ethical medical standards, acceptance does not imply endorsement by this journal, and the publisher reserves the right to reject any advertise- ment. POSTMASTER: Send address changes to Virginia Medical, 4205 Dover Road, Richmond VA 23221.

If your mailing address is to change, notify the Executive Editor at the earliest opportunity. Send both your new address and an old mailing label.

April 1989, Virginia Medical 147

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example, sheep-killing dogs. Dog wardens, game war- dens, sheriffs and others cooperated in rounding up these neglected dogs, many of them hungry and wasted. Rabies in dogs has now been almost com- pletely eliminated and is found chiefly in unvaccinated wild animals. However, it could return if we neglect prevention measures, and man’s close association with dogs makes these requirements very important.

I was State Commissioner of Health from 1951 to 1976, and I gave the sponsor of the dog vaccination law my assistance. The State Health Department was given considerable responsibility for helping control rabies. By law we were required to assist with the treatment of those bitten by rabid animals and to provide shots free of charge if the patient demanded it.

One day in the late 1930s, 21 people on the streets of Abingdon, Virginia, were bitten by one rabid, stray dog. As the local health officer there at the time, I personally gave the series of rabies shots to all of them — one shot a day, every day, including Saturdays and Sundays.

Mack I. Shanholtz, MD

5912 Upham Drive Richmond VA 23227

Dr. Shanholtz is chairman of the Legislative Relations Committee of the University of Virginia Medical Alumni Association.

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148 Virginia Medical, April 1989

Hidden Illness in the White House, by Kenneth R. Crispell, MD, and Carlos F. Gomez, with foreword by Sen. Birch Bayh. Durham, North Carolina, Duke University Press, 1988, 267 pp, with footnotes and index.

Illness in the White House has been a well-visited topic over the past eight years, in large part the result of having a septuagenarian as President. The at- tempted assassination of President Reagan and the several illnesses that followed his next two terms have particularly heightened interest in the Twenty-Fifth Amendment to the United States Constitution. Passed after the Kennedy assassination, the Twenty-Fifth Amendment provides different mechanisms by which the Vice President replaces the President when the latter becomes ill and incapacitated. Hidden Illness in the White House is a new addition to the literature. One of its authors, Dr. Crispell, is emeritus professor of medicine and law at the University of Virginia; the other, Carlos Gomez, was a medical student when the book was written. Quite properly, they raise more questions than can be answered and leave the reader praying that the Pesident’s physician is a person of strong character and practicality.

A disabled President, medically unable to function, can be replaced either voluntarily or involuntarily under the Twenty-Fifth Amendment.1 Under Section Three of the Amendment, the President can declare his own temporary disability. The Vice President serves as Acting President until the President declares that he has regained his health. This procedure was followed — in a manner of speaking — when President Reagan had colon surgery in 1985. Mr. Reagan wrote the Congress that Mr. Bush would be acting in his stead while he was under general anesthesia. Mr. Reagan refused, however, to name Mr. Bush Acting President as the Amendment requires, asserting that the drafters of the Amendment did not intend its application to such “brief and temporary periods of incapacity.”

The President can also be replaced without his consent. Section Four provides a procedure for the Vice President along with a majority of the Cabinet to declare the President incapacitated. The President has a right to contest that declaration, and if there is a conflict, the issue is settled by the Congress. While the matter is being decided (there are rigorous time con- straints), the Vice President, upon vote of the majority of the Cabinet, can remain Acting President.

The President’s personal physician is not an officer of state. While paid by the government for his serv-

ices, he is the President’s doctor with a confidential doctor-patient relationship that he is duty-bound to protect. Thus the dilemma: what if the President has a disabling disease but orders his personal doctor not to break the confidentiality of the relationship and di- vulge that fact? Where does this doctor’s duty lie, to his patient or to the nation as a whole? If the question of the President’s health is litigated in a Section Four congressional trial, can the President’s doctor be com- pelled to break the privilege and testify?

The authors by historical discussion of White House medical secrets concerning actual or alleged presiden- tial disabilities demonstrate that the White House physician in fact may have tremendous power to alter history by concealing medical data. They offer no current solutions for future abuses, however, other than the sensible suggestion that perhaps a President and his physician should work out in advance a protocol for disclosure of medical problems in the event they arise in the future. Of course, a protocol — and its authorization to break the patient privilege under certain circumstances — can always be revoked by a President sick but unwilling to yield power. Or the Congress can pass a law abolishing the privilege under certain defined circumstances. Yet it is clear that no matter what protocols or rules of law are in existence, the job of applying them to disclosure of the Presi- dent’s health problems will never be easy so long as some patient confidentiality exists. We can only hope that the President’s doctor has the mature judgment and moral fiber to properly balance the rights of his patient against the rights of the nation when the time inevitably comes. For those who are concerned with this dilemma, the book is good reading.

John D. Grad

Grad, Toothman, Logan & Chabot PO Box 1417-A44 Alexandria VA 22313

1 The first section of the Amendment clarifies that when the President vacates office by death, resignation or re- moval, the Vice President becomes President, not Acting President or some other position implying lack of full power of the President. The second section concerns the replace- ment of a Vice President when that office beomes vacant. This section was utilized in connection with the appointment of Gerald Ford after Spiro Agnew resigned, and then of Nelson Rockefeller, when Mr. Ford became President after Richard Nixon resigned in 1974.

The Injured Athlete, 2nd Edition, by Daniel N. Ku- lund, MD. Philadelphia, J. B. Lippincott Company, 1988, illustrated, 603 pp.

The first edition of this book, published in 1982, received widespread recognition as a sports medicine primer for all physicians. In this second edition the overall organization is unchanged, with excellent chapters on the role of the team physician, pre-

April 1989, Virginia Medical 151

participation exam, medical problems of athletes and sports psychology. The strength of the book lies in the clear and thorough discussion of each injury. Diagno- sis, prevention and treatment, including a complete guide to rehabilitation exercises, is presented. Signifi- cant improvements in this edition include a discussion of the principles and usage of electrical stimulation in rehabilitation and expansion of the chapter on low back pain. In addition, each chapter provides prescrip- tions for rehabilitation, including the use of rubber tubing and swimming pool exercises. The book’s pri- mary deficiency lies in the rudimentary presentation of surgical treatments of the shoulder and knee, especial-

ly in light of recent advances in the treatment of the anterior cruciate ligament. Isokinetic testing and its use in rehabilitative exercise are also cursorily pre- sented.

The Injured Athlete presents the Virginia approach based on a respected group’s experience with and interest in the care of athletes. This book makes an important contribution to the library of the primary care physician.

Frank A. Pettrone, MD 1715 North George Mason Drive Arlington VA 22205

Help for a troubled friend is only a phone call away.

If you suspect a colleague is experiencing problems with alcohol or drug abuse, don’t contribute to the "conspiracy of silence," call The Medical Society of Virginia’s Physicians' Health and Effectiveness Committee. A non-punitive approach through rehabilitation is an alternative. Your report will be kept confidential. Ask for Jeanne Douglas at MSV headquarters, (804) 353-2721.

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152 Virginia Medical, April 1989

Imagine a machine

THAT CAN DO THIS TO

We're proud to announce the introduction of Extra- corporeal Shock Wave Lithotripsy as a new feature of our kidney stone treatment program. This new device makes it possible to pulverize and eliminate kidney stones with- out invasive surgery Now you have the opportunity to participate in this state-of-the-art procedure at CAMC's High Tech Center here in Charleston, West Virginia.

The Lithotripter uses shock waves to bombard kid- ney stones into sand-like particles inside the body. The residue is then easily passed. Although the theory behind Lithotripsy is simple, the process is precise. The stone is pinpointed inside the body with fluoroscopy and shock wave firing is synchronized with the patient's heartbeat by electrocardiogram. Usually, the entire pro- cess takes about an hour.

As you can imagine, Lithotripsy offers many benefits to kidney stone patients. The process is less painful, entails fewer side effects, and recuperation is quicker than with conventional surgery. It's even less expensive than surgery.

We're encouraging all area urologists to apply for privileges in Extracorporeal Shock Wave Lithotripsy. We invite you to visit CAMC and see the lithotripter in action. Come and learn about this revolutionary therapy. We will happily provide you with a brochure for your use as well as brochures for your patients.

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VIRGINIA

MEDICAL

APRIL 1989

Analgesics:

The Physician’s Partner in Effective Pain Management

Ada G. Rogers, RN, New York , New York

Effective management of pain depends on sufficient knowledge of the pharmacol- ogy of analgesics, careful assessment of each patient’s pain, and a change of attitude toward the use of potent opioid (narcotic) analgesics. Utilizing extensive experience and the results of studies at Memorial Sloan-Kettering Cancer Center, the author rebuts physician misconceptions, recommends strategies for 25 medication prob- lems, and provides oral/parenteral equivalencies of the most common analgesics.

Surveys have demonstrated that many patients suffer needlessly because of undermedication due largely to insufficient knowledge of the phar- macology of analgesics, the misconceptions and atti- tudes of health care providers towards the use of opioid (narcotic) analgesics, and the fear of drug abuse.

For the past 37 years controlled double blind cross- over studies have been conducted at Memorial Sloan- Kettering Cancer Center to determine the relative potency of analgesics. More recently, studies also have involved the measurement of plasma levels in conjunction with the estimation of therapeutic and adverse effects. The results of these studies have provided information contributing to the better man- agement of patients with postoperative and cancer pain. The suggestions in this paper are primarily based on the results of some of these studies and on our experience with the use of analgesics in postoperative and cancer pain.1-2

From the Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York NY 10021 , where Ada Rogers is a research associate.

Our studies have shown consistently that there is considerable variation among patients in their re- sponses to analgesics. It is not uncommon for some physicians to prescribe or recommend one drug or a set of a combination of drugs and expect every patient to respond favorably. When this proves unsuccessful, the patient is often labeled a chronic complainer, overreacting, or more often “addicted,” even when there is evidence of organic disease. Patients are individuals. Even those patients with the same disease will respond in different ways. Each patient, therefore, should be carefully assessed. Some of the vital factors that need to be considered are presented in Table 1.

Eliminating Misconceptions and Myths

In the last decade a great effort has been made to identify problems in the management of pain. Many of the problems were linked to misconceptions and myths about the use of analgesics in patients. Defining certain characteristics or aspects of opioid analgesics and patients may help to eliminate some of these misconceptions and myths.

1. Use of potent opioid analgesics will always lead to drug abuse. The incidence of drug abuse when these

164 Virginia Medical, April 1989

drugs are used legitimately is less than \%. Once the pain is eradicated, most patients will discontinue the use of analgesics.

2. Withholding opioid analgesics will prevent drug abuse. It only compounds the problem. It takes twice as much medication to control severe pain. The longer the patient has to wait, the worse the patient will become.

3. Tolerance and physician dependence are synon- ymous with drug abuse. Tolerance is that characteris- tic which requires increasingly larger doses to provide the same effect as the

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